Quality of care among skilled nursing facilities: A mixed methods investigation of person-centered care and workplace environment

ABSTRACT

Skilled nursing facilities (SNFs) across the United States strive to provide a high quality of care for their residents. Person-centered care is often seen as a domain of quality of care as it individualizes care to the resident. Along with attending to care needs, direct care professionals (DCPs) must navigate aspects of their workplace environment, such as staff burnout and engagement, that influence the quality of care provided. Additionally, recently SNFs have experienced the impact of the coronavirus disease 2019 (COVID-19) pandemic, which was an unprecedented event that produced challenges for SNFs and influenced care practices due to increased regulations and change in social interactions and safeguards. Therefore, the aim of the current study was to examine multiscale influences on the quality of care in SNFs (e.g., person-centered approaches, workplace characteristics), reflecting the long-term goal to improve quality of care and resident outcomes in SNFs.An exploratory mixed methods approach was utilized for data collection, analysis, and interpretation. Eleven SNFs in Iowa were recruited for this study. The recruited SNFs represented varied SNF characteristics (e.g., bed count, staffing hours) and Accountable Care Organization (ACO) affiliation was also considered during recruitment. Administrators from the SNFs participated in interviews (N=11), during which the researcher gauged perceptions of person-centered care (PCC), staff burnout and engagement, management and leadership principles, views of resident outcomes, and staff training. DCPs completed surveys (N=83) to assess perceptions of PCC, staff burnout, and engagement. Additionally, Centers for Medicare and Medicaid Services data were utilized to assess SNF characteristics (e.g., profit status, bed count) and Minimum Data Set resident outcomes (e.g., falls, urinary tract infections).The impact of the COVID-19 pandemic on SNFs constituted the primary focus in the first study. Results indicated resident outcomes that were worse than the national average increased from 2019 to 2020 and then decreased from 2020 to 2021. Slopegraphs were employed to provide visualizations of trends in resident outcomes over time. Thematic analysis revealed administrators reported SNFs were impacted by the pandemic by staff concern regarding COVID-19, financial strain, resident isolation, new regulations and protocols, and staffing challenges (e.g., turnover, shift coverage). DCPs reported SNFs were impacted by the pandemic by limited or no family/friend visits;required masks and personal protective equipment (PPE);resident death;staffing challenges;and resident isolation. Lastly, DCPs reported that the COVID-19 pandemic impacted their day-to-day work and burnout a great deal;however, overall DCPs reported low to moderate feelings of burnout. Care practices, regulations and policies, staffing issues, and establishing a new normal are important implications based on the findings from this study.Identifying associations between resident outcomes and PCC, burnout, engagement, and SNF characteristics was the focus of the second study. Results indicated PCC was positively correlated with engagement and negatively correlated with burnout. Scatterplots produced visualizations of trends between resident outcomes and PCC, burnout, and engagement. Themes from administrators and DCPs were identified surrounding common contributors to burnout (e.g., low wages, short staffing), factors influencing staff engagement (e.g., events, providing one-on-one care), and implementation of PCC (e.g., care planning, involving the resident). Lastly, clustering of SNFs that were associated with PCC, burnout, engagement, and resident outcomes were discerned based on profit status, Accountable Care Organization affiliation, and bed count. (PsycInfo Database Record (c) 2022 APA, all rights reserved)