The Impact of the COVID-19 Pandemic on Staffing Levels in Philadelphia Nursing Homes: Disparities Based on the Racial Composition of Geographical Areas.

Research to assess and inform health policy is an essential component of the policymaking process to advance equity in public health practice. This study investigated health disparities during the COVID-19 pandemic (2020-2022) in older adult institutional settings in Philadelphia, PA, to inform policy initiatives, interventions, and infrastructure development. We first explored the changing patterns of nursing staffing levels (total direct care staff and registered nurses [RNs]) measured by hours per resident per day (HPRD) before and after COVID-19. Our findings revealed that HPRD levels consistently fell below the Centers for Medicare and Medicaid Services recommended standards from 2018 to 2022, with notable declines observed starting from 2021. Results from multilevel modeling showed significant declines in HPRD for total direct care nursing staff in nursing homes located in zip codes with a high proportion of Black residents (≥40%). In contrast, HPRD for RNs significantly declined in nursing homes located in zip codes with a lower proportion of Black residents (<40%). Moreover, higher reported direct care HPRD and RN HPRD were associated with any reported COVID-19 cases only within zip codes with a low proportion of Black residents. These findings indicate the need for additional policies to address these observed patterns in staffing levels. Our study provides a foundation for future policy reviews utilizing a conceptual framework that is health equity-centric for local and state health departments program and units intended for institutional care settings for older adults.

Workforce thresholds and the non-linear association between registered nurse staffing and care quality in long-term residential care: A retrospective longitudinal study of English care homes with nursing.

BACKGROUND: Care needs amongst 425,000 dependent older residents in English care homes are becoming more complex. The quality of care in these homes is influenced by staffing levels, especially the presence of registered nurses (RNs). Existing research on this topic, often US-focused and relying on linear assumptions, has limitations. This study aims to investigate the non-linear relationship between RN staffing and care quality in English care homes using machine learning and administrative data from two major care home providers. METHODS: A retrospective observational study was conducted using data from two English care home providers. Each was analysed separately due to variations in data reporting and care processes. Various care quality indicators and staffing metrics were collected for a 3.5-year period. Regression analysis and machine learning (random forest) were employed to identify non-linear relationships. Ethical approval was obtained for the study. RESULTS: Using linear methods, higher skill mix - more care provided by RNs - was associated with lower incidence of adverse outcomes, such as urinary tract infections and hospitalisations. However, non-linear skill mix-outcome relationship modelling revealed both low and high skill mix levels were linked to higher risks. The effects of agency RN usage varied between providers, increasing risks in one but not the other. DISCUSSION: The study highlights the cost implications of increasing RN staffing establishments to improve care quality, suggesting a non-linear relationship and an optimal staffing threshold of around one-quarter of care provided by nurses. Alternative roles, such as care practitioners, merit exploration for meeting care demands whilst maintaining quality. This research underscores the need for a workforce plan for social care in England. It advocates for the incorporation of machine learning models alongside traditional regression-based methods. Our results may have limited generalisability to smaller providers and experimental research to redesign care processes effectively may be needed. CONCLUSION: RNs are crucial for quality in care homes. Contrary to the assumption that higher nurse staffing necessarily leads to better care quality, this study reveals a nuanced, non-linear relationship between RN staffing and care quality in English care homes. It suggests that identifying an optimal staffing threshold, beyond which increasing nursing inputs may not significantly enhance care quality may necessitate reconsidering care system design and (human) resource allocation. Further experimental research is required to elucidate resource-specific thresholds and further strengthen evidence for care home staffing. TWEETABLE ABSTRACT: How much nursing care is needed to assure quality in care homes? Evidence from 2 English care home providers shows that nurse sensitive outcomes (an indicator of quality) are better when ~25 % of care is provided by nurses. Nurse shortages increase risks for residents.

The Relationship between Nursing Home Staffing and Health Outcomes Revisited.

OBJECTIVE: Nursing homes make staffing decisions in conjunction with choosing quality goals, potentially leading to endogeneity bias between staffing and quality. We use instrumental variables (IVs) to explore it. DESIGN: Retrospective statistical analysis of 2017-2019 Payroll-Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term Care Focus. SETTINGS AND PARTICIPANTS: A total of 11,261 nursing homes nationally. METHODS: We estimated separate models for each of 6 quality measures as dependent variables, and registered nurses (RNs), certified nurse assistants (CNAs), and licensed practical nurses (LPNs) as independent variables, including other control variables associated with quality. The models were estimated using both ordinary least squares (OLS) and 2-stage least squares (2SLS) methods, the latter accounting for endogeneity. The IVs were defined as the average staffing of competing nursing homes in the same market as the index facility. RESULTS: Estimated coefficients for the quality measures in the 2SLS models were up to 5 times larger than in the OLS models. The 2SLS estimates for antipsychotic medications use increased with higher RN staffing [0.279 (0.004 to 0.553)] and decreased with higher CNAs [-0.125 (-0.198 to -0.052)]. Hospitalizations decreased with more RNs [-1.328 (-1.673 to -0.983)] and LPN staffing [-0.483 (-0.755 to -0.211])] and increased with CNA [0.201 (0.109 to 0.293)] staffing. Emergency room visits decreased with higher RNs [-1.098 (-1.500 to -0.696)] and increased with CNAs [0.191 (0.084 to 0.298)]. Long-stay activities of daily living [-0.313 (-0.416 to -0.209)] and short-stay functioning [-0.481 (-0.598 to -0.364)] improved only with higher CNA staffing and pressure sores improved only with increased RN staffing [-0.436 (-0.836 to -0.035)]. CONCLUSIONS AND IMPLICATIONS: Our findings demonstrate the importance of accounting for endogeneity in studies of staffing and quality. Endogeneity changes conclusions about significance, direction, and magnitude of the relationship between staffing and specific quality measures. These findings highlight the need to further study and understand the nuanced relationship between different staffing types and different health outcomes such as the difference between the relationship of RN and CNA hours per resident day to antipsychotic quality measures.

RNs in nursing homes-It is not always about the numbers.

The compelling evidence that higher RN to resident ratios improve health outcomes in nursing homes underscores the necessity of implementing evidence-based RN nursing home staffing standards. However, there are other dimensions to RN staffing in nursing homes beyond the numbers or hours per resident day (HPRD) that influence the quality of care. Without attending to a broader focus on nurse staffing, the benefits of increased RN staffing levels will not be achieved. This article outlines how RN HPRD can be maximized by magnifying the RN's scope of practice and attending to how nursing care is organized and delivered in nursing homes using a nursing practice model framework. This framework addresses the accountability of the RN and the RN's role in supporting and facilitating: (1) collective decision-making among the nursing staff about the care of residents and the work environment, (2) continuity of information among care providers, and (3) ensuring residents have continuity with the care providers assigned to their care. Attention to the RN's expertise in gerontological nursing and leadership capacity further leverages the RN's ability to influence the quality of care for nursing homes residents.

Dementia, nurse staffing, and health outcomes in nursing homes.

OBJECTIVE: To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality. DATA SOURCES AND STUDY SETTING: A national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus. STUDY DESIGN: Retrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics. DATA COLLECTION/EXTRACTION METHODS: Hospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded. PRINCIPAL FINDINGS: We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome. CONCLUSIONS: These findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities.

[Development of advanced practice nursing in oncology and hematology-oncology in France: Early status report]. / Développement des infirmiers en pratique avancée en oncologie et hémato-oncologie en France : état des lieux précoce.

BACKGROUND: Advanced practice nursing was introduced in France in 2018, in response to health needs. The first advanced practice nurses were graduated since 2019 and were trained in one among four medical areas including oncology and onco-hematology. The purpose of this article is to make an early assessment of the development of the profession of oncology Advanced Practice Nurse in France. METHOD: An exploratory study was conducted. A sample of 44 onco-hematology IPA graduated in 2019 and 2020 was recruited from June 2021 to end of July 2021. The 44 participants completed a questionnaire, by phone interviews or self-administered. RESULTS AND CONCLUSION: The distribution of the 44 participants concerns 12 of the 13 regions of metropolitan France. This profession shows an employability for 86% of the first graduates. These professionals practice in health care institutions and rather in oncology, 71% in the framework of an organizational protocol established with the oncologist. They appear to be well accepted by patients and oncology teams. Further studies on performance and quality indicators will make it possible to evaluate the added value of the oncology Advanced Practice Nurses in the cancer patient's pathway.

The Current State of Nursing.

Workforce issues, challenges, and opportunities.

2021: A Year of Hope and Heartbreak.

Optimism that the pandemic would be over was short lived.

Using War Language in a Pandemic: Rhetoric or Responsibility?

Frontline workers deserve protection and follow-up support.

Gerenciamento do tempo no processo de trabalho dos enfermeiros em Unidade de Terapia Intensiva / Gestión del tiempo en el proceso de trabajo de enfermeros de la unidad de cuidados intensivos / Time management in the work process of nurses in the intensive care unit

RESUMO Objetivo analisar o gerenciamento do tempo dispensado por enfermeiros em intervenções de cuidados diretos e indiretos, em atividades associadas ao trabalho e atividades pessoais. Método estudo quantitativo, transversal, realizado em Unidade de Terapia Intensiva de um hospital universitário no Rio de Janeiro em janeiro de 2017. Foram realizadas observações diretas das atividades realizadas pelos enfermeiros em 18 plantões, totalizando 216 horas. O "Instrumento para mensuração da carga de trabalho" foi utilizado para estruturar a observação. Resultados os resultados mostraram que 21,5% do tempo dos enfermeiros foram dedicados às intervenções de cuidados diretos 44,7% aos cuidados indiretos, 6,1% às atividades associadas e 27,7% às atividades pessoais. Conclusão os enfermeiros utilizam maior parte do tempo em atividades não relacionadas ao cuidado direto ao paciente. Os achados podem ser utilizados pelos gestores para revisão e adequação do dimensionamento de profissionais na assistência direta e indireta e do processo de trabalho na Unidade.

RESUMEN Objetivo analizar la gestión del tiempo que brindan los enfermeros en las intervenciones asistenciales directas e indirectas, en actividades asociadas al trabajo y actividades personales. Método estudio cuantitativo, transversal, realizado en la Unidad de Cuidados Intensivos de un hospital universitario de Rio de Janeiro en enero de 2017. Se realizaron observaciones directas de las actividades realizadas por enfermeras en 18 turnos, totalizando 216 horas. Se utilizó la "Herramienta de medición de la carga de trabajo" para estructurar la observación. Resultados los resultados mostraron que el 21,5% del tiempo de los enfermeros se dedicó a intervenciones de cuidados directos, el 44,7% a cuidados indirectos, el 6,1% a actividades asociadas y el 27,7% a actividades personales. Conclusión los enfermeros dedican la mayor parte de su tiempo a actividades no relacionadas con la atención directa al paciente. Los hallazgos pueden ser utilizados por los gestores para revisar y adecuar el dimensionamiento de profesionales en la atención directa e indirecta y el proceso de trabajo en la Unidad.

ABSTRACT Objective to analyze time management by nurses in direct and indirect care interventions, in work-related and personal activities. Method this quantitative, cross-sectional study was conducted in the Intensive Care Unit of a university hospital in Rio de Janeiro in January 2017. Direct observations were made of nurses' activities in 18 shifts, totaling 216 hours. Mello's "Workload Measuring Tool" was used to structure the observations. Results 21.5% of nurses' time was devoted to direct care, 44.7% to indirect care, 6.1% to work-related activities and 27.7% to personal activities. Conclusion nurses spend most of their time on activities unrelated to direct patient care. These findings can be useful to managers in reviewing and adjusting both staffing in direct and indirect care and the unit's work process.

Does continuity in nursing staff matter? A pilot study on correlation of central line-associated bloodstream infections and employee turnover.

BACKGROUND: Understaffing has been previously reported as a risk factor for central line-associated bloodstream infections (CLABSI). No previous study addressed the question whether fluctuations in staffing have an impact on CLABSI incidence. We analyzed prospectively collected CLABSI surveillance data and data on employee turnover of health care workers (HCW) to address this research question. METHODS: In January 2016, a semiautomatic surveillance system for CLABSI was implemented at the University Hospital Zurich, a 940 bed tertiary care hospital in Switzerland. Monthly incidence rates (CLABSI/1000 catheter days) were calculated and correlations with human resources management-derived data on employee turnover of HCWs (defined as number of leaving HCWs per month divided by the number of employed HCWs) investigated. RESULTS: Over a period of 24 months, we detected on the hospital level a positive correlation of CLABSI incidence rates and turnover of nursing personnel (Spearman rank correlation, r = 0.467, P = 0.022). In more detailed analyses on the professional training of nursing personnel, a correlation of CLABSI incidence rates and licensed practical nurses (Spearman rank correlation, r = 0.26, P = 0.038) or registered nurses (r = 0.471, P = 0.021) was found. Physician turnover did not correlate with CLABSI incidence (Spearman rank correlation, r = -0.058, P = 0.787). CONCLUSIONS: Prospectively determined CLABSI incidence correlated positively with the degree of turnover of nurses overall and nurses with advanced training, but not with the turnover of physicians. Efforts to maintain continuity in nursing staff might be helpful for sustained reduction in CLABSI rates.

Admissions of COVID-positive patients to US nursing homes with personal protective equipment or staffing shortages.

BACKGROUND: US nursing homes are required to follow Centers for Disease Control guidance for COVID-19 transmission-based precautions (TBP) when admitting COVID-positive patients. OBJECTIVE: To assess how frequently nursing homes had shortages of personal protective equipment (PPE) or staffing in weeks when they admitted COVID-positive patients, which likely made it more difficult to follow TBP, and to compare facility characteristics by admissions practices. DESIGN AND SETTING: Facility-level data from the Nursing Home COVID-19 Public File for the period between June 7, 2020 and March 7, 2021 was combined with additional data. The percentages of nursing homes that admitted COVID-positive patients and that had shortages when admitting were calculated for each week. Descriptive statistics and logistic regression models were used to examine the relationship between facility characteristics and the likelihood of admitting COVID-positive patients. MEASUREMENTS: Facilities were categorized as having admitted COVID-positive patients in a week if one or more admissions requiring TBP were reported for that week. Facilities that reported having less than a 1-week supply of any type of PPE or being short any type of staff in a week were defined, respectively, as having a PPE shortage or staffing shortage in that week. RESULTS: Over the 40-week study period, 39% of US nursing homes admitted COVID-positive patients in at least 1 week in which they were experiencing PPE or staffing shortages. Facilities that admitted COVID-positive patients with shortages generally had lower Centers for Medicare and Medicaid Services overall five-star ratings than other facilities. Only a small percentage of facilities that admitted COVID-positive patients while facing shortages were located in counties with severe shortages of PPE or staffing. In logistic regression models, shortages were not associated with COVID-positive admissions. CONCLUSION: The widespread practice of admitting COVID-positive patients while facing shortages may have put nursing home residents and staff at heightened risk of COVID-19 infection.

Working conditions of Nursing professionals in coping with the Covid-19 pandemic.

OBJECTIVE: To trigger a reflection on the current working conditions of Nursing professionals in coping with the Covid-19 pandemic. METHOD: A theoretical-reflective study supported by studies from the Marxist perspective, national and international scientific articles, and official documents from the World Health Organization and the Federal Nursing Council. RESULTS: The daily work of Nursing professionals in the face of the Covid-19 pandemic presents unfavorable working conditions in Brazil and worldwide, with emphasis on the deficit of professionals, overload of activities, low pay, and personal protective equipment, often insufficient and inadequate, conditions that can lead to exhaustion, illness and death. CONCLUSION: This study can contribute to raising discussions about the need for improvements in the working conditions of Nursing professionals, especially in pandemic times and the impact on the health of these professionals.

Effect of Hurricane Irma on daily direct-care nurse staffing in nursing homes.

OBJECTIVES: To examine the effect of Hurricane Irma on staff-related financial expenditures and daily direct-care nurse staffing levels. DESIGN: Retrospective cohort study. SETTING: September 3-24, 2017 in the state of Florida, United States. Hurricane Irma made landfall on September 10, 2017. PARTICIPANTS: Six hundred and fifty-three nursing homes (NHs), 81 evacuated facilities, and 572 facilities that sheltered-in-place. MEASUREMENTS: This study used data from Payroll-Based Journaling (PBJ), Certification and Survey Provider Enhanced Reports (CASPER), and Florida's health providers' emergency reporting system. PBJ provided estimates of daily direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants. CASPER reported facility-level characteristics such as profit status, chain membership, and special care unit availability. Florida's emergency reporting system identified evacuation status during Hurricane Irma. Linear mixed-effects models were used to estimate the unique contribution of evacuation status on daily staffing increases over time from September 3 to 10. RESULTS: Among all facilities, we found significant increases in staffing for licensed practical nurses (p = 0.02) and certified nursing assistants (p < 0.001), but not for registered nurses (p = 0.10) before Hurricane Irma made landfall. From 1 week before landfall to 2 weeks after landfall (September 3-24), an additional estimated $2.41 million was spent on direct-care nurse staffing. In comparison to facilities that sheltered-in-place, evacuated facilities increased staffing levels of all nurse types (all p < 0.001). At landfall, evacuated facilities spent an estimated $93.74 on nurse staffing per resident whereas facilities that sheltered-in-place spent $76.10 on nurse staffing per resident. CONCLUSION: NHs face unprecedented challenges during hurricanes, including maintaining adequate direct-care nurse staffing levels to meet the needs of their residents. NHs that evacuated residents had an increase in direct-care nurse staffing that was greater than that seen in NHs that sheltered-in-place.

Nursing's Staffing Mandate: Build a More Flexible Workforce.

The COVID-19 pandemic exhausted the nursing workforce, casting doubt that future supply will meet demand. To preserve their workforces, nursing leaders are offering emotional support to the frontline. Although these efforts are essential, leaders are overlooking an untapped opportunity to safeguard staffing levels: creating a more flexible nursing workforce. In this article, the authors discuss flexible nurse staffing and suggest 4 key opportunities for improvement.

Where Do We Go from Here?

What's next for nursing after the pandemic.