Implementation and Evaluation of LVN LEAD. A leadership and supervisory training program for nursing home charge nurses.

Licensed practical/vocational nurses (LVNs) play an important role in U.S. nursing homes, with primary responsibility for supervising unlicensed nursing home staff. Research has shown that the relationship between charge nurses and certified nursing assistants (CNAs) has a significant impact on CNA job satisfaction and turnover as well as quality of care, yet nurses rarely receive supervisory training. The purpose of this project was to develop, pilot, and evaluate a leadership/supervisory training program for LVNs. Upon completion of the training program, many LVNs expressed and demonstrated a new understanding of their supervisory leadership and supervisory responsibilities. Directors of staff development are a potential vehicle for supporting LVNs' development as supervisors.

Exploring Variation in Certified Nursing Assistant Assignments From the Perspective of Nursing Home Residents: A Comparison of Adopters and Nonadopters of Consistent Assignment.

Objective: To describe and compare certified nursing assistant (CNA) staffing between adopter and nonadopters of consistent assignment. Data sources: One month of preexisting CNA assignment and scheduling sheets from a purposive sample of 30 homes. Study design: A descriptive comparative study was conducted to calculate and compare numbers of CNAs assigned per resident across homes. Data extraction: Resident names and CNA assignments were abstracted from assignment records and entered into the Advancing Excellence consistent assignment tool to calculate numbers of CNAs assigned per resident. Principal findings: Both variation and overlap existed in the number of CNAs per resident within and between homes. Adopters assigned significantly fewer CNAs per resident. Conclusion: Research is needed to determine how assignment variations affect resident perceptions of quality.

Sustaining Culture Change: Experiences in the Green House Model.

OBJECTIVE: To describe conditions that influence how Green House (GH) organizations are sustaining culture change principles and practices in a sample of GH skilled nursing homes. DATA SOURCES/STUDY SETTING: Primary data were collected at 11 skilled nursing GH organizations from 2012 to 2014. These organizations have adopted the comprehensive and prescriptive GH model of culture change. STUDY DESIGN: To develop an understanding of sustainability from the perspective of staff who are immersed in GH daily work, grounded theory qualitative methods were used. DATA COLLECTION METHODS: Data were collected using semi-structured interviews with 166 staff and observation of house meetings and daily operations. Data were analyzed using grounded dimensional analysis. PRINCIPAL FINDINGS: Organizations varied in their ability to sustain GH principles and practices. An organization's approach to problem solving was central to sustaining the model. Key conditions influenced reinforcement or erosion of GH principles and practices. CONCLUSIONS: Reinforcing the GH model requires a highly skilled team of staff with the ability to frequently and collaboratively solve both mundane and complex problems in ways that are consistent with the GH model. This raises questions about the type of human resources practices and policy supports that could assist organizations in sustaining culture change.

Inside the Green House "Black Box": Opportunities for High-Quality Clinical Decision Making.

OBJECTIVE: To develop a conceptual model that explained common and divergent care processes in Green House (GH) nursing homes with high and low hospital transfer rates. DATA SOURCES/SETTINGS: Eighty-four face-to-face, semistructured interviews were conducted with direct care, professional, and administrative staff with knowledge of care processes in six GH organizations in six states. STUDY DESIGN/DATA COLLECTION: The qualitative grounded theory method was used for data collection and analysis. Data were analyzed using open, axial, and selective coding. Data collection and analysis occurred iteratively. PRINCIPAL FINDINGS: Elements of the GH model created significant opportunities to identify, communicate, and respond to early changes in resident condition. Staff in GH homes with lower hospital transfer rates employed care processes that maximized these opportunities. Staff in GH homes with higher transfer rates failed to maximize, or actively undermined, these opportunities. CONCLUSIONS: Variations in how the GH model was implemented across GH homes suggest possible explanations for inconsistencies found in past research on the care outcomes, including hospital transfer rates, in culture change models. The findings further suggest that the details of culture change implementation are important considerations in model replication and policies that create incentives for care improvements.

The Green House Model of Nursing Home Care in Design and Implementation.

OBJECTIVE: To describe the Green House (GH) model of nursing home (NH) care, and examine how GH homes vary from the model, one another, and their founding (or legacy) NH. DATA SOURCES/STUDY SETTING: Data include primary quantitative and qualitative data and secondary quantitative data, derived from 12 GH/legacy NH organizations February 2012-September 2014. STUDY DESIGN: This mixed methods, cross-sectional study used structured interviews to obtain information about presence of, and variation in, GH-relevant structures and processes of care. Qualitative questions explored reasons for variation in model implementation. DATA COLLECTION/EXTRACTION METHODS: Interview data were analyzed using related-sample tests, and qualitative data were iteratively analyzed using a directed content approach. PRINCIPAL FINDINGS: GH homes showed substantial variation in practices to support resident choice and decision making; neither GH nor legacy homes provided complete choice, and all GH homes excluded residents from some key decisions. GH homes were most consistent with the model and one another in elements to create a real home, such as private rooms and baths and open kitchens, and in staff-related elements, such as self-managed work teams and consistent, universal workers. CONCLUSIONS: Although variation in model implementation complicates evaluation, if expansion is to continue, it is essential to examine GH elements and their outcomes.

Consistent assignment of nursing staff to residents in nursing homes: a critical review of conceptual and methodological issues.

PURPOSE OF STUDY: Consistent assignment of nursing staff to residents is promoted by a number of national organizations as a strategy for improving nursing home quality and is included in pay for performance schedules in several states. However, research has shown inconsistent effects of consistent assignment on quality outcomes. In order to advance the state of the science of research on consistent assignment and inform current practice and policy, a literature review was conducted to critique conceptual and methodological understandings of consistent assignment. DESIGN AND METHODS: Twenty original research reports of consistent assignment in nursing homes were found through a variety of search strategies. RESULTS: Consistent assignment was conceptualized and operationalized in multiple ways with little overlap from study to study. There was a lack of established methods to measure consistent assignment. Methodological limitations included a lack of control and statistical analyses of group differences in experimental-level studies, small sample sizes, lack of attention to confounds in multicomponent interventions, and outcomes that were not theoretically linked. IMPLICATIONS: Future research should focus on developing a conceptual understanding of consistent assignment focused on definition, measurement, and links to outcomes. To inform current policies, testing consistent assignment should include attention to contexts within and levels at which it is most effective.

Developing the green house nursing care team: variations on development and implementation.

PURPOSE OF THE STUDY: A core component of the Green House nursing home model is an altered supervisory relationship between the nurse and direct care workers. Some have expressed concern that the Green House model might weaken professional nursing oversight, threatening the quality of clinical care. This qualitative research study explores the role of the nurse as implemented in the Green House model, focusing on how variations in the nursing team influence clinical care practices. DESIGN AND METHODS: Dimensional analysis, a "second generation" grounded theory methodology, was used to conduct this study. Data were collected through observations and interviews with 37 nurses, 68 CNAs, and 11 Guides working at 11 Green House sites. RESULTS: Implementation of the nursing role within the Green House model varied both within and across sites. Four nursing model types were identified: Traditional, Visitor, Parallel, and Integrated. Care processes, CNA/Shahbaz skill development, and worker stress varied with each nursing model. IMPLICATIONS: Government policies have been enacted to support culture change. However, there is currently little guidance for regulators, providers, or consumers regarding variability in how culture change practices are implemented and consequences of these variations. This article outlines the importance of understanding these practices at a level of detail that distinguishes and supports those that are most promising.

A "recipe" for culture change? Findings from the THRIVE survey of culture change adopters.

PURPOSE OF THE STUDY: Descriptions of culture change adoption are often complex and varied, creating a challenge for those seeking guidance about which of the many components of culture change to adopt and in what order and combination. DESIGN AND METHODS: To begin to address this question, members of The Research Initiative Valuing Eldercare (THRIVE) developed and distributed an online survey to 327 known culture change adopters. Of these, 164 (50%) completed the survey. Data were analyzed to identify adopted components, co-occurrence of adopted components, and differences in these across various types of nursing home models (i.e., traditional unit, household, and small house). RESULTS: Our findings support unique co-occurrence of components across nursing home models. Results also show that homes with more traditional environments have been able to implement certain culture change components without large capital investments required by renovations. IMPLICATIONS: The adoption patterns suggest that the co-occurrence of components should be considered when pursuing organizational transformations to support culture change.