Health Care Administration and Organization

Collection of articles on Health Care Administration and Organization is available here.

Aged care staff perceptions of an online training program for responsive behaviours of residents with dementia.
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Almutairi H, Stafford A, Etherton-Beer C, Flicker L, Saunders R.
Australasian journal on ageing. 2022 Jun;41(2):e112–21.
OBJECTIVE: To explore residential aged care staff perceptions of an online training program on the management of antipsychotic medications for responsive behaviour in residential aged care. METHODS: A qualitative process evaluation was undertaken in four residential aged care facilities of one organisation in Australia. Five focus group interviews were conducted with 25 participants including nurses, care workers, occupational therapists and assistants. RESULTS: Direct care staff found that the training program increased their awareness and knowledge of responsive behaviours associated with dementia. Inductive thematic analysis identified three themes: (1) impact of online learning for dementia care; (2) applying online learning in dementia practice; and (3) realising the benefits and challenges of online learning. CONCLUSIONS: From the perspective of the participants, the online training program had a positive effect on their knowledge, communication and practice of caring for residents with dementia with responsive behaviours.

The Advanced Practice Registered Nurse Leadership Role in Nursing Homes: Leading Efforts Toward High Quality and Safe Care.
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Bakerjian D.
The Nursing clinics of North America. 2022 Jun;57(2):245–58.
This article highlights the critical role of advanced practice registered nurses in the care of older adults living in nursing homes. This population is one of the frailest, marginalized, and often neglected in the United States. The COVID-19 pandemic impact on nursing homes resulted in a stunning number of infections and subsequent resident deaths. This is a shameful reminder of the many challenges and gaps in the nursing home industry including inadequate staffing, high staff turnover, improper isolation technique, and lack of fundamental knowledge of how to adequately implement infection prevention and control processes. Strong advanced practice registered nurse leadership may have mitigated some of these factors.

Age-Friendly Nursing Homes: Opportunity for Nurses to Lead.
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Bonner A, Fulmer T, Pelton L, Renton M.
The Nursing clinics of North America. 2022 Jun;57(2):191–206.
Age-Friendly Health Systems is a movement to ensure that all care and support for and with older adults across all settings is age-friendly care. Age-Friendly Health Systems provide staff, leadership, and care partner education based on the 4M Framework (What Matters, Medications, Mentation, Mobility). Nursing homes and other settings are often left out of local, state, or federal strategic plans on aging. In addition, limited quality and quantity of nursing home staff impact new program implementation. We consider how programs and services to support older adults can create and sustain an Age-Friendly Ecosystem, including a meaningful role for nursing homes.

Geropsychiatric Nursing Leadership in Long-Term Care.
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Cacchione PZ, Spurlock W, Richards K, Harris M.
The Nursing clinics of North America. 2022 Jun;57(2):233–44.
Geropsychiatric nursing (GPN) leaders in long-term care settings have a 25-year tradition of innovation that has strikingly improved mental health and quality of life for older adult residents. The impact of the Coronavirus disease of 2019 (COVID-19) on the mental health of older adult residents and today’s evolving health care systems requires additional GPN leaders well-prepared to advocate, plan, and deliver care for this vulnerable population. In this article, the authors discuss GPN leadership in the context of its history, the role of professional organizations, and educational competencies. A leadership exemplar is provided as well as recommendations for clinical practice and research.

The resilience of nursing staffs in nursing homes: concept development applying a hybrid model.
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Chang SO, Kim EY.
BMC nursing. 2022 May;21(1):129.
BACKGROUND: The resilience of nursing home (NH) nursing staff is emphasized to improve the quality of care provided, but the concept has not been clearly defined. By composing such a definition through concept development, a basis for active research in the future can be established. AIM: To identify the definition and conceptual characteristics of the concept of resilience of NH nursing staffs. METHOD: In this study, the concept was developed using Schwartz-Barcott and Kim’s hybrid model, which included theoretical, fieldwork, and final analysis stages. In the theoretical stage, a literature review on the definition and measurement of concepts was performed. For the fieldwork stage, 22 interviews were conducted with 7 participants, and a content analysis was performed. During the final analysis stage, the results of the theoretical and field work stages were integrated. RESULTS: Three dimensions, eight attributes, and three types were identified. The three dimensions are internal resources, external support, and positive coping with situations as they arise; the eight attributes are optimism, patience, mindfulness, supportive relationships, available resources, work-life boundary setting, self-development, and growth; and the three types are those who want to adapt themselves to the situation, those who actively seek to cope with stressful situations, and those who hold positive expectations for the future. CONCLUSION: Coping with difficult situations using internal resources and external support was a unique trait revealed in the resilience of NH nursing staff members. This study provided future research directions to improve the resilience of NH nursing staffs by revealing the characteristics of their resilience.

Antecedents of unfinished nursing care: a systematic review of the literature.
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Chiappinotto S, Papastavrou E, Efstathiou G, Andreou P, Stemmer R, Ströhm C, et al.
BMC nursing. 2022 Jun;21(1):137.
BACKGROUND: Unfinished Nursing Care (UNC) concept, that express the condition when nurses are forced to delay or omit required nursing care, has been largely investigated as tasks left undone, missed care, and implicit rationing of nursing care. However, no summary of the available evidence regarding UNC antecedents has been published. The aim of this study is to identify and summarise antecedents of UNC as documented in primary studies to date. METHODS: A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. MEDLINE, CINAHL, SCOPUS, and PROSPERO databases were searched for quantitative studies reporting the relationships between antecedents and UNC published after 2004 up to 21 January 2020. The reference lists of secondary studies have been scrutinised to identify additional studies. Two reviewers independently identified studies and evaluated them for their eligibility and disagreements were resolved by the research team. The quality appraisal was based on the Joanna Briggs Institute Critical Appraisal tools, according to the study designs. A data extraction grid was piloted and then used to extract data. The antecedents that emerged were thematically categorised with an inductive approach. RESULTS: Fifty-eight studies were included; among them, 54 were cross-sectional, three were cohort studies, and one was a quasi-experimental study. They were conducted mainly in the United States and in hospital settings. The UNC antecedents have been investigated to date at the (a) unit (e.g., workloads, non-nursing tasks), (b) nurse (e.g., age, gender), and (c) patient levels (clinical instability). CONCLUSIONS: At the unit level, it is highly recommended to provide an adequate staff level, strategies to deal with unpredictable workloads, and to promote good practice environments to reduce or minimise UNC. By contrast, at the nurse and patient levels, there were no clear trends regarding modifiable factors that could decrease the occurrence of UNC. The map of antecedents that emerged can be used to design interventional studies aimed at changing research from merely descriptive to that which evaluates the effectiveness of interventions.

Physician Practice in Ontario Nursing Homes: Defining Physician Commitment.
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Correia RH, Dash D, Poss JW, Moser A, Katz PR, Costa AP.
Journal of the American Medical Directors Association. 2022 May;
OBJECTIVES: To characterize the practice profile of nursing home (NH) physicians in Ontario, Canada. DESIGN: Population-based cross-sectional study. SETTING AND PARTICIPANTS: A total of 1527 most responsible physicians (MRPs) across 626 NHs in Ontario, Canada, for the calendar year, 2017. METHODS: We examined physician services within all publicly regulated and funded NH facilities. Descriptive summaries were generated to characterize MRPs and their practice patterns by the physician’s primary practice location, the NH facility size, and the proportion of physician billings that occurred within NHs. Community sizes were classified into quintiles based on population size and assigned as urban or rural. The number of ministry-designated NH beds were assessed by quintiles to examine physician services by facility size. We also assessed the proportion of physician billings within NHs by quintiles. RESULTS: MRPs tended to be older, male, and practice family medicine. The majority of MRPs practiced in communities with populations exceeding 100,000 residents, although physicians with greater NH billings tended to practice in rural locations. The mean number of NH residents that a physician was MRP for was positively associated with the community size. Physicians provided care for more NH residents than they were assigned most responsible. Fifty-one percent of physicians were MRP for 90% of all NH residents. CONCLUSIONS AND IMPLICATIONS: Our work provides an exemplar for characterizing physician commitment in NHs, using 2 approaches, according to the NH specialist model. We demonstrated the medical practice characteristics, locations, and billing patterns of physicians within Ontario NHs. Future work can investigate the association between physician commitment and the quality of care provided to NH residents. A greater understanding of physician commitment may lead to the development of quality metrics based on physician practice patterns.

Are Australians willing to pay more tax to support wage increases for aged care workers? Findings from a national survey.
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Crocker M, Milte R, Duff G, Lawless M, Corlis M, Ratcliffe J.
Australasian journal on ageing. 2022 May;
OBJECTIVE: To explore the perceptions of the Australian public regarding Australia’s aged care workforce, including their willingness to pay more tax to fund better pay and conditions for aged care workers. METHODS: An online survey was developed and administered to a representative sample of Australian adults (aged ≥18 years) by age group, gender and Australian state. Survey respondents completed a series of attitudinal statements to elicit their perceptions of the value of Australia’s aged care workforce and were asked to indicate their willingness to pay additional tax to fund better pay and conditions for aged care workers. Those who gave a positive response were then asked to indicate what percentage of additional tax per year they would be willing to pay to ensure better pay and conditions for aged care workers. RESULTS: A total of 2033 adult respondents completed the survey. A majority (78%) of respondents either ‘agreed’ or ‘strongly agreed’ that aged care workers should be paid more. Approximately half of the respondents (50.57%) expressed a willingness to pay more tax to ensure better pay and conditions for aged care workers. The mean willingness to pay was 1.31% additional tax overall, and mean percentage additional tax values were relatively consistent across key socio-demographic indicators. CONCLUSIONS: A majority of the Australian public are in favour of improving the wages and employment conditions of aged care workers. However, only one in two Australians is willing to pay more tax to ensure better pay and conditions for aged care workers.

Using Voice and Touchscreen Controlled Smart Speakers to Protect Vulnerable Clients in Long-Term Care Facilities.
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Davitt JK, Brown J.
Innovation in aging. 2022;6(4):igac024.
BACKGROUND AND OBJECTIVES: The Centers for Medicare and Medicaid Services restricted long-term care facility visitation to only essential personnel during the coronavirus disease 2019 pandemic. The Maryland Department of Human Services distributed Amazon Echoshow 8 voice and touchscreen controlled smart speakers (VTCSS) to a sample of their institutionalized guardianship clients to enhance caseworker access during the pandemic. RESEARCH DESIGN AND METHODS: This pilot study focused on understanding VTCSS use challenges and the effects on clients’ safety and well-being. Two focus groups were conducted with caseworkers (N = 16) who piloted the devices. The interviews were recorded, transcribed, and analyzed using open and axial coding. RESULTS: Four themes were identified, including challenges to providing casework during the pandemic (e.g., facility technology gaps), challenges to device installation and use (e.g., privacy concerns), strategies for overcoming challenges (e.g., alert features), and benefits (e.g., stimulation, care monitoring) and uses (e.g., enhanced access, entertainment). DISCUSSION AND IMPLICATIONS: VTCSS show great promise to engage the client, maintain visual access, and monitor quality of care. However, facilitating access to such technology requires planning and training before installation.

A qualitative study of senior management perspectives on the leadership skills required in regional and rural Australian residential aged care facilities.
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Dawes N, Topp SM.
BMC health services research. 2022 May;22(1):667.
BACKGROUND: With increasing recognition of the quality and safety issues in residential aged care, there is an urgent need to better understand what skills senior managers require to deliver on the spectrum of leadership functions in residential aged care facilities. This qualitative study sought to explore the leadership skills that positively influence the quality of care within Australian residential aged care facilities and better understand the professional development needs of senior managers to positively influence care within these complex environments. METHODS: We conducted semi-structured interviews with 19 senior managers purposively recruited from 14 high-performing non-government residential aged care facilities of varying geographical remoteness in northern Queensland, Australia. Participants held a range of professional roles, including Chief Executive Officer, Director of Nursing and Facility Manager, and had various professional qualifications. We used inductive thematic analysis to identify and categorise senior managers’ perspectives on the leadership skills and related strategies to promote quality of care. RESULTS: Senior managers reported leadership skills in five major domains: i) communication and relationship management, ii) stewardship, iii) professional development, iv) health care knowledge and v) information technology and finance. Most participants highlighted communication and relationship management skills and responding to regulatory change as influential to residential aged care quality performance. Participants with different professional backgrounds often emphasised different skills. CONCLUSIONS: Participants identified a broad range of skills and strategies required by senior managers in Australian residential aged care facilities. Identifying different skills by differently trained individuals suggests more work is needed to understand and develop sector-specific professional development approaches to better prepare individuals to lead in this complex service environment.

The Making of Nurse Leaders in the Nursing Home.
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Harris M, Kolanowski A, Greenberg S.
The Nursing clinics of North America. 2022 Jun;57(2):171–8.
Nurse leaders are first and foremost, registered nurses. Nursing leadership is critical for improving the care and quality of life for older adults. Visionary nurse leaders collaborate, motivate, influence, and inspire the achievement of values and goals to improve the quality of life for older adults in long-term care. Professional registered nurses are transformational servant nurse leaders who hold the key to nursing home reform.

Ownership Change and Care Quality: Lessons From Minnesota’s Experience With Value-Based Purchasing.
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Hass Z, Abrahamson K, Arling G.
Innovation in aging. 2022;6(4):igac022.
BACKGROUND AND OBJECTIVES: Minnesota’s implementation of a new nursing home value-based reimbursement (VBR) system in 2016 presented an opportunity to compare the response of nursing homes (NHs) to financial incentives to improve their quality and efficiency. The state substantially increased reimbursement for care-related costs and tied this rate increase to a composite quality score. Coinciding with rate increases of the new VBR system was an increase in ownership changes, with new owners being primarily for-profit entities from outside of Minnesota, including several private equity firms. Our objective was to examine NHs that underwent a change in ownership to determine their cost and quality response to the change. RESEARCH DESIGN AND METHODS: Our sample consists of 342 Minnesota NHs that submitted Medicaid cost reports each year from 2013 to 2019. A time differential two-way fixed-effects difference-in-difference model is used to assess changes in quality metrics by comparing measures in years prior to and years following the sale for NHs that changed ownership versus NHs with consistent ownership. Nursing home characteristics, revenue, and spending patterns are examined to understand differences in performance. RESULTS: Those NHs with ownership change experienced a decline in quality scores with notable changes to expenditure patterns. They performed worse on Minnesota Department of Health inspection scores and had nonsignificant declines in measures of quality of life and clinical care. They had declining staff dental and medical benefits and occupancy rates, greater revenue growth from Medicare Part B, and larger increases in administrative management fees. DISCUSSION AND IMPLICATIONS: Minnesota like many other states has given wide latitude for nursing home ownership changes, without specific oversight for the quality of care and expenditure patterns of new owners. Recommendations include strict guidelines for the transparency of ownership structures, quality performance targets, rigorous financial auditing, and enhanced regulatory oversight.

Paying for the view? How nursing home prices affect certified staffing ratios.
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Heger D, Herr A, Mensen A.
Health economics. 2022 May;
Many countries limit public and private reimbursement for nursing care costs for social or financial reasons. Still, quality varies across nursing homes. We explore the causal link between case-mix adjusted nurse staffing ratios as an indicator of care quality and different price components in Swiss nursing homes. The Swiss reimbursement system limits and subsidizes the care price at the cantonal level, which implicitly limits staffing ratios, while the residents cover the nursing home-specific lodging price privately. To estimate causal effects, we exploit (i) the exogeneity of the Swiss care price regulation, (ii) nursing-home fixed effects estimations and (iii) instrumental variables for the lodging price. Our estimates show a positive impact of prices on certified staffing ratios. We find that a 10% increase in care prices increases certified staffing ratios by 3-4%. A comparable 10% increase in lodging prices raises certified staffing ratios by 1.5-10% (depending on the model). Our findings highlight that price limits for nursing care impose a limit on staffing ratios. Furthermore, our results indicate that providers circumvent price limits by increasing lodging prices that are privately covered. Thus, this cost shifting implicitly shifts the financial burden to the residents.

Technological risks and ethical implications of using robots in long-term care.
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Hung L, Mann J, Perry J, Berndt A, Wong J.
Journal of rehabilitation and assistive technologies engineering. 2022;9:20556683221106916.
INTRODUCTION: The pandemic provides a unique opportunity to examine new directions in innovative technological approaches in long-term care (LTC) homes. While robotics could enhance staff capacity to provide care, there are potential technology risks and ethical concerns involved in technology use among older people residing in communal aged care homes. This qualitative descriptive study explores the technological risks and ethical issues associated with the adoption of robots in the specific context of LTC homes. METHODS: The research team including patient and family partners employed purposive and snowballing methods to recruit 30 LTC participants: frontline interdisciplinary staff, operational leaders, residents and family members, and ethics experts in dementia care. Semi-structured interviews were conducted. Thematic analysis was performed to identify themes that capture empirical experiences and perspectives of a diverse group of LTC stakeholders about robotic use. RESULTS: Technological risks include safety, increased workload, privacy, cost and social justice, and human connection. The findings offer practical insights based on the LTC perspective to contribute to the robot ethics literature. We propose a list of pragmatic recommendations, focusing on six principles (ETHICS): Engagement of stakeholders, Technology benefit and risk assessment, Harm mitigation, Individual autonomy, Cultural safety and justice, Support of privacy. CONCLUSIONS: There is both a growing interest as well as fear in using robotics in LTC. Practice leaders need to reflect on ethical considerations and engage relevant stakeholders in making technology decisions for everyday care.

Promoting good care of older people in institutions
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López J,; Pérez-Rojo G. (editors)
Madrid: Dykinson; 2022. Available from:
This book offers a complete, up-to-date and in-depth view of the aspects involved in good care of old adults living in institutions. It results from the I International Congress on Good Treatment of the Elderly in Institutions held in June 2021. This is not only a manual that describes and provides data on what mistreatment and good care are in the institutionalized care, furthermore, it allows the reader to find a new framework for understanding, evaluation, and intervention of the older adults in Institutions. Mistreatment has been associated with beating or visible wounds, but most times mistreatment is something more subtle, even invisible, and requires a special vision to be able to detect it. The COVID-19 health crisis has decisively affected to the old adult population living in institutions, the different chapters of this book put an effort into promoting a way of doing things differently, centering the care in the old people´s dignity, emotions, and their cognitive, social, and spiritual world. Authors from different disciplines and countries have participated: psychologists, doctors, anthropologists…, offering to the reader ways of action toward awareness, evaluation, prevention, and intervention for a good care in the Institutions.

Nursing Leadership and Palliative Care in Long-Term Care for Residents with Advanced Dementia.
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Lopez RP, Kris AE, Rossmassler SC.
The Nursing clinics of North America. 2022 Jun;57(2):259–71.
Alzheimer disease and related dementias (ADRD) are irreversible, progressive brain disorders. Many people with ADRD experience the final stage of the disease, advanced dementia, in nursing homes (NHs). Although palliative care, including symptom management and emotional support for caregivers, is advocated for those with advanced dementia, many NH residents experience potentially burdensome interventions, such as feeding tubes, hospital transfers, and intensive rehabilitation. Nurses play a critical role in ensuring high-quality palliative care to residents with advanced dementia. The aim of this article is to raise awareness of the palliative care needs of NH residents with advanced dementia.

Technology Acceptance and Usability of a Mobile App to Support the Workflow of Health Care Aides Who Provide Services to Older Adults: Pilot Mixed Methods Study.
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Miguel Cruz A, Lopez Portillo HP, Daum C, Rutledge E, King S, Liu L.
JMIR aging. 2022 May;5(2):e37521.
BACKGROUND: Health care aides are unlicensed support personnel who provide direct care, personal assistance, and support to people with health conditions. The shortage of health care aides has been attributed to recruitment challenges, high turnover, an aging population, the COVID-19 pandemic, and low retention rates. Mobile apps are among the many information communication technologies that are paving the way for eHealth solutions to help address this workforce shortage by enhancing the workflow of health care aides. In collaboration with Clinisys EMR Inc, we developed a mobile app (Mobile Smart Care System [mSCS]) to support the workflow of health care aides who provide services to older adult residents of a long-term care facility. OBJECTIVE: The purpose of this study was to investigate the technology acceptance and usability of a mobile app in a real-world environment, while it is used by health care aides who provide services to older adults. METHODS: This pilot study used a mixed methods design: sequential mixed methods (QUANTITATIVE, qualitative). Our study included a pre- and post-paper-based questionnaire with no control group (QUAN). Toward the end of the study, 2 focus groups were conducted with a subsample of health care aides (qual, qualitative description design). Technology acceptance and usability questionnaires used a 5-point Likert scale ranging from disagree (1) to agree (5). The items included in the questionnaires were validated in earlier research as having high levels of internal consistency for the Unified Theory of Acceptance and Use of Technology constructs. A total of 60 health care aides who provided services to older adults as part of their routine caseloads used the mobile app for 1 month. Comparisons of the Unified Theory of Acceptance and Use of Technology constructs’ summative scores at pretest and posttest were calculated using a paired t test (2-tailed). We used the partial least squares structural regression model to determine the factors influencing mobile app acceptance and usability for health care aides. The α level of significance for all tests was set at P≤.05 (2-tailed). RESULTS: We found that acceptance of the mSCS was high among health care aides, performance expectancy construct was the strongest predictor of intention to use the mSCS, intention to use the mSCS predicted usage behavior. The qualitative data support the quantitative findings and showed health care aides’ strong belief that the mSCS was useful, portable, and reliable, although there were still opportunities for improvement, especially with regard to the mSCS user interface. CONCLUSIONS: Overall, these results support the assertion that mSCS technology acceptance and usability are high among health care aides. In other words, health care aides perceived that the mSCS assisted them in addressing their workflow issues.

Multidimensional Aspects of Nurse Staffing in Nursing Homes.
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Mueller C.
The Nursing clinics of North America. 2022 Jun;57(2):179–89.
Nurse staffing involves determining, allocating, and delivering nursing resources and care to residents in order to achieve the desired and required quality of care and life for residents. A comprehensive evidence-based framework for nurse staffing in nursing homes is presented to be considered beyond the number of nurse staff and consequently the nurse staffing strategies needed to address care quality in nursing homes.

Factors associated with satisfaction and depressed mood among nursing home workers during the covid-19 pandemic.
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Navarro-Prados AB, García-Tizón SJ, Meléndez JC, López J.
Journal of clinical nursing. 2022 Jun.
AIMS AND OBJECTIVES: This paper aims to examine the satisfaction and depressed mood experienced by nursing home workers during the COVID-19 pandemic and associated variables. Specifically, to analyse the factors that may contribute to nursing home workers developing adaptive behaviours that promote satisfaction or, on the contrary, show characteristics associated with a negative mood. BACKGROUND: Nursing homes have faced unprecedented pressures to provide appropriately skills to meet the demands of the coronavirus outbreak. DESIGN: A cross-sectional survey design using the STROBE checklist. METHODS: Professionals working in nursing homes (n = 165) completed an online survey measuring sociodemographic and professional characteristics, burnout, resilience, experiential avoidance, satisfaction with life and depression. Data were collected online from April to July 2021, the time in which Spain was experiencing its fifth wave of COVID-19. Two multiple linear regression models were performed to identify salient variables associated with depressive mood and satisfaction. RESULTS: Resilience, personal accomplishment and satisfaction had a significant and negative relationship with depression and emotional exhaustion, depersonalisation and experiential avoidance had a positive relationship with depression. However, emotional exhaustion, depersonalisation and experiential avoidance had a negative and significant relationship with satisfaction and personal accomplishment, and resilience had a positive and significant relationship with satisfaction. In addition, it was found that accepting thoughts and emotions when they occur is beneficial for developing positive outcomes such as satisfaction. CONCLUSIONS: Experiential avoidance was an important predictor of the effects that the COVID-19 pandemic can have on nursing home workers. RELEVANCE TO CLINICAL PRACTICE: Interventions focusing on resources that represent personal strengths, such as acceptance, resilience and personal accomplishment, should be developed. NO PATIENT OR PUBLIC CONTRIBUTION: The complex and unpredictable circumstances of COVID’s strict confinement in the nursing home prohibited access to the centres for external personnel and family members. Contact with the professionals involved could not be made in person but exclusively through online systems. However, professionals related to the work environment have subsequently valued this research positively as it analyses ‘How they felt during this complicated process’.

Connecting Through Conversation: A Novel Video-Feedback Intervention to Enhance Long-Term Care Aides’ Person-Centred Dementia Communication.
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O’Rourke DJ, Lobchuk MM, Thompson GN, Lengyel C.
Gerontology & geriatric medicine. 2022;8:23337214221101264.
OBJECTIVE: To pilot test a novel communication intervention incorporating a video-feedback component on the person-centred dementia communication skills of long-term care aides. METHODS: Effectiveness was assessed using a single group pre-test/post-test design. 11 care aide-resident dyads participated in the study. Objective outcomes included provider statements demonstrating linguistic (i.e., reciprocity, clarity/coherence, and continuity categories) and relational elements of person-centred dementia communication, measured via video-recorded observations of usual care interactions. Subjective outcomes of care aide communication confidence/competence, satisfaction with the resident relationship, relationship closeness, and self-reflection at work were measured using self-report questionnaires. RESULTS: In respect to observed person-centred dementia communication skills, there was an increase in the use of linguistic statements in the reciprocity and continuity categories, as well as total linguistic statements overall. Relational statements and overall person-centred dementia communication (i.e., linguistic plus relational strategies) increased. Care aide-reported communication confidence and competence, relationship closeness with the resident, and self-reflection at work also increased after the communication intervention. DISCUSSION: The communication intervention showed promise as an effective approach to enhance person-centred dementia communication behaviours in care aides. These results support undertaking a larger trial to examine the intervention’s effectiveness more fulsomely.

”We usually choose safety over freedom”: results from focus groups with professional caregivers in long-term dementia care.
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Portegijs S, van Beek APA, van Tuyl LHD, Wagner C.
BMC health services research. 2022 May;22(1):677.
BACKGROUND: People with dementia living in nursing homes are mostly sedentary, which is a consequence of various personal, environmental and organizational factors. Until now, studies on physical activity and safety in dementia have focused on residents and caregivers from the viewpoint of (individual) care provision and health benefits. There has been little to no focus on the possible influence of group dynamics between care providers with regard to physical activity and safety. The aim of this study is to gain more insight into the viewpoints and intentions of groups of professional caregivers towards safety and physical activity and the potential influence of the group-oriented setting in long-term care on physical activity of individual residents. METHODS: A qualitative study comprising three focus group discussions including professional caregivers (n = 15) was conducted within two long-term care organizations in the Netherlands. Focus group discussions were structured using an interview guide derived from a preliminary framework, based on existing literature and complemented with clinical expertise. RESULTS: Seven themes could be derived from the focus group discussions that influence physical activity and safety: 1) Individual health and abilities; 2) Balancing physical activity and safety; 3) Physical restraints; 4) Group interests versus the individual interests; 5) Organization of care and physical environment; 6) Perceived responsibilities and tasks of professional caregivers and 7) Change is challenging. CONCLUSIONS: Due to multiple influencing factors, the balance for care providers in long-term care generally tends towards safety over physical activity. Furthermore, in order to stimulate physical activity various limitations are experienced, including the organization of care, the general health of the residents and difficulty to achieve changes in daily care. Most importantly, the group interests of both the professional caregivers and the residents have a substantial influence on the incorporation of physical activity in daily care.

Explaining spatial accessibility to high-quality nursing home care in the US using machine learning.
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Reddy BP, O’Neill S, O’Neill C.
Spatial and spatio-temporal epidemiology. 2022 Jun;41:100503.
In this study we measure and map the system-wide spatial accessibility to good quality nursing home care for all counties in the contiguous United States, and use an ‘imputed post-lasso’ machine learning technique to systematically examine this accessibility measure’s associations with a broad range of county-level socio-demographic variables. Both steps were carried out using publicly available datasets. Analyses found clear evidence of spatial patterning in accessibility, particularly by population density, state and the populations of specific racial minorities. This has implications for outcomes that extend beyond the care homes and we highlight a number of policy measures that may help to address these shortcomings. The ‘out-of-sample’ predictive performance of the machine learning approach highlights the method’s usefulness in identifying systematic differences in accessibility to services.

Nursing Home, Ward and Worker Level Determinants of Perceived Quantitative Work Demands: A Multi-Level Cross-Sectional Analysis in Eldercare.
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Stevens ML, Karstad K, Januario LB, Mathiassen SE, Rugulies R, Hallman DM, et al.
Annals of work exposures and health. 2022 Jun.
INTRODUCTION: Perceived quantitative demands at work have been associated with poor mental and physical health, long-term sickness absence and subsequent early retirement. Identifying modifiable determinants of perceived quantitative demands at different levels of the organization is key to developing effective interventions. The aim of the study was to identify determinants of perceived quantitative demands at work and examine the extent to which they occur at different levels of the eldercare organisation (i.e. the worker, ward and nursing home levels). METHODS: We collected data on 383 eldercare workers in 95 wards at 20 nursing homes in Denmark using workplace observations and questionnaires to workers and their managers. Perceived quantitative work demands were assessed using two items from the Copenhagen Psychosocial Questionnaire, II. We identified contributions to overall variability from the three organisational levels using variance components analysis, and examined associations between determinants at these three levels and quantitative demands. RESULTS: Almost all (90.9%) the variability in perceived quantitative demands occurred between eldercare workers (within wards). Determinants significantly associated with lower quantitative demands were: having a job as a care helper, working fixed evening shifts, being born outside Denmark, having lower influence at work, higher quality of leadership and lower emotional demands. None of the investigated physical factors (e.g. resident handlings, push/pull tasks, step-count) were associated with perceived quantitative demands. CONCLUSION: We found that the variability in perceived quantitative demands occurred primarily between eldercare workers within wards. Our study indicates that psychosocial work environment factors are the strongest modifiable determinants of perceived quantitative demands in eldercare, while organisational factors related to job position, shift, and resident-staff ratio also play a role. Interventions should test if changes in these determinants can reduce perceived quantitative demands at work in eldercare.

Understanding person-centered dementia care from the perspectives of frontline staff: Challenges, opportunities, and implications for countries with limited long-term care resources.
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Wang J, Bian X, Wang J.
Geriatric nursing (New York, NY). 2022 May;46:39–45.
Semi-skilled or unskilled nursing care aides primarily provide direct care to residents in long-term care (LTC) facilities in China and many other countries around the world. There has been a significantly increased commitment from nurses and other formally trained professionals to provide person-centered care (PCC) for people with dementia (PwD). However, it is still unclear how nursing care aides who provide direct care to older residents with dementia understand and adopt PCC in their daily work. It is of utmost importance to understand person-centered dementia care from the perspectives of care aides, and to identify implications to facilitate and sustain their efforts in providing quality care for older residents with dementia. We found that the seemingly beneficial mental models used by care aides in their work can hinder them from playing a more adaptive role in tailoring their care to the needs of older residents. Infantilizing older residents with dementia and labeling them using mother wit can prevent meaningful, equal, and person-centered conversations between both parties. Care aides do not have regular formal interactions and sensemaking with nurses and other professionals in nursing homes. Increasing interactions and communication between care aides and health care professionals in nursing homes can lead to insight for changing the approach to in-service training to achieve better acceptance by care aides. The current study derives implications for operationalizing and embedding the principles of PCC in daily care.

Key Care Provision Aspects That Affect Care Transition in the Long-Term Care Systems: Preliminary Review Findings.
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Wieczorek E, Kocot E, Evers S, Sowada C, Pavlova M.
International journal of environmental research and public health. 2022 May;19(11).
The aim of this brief report is to present the protocol and preliminary findings of a systematic review on key aspects of care provision that affect care transition of older adults 60+ within the long-term care systems. This brief report describes and classifies the relevant literature found in the review with the purpose to provide a base for further full systematic reviews, and to outlines a model of organizational and financing aspects that affect care transition. Our search was conducted in MEDLINE, Embase and CINAHL on 2 March 2020, before the COVID-19 pandemic. The protocol was registered at the International Prospective Register of Systematic Reviews (number: CRD42020162566). Ultimately, 229 full-text records were found eligible for further deliberation. We observed an increase in the number of publications on organizational and financial aspects of care transition since 2005. Majority of publications came from the United States, United Kingdom and Australia. In total, 213 (92%) publications discussed organizational aspects and only 16 (8%) publications were related to financial aspects. Records on organizational aspects were grouped into the following themes: communication among involved professional groups, coordination of resources, transfer of information and care responsibility of the patient, training and education of staff, e-health, education and involvement of the patient and family, social care, and opinion of patients. Publications on financial aspects were grouped into provider payment mechanisms, incentives and penalties. Overall, our search pointed out various care provision aspects being studied in the literature, which can be explored in detail in subsequent full systematic reviews focused on given aspects. We also present a model based on our preliminary findings, which enables us to better understand what kind of provision aspects affect care transition. This model can be tested and validated in subsequent research. Understating factors that affect care transition is crucial to improve the quality of transitions and ultimately the outcomes for the patients.

Hospitals serving nursing home residents disproportionately penalized under hospital readmissions reduction program.
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Ye Z, Temkin-Greener H, Mukamel DB, Li Y, Dumyati GK, Intrator O.
Journal of the American Geriatrics Society. 2022 Jun.
BACKGROUND: Risk factors common to nursing home (NH) residents are potentially not fully captured by the Hospital Readmissions Reduction Program (HRRP). The unique challenges faced by hospitals that disproportionately serve NH residents who are at greater risk of readmissions have not been studied. METHODS: Using 100% Medicare Provider Analysis and Review File and the Minimum Data Set from 2010-2013, we constructed a measure of hospital share of NH-originating hospitalizations (NOHs). We defined hospital share of NOHs as the proportion of inpatient stays by patients aged 65 or older who were directly admitted from NHs. To evaluate the impact of the share of NOHs on readmission penalties, we categorized hospitals into quartiles according to their share of NOHs and estimated the differences in the adjusted penalties across hospital quartiles after accounting for hospital characteristics, market characteristics and state fixed effects. We repeated the analyses for the penalties incurred in each year between 2015 and 2019. RESULTS: Hospitals varied substantially in the share of NOHs (median [interquartile range], 11.3% [8.2%-15.1%]), with limited variation over time. In 2015, hospitals in the highest quartile of NOH received on average 0.58% Medicare payment reduction compared to 0.44% reduction among those in the lowest quartile (32.9% higher penalties, p < 0.001). The increase in penalties continued to grow in 2017 and 2018 when the HRRP expanded to include additional target conditions (47.3% and 66.7%, respectively, p < 0.001 for both). Although the effect diminished in 2019 following the additional adjustment for hospital’s dual-eligible share, hospitals in the highest quartile of NOH still incurred 43.0% (p < 0.001) higher penalties than those in the lowest quartile. CONCLUSIONS: Hospitals varied considerably in their share of NOHs. Hospitals having a higher share of NOHs were disproportionately penalized for excess readmissions, even under the revised policy that adjusts for the share of dual-eligible admissions.

An Online Mindfulness-based Intervention for Certified Nursing Assistants in Long-term Care.
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Young CC, Kesler S, Walker VG, Johnson A, Harrison TC.
Journal of holistic nursing : official journal of the American Holistic Nurses’ Association. 2022 Jun;8980101221105709.
Purpose: Certified nursing assistants (CNAs) make up the largest segment of the long-term care (LTC) setting workforce, however, they are at high risk of job dissatisfaction and burnout. Evidence suggests that mindfulness-based interventions (MBIs) might be particularly relevant and useful for CNAs in reducing psychological distress, improving job satisfaction, and reducing burnout, but little research has investigated this possibility. A feasibility study of an online MBI for CNAs in LTC settings was therefore conducted. Methods: CNAs completed assessments at baseline and posttest. Paired t-tests assessed changes in mindfulness, psychological distress (i.e., depressive and anxiety symptoms, and stress), and professional quality of life. Results: Of the 19 CNAs who started the intervention, N = 13 (68%) completed it and provided postintervention data. Depressive symptoms were significantly decreased postintervention (F = 6.26, p = .036, d = .47). Conclusions: MBIs may have beneficial effects for CNAs in LTC settings. Further research with a larger CNA population will increase the power and relevance of these findings, ultimately contributing to the improvement of patient outcomes in LTC.