Working Dynamics of Licensed Nurses and Nurse Aides in Nursing Homes: A Scoping Review.

Collaboration between licensed nurses (LNs) and nurse aides (NAs) is critical in the provision of quality care for residents living in nursing homes (NHs). The current scoping review explores how working dynamics between LNs and NAs in the NH setting are researched and described in the literature. Thirty-five articles were identified and reviewed that address the LN/NA relationship in the context of (a) the LN role as a supervisor and leader; (b) variation in structure; (c) expanding, understanding, and supporting staff roles; and (d) communication. We found that the LN/NA relationship has been primarily explored through the LN lens and often studied in the context of role expansion and revision associated with new models of care. Our contribution to the literature includes the following main points: efforts to improve LN/NA collaboration may be hindered without substantial structural change; collaboration may be limited within the hierarchal LN/NA relationship; LNs and NAs in NHs need greater support, recognition, and empowerment; and NAs require a representative voice. [Journal of Gerontological Nursing, 48(5), 27-34.].

Nurse Managers' Experiences With Electronic Health Records in Quality Monitoring.

Little is known about how hospital-based nurse managers use electronic health records (EHR) to monitor nurse-sensitive quality measures, or about how they learn to do so. This article describes the role of nurse managers in quality monitoring, their experience in using the EHR to monitor nurse-sensitive quality measures, and their related training. A convenience sample of nurse managers and directors (n = 28) was recruited to participate in semistructured interviews. The resulting data were analyzed, using content analysis. This study revealed 3 components of the nurse manager's quality-monitoring role: monitoring documentation, monitoring practice, and performing investigations. Facilitators for accessing EHR information included ease of navigation, timeliness and accessibility of reports, and usefulness of EHR tools. Participants described a range of formal and informal approaches to learning how to access information for quality monitoring in general and for the EHR specifically. The findings provide direction for further exploration of the EHR structures and processes needed to support nurse managers' information needs and quality-monitoring training.

Leadership in Nursing Homes: Directors of Nursing Aligning Practice With Regulations.

Nursing homes use team nursing, with minimal RN presence, leaving the majority of direct care to licensed practical/vocational nurses (LPNs/LVNs) and unlicensed assistive personnel (UAP), including medication aides. The current article describes challenges faced by nursing home directors of nursing (DONs) leading and managing a team nursing approach, including consideration of scope of practice, delegation and supervision regulations, and related policy implications. A secondary data analysis was performed of qualitative data from a study to develop and test DON guidelines for delegation in nursing home practice. A convenience sample (N = 29) of current or previous DONs and other nursing home leaders with knowledge and expertise in the DON role participated in in-depth, guided interviews. The findings highlight a core concern to nursing licensure policy and regulation: knowledge and practice gaps related to scope of practice and delegation and supervision among DONs, RNs, and LPNs/LVNs, as well as administrators, and the role of nursing leaders in supporting appropriate delegation practices. The findings offer directions for research and practice in addressing challenges in aligning team nursing practices with regulatory standards as well as the related gaps in knowledge among DONs, administrators, and nursing staff. [Journal of Gerontological Nursing, 44(6), 10-14.].

Nursing Home Administrator Quality Improvement Self-Efficacy Scale.

BACKGROUND: Nursing home (NH) quality improvement (QI) is challenging. The critical role of NH leaders in successful QI is well established; however, current options for assessing the QI capabilities of leaders such as the licensed NH administrator are limited. PURPOSE: This article presents the development and preliminary validation of an instrument to measure NH administrator self-efficacy in QI. METHODOLOGY/APPROACH: We used a mixed-methods cross-sectional design to develop and test the measure. For item generation, 39 NH leaders participated in qualitative interviews. Item reduction and content validity were established with a sample of eight subject matter experts. A random sample of 211 administrators from NHs with the lowest and highest Centers for Medicare and Medicaid Services Five-Star Quality ratings completed the measure. We conducted exploratory and confirmatory factor analyses and tested the measure for internal reliability and convergent, discriminant, and known group validity. FINDINGS: The final measure included five subscales and 32 items. Confirmatory factor analysis reaffirmed the factorial structure with good fit indices. The new measure's subscales correlated with valid measures of self-efficacy and locus of control, supporting the measure's convergent and discriminant validity. Significant differences in most of the subscales were found between the objective (Centers for Medicare and Medicaid Services Five-Star Quality rating) and subjective (Self-Rated Facility QI Index) quality outcomes, supporting the measure's known group validity. PRACTICE IMPLICATIONS: The instrument has usefulness to both NH organizations and individual NH administrators as a diagnostic tool to identify administrators with higher/lower chances of successfully implementing QI. Organizations and individuals can use this diagnostic to identify the administrator's professional development needs for QI, in general, and specific to the instrument's five subscales, informing directions for in-house training, mentoring, and outside professional development. Attending to NH administrators' QI professional development needs prior to implementing QI holds promise to enhance the chances for successful implementation of QI, which is urgently needed in many NHs.

Interprofessional Huddle: One Children's Hospital's Approach to Improving Patient Flow.

Admitting pediatric patients promptly to the appropriate unit where they can receive specialty care is of critical importance to safe, quality care. A daily morning huddle was implemented at one children's hospital as a quality improvement project. The aim of this project was to improve patient flow throughout the children's hospital by improving interprofessional and interdepartmental communication and collaboration. This article reports on changes in patient flow before and after implementation of the daily huddle, as measured by pediatric emergency department (ED) boarding times. This retrospective, descriptive study was conducted at a regional children's hospital within an academic hospital. Data were collected from the electronic medical record over two separate time periods coinciding with pre/post-huddle implementation. Non-random, purposive sampling was used, resulting in a prehuddle sample (n = 450) and post-huddle sample (n = 329). Times were significantly shorter after huddle implementation compared to pre-huddle (p < 0.001) from admission orders in the ED to transfer to the PICU or pediatric ward. The median time decreased from 3.0 to 2.6 hours post-huddle implementation. These findings suggest huddles as one potential factor in the formula to improve patient flow from the ED by enhancing interprofessional and interdepartmental collaboration and communication. Findings from this study are of vital importance to pediatric patients, nurses, and physicians. Promptly admitting patients from the ED to the appropriate unit where they can receive needed specialty care that potentially improves the quality and safety of patient care is paramount. Further research is needed to determine what format and contexts the huddle can be utilized to facilitate efficient patient flow and improve patient outcomes.

Evaluation of a peer mentoring program for early career gerontological nursing faculty and its potential for application to other fields in nursing and health sciences.

BACKGROUND: As the retirement rate of senior nursing faculty increases, the need to implement new models for providing mentorship to early career academics will become key to developing and maintaining an experienced faculty. PURPOSE: This evaluation of a peer mentorship program for predoctoral and postdoctoral gerontological nurses examined its efficacy, utility, and potential for improvement. METHODS: A web-based survey was developed, implemented, and completed by 22 mentees and 17 mentors (71% and 61% response rates, respectively) as part of the evaluation. DISCUSSION: The peer mentorship program was found to be valuable by both mentors (64.7%) and mentees (72.7%) in helping mentees further develop their careers and networks and providing mentors with supported mentorship experience. CONCLUSION: The peer mentorship program could serve as a model for other professional organizations, academic institutions, and consortiums to enhance and extend the formal vertical mentorship provided to early academic career individuals.

Development and implementation of a peer mentoring program for early career gerontological faculty.

PURPOSE: The Hartford Gerontological Nursing Leaders (HGNL) formerly known as the Building Academic Geriatric Nursing Capacity Initiative (BAGNC), in conjunction with the National Hartford Centers of Gerontological Nursing Excellence (NHCGNE), developed and executed a peer mentoring program beginning in 2011 to enhance both (a) the experience of newly selected scholars and fellows to the NHCGNE and (b) the ongoing professional development of HGNL members. The purpose of this article is to describe key strategies used to develop and execute the peer mentoring program and to present formative program evaluation. DESIGN: The program was launched in January 2011 with seven peer mentor and mentee matches. In June 2012, the peer mentoring committee solicited feedback on the development of the peer mentoring program and changes were made for the subsequent cohorts. FINDINGS: An additional 12 matches were made in the following 2 years (2012 and 2013), for a total of 31 matches to date. We have learned several key lessons from our three cohorts regarding how to structure, implement, and carefully evaluate a peer mentoring program. CONCLUSIONS: Informal evaluation of our peer mentoring program noted several challenges for both peer mentors and mentees. Having knowledge of and addressing those challenges may increase the overall quality and effectiveness of peer mentoring programs and, in turn, benefit academic nursing by strengthening the faculty workforce. CLINICAL RELEVANCE: Findings from development and implementation of a peer mentoring program for gerontological faculty could lead to new and adaptable programs in a variety of clinical and education settings.

RNs' Transitions into Director of Nursing Positions in Nursing Homes: Hiring Practices and Role Development.

The current paper discusses RNs' transitions into their first nursing home director of nursing (DON) position, including hiring practice and role development. A convenience sample of 29 current and previous DONs and nursing home administrators completed semistructured interviews for the current qualitative, descriptive study. Using thematic analysis, the finding revealed three primary themes: (a) DON hiring criteria are not necessarily matched to role demands; (b) various pathways to developing DON expertise suggest an undervaluing of the competencies needed to effectively enact this nursing leadership position; and (c) although limited formal training for the DON position was well-acknowledged, concerns or reports of the consequences varied, and there is no consensus as to the optimal route to preparation. Overall, the current study findings highlight gaps across practice, policy, and research, emphasizing the consequences of limited attention to gathering evidence of the breadth and depth of DON role demands and related role qualifications.

Nursing home administrator self-assessed preparedness.

BACKGROUND: Nursing home administrators (NHAs) are in key positions to improve nursing home quality. NHAs require state-level licensure, which involves passing a national NHA licensure examination and fulfilling state-level licensure requirements that vary widely across states. With multiple pathways to NHA licensure, little is known about NHAs' preparation and training to meet the complex demands of this position. PURPOSE: The aim of this study was to explore NHAs' self-assessed person-job fit based on NHAs' self-rated preparedness and the importance of the activities that supported their preparation. METHODOLOGY/APPROACH: A descriptive cross-sectional design was used to collect data from NHAs (N = 175) randomly recruited from nursing homes in five states, with a mailed self-administered questionnaire. Data analysis included descriptive statistics, correlations, and t tests/ANOVA. FINDINGS: Thirty percent of respondents reported they were well prepared, overall, for their first NHA position. The findings suggest NHA preferences for more formalized ways to develop their entry-level competencies, with lower preference for On-the-job training, Previous job experience, and Self-study and higher preference for Administrator-in-training, Bachelor's degree programs, and Mentoring. PRACTICE IMPLICATIONS: There is an urgent need for NHAs who are well prepared to effectively address our nation's mandates for nursing home quality improvement. With multiple pathways to NHA licensure, this exploratory study provides initial insights about NHAs' self-assessed preparation and training. The findings suggest that NHAs prefer more formalized ways to prepare for the NHA position. Research is needed to identify specific teaching/learning practices and on-the-job training that maximize the NHAs' preparation to meet their job demands.

A Fresh Look at the Nursing Home Workforce Crisis: Transforming Nursing Care Delivery Models.

The current State of the Science Commentary focuses on workforce challenges in the nursing home (NH) setting that lie within the purview of professional nursing-what professional nurses can do to promote high-quality person-centered care within a context of existing resources-individually and broadly across the collective profession. Historically, three models of care delivery have characterized the way in which nursing care is organized and delivered in different settings: primary nursing, functional nursing, and team nursing. Based on the existing evidence, we call for scientific leadership in the redesign, testing, and implementation of a nursing care delivery model that operationalizes relationship-centered team nursing. This integrative model incorporates successful evidence-based approaches that have the potential to improve quality of care, resident quality of life, and staff quality of work life: clear communication, staff empowerment, coaching styles of supervision, and family/care partner involvement in care processes. In addition to the needed evidence base for NH care delivery models, it is imperative that educational programs incorporate content and clinical experiences that will enable the future nursing workforce to fill the leadership gap in NH care delivery. [Research in Gerontological Nursing, 16(1), 5-13.].

Managing up, down, and across the nursing home: roles and responsibilities of directors of nursing.

The director of nursing (DON) is an essential member of the top management team in nursing homes and in a key position to improve the quality and value of care. This article describes and examines the roles and responsibilities of DONs as perceived by a convenience sample of current/previous DONs and nursing home administrators (n = 29). Data were collected through in-depth semistructured interviews and analyzed using content analysis and thematic analysis. The findings reveal a broad scope and wide variation in the DON position across settings, with inextricable linkages between clinical care and other aspects of care delivery, such as managing fiscal and human resources (HR). As RN licensure is the only Federal requirement for the DON position, suggesting a clinical focus, the findings highlight a policy-practice gap. Research is needed to address this gap, focusing on the requisite preparation DONs need to effectively and cost-efficiently lead initiatives for quality improvement.

Collaboration Between Licensed Nurses and Certified Nurse Aides in the Nursing Home: A Mixed Methods Study.

The current mixed methods study explored how nursing team collaboration is perceived and experienced in four nursing homes (NHs) in the western United States. Licensed nurses (LNs) and certified nurse aides (CNAs) completed two survey tools to assess their perception of collaboration and team-work in their current work environment. LNs and CNAs were paired and interviewed individually and as a caregiving pair to explore the lived experience of collaboration in NH residents' care. Quantitative survey results were analyzed, and participants reported a collaborative working environment with equally strong ratings in the following categories: partnership, cooperation, and coordination; they agreed with statements reflective of teamwork, including team structure, leadership, situation monitoring, mutual support, and communication. No significant differences were found between LN and CNA responses or between team members in any of the four participating facilities. Qualitative survey data were analyzed using a thematic analysis approach. Findings revealed five primary themes, including essential elements in successful team collaboration-perspective, coworker connection, communication, mutual support, and "it makes a difference"-and ways teamwork and collaboration impact resident care. These findings provide rich insights into successful LN/CNA collaboration for academic and clinical LN and CNA educators. [Research in Gerontological Nursing, 15(1), 16-26.].

Interdisciplinary collaboration in geriatrics: advancing health for older adults.

The call for interdisciplinary research, education, and practice is heightened by the recognition of the potential it holds in generating creative solutions to complex problems in health care and to improving quality and effectiveness of care. With the aging of the population and the complex issues in caring for older adults, interdisciplinary collaboration is particularly salient to the field of geriatrics. However, despite interest in this approach for several decades, adoption has been slow and dissemination is not widespread. This article provides examples of recent initiatives and presents driving and restraining forces involved in adoption of interdisciplinary approaches.

Assuring Quality in Nursing Homes: The Black Box of Administrative and Clinical Leadership-A Scoping Review.

BACKGROUND AND OBJECTIVES: Licensed nursing home administrators (NHA) and directors of nursing (DON) are responsible for nursing home quality and assuring optimal performance and job satisfaction/retention of their nursing home workforce. NHA/DON-focused studies have generated important foundational knowledge over the last three decades; yet, targeted research is needed to understand and apply the complexities of the black box of this top management team. This scoping review identifies, reviews, synthesizes, and maps the topical areas of research in NHA/DON positions in U.S. nursing homes. RESEARCH DESIGN AND METHODS: We conducted searches of 5 databases, yielding 3,479 records; screening/review yielded 88 unique records. We used thematic analysis to code the primary foci of the studies and the variables associated with the concepts of interest. RESULTS: Most papers (n = 40) focused on role characteristics, 23 examined approaches to management and leadership, 24 focused on perceptions about the role, and the remaining 12 examined role structure. The role-related themes linked to outcomes (n = 42), processes (n = 27), and structures (n = 30). DISCUSSION AND IMPLICATIONS: We highlight important gaps for future research and offer a call to action for research, policy, practice, and education collaborations to accelerate the rate of research and translate the findings into best practices for NHA/DON to lead and manage the nursing home workforce and build capacity to ensure person-centered, high-quality care. Based on foundational descriptive studies, it is time to use what is known to design and implement interventions that enhance the capacity of NHA/DON to improve the structures, processes, and outcomes of nursing homes.

Assisted Living: Optimal Person-Environment Fit.

Assisted living (AL) is a well-established alternative to nursing homes, promoting autonomy and choice in a residential environment. This article examines the opportunities that AL affords for older adults and areas for further research to optimize the fit between resident needs and the AL environment. The model of person-environment fit provides an organizing framework for our commentary. The environment of AL emphasizes choice, independence, and privacy. The acuity of health care needs in AL residents has evolved since its inception. Unlike earlier residents, many today live with multiple chronic conditions and need for functional supports. Regulated by states, there is high variability in oversight, staffing, and resources available in AL. Families play an important role in supporting residents, yet expectations for their engagement may not be clear. Descriptive research abounds but there is a need for more sophisticated approaches to understanding how the AL environment can provide optimal supports for older adults, across all states and across income and racial/ethnic groups. There are several methodological challenges to AL research, including the high variability among AL settings and across states, the lack of common data elements, and difficulty accessing representative samples. With the popularity of AL as an option, it will be important to continue to examine how this environment can evolve to meet the changing needs of the resident population, while balancing the elements of autonomy and affordability. [Research in Gerontological Nursing, 14(1), 5-12.].

Communication between nurses and unlicensed assistive personnel in nursing homes: explicit expectations.

Effective communication is at the core of quality improvement efforts. This study identified and explored the written guidelines for what, how, and when nurses and unlicensed assistive personnel (UAP) are expected to communicate regarding residents' status and care needs. Documents from six nursing homes were analyzed for this descriptive study, from which two primary themes emerged. First, extensive and explicit guidelines were identified for UAP-to-nurse communication, in comparison to few corresponding guidelines for nurses. Second, written guidelines for UAP communication were identified in multiple documents, with variations across sites in the situations requiring communication, the level of detail, and the format for how UAP-to-nurse communication should occur (i.e., verbal, written). This study raises the issue of the extent to which explicit organizational structures and written guidelines support and reinforce nurses' scope of practice, the translation of UAP role expectations into actual practice, and the effectiveness of communication to promote quality care.

The pivotal role of the director of nursing in nursing homes.

The impending wave of aging boomers heightens long-standing concerns for the quality and cost of nursing home care. As industry and policy leaders continue efforts to remedy substandard nursing home care delivery practices, development of a well-prepared and adequately supported workforce of directors of nursing (DONs) is essential to ensuring the industry's readiness for the aging wave population. Directors of nursing are in pivotal positions to influence nursing home quality and costs; however, research demonstrating the extent of this influence-actual and potential-is lacking, and industry leaders have collectively failed to address the current or future capacity of this workforce. A long history of inattention to the DON position, coupled with low expectations for the competencies and requisite educational preparation, has potentially compromised the capacity of DONs to promote and sustain high-quality, cost-effective nursing home care. The purpose of this article is to provide a comprehensive overview and discussion of the current and potential capacity of DONs to lead the delivery of high-quality, cost-effective nursing home care from industry, educational and professional development, healthcare policy, and organizational contexts. Proposed strategies and recommendations to enhance and promote the future capacity of DONs are also presented.

New Directions to Advance Family Caregiving Research.

This supplement describes the content, processes, and outcomes of the Research Priorities in Caregiving Summit convened by the Family Caregiving Institute (FCI) at the Betty Irene Moore School of Nursing at UC Davis in March 2018. As described in the editorial introduction and the supplement's four papers, the summit sought to integrate and cross-pollenate the already compendious work on family caregiving to describe ways forward in the field. Thought-provoking commissioned synthesizing papers on issues of heterogeneity and trajectories of caregiving and its cultural embeddedness and on the potential of technology to shape and enhance caregiving interventions set the stage for a highly disciplined, multistaged process that resulted in the drafting of a set of research themes and priorities that were later finalized by faculty at the FCI.

A qualitative study exploring the perceptions and motivations of patients with heart failure who transitioned from non-adherence to adherence.

BACKGROUND: Management of heart failure (HF) involves complex self-care recommendations. Many patients have difficulty adhering to these recommendations, and mechanisms that support behavior change are poorly understood. OBJECTIVE: The objective of this study was to explore the perceptions and motivations of individuals with HF who became adherent to HF treatment recommendations after being non-adherent. METHODS: This was a qualitative descriptive study. Participants were recruited from cardiology clinics and completed a semi-structured interview on their experiences and motivations for self-care behavior change. Data was analyzed using thematic analysis. The sample size (n = 8) was sufficient to achieve saturation. RESULTS: Five themes were identified: experiencing mortality, optimism and hope, making connections between behavior and health, self-efficacy, and the role of the clinician. The temporal chronological sequence of these themes across participants varied. CONCLUSIONS: This study adds to our current understanding of HF self-care by suggesting mechanisms that may enhance existing self-care interventions, and demonstrating the important role of the clinician.

The health care aide position in nursing homes: A comparative survey of nurses' and aides' perceptions.

BACKGROUND: The health care aide position embodies one of the most basic paradoxes of long-term care for older adults: those who have the most contact and most intensive interaction with nursing-home residents are also those having the least training, authority, and status within the system. They therefore hold one of the keys to quality care in many settings, especially nursing homes. In the absence of agreement on the position's roles, responsibilities, and authority, it is important to examine how the position is perceived by the key members in the long-term-care framework. OBJECTIVES: The current study examined and compared health care aides' and nurses' perceptions of the position in nursing-home settings in Israel, using a standardized tool developed for this inquiry. The comparison accounted for potential intervening factors that may help better understand the job requirements and boundaries. DESIGN: A comparative survey design. SETTINGS: 30 nursing homes (of at least 20 beds) in northern Israel. PARTICIPANTS: We used convenience sampling to recruit 369 health care aides and 261 nurses (a total of 630 participants). METHODS: The main instrument of data collection was specially designed and validated for this study. It was based on a qualitative study that defined basic content units representing tasks importance, knowledge, and personal characteristics for the job. RESULTS: Participants found it difficult to prioritize the job components or to differentiate between core tasks and characteristics and the secondary aspects of their job. General care, profession-specific knowledge, and emotional abilities were endorsed the most by participants. Cleaning, communication, and safety were ranked lower (although rankings were still considerably high). However, previous experience as a health care aide undermined incumbents' perceptions of their own responsibilities and professionalism. Incumbent health care aides rated most factors higher than nurses did, with the exception of the importance of communication. CONCLUSION: Our results may help decision makers understand the complexity around the health care aide position, manage and develop it more effectively while setting standards (training and certification, performance appraisal, and more) for professionalization processes and better defining the division of nursing work between health care aides and nurses.