Psychological distress symptoms in nurses and their intention to leave: A cross-sectional secondary data analysis.

AIM: This study aimed to examine the psychological symptoms of distress among nurses in relation to their intention to leave. DESIGN: This study was a secondary data analysis of a cross-sectional survey collected between November 2020 and March 2021. METHODS: Chi-square was used to examine the associations between the demographic characteristics and intention to leave and psychological distress symptoms-feeling depressed, anxious and worried. Multiple linear regression analyses were performed to examine if work settings, position (staff, charge, administrators, educators/researchers and advanced practice registered nurses) and years of experience were associated with psychological distress and intention to leave. A mediation analysis examined if psychological distress mediated the relationship between years of experience and intention to leave. RESULTS: Overall, psychological distress was significantly positively associated with intention to leave and negatively associated with years of experience. Nurses with less than 2 years of experience had increased psychological distress, while nurses with >25 years of experience had decreased psychological distress. Both groups of nurses had increased intention to leave compared to those with 16-25 years of experience. Psychological distress partially mediated intention to leave in nurses with less than 2 years of experience and more so among nurses with >25 years of experience. CONCLUSIONS: This study suggests that nurses encounter psychological distress symptoms, such as feeling anxious, depressed and worried, that contribute to an increased intention to leave. Among the workplace locations, nurses practicing in nursing homes had the highest intention to leave. IMPACT: The study emphasizes that organizations need to focus on mitigating distress across all levels of nurses to promote retention efforts and intention to stay. REPORTING METHOD: The authors adhered to the STROBE guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient contribution. Completion of the survey in the original study (NWWS) implied consent from the participating nurses.

Workplace access, burnout, and prescription drug misuse among Korean hospital nurses: a cross-sectional study.

BACKGROUND: Prescription drug misuse has been identified as a global issue of concern. Nurses' prescription drug misuse is linked to personal health problems and impaired nursing care. This study explored the level of South Korean hospital nurses' prescription drug misuse and examined associations with workplace access and burnout. METHODS: This cross-sectional study used data from 1142 nurses working in South Korean hospital settings. Nurses completed the online survey anonymously. Descriptive analysis, logistic regression, and Shapley value assessment were conducted. RESULTS: Pain relievers (44.2%), IV drips (26.8%), and antibiotics (13.5%) were the most commonly misused drugs among hospital nurses. Accessibility in the workplace was high, with nurses reporting frequent administration of IV drips, pain relievers, and antibiotics and perceiving these drugs as easily accessible. Logistic regression demonstrated that perceived availability was significantly related to misuse across all drug types. Burnout was associated with IV drips, sleeping pills, and steroids, increasing the likelihood of misuse. Shapley feature importance analysis highlighted perceived availability as the most influential factor for IV drips, pain relievers, and steroids, while burnout emerged as crucial for antibiotics and sleeping pills. Notably, age played a significant role in appetite suppressant misuse, distinguishing it from other drugs. CONCLUSION: Our results revealed that workplace access and burnout are associated with nurses' prescription drug misuse. Effective educational strategies are essential for enhancing nurses' willingness to seek help for personal health issues. Hospital organizations play a crucial role in facilitating access to healthcare and fostering a supportive environment for nurses to seek treatment when necessary. Additionally, governmental policies should prioritize the implementation of active surveillance systems to monitor medication usage in healthcare settings, thereby mitigating drug misuse among healthcare professionals. By addressing these issues, we can ensure the well-being of nurses and promote a safer healthcare environment.

Moral distress in nurse leaders-A scoping review of the literature.

Nurse leaders face immense organizational pressures exacerbating their distress, which has not been prioritized as much as frontline nurses. This review synthesized the literature to examine theoretical models, measures, contributing factors, outcomes, and coping strategies related to moral distress in nurse leaders. PubMed, Embase, CINAHL, and PsycINFO were searched, and 15 articles-2 quantitative and 13 qualitative studies were extracted. The scoping review identified one study using a theoretical model and two measures-the ethical dilemmas questionnaire and the Brazilian moral distress scale. Contributing factors of moral distress include internal and organizational constraints, increased workload, and lack of support impacting physical and emotional well-being and intention to quit. This review did not yield any intervention studies emphasizing the need for research to identify specific predictors of moral distress and examine their relationship to nurse leader retention, so organizations can explore targeted interventions to promote coping and mitigate distress.

State-level nursing home in-service dementia training requirements and inappropriate psychotropic medication use.

BACKGROUND: Although non-pharmacological interventions, which are staff intensive, are recommended for behavioral symptoms of dementia, psychotropics are often prescribed in nursing homes (NHs), with insufficient nurse staffing levels and dementia care training. Since 2017, deficiency citations can be assigned for inappropriate psychotropics use (F-758 tag). Some states require in-service dementia training above federal minimums, but it is unknown whether extra dementia training requirements were related to fewer F-758 citations for residents with dementia and whether nurse staffing influenced the relationship between receiving F-758 citations and having additional state-level dementia training requirements. PURPOSE: To relate F-758 citation occurrence to extra in-service dementia training regulations and to explore how the relationships are affected by nurse staffing levels. METHOD: Generalized linear mixed models were used to examine F-758 citation occurrence in relation to state-level in-service dementia training regulations. Stratification was also conducted to compare the effects in NHs with low versus high nurse staffing. FINDINGS: Requiring in-service dementia training with extra hours was inversely related to receiving F-758 tags. That relationship was also noted in NHs with lower registered nurse and certified nurse assistant staffing. DISCUSSION: In-service dementia training may be helpful in reducing inappropriate psychotropics use, particularly in facilities with lower nurse staffing.

Wake-up Call: Night Shifts Adversely Affect Nurse Health and Retention, Patient and Public Safety, and Costs.

The purpose of this mini review is to (1) summarize the findings on the impact of night shift on nurses' health and wellness, patient and public safety, and implications on organizational costs and (2) provide strategies to promote night shift nurses' health and improve organizational costs. The night shift, compared with day shift, results in poorer physical and mental health through its adverse effects on sleep, circadian rhythms, and dietary and beverage consumption, along with impaired cognitive function that increases nurse errors. Nurse administrators and health care organizations have opportunities to improve nurse and patient safety on night shifts. Low-, moderate-, and higher-cost measures that promote night nurses' health and well-being can help mitigate these negative outcomes. The provided individual and organizational recommendations and innovations support night shift nurses' health, patient and public safety, and organizational success.

Research priorities to reduce risks from work hours and fatigue in the healthcare and social assistance sector.

BACKGROUND: The services of Healthcare and Social Assistance (HCSA) workers are needed by society around the clock. As a result, these workers are exposed to shift work and long work hours. The combination of demanding work schedules and other hazards in the HCSA work environment increases the health and safety risks to these workers, as well as to their patients/clients and the public. METHODS: This paper has three aims: (1) provide an overview of the burden of shift work, long hours, and related sleep and fatigue problems in this sector; (2) suggest research priorities that would improve these; and (3) discuss potential positive impacts of addressing these research priorities for the health and safety of workers and the public. The authors used a modified Delphi approach to anonymously rank-order priorities for improving HCSA worker health and safety and public safety. Input was also obtained from attendees at the 2019 National Institute for Occupational Safety and Health (NIOSH) Work Hours, Sleep, and Fatigue Forum. RESULTS: The highest rated research priorities were developing better designs for work schedules, and improving the HCSA culture and leadership approaches to shift work and long work hours. Additional priorities are identified. CONCLUSION: Research in these priority areas has the potential to benefit HCSA workers as well as their patients/clients, employers, and society.

Nurse staffing and deficiency of care for inappropriate psychotropic medication use in nursing home residents with dementia.

PURPOSE: Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non-pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F-tag for deficiencies of care, targeting inappropriate psychotropic medication use (F-758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms. DESIGN: This was secondary data analysis of a cross-sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll-Based Journal) data from 14,548 Medicare or Medicaid-certified facilities surveyed between December 1, 2017 and December 31, 2018. METHODS: Staffing measures included nursing hours per resident day and registered nurse skill-mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid. RESULTS: There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44-0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77-0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79-0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill-mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04-0.26). CONCLUSION: Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill-mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non-pharmacological interventions and reduce inappropriate psychotropic medication use. CLINICAL RELEVANCE: Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high-quality dementia care.

Workplace Exposures and Prescription Drug Misuse Among Nurses.

OBJECTIVE: This study examined the association between workplace exposure and prescription drug misuse in nurses. BACKGROUND: Studies have found RNs and other health providers have higher rates of prescription misuse than the general population and have suggested that workplace exposures along with excessive job demands create circumstances fostering misuse. METHODS: Survey data from 1170 RNs on workplace exposures (availability, frequency of administration, knowledge of substances, and workplace controls) were described by workplace, position, and specialty. Exposures were then related to prescription drug misuse using logistic regression. RESULTS: Each workplace exposure was associated with past year prescription drug misuse. An index combining all exposures was significantly related to misuse ( P = 0.001), and odds of misuse increased by 38% for each point increase in the exposure index. CONCLUSIONS: Consideration of the health and well-being of nurses at higher odds of exposure to prescription drugs with misuse potential is warranted. Workplace support to help nurses maintain and restore their health should be a priority.

Bullying experience and the work environment in nurses: A cross-sectional data analysis.

AIMS: This study aimed to examine the degree and severity of workplace bullying in nurses and to assess the relationship between bullying and work environment factors. BACKGROUND: Workplace bullying occurs in nursing at an alarming rate and may escalate with more adverse working conditions. METHODS: Online survey data from a nationally representative sample of 1,170 U.S. registered nurses, collected between 2020 and 2021, were analysed. Five items measuring workplace bullying were used to identify bullying subgroups (unbullied, bullied but unrecognized, moderate bullying and severe bullying) using latent profile analysis. Ordinal logistic regression examined relationships between workplace factors and bullying. RESULTS: Over 40% of nurses reported being bullied in the past year. Four bullying subgroups were distinguished. Inadequate staffing, lack of time to get the job done and lack of breaks away from the work area were all significantly associated with severe bullying. CONCLUSION: Ensuring adequate staffing based on patient needs and nurse competency can mitigate workplace bullying in nurses. Further studies are needed to examine the effectiveness of stress reduction programmes on bullying using longitudinal designs. IMPLICATIONS FOR NURSING MANAGEMENT: This result indicates a critical need to improve nursing work environments, which could provide many benefits for nursing workforces, including potential to lessen bullying severity that adversely affects nurse well-being.

Comparing residential long-term care regulations between nursing homes and assisted living facilities.

BACKGROUND: Nursing homes (NHs) are federally regulated under uniform standards, whereas assisted living facilities (ALFs) use individual state regulations for staffing, training, and oversight of care quality and safety. PURPOSE: To describe ALF staffing, training, inspection, and enforcement regulations for 50 U.S. states and the District of Columbia, and compare them to NH regulations. Publication of ALF quality and safety outcomes data also was assessed and compared to NHs. METHODS: Regulatory data were compiled from administrative and regulatory data sources, state websites, and regulatory compendia. FINDINGS: NHs followed a standard set of regulations, whereas ALF regulations varied widely. Overall, state ALF regulations were less stringent than NH in all categories. DISCUSSION: As ALF populations and acuity levels increase, staffing, training, nursing presence, and outcomes data requirements are warranted, and could be tailored from NH regulations to protect ALF quality and safety.

National opioid prescribing trends in emergency departments by provider type: 2005-2015.

PURPOSE: To describe opioid prescribing practice patterns and trends in emergency department visits (EDs) by provider type: physicians and advanced practice providers (APPs), which include nurse practitioners (NPs) and physician assistants (PAs). METHODS: The data source was the ED visit files of the 2005-2015 National Hospital Ambulatory Care Survey. The study sample was opioid prescription-related ED visits. Descriptive and multinomial logistic regression analyses were conducted to assess the proportion of opioid prescription-related visits by provider type over time in total and by patient age group. We then characterized opioid prescribing practices of NPs, PAs, and physicians according to type of opioid and pain-related diagnosis. RESULTS: From 2005 to 2015, there was a 116.7% increase in the proportion of the opioid prescription-related visits seen by NPs and a 61.2% increase seen by both APPs and physicians. In contrast, the proportion of the physician-only visits decreased (-8.3%). When stratified by age group, the growth was particularly notable among the visits with patients aged 65 and older seen by both APPs and physicians (AOR = 2.35, 95% CI = 1.69, 3.25). Proportionally less hydromorphone and morphine was prescribed by APPs than by physicians. Opioids were prescribed more often by APPs in visits involving dental and injury-related pain, whereas physicians prescribed opioids more in abdominal and chest pain-related visits. CONCLUSIONS: From 2005 to 2015, APPs, particularly NPs played an increasing role in opioid prescribing in EDs. Opioid prescribing practices of APPs and physicians varied by patient condition as well as by opioid type.

Variation Across U.S. Assisted Living Facilities: Admissions, Resident Care Needs, and Staffing.

PURPOSE: Though more people in the United States currently reside in assisted living facilities (ALFs) than nursing homes, little is known about ALF admission policies, resident care needs, and staffing characteristics. We therefore conducted this study using a nationwide sample of ALFs to examine these factors, along with comparison of ALFs by size. DESIGN: Cross-sectional secondary data analysis using data from the 2010 National Survey of Residential Care Facilities. METHODS: Measures included nine admission policy items, seven items on the proportion of residents with selected conditions or care needs, and six items on staffing characteristics (e.g., access to licensed nurse, aide training). Facilities (n = 2,301) were divided into three categories by size: small, 4 to 10 beds; medium, 11 to 25 beds; and large, 26 or more beds. Analyses took complex sampling design effects into account to project national U.S. estimates. FINDINGS: More than half of ALFs admitted residents with considerable healthcare needs and served populations that required nursing care, such as for transfers, medications, and eating or dressing. Staffing was largely composed of patient care aides, and fewer than half of ALFs had licensed care provider (registered nurse, licensed practical nurse) hours. Smaller facilities tended to have more inclusive admission policies and residents with more complex care needs (more mobility, eating and medication assistance required, short-term memory issues, p < .01) and less access to licensed nurses than larger ALFs (p < .01). CONCLUSIONS: This study suggests ALFs are caring for and admitting residents with considerable care needs, indicating potential overlap with nursing home populations. Despite this finding, ALF regulations lag far behind those in effect for nursing homes. In addition, measurement of care outcomes is critically needed to ensure appropriate ALF care quality. CLINICAL RELEVANCE: As more people choose ALFs, outcome measures for ALFs, which are now unavailable, should be developed to allow for oversight and monitoring of care quality.

Work-related factors, job satisfaction and intent to leave the current job among United States nurses.

AIMS AND OBJECTIVES: To examine the relationships of work-related factors (e.g., autonomy, work schedule, supervisory and peer support) to nurses' job satisfaction and intent to leave their current position. BACKGROUND: Low job satisfaction and high turnover of nurses are major problems for health care. To improve nurse retention, work-related factors associated with job satisfaction and intent to leave should be investigated. DESIGN: A cross-sectional secondary data analysis. METHODS: Data were obtained in 2004 from Wave 3 of the Nurses' Worklife and Health Study. A random sample of 5000 actively licenced nurses in Illinois and North Carolina (two U.S. states) were sent the survey in wave 1, of which 1641 actively working bedside nurses participated in wave 3. We examined associations of various work-related factors with job satisfaction and intent to leave the current position. RESULTS: Nurses who were dissatisfied with their job reported significantly higher psychological demands and lower autonomy than nurses who were satisfied. Nurses were significantly less satisfied with their jobs when they worked longer hours with inadequate breaks or sick days. Lack of support from peers and supervisors was also related to significantly lower odds of job satisfaction. For intention to leave, nurses who said they planned to leave their current job reported significantly lower autonomy and less support from their peers than nurses who intended to stay. CONCLUSION: A variety of modifiable work-related factors were significantly related to job satisfaction and intention to leave the current job among nurses. Future research should focus on developing interventions that could mitigate these factors (e.g., by improving work schedules, increasing autonomy and/or nurse support). The impact of such interventions on job satisfaction and intention to leave the current position could then be evaluated. RELEVANCE TO CLINICAL PRACTICE: To increase nurse retention, improved schedules, autonomy and supportive work environments should be promoted.

Electronic Personal Health Record Use Among Nurses in the Nursing Informatics Community.

An electronic personal health record is a patient-centric tool that enables patients to securely access, manage, and share their health information with healthcare providers. It is presumed the nursing informatics community would be early adopters of electronic personal health record, yet no studies have been identified that examine the personal adoption of electronic personal health record's for their own healthcare. For this study, we sampled nurse members of the American Medical Informatics Association and the Healthcare Information and Management Systems Society with 183 responding. Multiple logistic regression analysis was used to identify those factors associated with electronic personal health record use. Overall, 72% were electronic personal health record users. Users tended to be older (aged >50 years), be more highly educated (72% master's or doctoral degrees), and hold positions as clinical informatics specialists or chief nursing informatics officers. Those whose healthcare providers used electronic health records were significantly more likely to use electronic personal health records (odds ratio, 5.99; 95% confidence interval, 1.40-25.61). Electronic personal health record users were significantly less concerned about privacy of health information online than nonusers (odds ratio, 0.32; 95% confidence interval, 0.14-0.70) adjusted for ethnicity, race, and practice region. Informatics nurses, with their patient-centered view of technology, are in prime position to influence development of electronic personal health records. Our findings can inform policy efforts to encourage informatics and other professional nursing groups to become leaders and users of electronic personal health record; such use could help them endorse and engage patients to use electronic personal health records. Having champions with expertise in and enthusiasm for the new technology can promote the adoptionof electronic personal health records among healthcare providers as well as their patients.

Electronic personal health record use among registered nurses.

INTRODUCTION: Nurses promote self-care and active participation of individuals in managing their health care, yet little is known about their own use of electronic personal health records (ePHRs). The purpose of this study was to examine factors associated with ePHR use by nurses for their own health management. METHODS: A total of 664 registered nurses working in 12 hospitals in the Maryland and Washington DC area participated in an online survey from December 2013 to January 2014. Multiple logistic regression models identified factors associated with ePHR use. RESULTS: More than a third (41%; 95% confidence interval [CI], 0.37-0.44) of the respondents were ePHR users. There was no variation between ePHR users and nonusers by demographic or job-related information. However, ePHR users were more likely to be active health care consumers (i.e., have a chronic medical condition and take prescribed medications; odds ratio [OR] = 1.64; 95% CI, 1.06-2.53) and have health care providers who used electronic health records for care (OR = 3.62; 95% CI, 2.45-5.36). CONCLUSIONS: Nurses were proactive in managing their chronic medical conditions and prescribed medication use with ePHRs. ePHR use by nurses can be facilitated by increasing use of electronic health records.

A comparison of work characteristics and health status between Korean and US hospital nurses.

AIM: A rigorous examination of the occupational features across cultures helps draw policy recommendations for nurses' quality care practices and good health. This study aimed to explore the differences in work characteristics and health status between Korean and US hospital nurses. DESIGN: For this comparative secondary data analysis study, we constructed a dataset with 304 pairs of nurses from Korea and the United States, matched by age and gender. METHODS: We used the data from the 2020 Korean Hospital Nurses Health Behaviors and Health Status study, collected from May to July 2020, and the Nurse Worklife and Wellness Study (NWWS), conducted between November 2020 and February 2021. RESULTS: Compared to nurses in the United States, Korean nurses rated their job-related conditions much lower, had lower intentions to stay in their current workplace and were less satisfied with their jobs. Korean nurses reported that organizational support and employee health resources were less prevalent and their levels of healthy behaviour practice and health status were lower than their US counterparts. Nurses in Korea require better practice environments and employee health support. Adequate workload and staffing levels are needed to improve job conditions for Korean nurses. Organizational support and employee health resources should always be accessible at nurses' workplaces.

Turnover, staffing, skill mix, and resident outcomes in a national sample of US nursing homes.

OBJECTIVES: The authors examined the relationship of staff turnover to selected nursing home quality outcomes, in the context of staffing and skill mix. BACKGROUND: Staff turnover is a serious concern in nursing homes as it has been found to adversely affect care. When employee turnover is minimized, better care quality is more likely in nursing homes. METHODS: Data from the National Nursing Home Survey, a nationally representative sample of US nursing homes, were linked to Nursing Home Compare quality outcomes and analyzed using logistic regression. RESULTS: Nursing homes with high certified nursing assistant turnover had significantly higher odds of pressure ulcers, pain, and urinary tract infections even after controlling for staffing, skill mix, bed size, and ownership. Nurse turnover was associated with twice the odds of pressure ulcers, although this was attenuated when staffing was controlled. CONCLUSIONS: This study suggests turnover may be more important in explaining nursing home (NH) outcomes than staffing and skill mix and should therefore be given greater emphasis.

Nursing students' perceived knowledge, therapeutic attitudes, and interest in addictions education.

BACKGROUND: Nurses care for people who use substances (SU) and have addictions across healthcare settings; however, education has been lacking about these issues. Experiences working with patients with SU paired with lack of knowledge may negatively affect attitudes. PURPOSE: Prior to designing an addictions curriculum, we aimed to assess nursing students' perceived knowledge, attitudes, and educational interests in SU and addictions, and compare pre-licensure nursing students to registered nurses and advanced practice RNs (RN/APRNs). METHODS: The student body at a large mid-Atlantic school of nursing was surveyed online, Fall 2019. Of 1987 students, 647 (33 %) responded; 567 complete responses were analyzed. Pre-licensure and RN/APRN student responses were compared, and comments were summarized. RESULTS: Virtually all students agreed that it is important to be educated about SU and addictions (96 %). Students were interested in addiction courses (80 %) and a graduate certificate program (61 %), and 70 % of undergraduates were in favor of an addictions focus area as part of their BSN degree program. Perceived knowledge to address addictions was rated moderately overall. As far as learning needs, students felt they knew the least about problem gambling, communicating about SU, considering readiness to change and using community resources. RN/APRNs rated their motivation and job satisfaction in working with people with SU lower than pre-licensure students. CONCLUSIONS: Students' responses supported and informed the development of addictions curricula, with a broad focus on addictions including substances, gambling and other addictions. Elective courses, an undergraduate focus area, and a graduate-level certificate were developed, piloted, and are now offered by the School of Nursing.

Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia.

OBJECTIVES: The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia. DESIGN: A mixed-methods study was performed. SETTING AND PARTICIPANTS: During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica. METHODS: Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ2 tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports. RESULTS: Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on Pro Re Nata (PRN) psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P < .001), attempt gradual drug reduction (P < .001), and provide adequate indications for psychotropics use (P < .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P < .001) and provide nonpharmacologic interventions (P < .001). CONCLUSIONS AND IMPLICATIONS: This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

Nurses' work schedule characteristics, nurse staffing, and patient mortality.

BACKGROUND: Although nurse staffing has been found to be related to patient mortality, there has been limited study of the independent effect of work schedules on patient care outcomes. OBJECTIVE: To determine if, in hospitals where nurses report more adverse work schedules, there would be increased patient mortality, controlling for staffing. METHODS: A cross-sectional design was used, with multilevel data from a 2004 survey of 633 nurses working in 71 acute nonfederal hospitals in North Carolina and Illinois. Mortality measures were the risk-adjusted Agency for Healthcare Research and Quality Inpatient Quality Indicators, and staffing data were from the American Hospital Association Annual Survey of hospitals. Principal components analysis was conducted on the 12 work schedule items to create eight independent components. Generalized estimating equations were used to examine the study hypothesis. RESULTS: Work schedule was related significantly to mortality when staffing levels and hospital characteristics were controlled. Pneumonia deaths were significantly more likely in hospitals where nurses reported schedules with long work hours (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.17-1.73, p < .01) and lack of time away from work (OR = 1.24, 95% CI = 1.03-1.50, p < .05). Abdominal aortic aneurysm was also associated significantly with the lack of time away (OR = 1.39, 95% CI = 1.11-1.73, p < .01). For patients with congestive heart failure, mortality was associated with working while sick (OR = 1.39, 95% CI = 1.13-1.72, p < .01), whereas acute myocardial infarction was associated significantly with weekly burden (hours per week; days in a row) for nurses (OR = 1.33, 95% CI = 1.09-1.63, p < .01). DISCUSSION: In addition to staffing, nurses' work schedules are associated with patient mortality. This suggests that work schedule has an independent effect on patient outcomes.