Severe neighborhood deprivation and nursing home staffing in the United States.

BACKGROUND: Low nursing home staffing in the United States is a growing safety concern. Socioeconomic deprivation in the local areas surrounding a nursing home may be a barrier to improving staffing rates but has been poorly studied. Thus, the objective of this paper was to assess the relationship between neighborhood deprivation and nursing home staffing in the United States. METHODS: This cross-sectional study used 2018 daily payroll-based staffing records and address data for 12,609 nursing homes in the United States linked with resident assessment data. Our primary exposure of interest was severe economic deprivation at the census block group (neighborhood) level, defined as an area deprivation index score ≥85/100. The primary outcome was hours worked per resident-day among nursing home employees providing direct resident care. Marginal linear regression models and generalized estimating equations with robust sandwich-type standard errors were used to estimate associations between severe neighborhood deprivation and staffing rates. RESULTS: Compared to less deprived neighborhoods, unadjusted staffing rates in facilities located within severely deprived neighborhoods were 38% lower for physical and occupational therapists, 30% lower for registered nurses (RNs), and 5% lower for certified nursing assistants. No disparities in licensed practical nurse (LPN) staffing were observed. In models with state-level and rurality fixed effects and clustered on the county, a similar pattern of disparities was observed. Specifically, RN staffing per 100 resident-days was significantly lower in facilities located within severely deprived neighborhoods as compared to those in less deprived areas (mean difference: 5.6 fewer hours, 95% confidence interval [CI] 4.2-6.9). Disparities of lower magnitude were observed for other clinical disciplines except for LPNs. CONCLUSIONS: Significant staffing disparities were observed within facilities located in severely deprived neighborhoods. Targeted interventions, including workforce recruitment and retention efforts, may be needed to improve staffing levels for nursing homes in deprived neighborhoods.

Work like a Doc: A comparison of regulations on residents' working hours in 14 high-income countries.

BACKGROUND: Medical residents work long, continuous hours. Working in conditions of extreme fatigue has adverse effects on the quality and safety of care, and on residents' quality of life. Many countries have attempted to regulate residents' work hours. OBJECTIVES: We aimed to review residents' work hours regulations in different countries with an emphasis on night shifts. METHODS: Standardized qualitative data on residents' working hours were collected with the assistance of experts from 14 high-income countries through a questionnaire. An international comparative analysis was performed. RESULTS: All countries reviewed limit the weekly working hours; North-American countries limit to 60-80 h, European countries limit to 48 h. In most countries, residents work 24 or 26 consecutive hours, but the number of long overnight shifts varies, ranging from two to ten. Many European countries face difficulties in complying with the weekly hour limit and allow opt-out contracts to exceed it. CONCLUSIONS: In the countries analyzed, residents still work long hours. Attempts to limit the shift length or the weekly working hours resulted in modest improvements in residents' quality of life with mixed effects on quality of care and residents' education.

Automated Emails to Improve Evening Staffing for Anesthesiologists.

Scheduling flexibility and predictability to the end of a clinical workday are strategies aimed at addressing physician burnout. A voluntary relief shift was created to increase the pool of anesthesiologists providing end of the day relief. We hypothesized that an automated email reminder would improve the number of evening relief shifts filled and increase the number of anesthesiologists participating in the program. An automated email reminder was implemented, which selectively emailed anesthesiologists without a clinical assignment one day in advance when the voluntary relief shifts were not filled, and anticipated case volume past 4:00 PM was expected to exceed the capacity of the on-call team. After implementation of the automated email reminder, the median number of providers who worked the relief shift on a typical day was 2.6, compared to 1.75 prior to the intervention. After the initial increase in the number of volunteers post-intervention, the trend in the weekly average number of volunteers tended to decrease but remained higher than before the intervention. A total of 22 unique anesthesiologists chose to participate in this program after the intervention. An automated email reminder increased the number of anesthesiologists volunteering for a relief shift. Leveraging automation to match staffing needs with case volume allows for recruitment of additional personnel on the days when volunteers are most needed. Increasing the pool of anesthesiologists available to provide relief is one strategy to improve end of the day predictability and work-life balance.

Implementing a patient acuity tool: Perceived effectiveness for more equitable staff assignments.

PURPOSE: This study aimed to assess the acceptability, relevance, and effectiveness of a patient acuity tool (PAT) among part-time and full-time RNs. METHODS: A pre- and post-test intervention was used to evaluate a PAT among part-time and full-time RNs on a 28-bed telemetry unit at a Magnet®-designated hospital. An eight-item PAT questionnaire measured nurse acceptability. Relevance was evaluated using the RN Opinion of Relevance of Concepts of the PAT Questionnaire, and effectiveness was evaluated using the RN Opinion of Effectiveness of the PAT Questionnaire. RESULTS: A total of 22/33 (66.6%) RNs participated and completed the PAT questionnaire that measured nurse acceptability of the PAT assessment process. Statistically significant differences were demonstrated between two out of eight variables pre-post intervention; "the way we currently evaluate patient acuity assists the charge nurse in making nurse-patient assignments" (t 3.070, df 22, P = .006), "the way we currently evaluate patient acuity is an accurate assessment of acuity" (t 2.390, df 22, P = .026). CONCLUSION: Acuity tools should be specific for a nursing unit and adapt to staffing and patient needs, which can include a change in a patient's condition, unexpected discharges and/or admissions, and psychosocial components.

The Association between Nursing Skill Mix and Patient Outcomes in a Mental Health Setting: An Observational Feasibility Study.

Higher levels of educational preparation for nurses are associated with lower mortality rates in both medical and surgical wards. In mental health inpatient wards, few studies have examined whether specialist mental health nurse training has any impact on patient outcomes. The aim of this retrospective observational study was to establish the feasibility of extracting and linking nurse education and inpatient outcome data from hospital administrative sources to inform the design of future mental health nursing skill mix studies. Study participants were people experiencing mental ill-health and admitted to psychiatric inpatient care for at least 24 h. The exposure was the ratio of mental health nurses to comprehensive nurses for each patient for each day of their admission. The outcome was readmission for psychiatric inpatient care within 12 months of discharge from the index admission. Confounders were patient demographic (age, gender) and clinical characteristics (diagnosis, legal status, community follow-up). Forty-four patients included in the study were inpatients for a total of 595 days. The median hospital stay was 12 days (IQR = 7-17). In total, 11 (25%) patients were readmitted. In the readmitted and not readmitted groups, the median skill mix ratio was 5 (IQR = 5-7) and 5 (1-6), respectively. It was feasible to extract and code patient and nurse data from hospital databases and link them together. However, a substantial amount of manual post hoc recoding was required to enable us to calculate the exposure (mental health to comprehensive nurse ratio) in a precise way. It may be realistic to automate our methodology in an appropriately powered mental health nursing skill mix study. Australian and New Zealand clinical trial registry: ACTRN12619001337167p.

Understanding Nursing Home Spending And Staff Levels In The Context Of Recent Nursing Staff Recommendations.

To provide context for evaluating proposed nursing home staff regulations, we examined the proportion of facility revenues spent on nursing staff, as well as nursing staff levels in hours worked and paid per resident day, in 2019. Nationally, the median proportion of revenues spent on nursing staff was 33.9 percent, and median nursing staff levels were 3.67 hours worked and 4.08 hours paid per resident day. Facilities with higher shares of Medicaid residents spent a larger share of revenues on nursing staff but had lower staffing levels. States varied significantly with respect to median spending on nursing staff (26.8-44.0 percent of revenues) and median nursing staff levels (3.2-5.6 hours worked and 3.6-5.7 hours paid per resident day). These findings indicate that raising the proportion of revenues spent by nursing homes on nursing staff to a regulated minimum would not guarantee the achievement of adequate nursing staff levels unless it was paired with other regulatory mechanisms.

The Role Of Real Estate Investment Trusts In Staffing US Nursing Homes.

In 2021 real estate investment trusts (REITs) held investments in 1,806 US nursing homes. REITs are for-profit public or private corporations that invest in income-producing properties. We created a novel database of REIT investments in US nursing homes, merged it with Medicare cost report data (2013-19), and used a difference-in-differences approach within an event study framework to compare staffing before and after a nursing home received REIT investment with staffing in for-profit nursing homes that did not receive REIT investment. REIT investment was associated with average relative staffing increases of 2.15 percent and 1.55 percent for licensed practical nurses (LPNs) and certified nursing assistants (CNAs), respectively. During the postinvestment period, registered nurse (RN) staffing was unchanged, but event study results showed a 6.25 percent decrease in years 2 and 3 after REIT investment. After the three largest REIT deals were excluded, REIT investments were associated with an overall 6.25 percent relative decrease in RN staffing and no changes in LPN and CNA staffing. Larger deals resulted in increases in LPN and CNA staffing, with no changes in RN staffing; smaller deals appeared to replace more expensive and skilled RN staffing with less expensive and skilled staff.

Nursing Assistant Staffing Model: Implementation and Outcome Evaluation in Taiwan Hospitals.

BACKGROUND: A key policy of the Taiwan healthcare system is promoting the hiring of nursing assistants (NAs) to reduce the workload of nurses. However, few studies in the literature have compared the relative effectiveness of different nurse staffing policies, and no studies have addressed the impact of the NA staffing (NAS) model. PURPOSE: This study explored the current status of the NAS model as implemented in Taiwan hospitals and to investigate the methods used to evaluate the outcomes of NAS model implementation. METHODS: A cross-sectional online survey was performed in hospitals nationwide from June 1 to December 31, 2018. There were 153 government-accredited hospitals being invited to participate in the survey. RESULTS: Of the 139 hospitals that completed the online survey, 26% (36 hospitals) had implemented the NAS model. Many of the hospitals had hired full-time, certified NAs. Most of the tasks assigned to NAs were in the nonprofessional/general and technical work categories. In addition, medical wards were the most frequently assigned workplace, especially on day shifts. Few of the surveyed hospitals had evaluated the effectiveness of the NAS model. Improvement after implementation of the NAS model (based on the 35 outcome indicators) was found to vary significantly. The most commonly used outcome indicator was patient satisfaction. All the stakeholders, including patients, family caregivers, nurses, and nurse supervisors, supported implementation of the NAS model. However, some of the participants expressed concerns regarding the difficulties involved with model implementation. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Although the NAS model may be beneficial, further empirical research is necessary to confirm the contributions of NAs. Additional evidence regarding the benefits of the NAS model for hospital performance and patient outcomes may be expected to motivate more hospital administrators to adopt this model.