Carol P. Vojir

Determining mild, moderate, and severe pain equivalency across pain-intensity tools in nursing home residents

Older adults in nursing homes experience pain that is often underassessed and undertreated. Visual analog pain-intensity scales, recommended for widespread use in adults, do not work well in the older adult population. A variety of other tools are in use, including the Verbal Descriptor Scale, the Faces Pain Scale (FPS), and the Numeric Rating Scale. These tools are more acceptable to older adults, but no agreement exists about how to compare the resulting pain-intensity scores across residents. This study examined the equivalency of pain-intensity scores for 135 nursing home residents who reported their pain on the three different instruments. The results were validated with a second sample of 135 nursing home residents. The pain levels across the three tools were highly correlated, but residents were found to underrate higher pain intensity on the FPS. A modification of scoring for the FPS led to greater agreement across the three tools. The findings have implications for use of these tools for quality improvement and public reporting of pain.

Patient and Staff Safety: Voluntary Reporting

Central to efforts to assure the quality of patient care in hospitals is having accurate data about quality and patient problems. The purpose was to describe the reporting rates of medication administration errors (MAE), patient falls, and occupational injuries. A questionnaire was distributed to staff nurses (N = 1105 respondents) in a national sample of 25 hospitals. This addressed voluntary reporting, work environment factors, and reasons for not reporting occurrences. More than 80t indicated that all MAEs should be reported, but only 36% indicated that near misses should be reported. Perceived levels of actual reporting were: 47% of MAEs, 77% of patient falls, 48% of needlesticks, 22% of other exposures to body fluids, and 17% of back injuries. Administrative response to reports, personal fears, and unit quality management were related to reporting. Patient and staff safety occurrences are underreported. Strong quality management processes and positive responses to reports of occurrences may increase reporting and enhance safety.

Exploring nursing home staff's perceptions of communication and leadership to facilitate quality improvement

Leadership and clinical staff were surveyed to explore communication and leadership in nursing homes. Registered nurses and other professionals perceived communication as better than their nursing colleagues did. Overall, results suggest all factors of communication could improve. In terms of leadership, licensed practical nurses perceived less clarity of expectations, encouragement of initiative, and support than other groups. The study provides insight into what is organizationally necessary to improve quality of care in nursing homes.

Assessing the appropriateness of pain medication prescribing practices in nursing homes

OBJECTIVES: To test a tool for screening the quality of nursing home (NH) pain medication prescribing.

Nursing home culture: a critical component in sustained improvement.

In the third in a series of articles exploring working conditions and quality improvement in nursing homes, 31 nursing homes were surveyed using an adaptation of the Competing Values Framework (CVF) Organizational Assessment. The CVF provides information about the organizational culture through describing dominant perceived values, distribution of values across organizational characteristics, and orientation of values toward flexibility. Staff reported a dominant group culture, reflecting a family and team orientation within their settings. Leaders, however, were more often reported to reflect a hierarchy value orientation, emphasizing efficiency of operations and following rules and procedures.

Nurse Staffing Levels: Impact of Organizational Characteristics and Registered Nurse Supply

OBJECTIVE To assess the impact of nurse supply in the geographic areas surrounding hospitals on staffing levels in hospital units, while taking into account other factors that influence nurse staffing. DATA SOURCES Data regarding 279 patient care units, in 47 randomly selected community hospitals located in 11 clusters in the United States, were obtained directly from the hospitals from the U.S. Census report, National Council of State Boards of Nursing, and The Centers for Medicare and Medicaid Services. STUDY DESIGN Cross-sectional analyses with linear mixed modeling to control for nesting of units in hospitals were conducted. For each patient care unit, the hours of care per patient day from registered nurses (RNs), LPNs, nursing assistants, and the skill-mix levels were calculated. These measures of staffing were then regressed on type of unit (intensive care, medical/surgical, telemetry/stepdown), unit size, hospital complexity, and RN supply. PRINCIPAL FINDINGS RN hours per patient day and RN skill mix were positively related to intensity of patient care, hospital complexity, and the supply of RNs in the geographic area surrounding the hospital. LPN hours, and licensed skill mix were predicted less reliably but appear to be used as substitutes for RNs. Overtime hours increased in areas with a lower RN supply. Vacancy and turnover rates and the use of contract nurses were not affected by nurse supply. CONCLUSIONS This study is the first to show that hospital RN staffing levels on both intensive care and nonintensive care units decrease as the supply of RNs in the surrounding geographic area decreases. We also show that LPN hours rise in areas where RN supply is lower. Further research to describe the quality of hospital care in relation to the supply of nurses in the area is needed.

Linking nursing home working conditions to organizational performance.

Abstract: Exploring selected working conditions and performance in nursing homes suggests that high and low performers can be determined based on both quantitative and qualitative findings.

Assessing nursing homes' capacity to create and sustain improvement.

Nursing home leadership and staff in 32 nursing homes were surveyed using an adaptation of Shortells Organization and Management Survey. An earlier psychometric assessment of Shortells communication and leadership scales raised concerns about the reliability of these scales in the nursing home setting. Exploratory factor analysis was performed to determine if another scale structure should be considered. Using principal-axis extraction with a varimax rotation, a 5-factor solution that accounted for 47% of item variance was defined.

SYMPTOM MANAGEMENT OUTCOMES : DO THEY REFLECT VARIATIONS IN CARE DELIVERY SYSTEMS?

OBJECTIVES Symptom management is increasingly recognized as a critical element of patient care, particularly in managing chronic illness. However, research on outcomes related to symptom management is in its infancy, except for the symptom of pain. This symptom was therefore chosen as a prototype to review the state of the science regarding relations between organizational variables and symptom management outcomes and to illustrate the issues regardless of the symptom managed. This article discusses pain outcome measures appropriate for acute and cancer pain, proposes attributes of the care delivery system that may affect outcome measures, and identifies challenges associated with this type of research. METHODS Review of quality assurance studies raises issues concerning the adequacy of currently used outcomes for pain and satisfaction with pain management. Although considerable effort has been expended in developing pain measurement in adults and children, critical issues for examining pain management outcomes include deciding what perspectives should be used as the most valid indicator of the pain outcome and when the measures should be obtained. RESULTS Critical concerns are raised about the measure of satisfaction with pain management and its appropriateness as the end-result outcome. A key issue is whether respondents actually disentangle satisfaction with pain management from satisfaction with other aspects of care, including caring dispositions of health-care providers. Finally, the question is raised: Are pain outcomes affected by organizational context? CONCLUSIONS Although the answer to this question is unknown, a few research studies suggest that organizational context is likely to influence pain outcomes. It is clear, however, from ongoing work that until several conceptual, methodological, and analytic challenges are resolved, research is unlikely to capture the influence of variations in care delivery systems on symptom management outcomes.

Ethnic differences in posttraumatic stress disorder after musculoskeletal trauma

BACKGROUND Psychological distress is known to contribute to poor outcomes in orthopedic patients. Limited information exists concerning ethnic differences in psychological sequelae after musculoskeletal injury. This study examined ethnic variations in prevalence of posttraumatic stress disorder (PTSD) after musculoskeletal trauma. METHODS A secondary analysis was conducted using data collected for a study examining PTSD after musculoskeletal trauma. Two hundred eleven consecutive patients with musculoskeletal injuries were enrolled. Psychological status was assessed using the Revised Civilian Mississippi Scale for PTSD. A chart review was completed to gather demographic and injury information. Independent samples t tests, Fishers exact, Chi-square, and logistic regression analyses were performed to assess differences. RESULTS Ninety-six (45.5%) Hispanic and 115 (54.5%) non-Hispanic White adults participated. Few significant demographic or health differences were found. No significant differences were found regarding injury characteristics. Fishers exact tests indicated a higher prevalence of PTSD symptomatology among Hispanics than non-Hispanic Whites (p < 0.01). Additionally, U.S. born Hispanics were more likely than non-U.S. born Hispanics to have PTSD symptomatology (p = 0.004). Odds ratios indicated that women (OR = 2.2), persons with a psychiatric comorbidity (OR = 5.1), Hispanics (OR = 6.6), and persons born in the United States (OR = 3.7) had an increased likelihood of PTSD symptomatology. CONCLUSIONS Results indicate an ethnic difference in prevalence of PTSD symptomatology after musculoskeletal injury. Hispanic participants were nearly seven times more likely to be positive for PTSD symptomatology. Furthermore, U.S. born Hispanic participants had a higher prevalence of PTSD symptomatology. Future research should explore factors contributing to these differences.