Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis.

Starting in 2016, Centers for Medicare and Medicaid Services implemented the first phase of a 3-year multi-phase plan revising the manner in which nursing homes are regulated. In this revision, attention was placed on the importance of certified nursing assistants (CNAs) to resident care and the need to empower these frontline workers. Phase II mandates that CNAs be included as members of the nursing home interdisciplinary team that develops care plans for the resident that are person-centered and comprehensive and reviews and revises these care plans after each resident assessment. While these efforts are laudable, there are no direct guidelines for how to integrate CNAs in the interdisciplinary team. We recommend the inclusion of direct guidelines, in which this policy revision clarifies the expected contributions from CNAs, their responsibilities, their role as members of the interdisciplinary team, and the expected patterns of communication between CNAs and other members of the interdisciplinary team.

SOARING: A Residency Program for Unlicensed Assistive Personnel: Meeting the Demands While Retaining Highly Skilled, Engaged Clinical Technicians.

A complex healthcare environment requires an optimal nursing skill mix at a reasonable cost to sustain safe, quality, and efficient patient care. An innovative, unlicensed assistive personnel residency program was developed to fill open positions with a skillful, confident, and engaged clinical technician workforce. The program resulted in highly skilled and confident clinical technicians, a 4% increase in engagement scores, and a 14% increase in retention rate.

Analysis of records by nursing technicians and nurses in medical records.

OBJECTIVES: to analyze the main non-conformities of the nursing records of a public hospital in Natal, Brazil. METHODS: this is a descriptive, cross-sectional study, with a quantitative approach. This study was conducted in nursing departments of medical and surgical wards. The sample was composed of 120 medical records of inpatients between October and December 2016. The obtained data were tabulated and analyzed by simple statistics in absolute and relative frequency using the 2013 Microsoft Excel software. The Pareto Diagram was used to evaluate the non-conformities of the records. RESULTS: the main problems in the nursing records were the absence of the professional category and the nursing council number, responsible for 41.8% of the non-conformities in the records of nursing technicians; for nurses' records, the main non-conformities were the absence of time and the illegible handwriting, with 61.2%. CONCLUSIONS: the study showed that nursing professionals perform their records incompletely and often do not document the care provided.

Learning transfer and transition of certified nursing assistants' to baccalaureate nursing programs.

BACKGROUND: Certified nursing assistants (CNAs) provide vital care to patients in a variety of care settings, yet little is known about their transition and transfer of learning to baccalaureate nursing education. Faculty play a key role in helping them successfully progress through their educational journey. PROCEDURE: Using a qualitative descriptive design, semi-structured interviews of eight CNAs enrolled in U.S. schools in the south-central region of Pennsylvania were conducted. Data were analyzed using content and thematic analysis. RESULTS: The influence of prior health care experience afforded participants confidence in their transition to BSN education, as well as accelerated learning. Three themes emerged from participant data related to transfer of learning: jumping in and demonstrating confidence from the beginning, learning from a foundation to transform my thinking from tasks to process, and merging new learning into practice. Results support that even if CNAs face varying challenges entering nursing education, most possess some clinical reasoning and critical thinking skills, as well as experience working with patients and within teams. CONCLUSIONS: All of which can influence the learning experience. Findings can help faculty identify CNAs' strengths, which may facilitate learning transfer, foster leadership potential, and engage them in peer teaching and mentoring; ultimately positively influencing the transition to practice.

Analysis of records by nursing technicians and nurses in medical records / Análisis de los registros médicos de técnicos de enfermería y de enfermeros / Análise dos registros de técnicos de enfermagem e enfermeiros em prontuários

ABSTRACT Objectives: to analyze the main non-conformities of the nursing records of a public hospital in Natal, Brazil. Methods: this is a descriptive, cross-sectional study, with a quantitative approach. This study was conducted in nursing departments of medical and surgical wards. The sample was composed of 120 medical records of inpatients between October and December 2016. The obtained data were tabulated and analyzed by simple statistics in absolute and relative frequency using the 2013 Microsoft Excel software. The Pareto Diagram was used to evaluate the non-conformities of the records. Results: the main problems in the nursing records were the absence of the professional category and the nursing council number, responsible for 41.8% of the non-conformities in the records of nursing technicians; for nurses' records, the main non-conformities were the absence of time and the illegible handwriting, with 61.2%. Conclusions: the study showed that nursing professionals perform their records incompletely and often do not document the care provided.

RESUMEN Objetivos: evaluar las no conformidades principales de los registros de enfermería de un hospital público del Nordeste en la ciudad de Natal (Brasil). Métodos: estudio descriptivo, transversal, de enfoque cuantitativo. Se llevó a cabo en enfermerías médicas y quirúrgicas. La muestra constó de 120 registros médicos de pacientes hospitalizados entre octubre y diciembre de 2016. Los datos obtenidos fueron tabulados y analizados por estadística simple en frecuencias absoluta y relativa con el software Microsoft Excel 2013. Se utilizó el Diagrama de Pareto en la evaluación de las no conformidades de los registros. Resultados: entre los principales problemas en los registros de enfermería, se destacó la ausencia de la categoría profesional y del número de la comisión, responsables de un 41,8% de las no conformidades en los registros de técnicos de enfermería, mientras que en las anotaciones de los enfermeros se sobresalió la ausencia de hora y caligrafía ilegible, con un 61,2%. Conclusiones: el estudio demostró que los profesionales de enfermería hacen sus registros de forma incompleta y que muchas veces no documentan el cuidado ofertado.

RESUMO Objetivos: analisar as principais não conformidades dos registros de enfermagem de um hospital público do Nordeste na cidade de Natal. Métodos: estudo descritivo, transversal, abordagem quantitativa. Realizado em enfermarias médicas e cirúrgicas. Amostra composta de 120 prontuários de pacientes internados entre outubro e dezembro de 2016. Os dados obtidos foram tabulados e analisados por estatística simples em frequência absoluta e relativa com o software Microsoft Excel 2013. Para avaliar as não conformidades dos registros, usou-se o Diagrama de Pareto. Resultados: como principais problemas nos registros de enfermagem, destacou-se a ausência da categoria profissional e número do conselho, responsáveis por 41,8% das não conformidades nos registros de técnicos de enfermagem, enquanto nas anotações dos enfermeiros foram a ausência de hora e as letras ilegíveis, com 61,2%. Conclusões: o estudo evidenciou que os profissionais de enfermagem realizam seus registros de forma incompleta e que muitas vezes não documentam o cuidado prestado.

Infrecuente lavado de manos antes de recepcionar material estéril en un hospital de Lima-Perú / Infrequent hand-washing before receiving sterile material in a hospital in Lima-Peru

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Uncovering the Disconnect Between Nursing Workforce Policy Intentions, Implementation, and Outcomes: Lessons Learned From the Addition of a Nursing Assistant Role.

The use of nursing assistants has increased across health systems in the past 20 years, to alleviate licensed nurses' workload and to meet rising health care demands at lower costs. Evidence suggests that, when used as a substitute for licensed nurses, assistants are associated with poorer patient and nurse outcomes. Our multimethods study evaluated the impact of a policy to add nursing assistants to existing nurse staffing in Western Australia's public hospitals, on a range of outcomes. In this article, we draw the metainferences from previously published quantitative data and unpublished qualitative interview data. A longitudinal analysis of patient records found significantly higher rates adverse patient outcomes on wards that introduced nursing assistants compared with wards that did not. These findings are explained with ward-level data that show nursing assistants were added to wards with preexisting workload and staffing problems and that those problems persisted despite the additional resources. There were also problems integrating assistants into the nursing team, due to ad hoc role assignments and variability in assistants' knowledge and skills. The disconnect between policy intention and outcomes reflects a top-down approach to role implementation where assistants were presented as a solution to nurses' workload problems, without an understanding of the causes of those problems. We conclude that policy makers and managers must better understand individual care environments to ensure any new roles are properly tailored to patient and staff needs. Further, standardized training and accreditation for nursing assistant roles would reduce the supervisory burden on licensed nurses.

Nursing Assistants' Use of Personal Protective Equipment Regarding Contact With Excreta Contaminated With Antineoplastic Drugs.

PURPOSE: To examine the feasibility of observing and interviewing nursing assistants about handling of antineoplastic drugs contaminated with excreta, acceptability of a measure of personal protective equipment (PPE) use with nursing assistants, and predictors of PPE use. PARTICIPANTS & SETTING: 27 nursing assistants in an inpatient hematology-oncology unit at an academic medical center in the southeastern United States. METHODOLOGIC APPROACH: This was an exploratory, multimethod study using observation, verbally administered questionnaires, and interviews. Research variables included recruitment rates, acceptability of observation, and understandability of a safe-handling instrument. FINDINGS: Observed use of double gloves, chemotherapy gowns, and face shields was low; use of plastic-backed pads when flushing excreta was high. IMPLICATIONS FOR NURSING: Nursing assistants are willing to participate in research. Standardized training and education about PPE use are needed.

Health promotion by nursing technicians from the nurses' perspective.

OBJECTIVE: to analyze education and practice of nursing technicians in health promotion, from the perspective of teaching nurses of technical course and Primary Health Care nurses. METHOD: an exploratory study with qualitative data analysis, carried out in the city of São Paulo, through semi-structured interviews with nine public technical professors and 16 nurses from the basic health network. Data thematic analysis was carried out. RESULTS: three thematic categories have emerged: Conceptions and experiences on health promotion; Nursing technician's practice in health promotion; and Nursing technician education on health promotion. FINAL CONSIDERATIONS: it is necessary to review the centrality given to technicalism in the education and practice of nursing technicians, contemplating the health promotion and seeking the development of professional competence for the construction of transformative practices aimed at valuing the autonomy and proactivity of the people in health and quality of life production.

Health promotion by nursing technicians from the nurses' perspective / Promoción de la salud por técnicos en enfermería, en la perspectiva de enfermeros / Promoção da saúde por técnicos em enfermagem, na perspectiva de enfermeiros

ABSTRACT Objective: to analyze education and practice of nursing technicians in health promotion, from the perspective of teaching nurses of technical course and Primary Health Care nurses. Method: an exploratory study with qualitative data analysis, carried out in the city of São Paulo, through semi-structured interviews with nine public technical professors and 16 nurses from the basic health network. Data thematic analysis was carried out. Results: three thematic categories have emerged: Conceptions and experiences on health promotion; Nursing technician's practice in health promotion; and Nursing technician education on health promotion. Final considerations: it is necessary to review the centrality given to technicalism in the education and practice of nursing technicians, contemplating the health promotion and seeking the development of professional competence for the construction of transformative practices aimed at valuing the autonomy and proactivity of the people in health and quality of life production.

RESUMEN Objetivo: analizar la formación y praxis del técnico en Enfermería en la promoción de la salud, bajo la perspectiva de enfermeros docentes de curso técnico y de la Atención Primaria de Salud. Método: estudio exploratorio con análisis cualitativo de datos, realizado en municipio paulista, por medio de entrevistas semiestructuradas con nueve docentes de curso técnico público y 16 enfermeros de la red básica de salud. Se procedió al análisis temático de los datos. Resultados: se configuraron tres categorías temáticas: Concepciones y experiencias sobre promoción de la salud; Práxis del técnico en Enfermería en la promoción de la salud; y Formación del técnico en Enfermería para promoción de la salud. Consideraciones finales: se hace necesario revisar la centralidad dada al tecnicismo en la formación y praxis del técnico en Enfermería, contemplando la promoción de la salud y buscando el desarrollo de la competencia profesional para la construcción de prácticas transformadoras orientadas a la valorización de la autonomía y la proactividad de las personas en la producción de salud y calidad de vida.

RESUMO Objetivo: analisar a formação e práxis do técnico em enfermagem na promoção da saúde, sob a perspectiva de enfermeiros docentes de curso técnico e da Atenção Primária à Saúde. Método: estudo exploratório com análise qualitativa de dados, realizado em município paulista, por meio de entrevistas semiestruturadas com nove docentes de curso técnico público e 16 enfermeiros da rede básica de saúde. Procedeu-se à análise temática dos dados. Resultados: configuraram-se três categorias temáticas: Concepções e experiências sobre promoção da saúde; Práxis do técnico em enfermagem na promoção da saúde; e Formação do técnico em enfermagem para promoção da saúde. Considerações finais: faz-se necessário rever a centralidade dada ao tecnicismo na formação e práxis do técnico em enfermagem, contemplando a promoção da saúde e buscando o desenvolvimento da competência profissional para construção de práticas transformadoras voltadas para valorização da autonomia e proatividade das pessoas na produção de saúde e qualidade de vida.

Handover of care and of information by community midwives, maternity care assistants and Preventive Child Healthcare professionals, a qualitative study.

INTRODUCTION: Handover of care has been internationally acknowledged as an important aspect in patient safety. Families who are vulnerable due to low socio-economic status, a language barrier or poor health skills, benefit especially from a decent handover of care from one healthcare professional to another. The handover from primary midwifery care and maternity care to Preventive Child Healthcare (PCHC) is not always successful, especially not in case of vulnerable families. AIM: Obtaining insight in and providing recommendations for the proces of handover of information by primary midwifery care, maternity care and PCHC in the Netherlands. METHODS: A qualitative research through semi-structured interviews was conducted. Community midwives, maternity care nurses and PCHC nurses from three municipalities in the Netherlands were invited for interviews with two researchers. The interviews took place from February to April 2017. The qualitative data was analyzed using NVivo11 software (QSR International). RESULTS: A total of 18 interviews took place in three different municipalities with representatives of the three professions involved with the handover of care and of information concerning antenatal, postnatal and child healthcare: six community midwives, six maternity care assistants and six PCHC nurses. All those interviewed emphasized the importance of good information transfer in order to provide optimum care, especially when problems within the family ar present. In order to improve care, a large number of healthcare professionals prefered a fully digitized handover of information, providing the privacy of the client is warrented and the system works efficiently. To provide high quality care, it is considered desirable that healthcare workers get to know each other and more peer agreements are prepared. The 'obstetric collaborative network' or another structured meeting was considered most suitable for this exchange. CONCLUSION: This study shows that the handover of care and of information between professionals in the fields of antenatal, postnatal and child healthcare is gaining awareness, but a more rigorous chain of care and collaboration between these disciplines is desired. Digitizing seems important to improve the handover of information.

Medication administration - nursing workload and patient safety in clinical wards.

OBJECTIVE: to analyze the characteristics of the work organization performed by nursing staff regarding medication administration procedures and their implications on the workload of these professionals and on patient safety. METHOD: the study design is exploratory, with mixed method research and an ecological restorative approach. Data were collected between January 2014 and March 2015, in three inpatient units of a teaching hospital in the south of Brazil, by means of photo walkabout and focus groups, in the qualitative step. In the quantitative phase data were collected from the 162 lists of patients assigned to nursing technicians during their work shifts. RESULTS: the administration of medications has an impact on the professionals' workload and patient safety. FINAL CONSIDERATIONS: there are weaknesses in the process that may contribute to medication administration errors, which are related to the number of doses and the number of patients assigned to each professional.

Examining the Impact of Knowledge Translation Interventions on Uptake of Evidence-Based Practices by Care Aides in Continuing Care.

BACKGROUND: Dissemination of evidence-based practices has been a long-standing challenge for healthcare providers and policy makers. Research has increasingly focused on effective knowledge translation (KT) in healthcare settings. AIMS: This study examined the effectiveness of two KT interventions, informal walkabouts and documentation information sessions, in supporting care aide adoption of new evidence-based practices in continuing care. METHODS: The Sustaining Transfers through Affordable Research Translation (START) study examined sustainability of a new practice, the sit-to-stand activity completed with residents in 23 continuing care facilities in Alberta, Canada. At each facility, two informal walkabouts and two documentation information sessions were conducted with care aides during the first 4 months. To assess their effect, uptake of the sit-to-stand activity was compared 4 days prior to and 4 days after each intervention, as well as the entire first and fourth months of the study were compared. Data were analyzed using mixed linear regression models created to estimate the changes in uptake. RESULTS: Data were collected from 227 residents. After controlling for age, sex, dementia, and mobility, a 5.3% (p = .09) increase in uptake of the mobility activity was observed during the day shift and 6.1% (p = .007) increase in uptake of the mobility activity during the evening shift. Site size had a significant effect on the outcome with medium-sized facilities showing a 12.6% (SE = .07) increase over small sites and a 18.2% (SE = .05) increase over large sites. These results suggest that repeated KT interventions and sufficient time are key variables in the successful implementation of new practices. LINKING EVIDENCE TO ACTION: Consideration of time, repetition, and facility-specific variables such as size may generate simple, cost-effective KT interventions in healthcare settings.

Medication administration - nursing workload and patient safety in clinical wards / Administração de medicamentos - carga de trabalho de enfermagem e segurança do paciente em unidades clínicas hospitalares / Administración de medicamentos - carga de trabajo de enfermería y seguridad del paciente en unidades clínicas

ABSTRACT Objective: to analyze the characteristics of the work organization performed by nursing staff regarding medication administration procedures and their implications on the workload of these professionals and on patient safety. Method: the study design is exploratory, with mixed method research and an ecological restorative approach. Data were collected between January 2014 and March 2015, in three inpatient units of a teaching hospital in the south of Brazil, by means of photo walkabout and focus groups, in the qualitative step. In the quantitative phase data were collected from the 162 lists of patients assigned to nursing technicians during their work shifts. Results: the administration of medications has an impact on the professionals' workload and patient safety. Final considerations: there are weaknesses in the process that may contribute to medication administration errors, which are related to the number of doses and the number of patients assigned to each professional.

RESUMO Objetivo: analisar as características da organização do trabalho da equipe de enfermagem quanto aos procedimentos de administração de medicamentos e suas implicações na carga de trabalho desses profissionais e na segurança do paciente. Método: estudo exploratório, com método misto de pesquisa e abordagem restaurativa ecológica. Os dados foram coletados entre janeiro de 2014 e março de 2015, em três unidades de internação de um hospital universitário do sul do Brasil, por meio de caminhada fotográfica (CF) e grupos focais (GF) na etapa qualitativa. Na fase quantitativa, foram coletados dados das 162 listas de pacientes atribuídos aos técnicos de enfermagem durante seus turnos de trabalho. Resultados: a administração de medicamentos impacta na carga de trabalho dos profissionais e na segurança dos pacientes. Considerações finais: as fragilidades existentes no processo podem contribuir para erros na administração de medicamentos, que estão relacionados com o número de doses e ao número de pacientes atribuídos a cada profissional.

RESUMEN Objetivo: analizar las características de la organización del trabajo real del equipo de enfermería en cuanto a los procedimientos de administración de medicamentos y sus implicaciones en la carga de trabajo de estos profesionales y en la seguridad del paciente. Método: investigación exploratoria con método mixto y enfoque ecológico y restaurativo. Los datos fueron recolectados entre enero de 2014 y marzo de 2015 en tres unidades de internación de un hospital universitario del sur de Brasil, por medio de caminada fotográfica (CF) y grupos focales (GF) en la etapa cualitativa. En la fase cuantitativa, se recogieron datos de las 162 listas de pacientes asignados a los técnicos de enfermería durante sus turnos de trabajo. Resultados: la administración de medicamentos tiene un impacto en la carga de trabajo de los profesionales y en la seguridad del paciente. Consideraciones finales: hay debilidades en el proceso que pueden contribuir a los errores de administración de medicamentos, que están relacionados con el número de dosis y el número de pacientes asignados a cada profesional.

The meanings of the unlicensed assistive personnel role in nursing homes: A triadic job analysis perspective.

AIM: This study described and analyzed how older residents, professional nurses and unlicensed assistive personnel (UAP) perceive the meaning and content of the job carried out by UAP in nursing homes (NHs), as a basis for job analysis. BACKGROUND: Increasing numbers of NH beds and financial restraints have led UAP to become a significant part of the long-term care service system, yet in numerous contexts, the UAP job remains misunderstood and underexplored. METHOD: The research employed a qualitative phenomenological methodology. Data were collected from 50 semi-structured in-depth interviews with 18 UAP, 15 certified nurses and 17 older NH residents. RESULTS: We identified six content dimensions in the participants' descriptions regarding the meanings of the roles and duties of the UAP: (a) care for the physical environment, (b) bodily-physical care, (c) psycho-social interpersonal care, (d) professional hierarchy and boundaries, (e) UAP personal traits and (f) UAP skills, or the need for training and professional education. CONCLUSIONS: Future job definition and formal regulation of UAP should place more focus on the personal characteristics of UAP, as a prerequisite to enter the job. IMPLICATIONS FOR NURSING MANAGEMENT: The study takes a step forward toward better defining the professional boundaries delineating the meaning of the UAP position.

Greek nurses' knowledge on the prevention of surgical site infection: an investigation.

OBJECTIVE: The aim of the study was to investigate nurses' knowledge regarding the prevention of surgical site infection (SSI), and to examine the relationship between nurses' demographic characteristics and educational level and their level of knowledge in prevention of SSIs. A further aim was to examine the differences in nurses' knowledge with respect to selected variables and to identify the most significant predictors of nurses' knowledge regarding the prevention of SSIs, to support the provision of high-quality nursing care. METHOD: A prospective, observational study of a convenience sample of nurses and assistant nurses working in surgical departments, in a public general hospital for adults in Attica, during May to August 2016. For data collection, an anonymous self-completion questionnaire was developed and tested for comprehension and acceptability. RESULTS: Data was collected from 148 nurses and assistant nurses, 121 (81.8%) were female, 73.6% were aged 36-50 years and 43.9% had 11-20 years of experience. With regards to educational level, 66.2% had a degree from a technological educational institute and 10.1% had a Master's degree. Furthermore, 18.2% had a surgical specialty and 59.5% had received special training on surgical infections. The majority of respondents did not chose the correct definition of the time of occurrence of SSIs. Several statistically significant correlations were observed between knowledge on safer hair removal and respndent age (p=0.037), educational level (p=0.003), professional experience (p=0.048), and training in SSIs (p=0.009). CONCLUSION: The results of this study revealed that the majority respondents had a high level of knowledge regarding the prevention of SSIs, which contrasted with a low level of knowledge regarding their full definition of the time of occurrence.

The associations between staffing hours and quality of care indicators in long-term care.

BACKGROUND: Long-term care (LTC) staffing practices are poorly understood as is their influence on quality of care. We examined the relationship between staffing characteristics and residents' quality of care indicators at the unit level in LTC homes. METHODS: This cross-sectional study collected data from administrative records and resident assessments from July 2014 to June 2015 at 11 LTC homes in Ontario, Canada comprising of 55 units and 32 residents in each unit. The sample included 69 registered nurses, 183 licensed/registered practical nurses, 858 nursing assistants, and 2173 residents. Practice sensitive, risk-adjusted quality indicators were described individually, then combined to create a quality of care composite ranking per unit. A multilevel regression model was used to estimate the association between staffing characteristics and quality of care composite ranking scores. RESULTS: Nursing assistants provided the majority of direct care hours in LTC homes (76.5%). The delivery of nursing assistant care hours per resident per day was significantly associated with higher quality of resident care (p = < 0.01). There were small but significant associations with quality of care for nursing assistants with seven or more years of experience (p = 0.02), nursing assistants late to shift (p = < 0.01) and licensed/registered practical nurses late to shift (p = 0.02). CONCLUSIONS: The number of care hours per resident per day delivered by NAs is an important contributor to residents' quality of care in LTC homes. These findings can inform hiring and retention strategies for NAs in LTC, as well as examine opportunities to optimize the NA role in these settings.

Importance of clinical educators to research use and suggestions for better efficiency and effectiveness: results of a cross-sectional survey of care aides in Canadian long-term care facilities.

OBJECTIVE: This study explored the effect of clinical educators as facilitators of research use and how it may be modified by organisational context in the settings. DESIGN: Cross-sectional observational study. SETTING: A representative sample of 91 residential long-term care (LTC) facilities across Western Canada. PARTICIPANTS: We used surveys to collect data from the frontline care aides and information about the organisational context of the care units. OUTCOME MEASURE AND EXPLANATORY VARIABLES: We assessed research use (the outcome) with the Conceptual Research Utilization (CRU) scale. Explanatory variables in the multiple regression analysis were facilitation, organisational context and the interaction terms. Facilitation was measured by the frequency of contacts between care aides and clinical educator or person who brings new ideas about resident care. Three core organisational context variables were measured using the Alberta Context Tool. RESULTS: We included data of 3873 care aides from 294 care units in the LTC facilities. We found significant associations between CRU and facilitation, leadership, culture and evaluation. Interactions of facilitation x leadership and facilitation x culture were negative. The coefficient of the facilitation x evaluation term in the regression model was positive (0.019, 95% CI 0.012 to 0.026), suggesting synergistic effects between facilitation and a well-developed process to evaluate care quality using relevant data. CONCLUSIONS: Findings indicate clinical educators are effective facilitators of research use among the care aides, but the effect is modified by organisational context. For greatest impact, managers can direct efforts of the clinical educators to care units where leadership and culture ratings are lowest, but a proficient feedback and evaluation process is in place. This understanding enables managers to deploy clinical educators (a scarce resource in LTC settings) most efficiently.