Nicholas G. Castle

Financial Exploitation and Psychological Mistreatment Among Older Adults: Differences Between African Americans and Non-African Americans in a Population-Based Survey

PURPOSE to examine racial differences in (a) the prevalence of financial exploitation and psychological mistreatment since turning 60 and in the past 6 months and (b) the experience-perpetrator, frequency, and degree of upset-of psychological mistreatment in the past 6 months. DESIGN AND METHODS random digit dial telephone recruitment and population-based survey (telephone and in-person) of 903 adults aged 60 years and older in Allegheny County (Pittsburgh), Pennsylvania (693 non-African American and 210 African American). Covariates included sex, age, education, marital status, household composition, cognitive function, instrumental activities of daily living/activities of daily living difficulties, and depression symptoms. RESULTS prevalence rates were significantly higher for African Americans than for non-African Americans for financial exploitation since turning 60 (23.0% vs. 8.4%) and in the past 6 months (12.9% vs. 2.4%) and for psychological mistreatment since turning 60 (24.4% vs. 13.2%) and in the past 6 months (16.1% vs. 7.2%). These differences remained once all covariates were controlled in logistic regression models. There were also racial differences in the experience of psychological mistreatment in the past 6 months. Risk for clinical depression was also a consistent predictor of financial exploitation and psychological mistreatment. IMPLICATIONS although the results will need to be replicated in national surveys, the study suggests that racial differences in elder mistreatment are a potentially serious issue deserving of continued attention from researchers, health providers, and social service professionals.

Staff turnover and quality of care in nursing homes.

Purpose:In this work, the association between nurse aide (NA) plus licensed practical nurse (LPN) and registered nurse (RN) turnover and quality indicators in nursing homes is examined. Design and Methods:Indicators of care quality used are the rates of physical restraint use, catheter use, contractures, pressure ulcers, psychoactive drug use, and certification survey quality of care deficiencies. In addition, we used a quality index combining these indicators. Turnover information came from primary data collected from 354 facilities in 4 states and other information came from the 2003 Online Survey, Certification and Reporting data. The turnover rates were grouped into 3 categories, low, medium, and high, defined as 0% to 20%, 21% to 50%, and greater than 50% turnover, respectively. Results:The average 1-year turnover rates identified in this study were high at 85.8% for NAs and LPNs and 55.4% for RNs. Multivariate analysis shows that decreases in quality are associated with increases in RN turnover, especially increases from low-to-moderate levels of turnover, and with increases in NA and LPN turnover, especially increases from moderate-to-high levels of turnover. Implications:These findings are significant because the belief that staff turnover influences quality is pervasive. The cross-sectional results are only able to show associations, nonetheless, few empirical studies in the literature have shown this relationship.

Facility characteristics associated with hospitalization of nursing home residents: results of a national study.

OBJECTIVES To test the effect of facility characteristics on the probability of hospitalization of nursing home residents, controlling for resident characteristics and the competing risk of death. RESEARCH DESIGN Study data were derived from the evaluation of the implementation of the Resident Assessment Instrument, the Minimum Data Set (MDS) in 1993. The data consisted of 2080 residents in 253 NHs as well as the annual On-Line Survey Certification of Automated Records (OSCAR). MEASURES Multinomial logistic regression was used to determine the effects of selected resident and facility characteristics on hospitalization or death within 6 months of baseline, adjusting for the complex sampling design (using SUDAAN). RESULTS By controlling for resident demographics, advance directives, diagnoses, selected clinical signs, and type of payer, we found that homes with special care units, more physicians (above the median 0.08 FTE physicians on staff or contract), and any physician extenders (nurse practitioners or physician assistants) were less likely to hospitalize their residents. Homes in which over 3.6% of the residents received respiratory treatment were more likely to hospitalize their residents. CONCLUSIONS Findings suggest that Medicare HMOs should consider the capacity of nursing facilities, especially in terms of medical care capacity and clinical resources, to limit hospital admissions.

What Is Nursing Home Quality and How Is It Measured

PURPOSE In this commentary, we examine nursing home quality and indicators that have been used to measure nursing home quality. DESIGN AND METHODS A brief review of the history of nursing home quality is presented that provides some context and insight into currently used quality indicators. Donabedians structure, process, and outcome (SPO) model is used to frame the discussion. Current quality indicators and quality initiatives are discussed, including those included in the Facility Quality Indicator Profile Report, Nursing Home Compare, deficiency citations included as part of Medicare/Medicaid certification, and the Advancing Excellence Campaign. RESULTS Current quality indicators are presented as a mix of structural, process, and outcome measures, each of which has noted advantages and disadvantages. We speculate on steps that need to be taken in the future to address and potentially improve the quality of care provided by nursing homes, including report cards, pay for performance, market-based incentives, and policy developments in the certification process. Areas for future research are identified throughout the review. IMPLICATIONS We conclude that improvements in nursing home quality have likely occurred, but improvements are still needed.

Nursing Home Caregiver Staffing Levels and Quality of Care A Literature Review

In this research, the author reviewed 70 studies that had examined the relationship between staffing levels and quality in nursing homes (covering the years 1991 to 2006). The results of the review including all of this literature show that approximately 40% of the quality indicators examined show an association with nursing home staffing levels. Nevertheless, this finding is further interpreted in the context of the limitations of many of these prior studies. The author discusses the limitations of poor quality staffing data, small sample size, quality indicators used, methodological concerns, and underspecified models inherent to many prior studies. The author finds no study representing a “gold standard” exists in this area. Still, the few studies that seem methodologically most robust would seem to indicate that an association between nursing home staffing levels and quality exists. However, the author concludes that studies in this area need to be further enhanced.

Physical Restraints in Nursing Homes: A Review of the Literature Since the Nursing Home Reform Act of 1987:

The use of physical restraints is one of the most negative features of nursing home care. Their use significantly affects the quality of life of residents. In an attempt to limit the use of restraints, the Nursing Home Reform Act (NHRA) of 1987 contained provisions regulating their use. In this article, the authors review the literature on the use and consequences of physical restraints in nursing homes since the passage of the NHRA. First, they describe the history behind the use of restraints and define what is considered to be a physical restraint. Second, they examine the four most common justifications for restraint use. Third, they describe the incidence and prevalence of restraint use. Fourth, they address demographic and clinical characteristics of residents that have been found to be associated with restraint use. Fifth, they examine negative outcomes of restraining residents. Finally, they describe alternatives to using restraints.

Relocation of the elderly.

In this article, the author reviews 78 studies addressing the relocation of the elderly. He begins by defining the four major forms of relocation and describing the trends in the current health care marketplace precipitating relocation events. Next, he reviews the major findings of studies assessing the potential negative and positive outcomes of relocation. These outcomes include changes in mortality rates, morbidity, and psychological or social changes. In addition, factors associated with successful relocation are presented. Finally, the primary contribution of this article is that the author assesses the strengths and limitations of this prior literature and combines the research he reviews in an analytic model. This model helps show some opportunities for future research in the relocation of the elderly.

Hospitalization of Nursing Home Residents: A Review of the Literature, 1980-1995

In this article, the authors review the literature on the hospitalization of nursing home residents. First, they describe the incidence of hospitalization and the extent to which these rates differ due to data limitations, varying definitions of hospitalization, and changing health policies. Second, they describe the demographic and clinical characteristics of nursing home residents associated with hospitalization. Third, they review negative outcomes of hospitalization, including iatrogenic and nosocomial disease, mortality, and financial costs. Finally, they highlight several areas of concern this research raises and suggest areas for future studies.

Determinants of staff job satisfaction of caregivers in two nursing homes in Pennsylvania

BackgroundJob satisfaction is important for nursing home staff and nursing home management, as it is associated with absenteeism, turnover, and quality of care. However, we know little about factors associated with job satisfaction and dissatisfaction for nursing home workers.MethodsIn this investigation, we use data from 251 caregivers (i.e., Registered Nurses, Licensed Practical Nurses, and Nurse Aides) to examine: job satisfaction scores of these caregivers and what characteristics of these caregivers are associated with job satisfaction. The data were collected from two nursing homes over a two and a half year period with five waves of data collection at six-month intervals. The Job Description Index was used to collect job satisfaction data.ResultsWe find that, overall nursing home caregivers are satisfied with the work and coworkers, but are less satisfied with promotional opportunities, superiors, and compensation. From exploratory factor analysis three domains represented the data, pay, management, and work. Nurse aides appear particularly sensitive to the work domain. Of significance, we also find that caregivers who perceived the quality of care to be high have higher job satisfaction on all three domains than those who do not.ConclusionThese results may be important in guiding caregiver retention initiatives in nursing homes. The finding for quality may be especially important, and indicates that nursing homes that improve their quality may have a positive impact on job satisfaction of staff, and thereby reduce their turnover rates.

Caregiver staffing in nursing homes and their influence on quality of care: using dynamic panel estimation methods.

BackgroundThere is inconclusive evidence that nursing home caregiver staffing characteristics influence quality of care. In this research, the relationship of caregiver staffing levels, turnover, agency use, and professional staff mix with quality is further examined using a longitudinal analysis to overcome weaknesses of earlier research. MethodsThe data used came from a survey of nursing home administrators, Nursing Home Compare, the Online Survey Certification and Reporting data, and the Area Resource File. The staffing variables of Registered Nurses, Licensed Practical Nurses, and Nurse Aides were measured quarterly from 2003 through 2007, and came from 2839 facilities. Generalized method of moments estimation was used to examine the effects of changes in staffing characteristics on changes in 4 quality measures (physical restraint use, catheter use, pain management, and pressure sores). ResultsRegression analyses show a robust association between the staffing characteristic variables and quality indicators. A change to more favorable staffing is generally associated with a change to better quality. ConclusionsWith longitudinal information and quarterly staffing information, we are able to show that for many nursing homes improving staffing characteristics will improve quality of care.