Nursing Home Journal

NursingHomesJournal_1_.pdf

Home >Social Science homework help >Sociology homework help >Nursing Home Journal

Relationship between nursing staffing and quality of life in nursing homes

JuH HYUN SHIN

Division of Nursing, College o f Health Sciences, Ewba Womans University, Seodaemun-gu, Seoul, South Korea

A B S T R A C T : Purpose: To investigate the relationship between nurse staffing and quality of life in nursing homes. Methods: This is a descriptive, correlational study The independent variables were nursingstaffinghours per resident day (HPRD), skill mix HPRD, and turnover rate of'nursing staffi. The data for the dependent variables were collected using

the quality of life (QOL) section of minimum data set (MDS) version 3.0. Hierarchical linear models were used for data

analysis. Results: Few staffing variables were statistically associated with residents' QOL More RN HPRD wert associ- ated with better comfort and enfoyment domains, more licensed practical nurses (LPN) HPRD were associated with better

dignity, and more certified nurse assistant (CNA) HPRD were associated with better functional competence domains. In

terms of skill mix, the unique contribution ofmoreRNs (to less LPN or CNAs) was supported in the functional competence

of residents. However, surprising results were that: (a) as the HPRD ofRNs increased the scores of meaningful activity

and relationship decreased; and (b) the contribution ofLPNs (more LPNs to less RNs) were supported in the autonomy

and spiritual well-being domains. Interestingly, nursing staffi turnover is positively correlated with some domains of QOL:

(a) a higher score in the enjoyment domain with increased RN turnover; and (b) a higher score in privacy, relationship,

and individuality domains with increased turnover ofLPNs. Conclusion: This is a preliminary study to investigate the relationship between nursing staffing and QOL for nursing home residents. Further examination is needed to confirm the

relationship and provide policy guidelines, including nurse staffing recommendations.

KE-ITWORDS: nursing bome, quality of life, nursing staffing

In the United States, long-term care settingslike nursing homes are very common place for female elders at the end of their lives. Approximately 16,100 nursing homes care for 1.7 million elders and play a critical role (Center for Disease Control and Prevention, 2004). It is expected that in 2030 about 70 million people will be between the ages of 65-84 while 5 million people will be 85 years or older, and elders are pre- dominantly using nursing bomes in United States (Hicks, Rantz, Petroski, & Mukamel, 2004). Tberefore, elders with longer lives are more con- cerned about tbeir quality of life (QOL), rather than survival itself (Liddle & McKenna, 2000). However, residents are suffering from the poor quality of care, and QOL. Most components of quality of care itself are related to health issues. The emphasis on health-related QOL narrows QOL to the parts of life influenced by bealth conditions (Kane, 2003). Much of the health- related QOL may explain the lives of residents (Drageset et al., 2009) partially. More broadly, elements of QOL depend on Áe diverse needs

of people wbo live in a facility or at home (Guse & Masesar, 1999). As health care providers, it is necessary to determine all potential and cul- turally sensitive aspects and determining factors that may influence QOL, especially for residents in NHs, so that health care providers can pro- vide intervention to improve QOL (Aller & Van Ess Coeling, 1995). Interviews with residents in long-term care settings show that the major fac- tors defining residents' QOL include the ability for residents to communicate with others, care for themselves, and care for others.

Most residents spend most^of their time alone and cannot care for themselves or their environ- ment (Tesh, McNutt, Courts, & Barba, 2002). The experience of transition to and living in nursing homes is a challenging experience in many regards, including physical relocation and dramatic changes in relationships with family and friends, and staff (Guse & Masesar, 1999). Most residents suffer from the changed lifestyles imposed by living in a nursing home where the emphasis is placed on health problems and group

Volume 44, Issue 2, June 2013 (1QS( 1 3 3

Juh Hyun Shin

living (Kane, 2003). Life in nursing homes may be sterile, restricted, and involve loss of privacy and significant relationships in a hospital-like environment (Kane et al., 2003). While nurs- ing homes have achieved some improvement in quality of care, QOL has largely been ignored. Quality of care refers to the process and outcome of measures that effect residents' care directly including: nursing services, dietary services, den- tal services, and infection control; while the QOL is defined as 'the individual's perceptions of their position in life in the context of the culture and value system in which they lie, and in relation- ship to their goals, expectations, and standards' (World Health Organization QOL group, 2005). This study addressed several gaps in research by investigating the QOL of residents, beyond their quality of care. Most previous research has mea- sured only quality of care by using quality indica- tors of minimum data set (MDS) 2.0 which lacks measurement of QOL for psychosocial aspects of residents (Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000).

Many studies have identified staffing as one of the fundamental reasons for the poor quality of care provided to residents (Castle & Anderson, 2011; Castle & Myers, 2006). While the relation- ship between staffing and quality of care has been investigated, the relationship between staffing and QOL has been only minimally studied. The pur- pose of this study was to investigate the relation- ship between nurse staffing and QOL of residents in Unites States. The specific aims were: 1. What is the relationship between the nurs-

ing staff hours per resident day (HPRD) and QOL of residents in nursing homes (NHs)?

2. What is the relationship between the skill mix nursing staff HPRD and QOL in NHs?

3. What is the relationship between the turn- over rates of nursing staff and the QOL in NHs?

METHODS

Design of the study The design was a cross-sectional correlational study. The data came from two major sources, online survey certification and reporting (OSCAR) and the proposed MDS 3.0 data. Only

demographic information from MDS 2.0, and the proposed section F of MDS 3.0 was used.

Independent variables were nursing staff HPRD, skill-mix HPRD, and turnover rate of nursing staff. The source was the Center for Medicare and Medicaid's (CMS's) OSCAR. According to CMS (2011), HPRD has been calculated as 'the average hours worked by the licensed nurses or nursing assistants divided by total number of residents.' Calculating HPRD from the OSCAR requires recalculation into hours per day because staff hours are reported in 2 week periods, assuming that FTE work equals 70 hours per 2 weeks (M. Cowles, personal com- munication, March, 3, 2007). In this paper, HPRD was abbreviated as staff hours. The staff hours was divided into fiill-time equivalent hours and part-time hours. The ratios of: (a) RNs to LPNs/LVNs, and CNAs; and (b) RNs to LPNs/ LVNs plus CNAs were used to measure skill mix. The skill mix of NHs has been conceptualized as the variation in skill and educational background of nursing staff (Dellefield, 2000).

As turnover and staff turnover data did not exist, the actual turnover was obtained from the administrative staff (administrator, director of nursing [DON]) at each N H using the nurs- ing personnel data collection tool developed by Bostick (2002) and a crude turnover rate was cal- culated and used (Duxbury & Armstrong, 1982). The data for the dependent variables were col- lected by the researcher using the QOL section in the proposed MDS 3.0.

Sample/setting Simple random sampling was applied to recruit participants. The list of Iowa NHs was obtained from the Nursing Home Compare Site (CMS, 2006). There were a total of 455 NHs in Iowa (CMS, 2006); 66 NHs had 50-100 beds, within 70 miles of Iowa City, 33 of them were randomly selected. N H administrators were contacted for approval to interview and access residents' data. Eight NHs declined to participate, however, out of 33 a total of 25 NHs agreed to participate. The administrators of NHs that declined to participate gave reasons for not participating, including lack of time and reluctance to impose on residents.

134 Volume 44, Issue 2, June 2013 © eContent Management Pty Ltd

Nursing staffing and quality of life in nursing homes

Some administrators gave no explanations as to their reason for declining the offer. A total of 231 residents from 25 NHs were included. One N H was government-owned, 12 NHs were for-profit NHs and 12 NHs were not-for-profit NHs. Using the OSCAR designation for urban/rural, 15 NHs were located in a rural area and the other 10 were located in urban areas. OSCAR designates a place as an urban area if the county is in an urban sta- tistical area based on its core-based statistical area, otherwise it is rural.

Instnunents OSCAR: OSCAR includes the N H character- istics and the residents' health deficiencies col- lected during the three most current state surveys and additional complaint examinations (CMS, 2006). OSCAR is completed by N H adminis- trators, and collected by the state survey agen- cies that conduct on-site evaluations at least once every 15 months. The evaluation can be conducted when there are complaints regardless of the 15-month inspection cycle. A full-time employer collecting data, the state survey agen- cies enter survey information into the OSCAR database and update it if necessary (CMS, 2006). OSCAR is the only available electronic source regarding N H staffing (Straker, 1999).

The QOL seaion in the proposed MDS 3.0. QOL is subjective and should reflect the variety of experiences of residents (Kane et al., 2003). Self- reports have more validity in getting the lived expe- rience of residents than do staff or femily reports (Kane et al., 2003). The instruments to measure QOL for N H residents have been rarely developed. They include: quality of life index - nursing home version by Ferrans and Powers; World Health Organization (WHO) quality of life instruments; SF-36 health survey by Ware and Sherbourne; and comprehensive quality of life version by Deakin University research teams. While the SF-36 survey focused on health related QOL, the W H O QOL instrument has been developed to measure mainly adults. However, as an independent use of mea- surement instrument of QOL for N H residents has been very understudied, this study attempted to use one of well developed single instrument available (Carrier, West, & Ouellet, 2009).

The QOL (section F) in MDS 3.0 was selected for data colleaion in this study because this was developed to offset the limitation of quality indi- cators in MDS 2.0 and to advance a measurement that reflected the psychosocial aspects of N H residents' lives beyond health related quality of care aspects (Kane et al., 2003). Based on the literature review of instruments, opinions of professionals, group discussions, and stateholder's discussions, the University of Minnesota research team deter- mined 11 QOL domains. As QOL section in MDS 3.0 was regarded as a gold standard of mea- suring QOL for N H residents, this instrument was used in this study. As of August 2012, the proposed MDS 3.0 has been implemented in the United States after data collection of this research has been completed (CMS, 2012).

The University of Minnesota research team developed 54 questions for healthcare providers to ask residents directly to assess 11 domains: dignity; comfort; privacy; meaningful activity; relationships; spiritual well-being; autonomy; individuality; food enjoyment; security; and functional competence. The proposed version of the MDS 3.0 includes both dichotomous vari- ables and Likert scales because some residents may be able to answer only dichotomous-scaled questions while others can reply with Likert scales. In this study, residents were encouraged to answer using both the Likert scale and dichoto- mous scale because it was assumed that the QOL of MDS 3.0 is in a development stage so it may be more accurate to measure QOL using both of the scales. If the Likert scale was too difficult for some residents, only the dichotomous scale was used (Anderson, Issel, & McDaniel, 2003). Ten of the 11 domains were determined by confirma- tory factor analysis (A =̂ 1,988; Kane et al., 2003). The internal consistency (Cronbach's alpha) was reported from 0.52 (meaningful activity) to 0.76 (functional competence; Kane, 2003). Validity was tested by regression of each domain scale with summary measures; all 11 items were matched with summary items (CMS, 2007). Consequendy, the constructs were correlated (CMS, 2007). Overall findings suggest that QOL in the MDS 3.0 has value in assessing QOL for residents in NHs.

) eContent Management Pty Ltd Volume 44, Issue 2, June 2013 135

Juh Hyun Shin

Procedure Approval was obtained from the Institutional Review Board of the University of Iowa. The sample was the residents of the selected NHs. A researcher first randomly seleaed every fifth resident, DON defined the availability of residents based on their cognitive impairment to answer the questionnaire until the goal of the sample size per facility (10 per NH) was reached. Cognitive impairment of par- ticipants in some facilities made it impossible to interview 10 residents. Cognitive impairment was measured by the responsiveness screen described by Simmons and Ouslander (2005). Previous research used inclusion criteria of women residents who had at least 13 points in the mini mental status exam. However, this study tried to offeet this limitation to include more residents by applying the less strict inclusion criterion responsiveness screen proposed by Simmons and Ouslander. The participants were asked to say their names when requested or to reli- ably recognize two common objects (Simmons & Ouslander). If a participant could not answer these questions, that subject was excluded.

Both long-stay and recently admitted residents were included. If participants were alert, the researchers obtained their consent and collected data direcdy. For participants who were cogni- tively impaired, consent forms were obtained from their legal representatives and resident assent was obtained. Exclusion criteria were: comatose residents; male residents; terminally ill residents; and those with severe cognitive (unable to pass the responsiveness screen) and functional impairments. Residents who were younger than 60 and all male residents were excluded because the QOL of younger people and male elders was assumed to be different from that of female N H residents (CMS, 2007). Of the 231 participants, 224 participants answered by using both Likert and dichotomous scale, while seven participants answered using only the dichotomous.

DATA ANALYSIS

Hierarchical linear models were developed and used for data analysis. To control acuity and comparative analyses, resident-level covariates were examined to control acuity (case mix). Resident case mix was controlled because sicker

residents are assumed to have poorer outcomes (Harrington, Woolhandler, Mullan, Carrillo, & Himmelstein, 2002). Case mix encompasses the comprehensive profile of patients including func- tional and health status and clinical situations in which the provided care or interventions are not effective (Berlowitz et al., 1999). MDS categorizes residents into AA different resource utilization groups (RUGS) (Wunderlich & Kohler, 2001). The AA RUGs are classified based on seven major categories including: rehabilitation; extensive spe- cial care; clinical complexity; cognitive impair- ment; behavioral problems; and physical function (Mueller, 2000). RUGS was used to control for residents' different functional status. The range of the case-mix index was from 0—1.52. The smaller number represented healthier residents. Very few variables were significant at/> < 0.05 and a/> < 0.1 was selected to assess significant factors related to staffing on QOL of N H residents.

Demographics of residents Facility bed sizes ranged from 44—120 (mean = 70, SD = 18.53). Most of the resident participants were women (72.7%), white (99.1%), widowed (67.1%), with a high school diploma (52.8%). The sample of residents is similar to national data in terms of age, gender, and marital status. Seventy- five percent of residents were women and the majority of them were widowed (Gabrel, 2000). Lack of racial diversity in Iowa means the sample was not representative of the population parameter in terms of race. The average age of participants was 85.11 years (SD = 8.4) and about 26.8% of residents had been diagnosed with dementia. The average length of stay in the current N H was 1 year 9 months (SD = 26.89 months), which was shorter than the national average (2 years 4 months). The average time required to complete the QOL inter- view per resident was 26.06 minutes (SD = 10.8; see Table 1).

Descriptive characteristics of nurse staffing The average number of total RNs, LPNs, and CNAs were: 7.7 (SD = 4.28); 4.95 (SD = 2.86); and 28.32 (SD = 8.53) respectively. The average number of full-time employee RNs per N H was 4.63 (SD = 2.43) and that of part-time RNs was

136 Volume 44, Issue 2, June 2013 © eContent Management Pty Ltd

Nursing staffing and quality of life in nursing homes

TABLE 1 : DEMOGRAPHIC CHARACTERISTICS OF 231

RESIDENTS OF 25 NHs IN SOUTHEAST loWA, 2 0 0 7

Demographics Mean ± SD (N = 231)

Age (years), mean ± SD

Time residing in current NH (months)

Minutes required to complete questionnaire (minutes) Gender

Female, n (%)

Male, n (%)

Ethnicity

Caucasian (%)

Non-Caucasian (%)

Martial status

Widowed

Married

Divorced

Single

Highest level of education

Less than high school

High school

More than high school/college

Dementia diagnosis

Demented residents

Total residents

85.11 ±8.4

22.75 ± 26.89

26.06 ±10.8

168

229

155

122

231

72.7

27.3

99.91

0.87

67.1

15.2

7.3

10.4

21.2

52.8

26.8

100

SD = Standard Deviation.

3.1 (SD = 3.0). The average number of full-time employee LPNs was 3.46 (SD = 2.14) and that of part-time LPNs was 1.47 (SD = 1.7). The average number of CNAs per N H was 18.74 (SD = 6.87) and that of part-time CNAs was 9.57 (SD = 5.18).

The majority of RNs had an Associate Degree in Nursing (68%), however, a few had completed graduate school (1%). The average age of the RNs was 46.23 years (SD = 12.4), with 4.5 years pro- fessional experience and $21.23 per hour wage. Likewise, the majority of LPNs had completed 1 year training at a hospital, vocational/technical school, or community college (55.4%). The aver- age age of an LPN was 41.88 years, and the aver- age professional experience earned was 2.5 years, with a mean hourly wage of $18.52. The major- ity of CNAs had earned high school diplomas (61.7%) with the average age of 31.05 years, the

average professional experience of 17 months, and the mean hourly wage of $11.04.

Nursing staif hours per resident day The HPRD of the DONs, RNs, LPNs/LVNs and CNAs (full-time employee stafT hours, part-time staff hours, and compiled nursing staff hours per resident day of full-time employee and part time) were explored. Compiled stafT hours refer to the addition of fiill-time employee staff hours and part-time staff hours.

Registered Nurses HPRD: The amount of part- time RN stafï hours had a statistically signifi- cant positive influence on the comfort (t = 2.7, p < 0.05) and enjoyment (t = 1.99, p < 0.05) domains of residents (see Table 2). This finding indicates that the greater amount of part-time RN staff hours impacts on the pain management, noise, good sleep quality, and temperature of the NHs. A reason for a higher score in the enjoy- ment domain with increased part-time RN staff hours could be attributed to the fact that they are more cautious about the assurance that residents can get their favorite food, and therefore try to protect the residents from weight loss.

Despite these findings, the compiled RN staff hours had a statistically significant negative influ- ence on meaningful activity (t = -1.67, /> < 0.1; outdoor activity, religious life, activity provided by the facility, and boredom) and relationships (making friends, welcoming environment for families, having enjoyable conversation with oth- ers; t = -1.76, p< 0.1; see Table 3), which means the scores of meaningful activity and relation- ships were lower when more RN staff hours were provided to the residents. None of the D O N variables had a statistically significant influence on any domain of QOL. It is assumed that the majority of D O N work is based in administra- tive work and it includes less direct contact with residents than other nursing staff.

Licensed practical nurse, licensed vocational nurse HPRD: There was a statistically significant negative relationship between the amount of part- time LPN hours and comfort domain (t = - 2 . 1 , /) < 0.1; see Table 2). In other words, residents were less satisfied with their funaional com- petence when more part-time LPN hours than

5 eContent Management Pty Ltd Volume 44, Issue 2, June 2013 Cjs( 137

Juh Hyun Shin

a z

o LU V )

o o

S y

o it u-

K u o z

z u. o UJ U Z tu

N Oí

üi _i E S O ™ |2 O Ä

•te CN o* LO CN ̂ ^ r*»» lo ro LO PO ro lo ro "O CN LO LO O^ CN ^^ ^í CO f^ ^í N̂ ^^ ^í CO oo CO ^^ ^í PO ^^ ^0 Ô ^^ 00 ^í ^í Ö ' - Ö ' — O « - Ö Ö O Ö o o O O O * — O O ' - ' — O

^^ ^0 00 00 ^^ ^^ ^^ 00 ^^ ^0 ^^ ^0 C^ Ô ^0 ^ í

' - O Ö Ö Ö Ö Ö O C D O O ^ ' Ö O Ö O Ö Ö ^ Ö Ö

O O ' O O l O ' — O ^ C N I O C N O O " ^ T *". ^ ^ ^ ^ * ' 9 ^ . ^ ^ Ö Ö Ö Ö Ö Ö Ö Ö Ö Ö Ö Ö Ó O O O t - O O O O

O s . Q s c o O ' r ^ o O ' O i o r ^ r * - ^ o o m i o i o c N i o r ^ o o * — r*»» cĵ 'O CN LO ro ^ ">o ^ O CN oo t ^ * ~ o** r^ oo ^5 PO O O

^ ^ O O ?̂ ^ O ?̂ Q *~ ^ ^̂ ^ ^ ^ ^ Ç ?̂ ^ ^̂ ?̂

^^ Ô ^í ^í ^í ^í Ô ^^ ^^ ^^ 0̂ ^^ Ô CO ^^ CO 00 Ô ^ C N O ' ~ r O ' ~ | C N ' ~ ' ~ l O ^ O C O ^ ^ ^ C N O C N I O C N ^

ö < - ^ t - ^ ö o r " ö ö ^ ö ? ^ ö ö ö ö o ö « - ' ^ ö

c o c o c M - o o ^ o o rv o o i n O C O O O C N ^ P O ^ C N t - N q p O < ) C N P O ^ ' O C N p q *". ^. P ' " . ' ^ ' T ^ ' ^ P ^ . '^ o ö ö ö ö o ö o o * - ^ <? d ö ö ö ^ ö ö ^ ö ö

» - C N ^ ^ r ^ p r ^ o q c o p o ^ P ^ ^ ' ^ ' ~ . P ' ^ Í ^ T ^ o o O o 3̂ o o o Ç ^ ?̂ ^^ ^ ^^ ?̂ ^~ ^ ^ ^ ^^ ^

00 r̂ CO r̂ 'O oo co lo co oo "«o ^ oo PO ^ ^ CN ^ ^ Ô • > o o r o o o * > p o ^ p o o r o O L O c Ñ i c N L o ^ O P O C s i r v O Ö ^ Ö Ö Ö Ö ' - ^ O ' - ' O Ö ' - ^ ' t - Ö Ö C D Ö ^ O Ö

í - ^ P O O O ^ O ^ ^ O ^ - O O O ' ^ P O r ^ r - O O P O l D C N ^ O P O CN r^ 00 PO ^ "O r^ LO O O** O ^ ^5 ^ ^ ^~ O ^ ^ ^5 PO

^ d d o d ö ö d d o 9 9 d d ^ ^ r ^ c D d d c j í

i o c O ' ~ « ~ ' ~ f o r ^ < ~ ~ ' O C N r ^ r ^ O ^ - L O » — L O ' ^ P O ^ I O O O

^ d o o ^ d d ^ ^ c á d - ^ . ^ d c á c á o d c á o

% O Í o o C N * r - v O r ^ c N ' ^ ^ o * ^ r ^ r o c o i r t ^ ^ i - , . « í ^ p ^ p o q o q r - ; °^. '^. ' N " ! ' ^ ' " ' ^ . ' ^ ' N P ' * ; d c v i d ' - ^ ' - ' c N d d d d ö ö d c á d r - ^ d c á ^ ' t - ' d

I I I I l i l i

gi Q. z

ti z z o: o:

G) "O

o. -B E = 8 ^

< = z 15 U U>

Z Z o: Q:

z o;

t (S Q.

Il 8 ¿

^ E ̂ i E

Z Z < ^ ^ z

| - | O

t E :i a Ö

i R R g R P

o u

11 t E O O

o o

.i Ig 0} O) «

•i-i* H- E o

l-t:-: E cno " =6 V <1> - o

i S2 *

il 8"?

m a l

-.p

So ,

lic en

se e

ifo rt

o u

M F ,

n o ve

r; C

O UJ

-b e i

itu a l w

e ll

p ir

u c o -.p <u c ra ~ >• a o •§•

- a 1 . <i>

VU y 3 _ _

m o a.2

i l

S"! i it - ^ .2

i tt S!

138 Volume 44, Issue 2, June 2013 ) eContent Management Pty Ltd

Nursing staffing and quality of life in nursing homes

u LU

o o O ù y o

o s o û-

o !í¡ u

o t < u.

z o

3 u.

m O)

« ~ c o r o o * c o c o ^ c N r ^ C M C N r ^ i n > O ' — O ^ C N C M I T ) cp o cp o o o o o ^ o

pN. t— —̂ *— i r > CN ^3 O^ T— ^3 Ö Ö ó Ö Ö

«-; cq p cq d d r̂ cji

^ p O ' - Ö Ö Ö Ö Ö Ö O cp CM o ^ CM

í pj § Í:;

O s i r ) i ^ c o c o - o i o i / i r ^ O O - C N ' - C O r O C O ^ C N

»- T - O c M O p O O " -

c o c N r o c o r ^ i ^ C N C O C O c N p c q ^ q ^ o p c ^ ; p p r o < Y d d c p d d d < - ' T - ^ . - ^

CO i n o CM

CM - O CM CM

co ^ iT) m o^ CM p «— ID *— p CN

CM T- ,- o

-q co

cp d

co 1^ CM CM

co co •o ro

T- , - o o o v- «- ^ T-

«- >O ro m -o

T— h.. ro cq p r.. <> " - • d d d t - d d t -

I I I

^ if) o co co

CM CM

,- co >o co ^ CM *O IDO O «- T- ,- O

CN 1^ ro (>

^ d

r^ 1^ co co »- ro >o ro o CN

CM o^ r ^ r o p CN, »- O; T-

d d d dO O C p O O O O C M

o- co CM m o- t^ ^oc o p t r q r o ^ Ö Öo o Q »- T- »- o

I 1 I I I

^ c o —̂ * o « ~ c o i D i o r ^ r ^ r ^ * ~ p o ^ p c q t — p ^ ^ — ^ r ^

d « - ^ d c D . - ^ c 3 d o d I

Q o;

« 3 O

it 'S (/>

E t; 8 Z

z z O

s ta

i z"

s ta

ff ¡l e d

:o m

Z )

S ta

fu ll-

z o

"î/î d) E 1

z (J

u -I-

ë E É f .= V -n —'

Z Z Q. Q.

(Ú T 3

V t

ro o "^ a u

< < z z u u <u " a

i 4 V Q. t; E

S. 8 ^ p p p p p p p p pK F I- (-

£ . ^ •

e q u iv

fu i

a d

!-• fu

II a a o"

m pl

<u E

l-t i

jn t;

fu i

ss i<

n> O) ç 3 C

rt i

M A,

U iu

n u rs

io n a l

o c a t

-0 S

, llc

e n "

<à C c

15 u

p ra

c ti

Ic e n s

—

0 .

iu c3 C

- • £V t!

R é g i

Q Í

O) c c (D (D

M A

> ;

p <

0 .

0. 0

a «

c T OlO

ri v a c y ;

R l,

Q .

nc e;

Ä a! a Q

n a l

o t3

, fu

í¿

m fo

n 8 a."

rn o v e r:

d a y;

" re

s id

a e o

it rot! c

= n u rs

h o u

a ff

I/î

1 U)

¡ty ;

S ai

d iv

Q Z

u ri ty

'., se

lij in

e in

g :

e ll-

b it u a l

w ip

t; S

c u

n jo

y m

E N

E o co% n

:A U

T ,

Q .

io n si

la t

5 eContent Management Pty Ltd Volume 44, Issue 2, June 2013 Cjsf 139

fijl-time employee LPN hours were provided. It is assumed that full-time employee LPNs provide better and more stable care with: room tempera- ture; pain management; noise; sleep quality; and position change than part-time LPNs because they spend more time with residents, understand the residents better and are present more consistendy.

Both full-time employee LPN staff hours and the compiled full-time employee (i = 1.94, / ) < 0.1) and compiled part-time LPN staff hours (i = 2.34, p < 0.05) had a statistically significant positive influence on the dignity domain (see Table 3). In other words, residents were more sat- isfied with the way they were treated in politeness, respect, modesty, and nurses listening to them when more LPN hours were provided.

In relation to certified nurse aids HPRD, the part-time CNA staff hours had a statistically sig- nificant positive impact on the functional compe- tence domain (i = 1.76, / ) < 0.1) for the residents (see Table 2). The more part-time CNA hours residents have, the more chances there are to report to the RNs; and part-time CNAs take care of position change, room temperature, and noise. The total CNA staff hours had a statistically sig- nificant positive impact on the security domain (i = 2.08,/)< 0.05) as well (see Table 3). In other words, as more CNAs hours were provided, resi- dents felt more security. This finding su^ests that CNAs care for the majority of residents' activities of daily living, so that the more a CNA has con- tact hours with the residents, the higher the scores for functional competence and security.

Skill mix Skill mix was examined to see if it was a predictor of QOL for N H residents. The ratio of more RNs to less LPNs/LVNs was found to have a statisti- cally significant negative influence on the auton- omy (i = -1.84, /) < 0.1) and spiritiaal well-being (i = - 1 J,p < 0.1) domains (see Table 2). However, the ratio of more RNs to less LPNs/LVNs and CNAs had a statistically significant positive influ- ence on the functional competence (i = 1.87, p < 0.1; see Table 2, t = 1.67, p < 0.1; see Table 3) domain and overall summary item of residents' QOL (i = 1.77,p < 0.1 ; see Table 2). In odier words, RNs had a positive effea on resident-funaioning

competence, but a negative effect on the autonomy and spiritual-well-being domains. This may be because CNAs rather than RNs help the residents go to bed, get up, and change clothes, activi- ties that may improve autonomy-domain scores. Furthermore, CNAs are more involved in trans- porting residents to religious services and therefore residents have more opportunity to attend religious services like church or mass. RNs are responsible for indirect care including notifying doctors, chart- ing, and administering medications. The important thing is that the contribution of RNs was supported in the summary of all 11 QOL domains. This find- ing indicates that the greater amount of RN HPRD impacts positively on general QOL.

Turnover The turnover rate of RNs, LPN/LVNs, and CNAs (full-time employee, part-time and compiled) was investigated.

Turnover of RNs: Contrary to the researchers' expectations, the turnover of full-time employee RNs (i = 1.78, ;>< 0.1; see Table 2; t = 1.99, p < 0.05; see Table 2) and the turnover of compiled RN (i = 2.27, p < 0.05; see Table 3) had a statisti- cally significant positive impact on the enjoyment domains. A reason for a higher score in the enjoy- ment domain with increased RN turnover could be attributed to the fact that newly hired nurses are more cautious about the assurance that resi- dents can get their favorite food, and therefore try to protect residents against weight loss more than staff who had worked at NHs longer.

Turnover of LPNs: The turnover of full-time employee LPNs also had a statistically significant positive impact on the privacy (t = 1.66,/) < 0.1 see Table 3) and relationship domains (i = 2.04, p < 0.05 see Table 3). A reason for the higher score in privacy and relationship domains with increased turnover could be attributed to the fact that newly hired LPNs are more cautious about their relationships with residents and therefore try to protea the residents' privacy more than staff who had worked at NHs longer.

The turnover of full-time employee LPNs {t = 1.66, /» < 0.1; see Table 2) and the turnover of the compiled fiill-time employee and part- time LPNs (i = 2.19, ;>< 0.05; see Table 3) had

Nursing staffing and quality of life in nursing homes

a statistically positive impact on the individuality- domain. It may he inferred that the higher score of the individuality domain with increased turnover of LPNs results is because newly hired LPNs are more eager to establish rapport and learn about the residents including: information about their previous lives; experiences; and preferences than staff who worked at NHs for a long time.

Turnover of CNAs: As expeaed, there was a statis- tically significant negative relationship between the compiled turnover of ftill-time employees and part- time CNAs and the security {t = -1.82, p < 0.1) and individuality domains {t = -2.05, p < 0.05; see Table 3). In other words, the stable staffing of CNAs was important for the security and individu- ality of the residents. As CNAs spend more time with residents than RNs/LPNs, this impacts the security of possessions, clothes, getting help includ- ing calling doctors or nurses whenever they need, and security from other residents. In contrast to the findings of a positive relationship between tiunover of LPNs and individuality, the decreased turnover of CNAs would contribute to the higher scores of individuality of residents, which means consistent CNAs interaa more with residents and have more opportunity to learn and about the residents' previ- ous lives, preferences, and experiences.

DISCUSSION

This is a preliminary study to investigate the rela- tionship between nursing staffing and QOL in NHs. The majority of the previous studies showed that increased nursing staff, stable nurse staffing, and less frequent turnover positively contribute to a variety of residents' outcomes in NHs. The major difference between this study and previous stud- ies is that previous research focused on Q O C and measured QOL by measuring residents' outcomes.

Consistent with previous studies, some staff- ing variables had influence in predicting some QOL domains. More RN staff hours were associ- ated with better comfort and enjoyment domains, more LPN staff hours were associated with better dignity, and more CNA staff hours were associated with better functional competence domains in this study. In terms of skill mix, the unique contribu- tion of more RNs (to less LPNs/LVNs or CNAs) was supported in the functional competence of

residents. However, surprising results were that: (a) as the staff hours of RNs increased, the scores of meaningñil activity and relationship decreased; and (b) the contribution of LPNs/LVNs (more LPNs and LVNs to less RNs) were supported in the autonomy and spiritual well-being domains. One possible explanation is that RNs are more concerned about health-related issues, such as pain management and weight gain, than on over- all well-being of residents such as activities and friendship. However, this finding is particularly significant for nurses and nursing educators in that the basic philosophy of nursing (holistic care including dignity, autonomy, and individuality) should be emphasized for nursing students and nurses. Nurses should be encouraged to keep those concepts in practice so that more residents in NHs in the future will enjoy their life in NHs with improved QOL. This will aid residents in receiving high professional-nursing services with the protection of dignity, individuality, auton- omy, and respect.

Interestingly, this study found that nursing staff turnover is positively correlated with some domains of QOL for some residents: (a) higher score in enjoyment domain with increased RN turnover; (b) higher score in privacy, relationship, and individuality domains with increased turn- over of LPNs. It may be inferred that newly hired nursing staff are more cautious about residents' well-being (food preferences, weight loss), and rapport with residents including curiosity about residents' past lives. As expected, only stable staffing of CNAs (decreased turnover of CNAs) showed support for the security and individual- ity of the residents. One of the most important staffing factors that can impact quality is nurs- ing staff turnover. Turnover may represent losing staff who do not perform well or do not like their work, therefore bringing some positive benefits to residents despite the interference with relation- ships and continuity of care. However, the cur- rent research regarding the impact of turnover on residents' outcomes in NHs is limited. There is no database or systematic collection of turnover on a state or national level. Future research regarding turnover of nursing staff, top managers including administrators and D O N is necessary.

) eContent Management Pty Ltd Volume 44, Issue 2, June 2013 Cj)f 141

Juh Hyun Shin

LlMITÄnONS OF THE STUDY AND IMPUCATIONS FOR

FUTURE RESEARCH

The first limitation is that the whole study takes place in one state, Iowa. Iowa has a very homogeneous poptiladon with limited racial diversity. The findings are not generalizable to the rest of the United States. However, this limitation controlled for confounding faaors present in different environments of sample NHs. The environment of the participating NHs was similar in state regulation, weather, social, cul- tural, neighborhood, and race faaors.

The researchers could not interview residents at the NHs that denied participation. It may be possi- ble that those residents could have worse QOL than the residents in NHs that participated because the NHs that refiised may have worse environments or fewer services for the residents. The average num- ber of health deficiencies in the NHs that refiised to participate in this study was higher (6.4/NH) than NHs that participated in this study (4.8/NH) according to the Nursing Home Compare Website (CMS, 2007). Furthermore, N H staff who agreed to participate may have more enthusiasm for qual- ity improvement, and therefore external validity would be affeaed (Bostick, 2002).

This is not an interventional study but rather an observational study. This study is limited to showing the association or relationships among variables. The impact of nursing staff on resi- dent outcomes may be mediated by other factors including geriatric education, staffing turnover, job satisfaction, experience of staff, and supervi- sion (Maas, Buckwalter, & Specht, 1996).

Several fiiaors may not accurately reveal the rela- tionships of nursing staff to resident outcomes. The method of measuring nurse staffing is very impor- tant. In this study, the STAFF HOURS, skill mix and turnover were chosen as structiual variables. The process of nurse staffing is assumed to be a very important faaor in residents' outcomes. Further research that investigates the effeaiveness of pro- cess is necessary to transform research into practice: What nursing staff actually do (process), how nurs- ing staff interaa with residents, the assignment of RNs to different residents, and the impact on the residents. However, while structure is an indirect measure of quality, structure may have a direct influence on the process and outcomes, and may be considered an important faaor that impacts N H

1 4 2 Cjs( Volume 44, Issue 2, June 2013

residents' outcomes (Campbell, Roland, & Buetow, 2000). The inability to measure the influence of structtire, as mediated by process, on outcome may not reliably reflect the contributions of nursing staff in this study. Thus, fiitiue studies should address the process of staffing, which includes the effective aspects of advanced nursing education (use of nurse practitioners or clinical nurse specialists), appropri- ate allocation of direct and indirect care, and the Q O C provided by staff (Evans, 2001).

This study did not differentiate between direa and indirea care, which may be a fector in fijlly revealing nursing influence on outœmes. The contributions of nursing staflFmiĝ it be supported if direa and indirea nursing care were differentiated. Future studies should investigate the concrete relationship between direa and indirea care and resident outcomes; the OSCAR should indude a mandatory reporting system of dif- ferentiated direa- and indirea-care hours. Future research should investigate how resident outcomes are achieved, including what nursing staff actually do; how nursing staff interaa with residents, family, and other staff, and how nursing staff spend their time between direa and indirea care. Thus, smdy- ing the impaa of ownership on resident outcomes is necessaiy. Further examination of the relationship between nurse staffing and QOL is imperative to œn- firm the relationship and provide policy guidelines, including nurse staffing recommendations, in order to guarantee the optimal QOL for N H residents.

This study tried to include some dementia resi- dents using the responsiveness screen by Simmons and Ouslander (2005). However, answers by resi- dents with dementia may not reflea what they exacdy feel or experience. Thus, more research to measure QOL for residents with dementia sub- jectively and objectively is necessary in the future.

ACKNOWLEDGEMENTS

This project was supported from Gamma Chapter, Sigma Theta Tau International. This research was revised based on the dissertation of Juh Hyun Shin. Especially, I wish to acknowledge Dr. Janet Specht for support in conduaing this study.

REFERENCES Akinci, E, & Krolikowski, D . (2005). Nurse staffing levels

and quality of care in Northeastern Pennsylvania nurs- ing homes./%)//W//arrí>z¿-/2effarc/í, 18, 130-137.

Nursing staffing and quality of life in nursing homes

Aller, L. J., & Van Ess Coeling, H. (1995). Quality of life: Its meaning to the long-term care resident. Journal of Gerontoloff cal Nursing 21 {2), 20-25.

Anderson, R. A., Issel, L. M., & McDaniel, R. R., Jr. (2003). Nursing homes as complex adaptive systems: Relationship between management practice and resi- dent outcomes. Nursing Research, 52, 12-21.

Berlowitz, D. R., Anderson, J. J., Brandeis, G. H., Lehner, L. A., Brand, H. K., Ash, A. S., & Moskowitz, M. A. (1999). Pressure ulcer development in the VA: Characteristics of ntirsing homes providing best care. American foumal of Medical Quality, 14, 39—44.

Bostick, J. E. (2002). The relationship of nursing personnel and nursing home care quality (Unpublished doctoral dissertation). University of Missouri, Columbia, MO.

Campbell, S. M., Roland, M., & Buetow, S. (2000). Defining quality of care. Social Science Medicine, 51, 1611-1625.

Carrier, N., West, G. E., & Ouellet, D. (2009). Dining experience, foodservices and staffing are associated with quality of life in elderly nursing home resi- dents, foumal of Nutrition Health and Aging, 13{6), 565-570.

Centers for Medicare and Medicaid Services. (2006). 2006Nursing home compare. Retrieved from http:// vvfww.medicare.gov/NHCompare/Static/Related/ DatacoUection.asp?

Centers for Medicare and Medicaid Services. (2007). 2007 Quality of life, volume I. Retrieved from http:// www.cms.hhs.gov/NursingHomeQuali tyInits/05_ NHQIHighlishts.asp#TopOfPage

Centers for Medicare and Medicaid Services. (2012). Minimum Data Set 3.0fbr Nursing Homes. Retrieved from http://www.cms.hhs.gov/NtirsingHomeQtialityInits/ Downloads/MDS302010ImplementationTimeline.pdf

Dellefield, M. E. (2000). The relationship between nurse staffing in nursing homes and quality indicators. Journal of Gerontological Nursing, 26{G), 14-28.

Drageset, J., Eide, G. E., Nygaard, H. A., Bondevik, M., Nortvedt, M. W., ôc Natvig, G. K. (2009). The impact of social support and sense of coherence on health-related quality of life among nursing home residents-A questionnaire survey in Bergen, Norway. International Journal of Nursing Studies, 46{i), 65-75.

Duxbury, M. L , & Armstrong, G. D. (1982). Calctilating nurse turnover indices. Journal of Nursing Administration, 12(3), 18-24.

Evans, J. M. (2001). Staffing ratios in nursing fecilities: Where do we stsnH Journal of American Medical Directors Association, 2, 94-95.

Gabrel, C. S. (2000). Characteristics of elderly nursing home current residents and discharges: Data fiom die 1997 National Nursing Home Survey. Advance Data, 312,1-15.

Guse, L. W, & Masesar, M. A. (1999). Quality of life and successful aging in long-term care: Perceptions of resi- dents. Issues in Mental Health Nursing 20{6), 527-539.

Harrington, C , Woolhandler, S., Mullan, J., Carrillo, H., & Himmelstein, D. U. (2002). Does investor-ownership of ntirsing homes compromise the qtjality of care? International Journal of Health Services, 32, 315-325.

Harrington, C , Zimmerman, D., Karon, S. L, Robinson, J., & Beutel, P (2000). Nursing home staffing and its rela- tionship to deficiencies./»«rwiî/r ofGerontobgy, Series B Psychobgical Sciences and Social Sciences, 55, S278-S287.

Hicks, L. L., Rantz, M. J., Petroski, G. E, & Mukamel, D. B. (2004). Nursing home costs and quality of care outcomes. Nursing Economics, 22, 178-192, 175.

Kane, R. A. (2003). Definition, measurement, and correlates of quality of life in nursing homes: Toward a reasonable practice, research, and policy agenda. Gerontologist, 43, S28-S36.

Kane, R. A., Kling, K. C , Bershadsky, B., Kane, R. L , Giles, K., Degenholtz, H. B., ... Cutler L. J. (2003). Quality of life measures for nursing home residents. Joumak of Gerontology Series A: Biolo^cal Sciences and Medical Sciences, 58, 240-248.

Liddle, J., & McKenna, K. (2000). Quality of life: An overview of issues for use in occupational therapy outcome measurement. Australian Occupational Therapy Journal, 47, 77-85.

Maas, M., Buckwalter, K., & Specht, J. (1996). Nursing staff and qtiaÜty of care in ntusing homes. In G. S. Wtinderlich, E Sloan, & C. Davis (Eds.), Nursingstaffin hospitals and nursing homes: Is it adequate? (pp. 361—425). Washington, DC: Institute of Medicine, National Academy Press.

Mueller, C. (2000). The RUG-III case mix classifica- tion system for long-term care nursing facilities: Is it adequate for nurse st^ng^ Journal of Nursing Administration, 30, 535-543.

Simmons, S. E, & Ouslander, J. G. (2005). Resident and iamily satisfaction with incontinence and mobility care Sensitivity to intervention effects? Gerontologst, 45,318-326.

Straker, J. K. (1999). Reliability of OSCAR occupancy, cen- sus and staffi data: A comparison with the Ohio depart- ment of health annual survey of long-term care facilities (Tech. Rep. No. 3). Oxford, OH: Miami University, Scripps Gerontology Center.

Tesh, A. S., McNutt, K., Courts, N. E, & Barba, B. E. (2002). Charaaeristics of ntu-sing homes adopt- ing environmental transformations./owrwíí/o/" Gerontological Nursing, 28(,3), 28-34.

Wunderlich, G. S., & Kohler, P O. (Eds.). (2001). Improving the quality of long-term care. Washington, DC: Institute of Medicine, National Academy Press.

Received 01 February 2012 Accepted 04 October 2012

Copyright of Contemporary Nurse: A Journal for the Australian Nursing Profession is the property of eContent Management Pty. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.