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Quality of Care and Nursing Staff in Nursing Homes
Pages 426-452

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From page 426...
... The first section presents a broad picture of issues related to nursing homes and staff. It describes the nursing home environment, characteristics of nursing homes using trend data since 1992, roles and education of nursing staff, the relationship of resident needs to staffing, and quality-of-care measures in nursing homes.
From page 427...
... The definition of sufficient has been operationalized in conflicting ways. The regulatory agencies hold nursing homes to a standard of "highest practicable level" for resident care, yet the payment agencies provide funding for staffing at minimum levels.
From page 428...
... In addition, based on anecdotal information, more acute care problems are being managed within nursing homes to prevent the need for hospitalization. Characteristics of Nursing Homes A review of nursing home characteristics may be helpful in defining the context of nursing care.
From page 429...
... Of the RNs currently in nursing homes, 45.5 percent are diploma prepared, 31.7 percent are associate
From page 430...
... (American Health Care Association, 1995~. The salary level for nursing staff in nursing homes is significantly lower than for hospital-based nurses.
From page 431...
... Being the sole responsible clinician requires a nurse to have considerable clinical expertise. Whereas historically nurses in nursing homes were viewed more as house mothers than professionals, current resident care requires a highly qualified nursing staff, with licensed nurses needing a broad base of knowledge spanning basic nursing, rehabilitation, and psychiatric skills.
From page 432...
... Nurse Assistants The nurse assistant has provided the backbone of care in nursing homes. This individual is responsible for most of the day-to-day assistance with activities of daily living (ADL)
From page 433...
... The vast majority of nurses in nursing homes are diploma or associate degree prepared. Information from a survey done by the Community College-Nursing Home Partnership suggests that there is a limited inclusion of gerontology in the associate degree nurse (ADN)
From page 434...
... Most nurses who have extensive clinical experience in nursing homes do not have the academic credentials to be on a faculty of nursing, nor perhaps the desire. With a shortage of faculty prepared to be a role model and teacher, it is very difficult to build a cadre of graduating students with the knowledge and skills to effectively provide clinical and management expertise in nursing homes.
From page 435...
... A study of nursing homes in Maryland indicates that higher total staff levels are related to fewer nursing deficiencies (Johnson-Pawlson, 1993a)
From page 436...
... found RN staffing to be associated with better resident outcomes as measured through a composite of indicators, including number of resident developing decubitus ulcers per immobile resident, number of residents catheterized per incontinent resident, number of urinary tract infections per incontinent residents, and rate of antibiotic use per resident. Finally, a study of pressure sores in three Department of Veterans Affairs nursing homes concluded that better outcomes in preventing pressure sores was likely due to more favorable staffing (Rodman et al., 1993; Brandeis etal., 1994~.
From page 437...
... Several indicators of quality identified as important criteria were used for facility selection and included prevalence of pressure sores, use of restraints, and medication errors (Institute of Medicine, 1986; Rodman et al., 1994~. A constraint of facility selection was that information on indicators be available for all certified facilities in the OSCAR data set maintained by HCFA.
From page 438...
... The main independent variable is nurse staffing. The levels of nurse staffing were obtained from the facility characteristics portion of the OSCAR data set.
From page 439...
... , and the case-mix is significantly lower in high-quality facilities than low-quality facilities, 9.55 compared to 11.03. Nursing staff data for high- and low-quality facilities indicate a significant difference among the two groups for RN staff.
From page 440...
... . Given that high- and low-quality facilities differed by type of ownership and urban or rural location, facility characteristics were further examined for these variables.
From page 441...
... TABLE 4 Chi Square of High- and Low-Quality Facilities by Urban and Rural Location Quality of Care High Quality (%) Low Quality (%)
From page 442...
... 442 Cal :~ Ct ._ Cd O' 3 o Cal so _ sit A: 3 o o o Cal Em U)
From page 443...
... 443 ._ 3 o ._ 5:: o ._ Ct Cd 50 o it: Cal Cal Cal so C)
From page 444...
... Bivariate analyses of nursing staff and facility characteristics, displayed in Table 7, indicate a statistically significant relationship between hours per resident per day for each level of staff and occupancy rate, percent of Medicaid residents, and case-mix. As one would expect, an increase in occupancy is related to a decrease in nursing time.
From page 445...
... Finally, rural facilities are 1.58 times as likely to be in the high-quality category. Discussion It is important to note that the high-quality facilities selected in this study are not facilities that are necessarily providing care beyond federal and state requirements.
From page 447...
... The ongoing work of HCFA in the Case-Mix Demonstration Project is very important to determining the levels of staff needed to achieve desired outcomes. As nursing homes care for increasingly debilitated residents, there is a need for sufficient staff both in numbers and capabilities.
From page 448...
... It is also important to further examine different impacts on rural and urban facilities, since urban facilities in general staff at higher levels than rural facilities. A possible explanation for the higher staff levels is that the turnover rate is greater in urban areas because of numerous opportunities for jobs in the minimum wage category.
From page 449...
... Another limitation is that quality was defined using physical parameters and not psychologic or social parameters, even though these may be very important to residents. Conclusions Based on information presented in both sections of this paper, the overview of nursing homes and the analysis of the high- and low-quality facilities, several important conclusions can be drawn.
From page 450...
... If LPNs are to substitute for RNs and remain an important level of nursing staff, their capabilities in managing their role in nursing homes will need to be enhanced so that they can have a greater effect on positive resident outcomes. REFERENCES Abt Associates, Inc.
From page 451...
... Johnson-Pawlson, J The Relationship Between Nursing Staff Variables and Quality of Care in Nursing Homes.
From page 452...
... Activities of: Daily Living and Costs in Nursing Homes. Health Care Financing Review 15: 117-135, 1994.


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