RNs in nursing homes-It is not always about the numbers.

The compelling evidence that higher RN to resident ratios improve health outcomes in nursing homes underscores the necessity of implementing evidence-based RN nursing home staffing standards. However, there are other dimensions to RN staffing in nursing homes beyond the numbers or hours per resident day (HPRD) that influence the quality of care. Without attending to a broader focus on nurse staffing, the benefits of increased RN staffing levels will not be achieved. This article outlines how RN HPRD can be maximized by magnifying the RN's scope of practice and attending to how nursing care is organized and delivered in nursing homes using a nursing practice model framework. This framework addresses the accountability of the RN and the RN's role in supporting and facilitating: (1) collective decision-making among the nursing staff about the care of residents and the work environment, (2) continuity of information among care providers, and (3) ensuring residents have continuity with the care providers assigned to their care. Attention to the RN's expertise in gerontological nursing and leadership capacity further leverages the RN's ability to influence the quality of care for nursing homes residents.

Toward ensuring care quality and safety across settings: examining time pressure in a nursing home with observational time motion study metrics based on the Omaha system.

BACKGROUND: Meaningful data to determine safe and efficient nursing workload are needed. Reasoning a nurse can accomplish a finite number of interventions and location changes per hour, examination of time pressure using time motion study (TMS) methods will provide a comparable indication of safe and efficient workload for an individual nurse. METHODS: An observer shadowed 11 nurses at a 250-bed nursing home in the Southeastern United States and recorded 160 h of observations using TimeCaT, web-based TMS data recording software. Predefined Omaha System nursing interventions (N = 57) and locations (N = 8) were embedded within TimeCaT. The time-stamped data were downloaded from TimeCaT and analyzed using descriptive and inferential statistics. Five time pressure metrics were derived from previous TMS findings in acute care settings. RESULTS: Overall, nurses spent 66 s for each intervention, performed 65 interventions per hour, stayed 130 s at each location, changed locations 28 times per hour, and multitasked for 29% of working time. Computed hourly time pressure metrics enabled visualization of variability in time pressure metrics over time, with differences in multitasking by licensure, unit/role, and observation session time. CONCLUSIONS: Nursing home nurses consistently experienced a high degree of time pressure, especially multitasking for one-third of their working time. To inform staffing decision making and improve the quality of care, resident outcomes, and nurse satisfaction, it is critical to identify ways to mitigate time pressure. Additional research is needed to refine and extend the use of the time pressure metrics.

Calling all nurses-Now is the time to take action on improving the quality of care in nursing homes.

For a number of decades, nurses have raised concerns about nursing-related issues in nursing homes (NH) such as inadequate registered nurse (RN) staffing, insufficient RN and advanced practice registered nurse (APRN) gerontological expertise, and lack of RN leadership competencies. The NASEM Committee on the Quality of Care in Nursing Homes illuminated the long-standing issues and concerns affecting the quality of care in nursing homes and proposed seven goals and associated recommendations intended to achieve the Committee's vision: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments. This paper outlines concrete and specific actions nurses and nursing organizations can take to ensure the recommendations are implemented.

Interventions Employed By Licensed Nurses in Nursing Homes: Refinement and Validation of an Existing Omaha System Nursing Intervention Set.

Background and Purpose: Demands on long-term services and supports for older adults are growing, although geriatric workforce shortages have persisted for decades. Methods to define and quantify practice of licensed nurses in nursing homes are needed for work optimization within limited nurse resources available in nursing homes. This study aimed to refine and validate observable nursing interventions for nursing homes, using the Omaha System. Methods: Based on the existing corpus of Omaha System interventions for acute care nursing, this multi-phase, multi-method study included a mapping procedure of interviews from licensed nurses in nursing homes, the evaluation of content validity and coding of the interventions using a survey, and inter-observer reliability assessment using TimeCaT. Results: This study validated 57 observable interventions for nursing homes. Of the previously identified acute care nursing interventions, eight interventions were deemed out of scope. One additional intervention was identified. Refined intervention definitions were related to procedures common in acute care settings such as tracheal intubations/extubations and nasogastric tube insertion that were not performed in nursing homes. Expert agreement for content validity and coding of the interventions was high (S-CVI = 0.97), and inter-observer reliability levels (Cohen's κ value >0.4; proportion agreement >60%) were acceptable for all case studies. Implications for Practice: The validated observable Omaha System nursing interventions for nursing home practice have potential for use in future studies of nursing home practice to understand evidence-based practice, and gaps in care provided. The methodology may be extended to define observable interventions for other roles and settings.

The Relationships of Nursing Home Culture Change Practices With Resident Quality of Life and Family Satisfaction: Toward a More Nuanced Understanding.

Transforming nursing homes (NHs) from restrictive institutions to person-centered homes, referred to as NH culture change, is complex and multifaceted. This study, based on a survey of administrators in Minnesota NHs (n = 102), tested the domain-specific relationships of culture change practices with resident quality of life (QOL) and family satisfaction, and examined the moderating effect of small-home or household models on these relationships. The findings revealed that culture change operationalized through physical environment transformation, staff empowerment, staff leadership, and end-of-life care was positively associated with at least one domain of resident QOL and family satisfaction, while staff empowerment had the most extensive effects. Implementing small-home and household models had a buffering effect on the positive relationships between staff empowerment and the outcomes. The findings provide meaningful implications for designing and implementing NH culture change practices that best benefit residents' QOL and improve family satisfaction.

Expert nurse response to workforce recommendations made by The Coronavirus Commission For Safety And Quality In Nursing Homes.

COVID-19 has exposed the longstanding internal problems in nursing homes and the weak structures and policies that are meant to protect residents. The Centers for Medicare and Medicaid Services convened the Coronavirus Commission for Safety and Quality in NHs in April, 2020 to address this situation by recommending steps to improve infection prevention and control, safety procedures, and the quality of life of residents in nursing homes. The authors of this paper respond to the Final Report of the Commission and put forth additional recommendations to federal policymakers for meaningful nursing home reform: 1) ensuring 24/7 registered nurse (RN) coverage and adequate compensation to maintain total staffing levels that are based on residents' care needs; 2) ensuring RNs have geriatric nursing and leadership competencies; 3) increasing efforts to recruit and retain the NH workforce, particularly RNs; and 4) supporting care delivery models that strengthen the role of the RN for quality resident-centered care.

An Empirical Typology of Nursing Home Culture Change Implementation.

Culture change in nursing homes (NHs) is a broad-based effort to transform NHs from impersonal institutions to genuine person-centered homes. Culture change practices have been implemented increasingly with varying levels of success. This study (a) generated an empirical typology of culture change implementation across Minnesota NHs using latent profile analysis based on the survey data from administrators in 102 NHs and (b) examined variations in NH characteristics and quality outcomes associated with the typology. Three types of culture change implementation were identified: high performers, average performers, and low performers. The distributions of culture change scores were distinct across the three types, with low performers lagging far behind others in family and community engagement, and end-of-life care. High performers were distinguished through demonstrating better resident quality of life and higher family satisfaction. The findings provide empirical support for policymakers, providers, and advocates to direct culture change expansion and resource allocation.

The Effects of Nursing Home Culture Change on Resident Quality of Life in U.S. Nursing Homes: An Integrative Review.

Culture change is intended to transform nursing homes from impersonal institutions into person-centered homes. Despite a growing interest in studying culture change, empirical evidence for its effects on quality of life (QOL) has not been synthesized. The current integrative review examined how QOL outcomes were measured in culture change studies and analyzed the current evidence for culture change effects on QOL. Guided by a conceptual framework, this review systematically searched for literature in multiple databases and identified 11 eligible studies. QOL measures varied across studies, ranging from overall perception of life to specific measures associated with physical and psychosocial well-being. Overall, culture change demonstrated a positive trend in benefiting QOL. Although inconsistent evidence existed for most QOL measures, relatively consistent evidence was found to support positive effects on resident satisfaction and autonomy. Rigorous designs are needed for future studies to generate strong evidence. [Research in Gerontological Nursing, xx(x), xx-xx.].

Development of core competencies and a recognition program for gerontological nursing educators.

Despite efforts to implement learner competencies in gerontological nursing, a significant knowledge-attitude disassociation remains, with few students interested in pursuing careers in the care of older adults. One reason may be the lack of well-qualified faculty who can design engaging learning experiences with older adults and serve as positive role models for aging care. In response, the National Hartford Center of Gerontological Nursing Excellence commissioned the development of core competencies and a recognition program for educators in gerontological nursing. The goal of these competencies is to promote quality instruction in the care of older adults by describing a set of preferred skills characterizing faculty teaching gerontological content to nursing and interprofessional learners. These educator-focused competencies can guide individual career development for new and current educators who specialize in teaching about the care of older adults. They provide direction for selecting well-prepared individuals for gerontological nursing teaching positions and evaluating educator role performance. This paper describes the development of seven core competencies for nurse educators who teach in academic and professional development programs, as well as criteria for their recognition. An iterative development process was used to define the core competencies, along with descriptions and exemplars of each domain.

Professional networks and support for nursing home directors of nursing.

In this study, we examined the influence of professional network characteristics, available professional support, and perceived support quality on intent to stay among for-profit nursing home (NH) directors of nursing (DON). We hypothesized that the receipt of high quality professional support would be associated with DON intent to stay. DONs have a critical mandate to provide leadership that influences their facilities' work climate and care quality. Yet, they often struggle to manage overwhelming responsibilities and are left feeling alienated, frustrated, and intent on leaving their jobs. Professional support, accessed via professional networks, may help DONs combat frustration and mitigate turnover that threatens NH care quality. Using a descriptive survey design, we electronically surveyed all DONs employed by a single for-profit NH corporation to collect data pertaining to their professional networks, receipt of professional support, perceptions regarding support quality, and intentions to stay in their positions. One-hundred-ninety-five DONs (65%) responded, with 133 (44%) completing every survey component. We employed social network analysis methods to construct datasets linking descriptors of DON respondents with attribute information about 1,164 network members. Statistical analyses (ANOVAs, point biserial correlations, and binomial logistic regression) yielded several findings supporting our hypothesis: (i) DONs' professional networks closely resembled the teams in which they worked daily; (ii) DONs relied on this core network of individuals to provide task support primarily; (iii) DON-nursing home administrator relationships were most important; and (iv) perceptions of support quality and support from nursing home administrators were the strongest predictors of DON intent to stay.

Measurement of Nursing Home Culture Change: Systematic Review.

Nursing home culture change (NHCC) aims to change the way care is provided in nursing homes. Valid and reliable measures are needed to evaluate the impact of NHCC on outcomes. The current systematic review provides an overview of instruments designed to measure NHCC and criteria for others to evaluate and choose instruments according to their own purpose. Ten instruments were identified that measure NHCC on an organizational level. Lack of development description hindered their assessment, and studies examining the relationship between NHCC and outcomes are rare. A common limitation of the instruments reviewed was the lack of psychometric testing; thus, their validity and reliability need further exploration. [Res Gerontol Nurs. 2018; 11(2):103-112.].

Substance Use Disorder Among Nurses: A Curriculum Improvement Initiative.

Substance use disorder (SUD) among nurses is a serious practice issue that poses a significant risk to patients and nurses. However, the topic of SUD is inadequately addressed in nursing education. A comprehensive education strategy was implemented and evaluated in 2 prelicensure nursing programs to improve nursing students' knowledge, skills, and attitudes about SUD among nurses.

Recommendations From the International Consortium on Professional Nursing Practice in Long-Term Care Homes.

In response to the International Association of Gerontology and Geriatrics' global agenda for clinical research and quality of care in long-term care homes (LTCHs), the International Consortium on Professional Nursing Practice in Long Term Care Homes (the Consortium) was formed to develop nursing leadership capacity and address the concerns regarding the current state of professional nursing practice in LTCHs. At its invitational, 2-day inaugural meeting, the Consortium brought together international nurse experts to explore the potential of registered nurses (RNs) who work as supervisors or charge nurses within the LTCHs and the value of their contribution in nursing homes, consider what RN competencies might be needed, discuss effective educational (curriculum and practice) experiences, health care policy, and human resources planning requirements, and to identify what sustainable nurse leadership strategies and models might enhance the effectiveness of RNs in improving resident, family, and staff outcomes. The Consortium made recommendations about the following priority issues for action: (1) define the competencies of RNs required to care for older adults in LTCHs; (2) create an LTCH environment in which the RN role is differentiated from other team members and RNs can practice to their full scope; and (3) prepare RN leaders to operate effectively in person-centered care LTCH environments. In addition to clear recommendations for practice, the Consortium identified several areas in which further research is needed. The Consortium advocated for a research agenda that emphasizes an international coordination of research efforts to explore similar issues, the pursuit of examining the impact of nursing and organizational models, and the showcasing of excellence in nursing practice in care homes, so that others might learn from what works. Several studies already under way are also described.

Teaching the teacher: the Faculty Learning About Geriatrics (FLAG) program.

As the number of individuals older than 65 years increases, there is a concomitant need for more nurses to provide care meeting the unique needs of older adults. The nursing shortage presents a challenge to schools of nursing to educate enough practitioners in geriatric nursing. The John A. Hartford Foundation Center of Geriatric Nursing Excellence at the University of Minnesota has developed a program to prepare nurse faculty to meet this challenge. The program, Faculty Learning About Geriatrics (FLAG), is designed to develop expertise in geriatric nursing, teaching, and academic leadership among faculty from academic settings in the upper Midwest and tribal colleges. This article chronicles the authors' experience in designing, implementing, and evaluating the first year of the FLAG program.

Defining medication complexity and its effect on outcomes in community dwelling elders receiving home care.

Complexity of medication regimens in community dwelling elders is examined in relationship to emergent care use, hospitalization and self management of medications in this secondary data analysis of OASIS data and medication data from all 2004 open admissions to 15 home health care agencies. Preliminary findings and the use of innovative techniques are discussed highlighting the predictive potential for medication complexity in other settings, risk stratification, and design implications for both clinical tools and databases.

Quality improvement and incontinence in long-term care.

The quality improvement framework provides a practical way for nursing homes to prevent and reduce urinary incontinence (UI)for residents. It provides a means for facilities to identify organizational factors that may be hindering appropriate continence care from being provided to residents. It enables nursing homes to integrate evidence-based UI practices and monitor the consistent application of those practices by staff. The regular collection and analysis of data related to UI is essential for identifying problems,seeking accurate solutions, providing staff with feedback regarding their performance, and evaluating the overall quality of continence care provided to residents.