Psychological and Structural Burdens and Nursing Home Administrator Turnover Intentions During the COVID-19 Pandemic.

The COVID-19 pandemic created challenges for U. S. nursing home administrators (NHA) and staff. This study explored organizational and psychological factors associated with NHA stress, dissatisfaction, and turnover intent (TI) during the third year of the pandemic. Results from a nationwide, cross-sectional survey of 1139 NHAs were merged with Centers for Medicare and Medicaid Services nursing home survey deficiency, staffing, complaint, and other operations data. A hierarchical, generalized estimating equations model with ordered logit link found that NHAs with higher COVID stress (AOR = 1.65, 95% CI = 1.22, 2.23), higher use of agency/contract staff (AOR = 1.50, 95% CI = 1.08.2.09) and higher role conflict were more likely to indicate TI. NHAs with higher job satisfaction in workload, work content, and rewards were less likely to hold TI. Industry leaders should create strategies to reduce NHA's job stress and role conflicts and provide opportunities for improving staff recruitment and retention, reducing reliance on agency staffing.

Chinese Americans' Information Sources on, Preferred Types of, and Satisfaction with COVID-19 Vaccination.

According to the Centers for Disease Control and Prevention (CDC), about 87% of Asian Americans had received at least one dose of the COVID-19 vaccine as of July 2023. The purpose of this study is to identify the sources of information, preferred vaccine types, and levels of satisfaction related to COVID-19 vaccination among Chinese Americans, the largest subgroup of Asian immigrants living in the U.S. Our survey data were collected from 241 Chinese American early adopters of the COVID-19 vaccine, who completed at least one dose of the COVID-19 vaccine in June 2021. Our results indicated that their major information sources regarding COVID-19 vaccination included health officials and authorities, local news, family/friends/co-workers, social media platforms, and healthcare professionals. More than half of the participants expressed a preference for the Pfizer-BioNTech (New York, U.S.) vaccine based on the primary considerations of safety, efficacy, credibility of the developer, and availability. A majority of the participants felt satisfied with their experience of receiving the COVID-19 vaccination. Participants with higher levels of self-efficacy and subjective norms related to receiving the COVID-19 vaccine were more likely to express satisfaction with the vaccination. These findings provide valuable insights into Chinese Americans' information sources, vaccine preferences, and satisfaction levels regarding COVID-19 vaccination. This knowledge can help guide future vaccination interventions and campaigns.

Nurse Practitioner Employment in Relation to Nursing Staff Turnover and Resident Care Outcomes in US Nursing Homes.

OBJECTIVES: A growing number of nurse practitioners (NPs) are employed in nursing homes (NHs) through various NP staffing mechanisms. The purpose of this study was to examine if having NH-employed NPs was associated with nursing staff turnover and resident care outcomes measured as hospital utilization, infection control citations, and substantiated complaints in NHs in 2021-2022. DESIGN: A cross-sectional, retrospective study. SETTING AND PARTICIPANTS: A total of 13,966 NHs from payroll-based journal (PBJ) and claim-based quality measures published by the Centers for Medicare and Medicaid Services in 2021-2022. METHODS: Facilities were identified as having NH-employed NPs if at least 1 employed NP with paid working hours ≥10 per week was reported through the PBJ. We examined if having NH-employed NPs was associated with nursing staff turnover rates, unplanned hospital utilization, infection control citations, and substantiated complaints using doubly robust estimation that combined inverse probability weight representing the NH's likelihood of employing NPs and outcome regression. RESULTS: Approximately, 2.8% of NHs had employed NPs. Facilities with NH-employed NPs tended to be larger, hospital affiliated, and not for profit with greater medical and nursing staff availability. In addition, a significantly higher proportion of facilities with NH-employed NPs were in metropolitan areas or states with full NP practice independence. We found that facilities with NH-employed NPs had significantly lower registered nurse (adjusted ß, -5.40; 95% CI, -9.50 to -1.30) and certified nursing assistant turnover rates (adjusted ß, -3.35; 95% CI, -6.29 to -0.40). Facilities with NH-employed NPs also had significantly fewer long-stay resident hospitalizations, infection control citations, and substantial complaints compared with those with no NH-employed NPs. CONCLUSIONS AND IMPLICATIONS: This study highlights the value of NH-employed NPs to improve registered nurse and certified nursing assistant staff retention and NH resident outcomes. NH stakeholders and policymakers may consider various strategies to incentivize NP employment in NHs such as removing regulatory barriers to NP practice.

Nursing Faculty Job Satisfaction During COVID-19: A Mixed-Methods Study.

AIM: The aim of this study was to understand stress, resilience, and compassion satisfaction of nursing faculty during the COVID-19 pandemic and identify factors related to their job satisfaction. BACKGROUND: The impacts of COVID-19 on faculty stress, resilience, compassion satisfaction, and job satisfaction were unknown. METHOD: A mixed-methods survey was distributed electronically to nursing faculty in the United States. RESULTS: Compassion satisfaction and resilience were positively correlated with job satisfaction; stress and job satisfaction were negatively correlated. Feeling safe to teach, feeling supported by administration, and spending more hours teaching online were positively associated with job satisfaction. Three themes were identified: challenges in the workplace, struggles with personal stressors, and building capacity in the face of the unknown. CONCLUSION: Faculty reported a strong professional commitment to nursing education during the COVID-19 pandemic. Leadership that supported faculty through concern for their safety contributed to participants' ability to respond to the challenges experienced.

Exploring Factors Associated with Chinese-Americans' Willingness to Receive an Additional Hypothetical Annual Dose of the COVID-19 Vaccine.

Chinese-Americans are one of the largest groups of Asian-Americans in the US with distinctive behavioral and cultural characteristics that influence health service use. Although Chinese-Americans have significantly higher COVID-19-related mortality rates, relative to other racial and ethnic groups, limited literature is available examining their willingness to accept the COVID-19 vaccine. With recent development of the combination influenza-COVID-19 vaccine by biotechnology companies to mitigate COVID-19 infection, we examined factors associated with Chinese-Americans' acceptance of hypothetical annual doses of COVID-19 vaccination before the vaccine rollout. A total of 241 Chinese-Americans who received at least one dose of the COVID-19 vaccine completed an online questionnaire developed and based on health behavior theories. Our results indicated that Chinese-American participants who were satisfied with their prior COVID-19 vaccination experience, who had more accurate knowledge and perceived higher susceptibility of getting COVID-19, were more willing to receive the annual COVID-19 vaccine in the future. The findings of our current study may be used to guide the development of strategic messages to promote uptake of the annual COVID-19 vaccine by Chinese-Americans in the U.S.

Trends in COVID-19 cases, deaths, and staffing shortages in US nursing homes by rural and urban status.

The purpose of the study was to examine trends in COVID-19 cases, related deaths, and staffing shortages in nursing homes (NH) by rural and urban status from May 2020 to Feb 2021. Generalized linear mixed models with state-fixed effects were used to estimate the interaction effect of study period and rural/urban status on having at least: one COVID-19 case, one related death, and/or at least one week of staffing shortage using the NH COVID-19 data spanning the 40-week period. The findings revealed shortages in staff, particularly direct care providers, were greatly accelerated in rural NHs as the pandemic wore on over time. Conversely, staffing shortages in urban NHs were relatively stable despite the fluctuating COVID-19 cases over the same time period. The findings highlight the need of identifying effective strategies that prevent rural NHs from encountering staffing deficits in response to long-lasting natural disasters such as the COVID-19 pandemic.

Patterns of mental health service use among Medicaid-insured youths treated by nurse practitioners and physicians: A retrospective cohort study.

BACKGROUND: Despite the growing involvement of nurse practitioners in mental health services for children and adolescents, little is known about the patterns of mental health service use among youths treated by nurse practitioners compared to those by physicians. OBJECTIVES: To identify new users of psychotropic medications initiated by nurse practitioners and physicians among Medicaid-insured youths and to assess if receiving psychosocial services prior to or concurrent with medication initiation differs among youths treated by provider and specialty type. DESIGN: A retrospective cohort study. SETTINGS: We used Medicaid-insurance claims data in one mid-Atlantic state in the US. PARTICIPANTS: A total 12,991 Medicaid-insured youths aged 0-20 years who started psychotropic medications prescribed by nurse practitioners or physicians with primary care or psychiatric specialty during 2013-2014. METHODS: Providers were grouped into nurse practitioners and physicians and into primary care and psychiatric specialty. Descriptive statistics were performed to compare each class of psychotropic medications initiated and psychiatric diagnoses of enrollees according to provider type within each specialty. Using multinomial logistic regression with psychiatrists as a reference group, we estimated the odds of having a type of prescriber for psychotropic medication initiation for youths who received psychosocial services prior to a new start of the medication and concurrently, compared to that for those who did not, after adjusting for patients' demographic characteristics and diagnosis. RESULTS: Youths served by nurse practitioners resided in small and non-metropolitan areas significantly more often than those served by their physician counterparts. There was no major difference in a class of psychotropic medications initiated by nurse practitioners and physicians within each specialty type, except a higher proportion of antidepressants (13.5% versus 10.5%) and a lower proportion of attention deficit hyperactivity disorder medications prescribed (68.8% versus 74.0%) by primary care nurse practitioners compared to their physician counterparts. Youths who received psychosocial services prior to medication initiation were less likely to have primary care physicians (Adjusted odds ratio=0.15, 95% confidence interval=0.82, 1.33) or primary care nurse practitioners (Adjusted odds ratio=0.16, 95% confidence interval=0.12, 0.20) as their initiating prescriber than those who did not. CONCLUSIONS: Youths treated by nurse practitioners and physicians with or without psychiatric specialty showed unique patterns of mental health service use. Our findings can be used to build effective collaborations among provider and specialty type for quality of mental health services delivered to targeted populations in need.

State Nurse Practitioner Practice Regulations and U.S. Health Care Delivery Outcomes: A Systematic Review.

There is a great variation across states in nurse practitioner (NP) scope of practice moderated by state regulations. The purpose of this study was to synthesize the evidence from studies of the impact of state NP practice regulations on U.S. health care delivery outcomes (e.g., health care workforce, access to care, utilization, care quality, or cost of care), guided by Donabedian's structure, process, and outcomes framework. This systematic review was performed using Medline, CINAHL, PsycINFO, and PubMed according to Preferred Reporting Items for Systematic and Meta-Analysis on the literature from January 2000 to August 2019. The results indicate that expanded state NP practice regulations were associated with greater NP supply and improved access to care among rural and underserved populations without decreasing care quality. This evidence could provide guidance for policy makers in states with more restrictive NP practice regulations when they consider granting greater practice independence to NPs.

Nursing Home Administrator's Job Satisfaction, Work Stressors, and Intent to Leave.

This study examines how job satisfaction in six subscales and select stressors and demographic covariates influence nursing home administrator's (NHA) intentions to quit. Quantitative and qualitative data were collected from 311 NHAs in five states. Adjusted odds ratios and 95% confidence intervals for the ordered logistic regression models indicated that NHAs with satisfying work demands, rewards, and coworkers, and who experienced less role conflict and had fewer prior nursing home jobs had lower turnover intentions. Although generally satisfied, roughly 24% reported intending to quit. Surprisingly, NHAs reporting higher job skills were more likely to consider leaving, suggesting that talented NHAs may choose career advancement eased by stigma-free job-hopping in an industry with high mobility norms. Qualitative data suggested that job satisfaction/dissatisfaction was influenced by a more nuanced interpretation of satisfying and more taxing job facets and quitting triggers, including themes such as helping residents and struggling with regulations.

Nurse Staffing and Skill Mix Patterns in Relation to Resident Care Outcomes in US Nursing Homes.

OBJECTIVES: The purpose of this study was to identify patterns of nurse staffing and skill mix and estimate the impact of these patterns on rehospitalization and emergency department (ED) visits in nursing home (NH) residents. We also estimated the relative contribution of unique staffing patterns on variations in hospital and ED use rates. DESIGN: Retrospective secondary data analysis at the facility level, using administrative data. SETTING AND PARTICIPANTS: Data from Medicare/Medicaid certified NHs in the 2018 Certification and Survey Provider Enhanced Reporting System were merged with the NH Compare Claims-Based Quality Measures file, for those facilities with complete data available (N = 14,325). METHODS: Cluster analysis was performed to identify groups of NHs with similar nursing skill mix patterns, using measures that captured hours per resident day (HPRD) for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). We estimated the impact of cluster assignment on unplanned rehospitalization and ED visits using multivariate generalized estimating equations. Plots were generated to visualize simulation models that showed the relative contribution of unique staffing strategies to the outcomes, while holding other factors constant. RESULTS: We identified 3 nursing skill mix clusters: high-RN, high-LPN, and high-CNA, relative to national staffing averages. After controlling for regional and organizational characteristics, residents in NHs in the high-RN cluster had significantly lower rehospitalization and ED use compared with those in the high-LPN cluster, with a similar nonsignificant trend for the high-CNA vs high-LPN clusters. Though the high-RN cluster had CNA HPRD similar to the high-CNA cluster, it relied much less on LPN staffing. Whereas NHs in the high-LPN cluster had proportionally fewer hours of care by both CNAs and RNs. CONCLUSIONS AND IMPLICATIONS: NHs that emphasize LPN care in place of either RN or CNA care appears to exhibit higher rates of unplanned rehospitalization and ED visits among residents.

Comparing residential long-term care regulations between nursing homes and assisted living facilities.

BACKGROUND: Nursing homes (NHs) are federally regulated under uniform standards, whereas assisted living facilities (ALFs) use individual state regulations for staffing, training, and oversight of care quality and safety. PURPOSE: To describe ALF staffing, training, inspection, and enforcement regulations for 50 U.S. states and the District of Columbia, and compare them to NH regulations. Publication of ALF quality and safety outcomes data also was assessed and compared to NHs. METHODS: Regulatory data were compiled from administrative and regulatory data sources, state websites, and regulatory compendia. FINDINGS: NHs followed a standard set of regulations, whereas ALF regulations varied widely. Overall, state ALF regulations were less stringent than NH in all categories. DISCUSSION: As ALF populations and acuity levels increase, staffing, training, nursing presence, and outcomes data requirements are warranted, and could be tailored from NH regulations to protect ALF quality and safety.

Increasing Rates of Opioid Misuse Among Older Adults Visiting Emergency Departments.

OBJECTIVE: This study sought to investigate factors associated with opioid misuse-related emergency department (ED) visits among older adults and changes in outcomes associated with these visits, using multiple years of nationally representative data. METHODS: A retrospective analysis of the Nationwide Emergency Department Sample was conducted. Study inclusion was limited to adults aged 65 years and older. Diagnostic codes were used to identify opioid misuse disorder; sampling weights were used to adjust standard estimates of the errors. Descriptive and multivariate procedures were used to describe risk and visit outcomes. RESULTS: ED visits by older adults with opioid misuse identified in the ED increased sharply from 2006 to 2014, representing a nearly 220% increase over the study period. Opioid misuse was associated with an increased number of chronic conditions, greater injury risk, and higher rates of alcohol dependence and mental health diagnoses. CONCLUSION: The steep increase in opioid misuse observed among older adult ED visits underscores the critical need for additional research to better understand the national scope and impact of opioid misuse on older adults, as well as to better inform policy responses to meet the needs of this particular age group.

National opioid prescribing trends in emergency departments by provider type: 2005-2015.

PURPOSE: To describe opioid prescribing practice patterns and trends in emergency department visits (EDs) by provider type: physicians and advanced practice providers (APPs), which include nurse practitioners (NPs) and physician assistants (PAs). METHODS: The data source was the ED visit files of the 2005-2015 National Hospital Ambulatory Care Survey. The study sample was opioid prescription-related ED visits. Descriptive and multinomial logistic regression analyses were conducted to assess the proportion of opioid prescription-related visits by provider type over time in total and by patient age group. We then characterized opioid prescribing practices of NPs, PAs, and physicians according to type of opioid and pain-related diagnosis. RESULTS: From 2005 to 2015, there was a 116.7% increase in the proportion of the opioid prescription-related visits seen by NPs and a 61.2% increase seen by both APPs and physicians. In contrast, the proportion of the physician-only visits decreased (-8.3%). When stratified by age group, the growth was particularly notable among the visits with patients aged 65 and older seen by both APPs and physicians (AOR = 2.35, 95% CI = 1.69, 3.25). Proportionally less hydromorphone and morphine was prescribed by APPs than by physicians. Opioids were prescribed more often by APPs in visits involving dental and injury-related pain, whereas physicians prescribed opioids more in abdominal and chest pain-related visits. CONCLUSIONS: From 2005 to 2015, APPs, particularly NPs played an increasing role in opioid prescribing in EDs. Opioid prescribing practices of APPs and physicians varied by patient condition as well as by opioid type.

Comparing Nurse Practitioner and Physician Prescribing of Psychotropic Medications for Medicaid-Insured Youths.

Objective: To describe psychotropic medication prescribing practices of nurse practitioners (NP) and physicians for Medicaid-insured youths in 2012-2014 in a mid-Atlantic state where NP independent prescribing is authorized. Method: From annual computerized administrative claims data in a mid-Atlantic state, we analyzed 1,034,798 dispensed psychotropic medications prescribed by NPs and physicians for 61,526 continuously enrolled Medicaid-insured youths aged 2-17 years. Demographic and clinical characteristics of psychotropic medication users were compared for youths who received psychotropic medication dispensings by NP-only, physician-only, or by both providers using descriptive statistics and generalized estimating equations. We then characterized psychotropic medication prescribing practices by providers within each specialty. Results: From 2012 to 2014, the number of psychotropic medication dispensings increased from 346,922 to 349,080. There was a 50.9% increase in the proportion of psychotropic medications prescribed by psychiatric NPs (from 5.9% to 8.8%) and a 28.6% proportional increase by non-psychiatric NPs (from 4.9% to 6.3%). By contrast, the proportion of psychotropic medications prescribed by psychiatrists and by non-psychiatric physicians declined (56.9%-53.0% and 32.3%-31.8%, respectively). Youths diagnosed with depression or anxiety were more commonly treated by NP-only than by physician-only (AOR = 1.33, 95% CI = 1.24-1.43), whereas youths with two or more psychiatric comorbidities were significantly more commonly treated by both NP and physician providers (AOR = 1.44, 95% CI = 1.39-1.50). Psychiatric specialists prescribed the bulk of antidepressants (82.0%) and lithium (92.3%), with much lower prescribing by non-psychiatric specialists (18.0% and 7.7%, respectively). Antipsychotic orders originated from psychiatric specialists 7.4 times more than from their non-psychiatric specialty counterparts, whether physician or NP. Conclusions: NPs, relative to physicians, have taken an increasing role in prescribing psychotropic medications for Medicaid-insured youths. The quality of NP prescribing practices deserves further attention.

Nurse Practitioner Independent Practice Authority and Mental Health Service Delivery in U.S. Community Health Centers.

OBJECTIVE: Little is known about how nurse practitioner independent practice authority (NP-IPA) influences patient care. This study examined the effect of NP-IPA on patterns of mental health-related visits provided by NPs in U.S. community health centers (CHCs). METHODS: State NP regulatory information was linked to National Ambulatory Medical Care Survey data on NP- and physician-provided visits (N=61,457) in CHCs from 2006 through 2011. The proportion of NP-provided versus physician-provided mental health-related visits in states with NP-IPA was compared with the proportion in states without NP-IPA. The adjusted odds of mental health-related visits in CHCs provided by NPs in states with and without NP-IPA were compared by using multiple logistic regression models while accounting for the complex survey design. RESULTS: Between 2006 and 2011, the odds of NP- versus physician-provided mental health-related visits in CHCs were more than two times greater in states with NP-IPA than in states with no NP-IPA (adjusted odds ratio [OR]= 2.43, 95% confidence interval [CI]=1.12-4.60). In contrast, no significant difference between states with and without NP-IPA was noted in non-mental health-related CHC visits provided by NPs. Among all mental health-related visits, the odds of visits in which psychotropic medications were prescribed by an NP were more than three times higher in states with NP-IPA than in those without NP-IPA (adjusted OR=3.14, CI=1.50-6.54). CONCLUSIONS: Compared with physicians, NPs provided proportionally more CHC mental health-related visits in states with NP-IPA than in states without NP-IPA.

CNA Training Requirements and Resident Care Outcomes in Nursing Homes.

Purpose of the Study: To examine the relationship between certified nursing assistant (CNA) training requirements and resident outcomes in U.S. nursing homes (NHs). The number and type of training hours vary by state since many U.S. states have chosen to require additional hours over the federal minimums, presumably to keep pace with the increasing complexity of care. Yet little is known about the impact of the type and amount of training CNAs are required to have on resident outcomes. Design and Methods: Compiled data on 2010 state regulatory requirements for CNA training (clinical, total initial training, in-service, ratio of clinical to didactic hours) were linked to 2010 resident outcomes data from 15,508 NHs. Outcomes included the following NH Compare Quality Indicators (QIs) (Minimum Data Set 3.0): pain, antipsychotic use, falls with injury, depression, weight loss and pressure ulcers. Facility-level QIs were regressed on training indicators using generalized linear models with the Huber-White correction, to account for clustering of NHs within states. Models were stratified by facility size and adjusted for case-mix, ownership status, percentage of Medicaid-certified beds and urban-rural status. Results: A higher ratio of clinical to didactic hours was related to better resident outcomes. NHs in states requiring clinical training hours above federal minimums (i.e., >16hr) had significantly lower odds of adverse outcomes, particularly pain falls with injury, and depression. Total and in-service training hours also were related to outcomes. Implications: Additional training providing clinical experiences may aid in identifying residents at risk. This study provides empirical evidence supporting the importance of increased requirements for CNA training to improve quality of care.

Variation Across U.S. Assisted Living Facilities: Admissions, Resident Care Needs, and Staffing.

PURPOSE: Though more people in the United States currently reside in assisted living facilities (ALFs) than nursing homes, little is known about ALF admission policies, resident care needs, and staffing characteristics. We therefore conducted this study using a nationwide sample of ALFs to examine these factors, along with comparison of ALFs by size. DESIGN: Cross-sectional secondary data analysis using data from the 2010 National Survey of Residential Care Facilities. METHODS: Measures included nine admission policy items, seven items on the proportion of residents with selected conditions or care needs, and six items on staffing characteristics (e.g., access to licensed nurse, aide training). Facilities (n = 2,301) were divided into three categories by size: small, 4 to 10 beds; medium, 11 to 25 beds; and large, 26 or more beds. Analyses took complex sampling design effects into account to project national U.S. estimates. FINDINGS: More than half of ALFs admitted residents with considerable healthcare needs and served populations that required nursing care, such as for transfers, medications, and eating or dressing. Staffing was largely composed of patient care aides, and fewer than half of ALFs had licensed care provider (registered nurse, licensed practical nurse) hours. Smaller facilities tended to have more inclusive admission policies and residents with more complex care needs (more mobility, eating and medication assistance required, short-term memory issues, p < .01) and less access to licensed nurses than larger ALFs (p < .01). CONCLUSIONS: This study suggests ALFs are caring for and admitting residents with considerable care needs, indicating potential overlap with nursing home populations. Despite this finding, ALF regulations lag far behind those in effect for nursing homes. In addition, measurement of care outcomes is critically needed to ensure appropriate ALF care quality. CLINICAL RELEVANCE: As more people choose ALFs, outcome measures for ALFs, which are now unavailable, should be developed to allow for oversight and monitoring of care quality.

[Effects of assertive training on interpersonal relations, social behavior, and psychiatric symptoms in patients with a mental disorder].

PURPOSE: This study was designed to examine the effects of an assertive training program on interpersonal relations, and psychiatric symptoms in patients with a mental disorder. METHOD: The study employed a quasi experimental design. The subjects included 44 patients with a mental disorder, 20 in the experimental group, and 24 in the control group. Data was collected using structured questionnaires over a 3 month period. RESULTS: There were greater significant increases in scores of interpersonal relations and content of communication in the experimental group than the control group. Also, there was a greater significant decrease in the score of psychiatric symptoms in the experimental group than the control group. CONCLUSION: Assertive training has an effect on increasing content of communication and decreasing psychiatric symptoms.