Tobie H. Olsan

Nurses’ Job Satisfaction, Organizational Commitment, and Career Intent

ObjectiveThe objective of this survey was to define the characteristics of the nursing work force of a mixed urban/rural region of New York state and to determine the nurses’ level of job satisfaction and commitment to the work setting. BackgroundRecent investigations suggest nurses are highly dissatisfied with the demands of the healthcare environment and are expressing increased likelihood of leaving the work setting. These factors, in combination with the increasing age of the current nursing work force, are contributing to serious concerns about the future of patient care. MethodsA random sample survey was mailed to registered nurses in the Finger Lakes Region of New York State in June 2000. Items in the questionnaire addressed nurse characteristics, reasons for leaving or staying with an employing agency, one- and five-year career intent, and level of job satisfaction and organizational commitment. ResultsForty-six percent of the nurses returned completed questionnaires. Within this sample, most of the nurses were older, European American, and female. Personal and organizational characteristics contributed to differences in levels of job satisfaction, organizational commitment, and 1- and 5-year intent. In addition, many of the most satisfied and committed nurses reported their intent to leave nursing within the next 5 years. ConclusionsFindings of this investigation suggest the organizational environment, educational preparation, and personal characteristics of currently employed registered nurses affect their current job satisfaction, organizational commitment, and plans for continuing as a nurse.

Developing Palliative Care Practice Guidelines and Standards for Nursing Home–Based Palliative Care Teams: A Delphi Study

CONTEXT Lack of nursing home (NH)-specific palliative care practice guidelines has been identified as a barrier to improving palliative and end-of-life (EOL) quality of care. OBJECTIVES The objectives of this study were to (1) assess which of the guidelines developed by the National Consensus Project, and the corresponding preferred care practices endorsed by the National Quality Forum, are important and feasible to implement in NHs; and (2) identify the operational standards for palliative care teams in NHs. METHODS Two-round mail Delphi study. Based on the existing literature, a set of 7 domains with associated 22 palliative practice guidelines was drafted. We invited 48 NH leaders, including clinicians, to review the importance (10-point Likert scale) and the feasibility (5-point Likert scale) of these guidelines. Participants were also asked about palliative care team composition rounding frequency. RESULTS The response rate to both rounds was 85%. With regard to importance, the mean rating for all guidelines was 8 or higher (ie, highly important), but there was variability in agreement with regard to 5 of the guidelines. The same 5 guidelines were also considered more difficult to implement (eg, costly, unrealistic). Overall, 17 palliative care guidelines were identified for use by NH palliative care teams. Five disciplines (social work, certified nurse assistant, nurse, physician, and nurse practitioner or physician assistant) were identified as comprising a core team and 3 were proposed as extended or ad hoc members. CONCLUSION The palliative care guidelines and team standards identified in this study may be helpful in providing practical direction to NH administrators and staff looking to improve palliative care practice for their residents.

A Clinical Microsystem Model to Evaluate the Quality of Primary Care for Homebound Older Adults

The declining use of nursing homes and a growing aging population is increasing the demand for home-based primary care (HBPC) among chronically ill disabled homebound older adults and their informal caregivers. The problem this poses is that access to HBPC is limited. Typically, HBPC programs are small and available in only a few communities. Expansion of HBPC nationally has been hampered by limited awareness of this mode of care and by a dearth of research examining the quality and effectiveness of primary care delivered in the home. In this article, we address the need for stronger evidence demonstrating how well HBPC programs deliver and improve care by laying the foundation for more rigorous evaluation of HBPC services. First, an HBPC clinical microsystem model for evaluating program quality and effectiveness is described to clarify relationships among 5 elements essential for delivering high-quality primary care to homebound elders: purpose, patients, people (staff), processes, and patterns. Data for the model were identified through MEDLINE, CINAHL, and PubMed searches that produced 540 potentially relevant studies, from which 21 studies of HBPC programs and services were selected to construct the clinical microsystem. Second, in order to inform health policymaking about the design and financing of HBPC, findings from program evaluations reported in the selected studies are summarized. Finally, recommendations for future research are outlined, including epidemiological studies to estimate the proportion and characteristics of the homebound population for planning appropriate services and creating large databases for evaluating HBPC quality, costs, and outcomes. Ultimately, the scalability of HBPC to meet the demand of current and future older adults depends on incentives that value the home as a bona fide setting for delivering primary care.

Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol

BackgroundThe program “Implementing Goals of Care Conversations with Veterans in VA LTC Settings” is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive.MethodsThree projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives—meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans’ preferences expressed and documented, and acted on—to support action planning to improve performance.DiscussionWe will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration.

Ethics and managed care

Managed care in the USA is best understood in the context of the history of health care. It is an effort to manage the soaring costs of health care while retaining quality. Many ethical concerns arise because managed care organizations (MCOs) have dual purposes: to realize profits and to provide quality care. Dilemmas are created when persons in institutions are expected to play conflicting roles or when professionals, patients, or others in MCOs lose their voices as participating persons. These and other ethical concerns can be addressed by on-going processes of involvement of persons who have a stake in these organizational arrangements.

Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial

Background: Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested. Objective: Test the impact of PCTeams on end-of-life outcomes. Research Design: Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention’s placebo effect. Subjects: In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents). Measures: Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions. Results: Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P⩽0.01), but not pain or hospitalizations. Conclusions: The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.

Correction to: Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol

CorrectionThe authors would like to correct errors in the original article [1] that may have lead readers to misinterpret the scope, evidence base and target population of VHA Handbook 1004.03 “Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients’ Values, Goals, and Preferences”.

National Structural Survey of Veterans Affairs Home‐Based Primary Care Programs

To describe the current structural and practice characteristics of the Department of Veterans Affairs (VA) Home‐Based Primary Care (HBPC) program.