Laura M. Wagner

Examining the feasibility and utility of an SBAR protocol in long-term care

Ineffective nurse-physician communication in the nursing home setting adversely affects resident care as well as the work environment for both nurses and physicians. Using a repeated measures design, this quality improvement project evaluated the influence of SBAR (Situation; Background of the change; Assessment or appearance; and Request for action) protocol and training on nurse communication with medical providers, as perceived by nurses and physicians, using a pre-post questionnaire. The majority (87.5%) of nurses respondents found the tool useful to organize information and provide cues on what to communicate to medical providers. Limitations expressed by some nurses included the time to complete the tool, and communication barriers not corrected by the SBAR tool. Project findings, including reported physician satisfaction, support the use of SBAR to address both issues of complete documentation and time constraints.

Physical Restraints: Consensus of a Research Definition Using a Modified Delphi Technique

To develop an internationally accepted research definition of physical restraint.

Nurses' disclosure of error scenarios in nursing homes.

BACKGROUND Little work has explored the disclosure of errors in nursing homes (NHs). PURPOSE This paper reports how nurses would disclose hypothetical errors that occur in NH settings. METHOD A cross-sectional survey was given to a randomly selected sample of registered nurses (RNs) and registered practical nurses (RPNs) working in Ontario, Canada NHs. RESULTS Of 1,180 respondents, only half might provide full details and the cause of the error and provide steps in how the error would be prevented if they were in situations described by the hypothetical scenarios. Scenarios that were less serious had an almost 3 times higher likelihood of an explicit apology (OR 2.97; 95% CI 1.36-6.51; P = 0.007). Nurses who were RNs, had more education, had a prior history of disclosing a serious error, and agreed with full disclosure were more likely to respond to disclosing more information about the error. Nurses also reported numerous barriers to effective disclosure in their workplace. CONCLUSION Improvements in NH safety culture are necessary to enhance the error disclosure process.

Resident and Facility Factors Associated with the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set

Objective: This research examined resident and facility-specific factors associated with a diagnosis of a urinary tract infection (UTI) in the nursing home setting. Method: Minimum Data Set and Online Survey, Certification and Reporting system data were used to identify all nursing home residents in the United States on April 1, 2006, who did not have a UTI (n = 1,138,418). Residents were followed until they contracted a UTI (9.5%), died (8.3%), left the nursing home (33.2%), or the year ended (49.0%). A Cox proportional hazards model was estimated, controlling for resident and facility characteristics and for the state of residence. Result: The presence of an indwelling catheter was the primary predictor of whether a resident contracted a UTI (adjusted incidence ratio = 3.35, p < .001), but only 6.1% of the residents in the sample had such a catheter. Therefore, only one eighth of the UTIs were contracted by residents with a catheter. Thus, subsequent analysis examined the populations with and without catheters separately. Demographic characteristics (such as age) have a much greater association with incidence among residents without catheters. The association with facility factors such as percentage of Medicaid residents, for-profit, and chain status was less significant. Estimates regarding staffing levels indicate that increased contact hours with more highly educated nursing staff are associated with less catheter use. Discussion: Several facility-specific risk factors are of significance. Of significance, UTIs may be reduced by modifying factors such as staffing levels.

Implementation of Mental Health Huddles on Dementia Care Units.

Les comportements réactifs sont communs chez les résidents des unités de soins de longue durée (SLD), mais le personnel en soins directs reçoit peu de formation, de support ou d’opportunités de discuter et de collaborer pour gérer ces comportements. Pour ce projet de recherche-action participative, nous avons utilisé la technique du caucus de santé mentale pour faciliter la discussion et la gestion des comportements réactifs. Nous avons impliqué des membres du personnel en soins directs (p. ex., travailleurs de soutien personnel, infirmières autorisées et auxiliaires autorisées, personnel d’entretient) dans l’apprentissage de l’utilisation des caucus. Ces caucus ont servi de forums pour informer le personnel, résoudre des problèmes et développer des plans d’action centrés sur le client. Cinquante-six caucus ont eu lieu sur une période de 12 semaines, chacun impliquant de deux à sept membres du personnel en soins directs. Des groupes de discussion auxquels ont pris part nos participants ont indiqué une amélioration de la collaboration, du travail d’équipe, du support et de la communication au sein du personnel lors de la discussion de comportements réactifs spécifiques. Les caucus de santé mentale ont offert au personnel en SLD l’opportunité de collaborer et d’aborder des stratégies pour optimiser les soins du client. Des études supplémentaires sur l’impact des caucus sur les soins du client sont nécessaires. Client-responsive behaviours occur commonly among residents in long-term care (LTC) settings; direct-care staff, however, receive little education, support, or opportunities to discuss and collaborate on managing such behaviours. Our participatory action project introduced mental health huddles to support staff in discussing and managing client-responsive behaviours in long-term care. This research project engaged direct-care staff (e.g., personal support workers, registered practical nurses, housekeeping staff, and registered nurses) in learning how to use these huddles. Staff workers used huddles as a forum to stay informed, review work, problem solve, and develop person-centered action plans. Fifty-six huddles occurred over a 12-week period; two to seven direct-care staff participated in each huddle. Focus groups indicated improved staff collaboration, teamwork, support, and communication when discussing specific responsive behaviours. Huddles provided LTC staff with the opportunity to collaborate and discuss strategies to optimize resident care. Further research on how huddles affect resident care outcomes is needed.

Impact of infection preventionists on Centers for Medicare and Medicaid quality measures in Maryland nursing homes

Background Health care-associated infections are the leading cause of morbidity and mortality in US nursing homes (NHs). The objective of the research is to assess the impact of Maryland NH infection preventionists (IPs) on NH quality measures. Methods Two hundred thirty-four NHs were queried through mailed survey. These survey data were then linked with 2008 quality data from Nursing Home Compare and the On-line Survey Certification of Automated Records. Results Three of the 8 quality measures examined—influenza vaccination for both short- and long-stay residents and pressure ulcer prevention in high-risk residents—were significantly associated with the number of IPs. None of the quality measures were shown to be significant with IPs who received specialized training on infection prevention and management compared with those who did not receive specialized training. Conclusion IPs play a critical role in preventing and managing health care-associated infections in nursing homes, especially in the areas of influenza vaccination and pressure ulcer prevention among high-risk nursing home residents. Quality measures that reflect the effects of IP training may not have been elucidated yet. Further research is needed to support the IP role in order for policy to advocate for increased IP funding.

Staffing-Related Deficiency Citations in Nursing Homes

There is evidence that staffing characteristics influence quality of care in nursing homes. Federal and state surveyors conduct inspections of homes to assess their compliance with regulatory standards, including requirements related to staffing. Deficiency citations are issued when these standards are not met. This article examines the relationship between operational, facility, and market characteristics and organizational performance measured as staffing-related deficiency citations. Online Survey Certification of Automated Records (OSCAR) data from 2000 through 2007 were used with multinomial logistic regression analyses to identify factors associated with deficiency citations for staffing. Chain members and facilities with poor quality of care were more likely to receive deficiency citations for staffing. Greater bed count and competition between nursing homes were associated with a decreased likelihood of deficiency citations for staffing. Staffing-related deficiencies within nursing homes vary according to various operational, facility, and market characteristics.

Quality Care Outcomes in Nursing Homes: The Effects of a Nurse's Country of Origin and Education

The purpose of this article is to describe differences in nursing home quality outcomes among nurses who are foreign born and foreign educated, nurses who are foreign born and U.S. educated, and nurses who are U.S. born and U.S. educated. This cross-sectional study took place in 91 nursing homes across the United States. Full- and part-time licensed practical and registered nurses were asked to complete a survey, and data on their personal characteristics were linked to facility-level quality indicators. A total of 1,476 nurses were included. The findings indicate that facilities with more responding foreignborn, foreign-educated Filipino nurses exhibit lower quality of care in pain management, prevention of pressure ulcers, and catheter use, but higher quality of care regarding physical restraint use when compared with U.S.-born, U.S-educated and non-Filipino foreign-born and foreign-educated nurses. In facilities with more responding non-Filipino foreign-born, foreigneducated nurses, care quality was better than that of other groups in pain management and physical restraint use.

Hand Hygiene Practices Reported by Nurse Aides in Nursing Homes

Information from nurse aides describing their opinions of hand hygiene practices in nursing homes including perceived barriers to hand hygiene is presented. The information comes from a questionnaire developed for this investigation, with items addressing compliance, facility guidelines and protocols, training, hand washing facilities and materials, and hand washing barriers. Information from 4,211 nurse aides (response rate of 56%) working in a nationally representative sample of 767 nursing homes (participation rate = 51%) is used. We find that 57.4% of nurse aides comply with hand washing when caring for residents most of the time, while 21.7% always comply. With facilities, 43.3% sometimes check that hand washing is performed. In summary, self-reported compliance was poor, and facilities and materials were often lacking. These findings are useful in identifying issues and interventions, including the need for further initiatives to address hand hygiene practices.

Nursing Home Implementation of Health Information Technology: Review of the Literature Finds Inadequate Investment in Preparation, Infrastructure, and Training:

Health information technology (HIT) is increasingly adopted by nursing homes to improve safety, quality of care, and staff productivity. We examined processes of HIT implementation in nursing homes, impact on the nursing home workforce, and related evidence on quality of care. We conducted a literature review that yielded 46 research articles on nursing homes’ implementation of HIT. To provide additional contemporary context to our findings from the literature review, we also conducted semistructured interviews and small focus groups of nursing home staff (n = 15) in the United States. We found that nursing homes often do not employ a systematic process for HIT implementation, lack necessary technology support and infrastructure such as wireless connectivity, and underinvest in staff training, both for current and new hires. We found mixed evidence on whether HIT affects staff productivity and no evidence that HIT increases staff turnover. We found modest evidence that HIT may foster teamwork and communication. We found no evidence that the impact of HIT on staff or workflows improves quality of care or resident health outcomes. Without initial investment in implementation and training of their workforce, nursing homes are unlikely to realize potential HIT-related gains in productivity and quality of care. Policy makers should consider creating greater incentives for preparation, infrastructure, and training, with greater engagement of nursing home staff in design and implementation.