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Assisted living (AL) residences are residential long-term care settings that provide housing, 24-hour oversight, personal care services, health-related services, or a combination of these on an as-needed basis. Most residents require some assistance with activities of daily living and instrumental activities of daily living, such as medication management. A resident plan of care (ie, service agreement) is developed to address the health and psychosocial needs of the resident. The amount and type of care provided, and the individual who provides that care, vary on the basis of state regulations and what services are provided within the facility. Some states require that an RN hold a leadership position to oversee medication management and other aspects of care within the facility. A licensed practical nurse/licensed vocational nurse can supervise the day-to-day direct care within the facility. The majority of direct care in AL settings is provided by direct care workers (DCWs), including certified nursing assistants or unlicensed providers. The scope of practice of a DCW varies by state and the legal structure within that state. In some states, the DCW is exempt from the nurse practice act, and in some states, the DCW may practice within a specific scope such as being a medication aide. In most states, however, the DCW scope of practice is conscribed, in part, by the delegation of responsibilities (such as medication administration) by a supervising RN. The issue of RN delegation has become the subject of ongoing discussion for AL residents, facilities, and regulators and for the nursing profession. The purpose of this article is to review delegation in AL and to provide recommendations for future practice and research in this area. [ABSTRACT FROM AUTHOR]

The complexity of care in nursing homes has steadily increased during the past several years. Many nursing homes now provide care for both short-stay and long-stay patients who range in age from young to very old. At the same time, there has been a shortage of primary care physicians to provide care while nursing homes have been under intense scrutiny and pressure to improve the quality of care provided. Advanced practice nurses (APNs) are increasingly evident members of the nursing home workforce, providing both primary care to individual residents in collaboration with physicians and consultative services to nursing homes. This article reviews the research that documents the relationship between APNs and improved quality of care and begins a discussion of what constitutes APN best practices in the nursing home setting. [ABSTRACT FROM AUTHOR]

The System-transforming, Patient centered Longitudinal Interprofessional Community-based Education (SPLICE) Initiative was a Health Resources and Services Administration (HRSA) funded project designed to educate and train health professions learners in team-based primary care within a clinical environment. The SPLICE project team developed multiple learning activities including case studies and simulations that integrated the IPEC Core Competencies within clinical scenarios. The interprofessional aspects were also modeled by faculty facilitators from different professions. Each activity was thoroughly evaluated by the learners using mixed methods processes including data from retrospective pretest-posttest self-assessments, open-ended surveys, and focus groups. Faculty, staff, and learners invested countless hours of volunteer time due to the enthusiasm and passion for the work supported with HRSA funding to implement and evaluate the SPLICE initiative. Outcomes include the development of an enhanced primary care simulation template; the creation of 21 unique primary care simulations that integrated the IPEC competencies; improved confidence and competence in over 700 learners; over 110 faculty trained in simulation and debriefing skills; clinical skills training for Federally Qualified Health Center (FQHC) staff; improved quality improvement processes at a local FQHC; and a high rate of retention of the graduates in primary care. This project demonstrated a significant return on the investment beyond the initial HRSA funding., Competing Interests: The author declares no conflict of interest., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Background: An understanding of nurse well-being remains elusive, particularly in the current toxic health care environment. Therefore, a conceptual definition of nurse well-being is needed., Purpose: The purpose of this paper is to report results of a concept analysis of nurse well-being., Methods: Rodgers' Evolutionary Method of concept analysis was used to examine the attributes, antecedents, consequences, and related concepts of nurse well-being., Findings: Findings revealed varying levels of nurse well-being: individual, organizational and community. Individual attributes included happiness, satisfaction, optimism, compassion, gratitude, forgiveness, and sound body/spirit. Organizational/community attributes included teamwork, sense of mission, pride in work, and social integration. Antecedents reflected commonalities with Maslow's hierarchy of needs, ranging from basic human needs to self-actualization. Consequences included resilience, collegial relationships, continued growth and development, empowerment, purposeful work, and physical/mental health., Discussion: Standardized definitions of individual and organizational/community nurse well-being should guide future research and policy development. Organizations must build capacity for nurses' well-being and explore its connection to patient safety and quality outcomes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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., Competing Interests: Disclosure The author has nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Much progress has been made in advance care planning (ACP), especially related to end of life and palliative care. These advances have moved thinking about ACP from a checklist approach to an upstream recognition that ACP is an iterative process that should begin early in adulthood and be revisited with each milestone or life-changing event. It is recognized that there are many stages and milestones in adult life that contribute to changing loci of responsibility and life goals. These changes impact how individuals view their lives, the complexity of health care, and the myriad of health conditions they may encounter. ACP discussions should routinely be started and reexamined at the time of key life events like starting a career or a marriage and not delayed until hospitalization, the occurrence of a serious accident, or the development of a catastrophic illness., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Context : To identify VA and non-VA Emergency Department (ED) and hospital utilization by veterans with spinal cord injury and disorders (SCI/D) in California. Design: Retrospective cohort study. Setting : VA and Office of Statewide Health Planning and Development (OSHPD) in California. Participants : Total 300 veterans admitted to the study VA SCI/D Center for initial rehabilitations from 01/01/1999 through 08/17/2014. Interventions : N/A. Outcome Measures : Individual-level ED visits and hospitalizations during the first-year post-rehabilitation. Results: Among 145 veterans for whom ED visit data available, 168 ED visits were identified: 94 (55.2%) at non-VA EDs and 74 (44.8%) at the VA ED, with a mean of 1.16 (±2.21) ED visit/person. Seventy-seven (53.1%) veterans did not visit any ED. Of 68 (46.9%) veterans with ≥ one ED visit, 20 (29.4%) visited the VA ED only, 34 (50.0%) visited non-VA EDs only, and 14 (20.6%) visited both VA and non-VA EDs. Among 212 Veterans for whom hospitalization data were available, 247 hospitalizations were identified: 82 (33.2%) non-VA hospitalizations and 165 (66.8%) VA hospitalization with a mean of 1.17 (±1.62) hospitalizations/person. One hundred-seven (50.5%) veterans had no hospitalizations. Of 105 veterans with ≥ one hospitalization, 58 (55.2%) were hospitalized at the study VA hospital, 15 (14.3%) at a non-VA hospital, and 32 (30.5%) at both VA and non-VA hospitals. Conclusion: Non-VA ED and hospital usage among veterans with SCI/D occurred frequently. The acquisition of non-VA healthcare data managed by state agencies is vital to accurately and comprehensively evaluate needs and utilization rates among veteran populations.

The COVID-19 pandemic caused unparalleled morbidity and mortality across the globe. Health care agencies, public health departments, and academic institutions experienced widespread disruption to usual operations. These events had an adverse impact on the nursing workforce. Nurse leaders in California rallied to identify and remediate the effects of COVID-19 on the nursing workforce. This article describes the strategy and interventions. Nurse leaders should invest resources in state workforce centers to ensure the health and supply of a strong nursing workforce., (2021 by Elsevier Inc. All rights reserved.)

COVID-19 has exposed the longstanding internal problems in nursing homes and the weak structures and policies that are meant to protect residents. The Centers for Medicare and Medicaid Services convened the Coronavirus Commission for Safety and Quality in NHs in April, 2020 to address this situation by recommending steps to improve infection prevention and control, safety procedures, and the quality of life of residents in nursing homes. The authors of this paper respond to the Final Report of the Commission and put forth additional recommendations to federal policymakers for meaningful nursing home reform: 1) ensuring 24/7 registered nurse (RN) coverage and adequate compensation to maintain total staffing levels that are based on residents' care needs; 2) ensuring RNs have geriatric nursing and leadership competencies; 3) increasing efforts to recruit and retain the NH workforce, particularly RNs; and 4) supporting care delivery models that strengthen the role of the RN for quality resident-centered care., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: In fiscal year 2019, approximately $78 million was spent on veteran medical care alone apart from other civilian costs. Some veterans state their health care providers do not understand the military culture, which makes them uncomfortable seeking care in the private sector., Method: A nonexperimental cross-sectional study was conducted using a convenience sample of 127 RNs who completed an electronic survey of the Military Culture Certificate Program., Results: The total overall mean on the Knowledge and Awareness subscale was 4.38 of 6, representing a modest level of military knowledge. The Confidence in Skills and Abilities subscale also scored at a modest level, with an overall mean of 81.3 of 100. Although the nurses demonstrated modest knowledge levels of military culture and confidence skills, there were low scores in veteran referral to the appropriate resources., Conclusion: It is essential to educate nurses regarding how and where to refer veterans to the appropriate resources. Further studies should expand on this work. [ J Contin Educ Nurs . 2021;52(4):176-183.] .

Editor's note: This article is by 22 nursing gerontology experts who are all advocates of nursing home reform. They are listed at the end of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

In the United States, 1.4 million nursing home residents have been severely impacted by the COVID-19 pandemic with at least 25,923 resident and 449 staff deaths reported from the virus by June 1, 2020. The majority of residents have chronic illnesses and conditions and are vulnerable to infections and many share rooms and have congregate meals. There was evidence of inadequate registered nurse (RN) staffing levels and infection control procedures in many nursing homes prior to the outbreak of the virus. The aim of this study was to examine the relationship of nurse staffing in California nursing homes and compare homes with and without COVID-19 residents. Study data were from both the California and Los Angeles Departments of Public Health and as well as news organizations on nursing homes reporting COVID-19 infections between March and May 4, 2020. Results indicate that nursing homes with total RN staffing levels under the recommended minimum standard (0.75 hours per resident day) had a two times greater probability of having COVID-19 resident infections. Nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds had a higher probability of having COVID-19 residents. Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID-19 infections. Establishing minimum staffing standards at the federal and state levels could prevent this in the future.

Objectives: To study the effects of a nonpharmacologic intervention, Music and Memory (M&M), on residents with dementia and/or behavioral problems living in nursing homes (NHs)., Design: This was a prospective, mixed-methods cohort study., Setting and Participants: In total, 4107 residents in 265 California NHs and that reported data at least twice during the 3-year study period were enrolled., Measures: We used a quarterly rolling enrollment process; participants provided data at baseline and quarterly via an online survey that included select resident level data from the Minimum Data Set (psychotropic drug use, cognition, behaviors, mood, pain, and falls), experience with the M&M program, and resident use of music. NHs were eligible if they were Medicare- and Medicaid-certified and had 15 residents with a diagnosis of dementia or cognitive impairment or exhibited significant behavioral symptoms., Results: M&M was associated with reductions in psychotropic medication use, reduced behaviors, and improved mood. The odds of antipsychotic use declined by about 11%, of antianxiety medications by 17%, and antidepressants by 9% per quarter. Aggressive behaviors, depressive symptoms, pain, and falls also declined significantly over time. The odds of residents exhibiting aggressive behaviors declined by 20% per quarter, depressive symptoms by 16%, reported pain by 17%, and falls by 8%., Conclusions and Implications: This is the largest study of M&M to date. We found clinically and statistically significant reductions in psychotropic medications and improved behaviors in residents using M&M. Although the study showed positive results overall, the lack of a control group was a significant limitation that precluded determining how much more improvement participating residents experienced compared with nonparticipants. Future studies should include a control group so that better conclusions can be drawn regarding the effectiveness of the M&M program., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

US nursing homes are required to have sufficient nursing staff with the appropriate competencies to assure resident safety and attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident. Minimum nurse staffing levels have been identified in research studies and recommended by experts. Beyond the minimum levels, nursing homes must take into account the resident acuity to assure they have adequate staffing levels to meet the needs of residents. This paper presents a guide for determining whether a nursing home has adequate and appropriate nurse staffing. We propose five basic steps to: (1) determine the collective resident acuity and care needs, (2) determine the actual nurse staffing levels, (3) identify appropriate nurse staffing levels to meet residents care needs, (4) examine evidence regarding the adequacy of staffing, and (5) identify gaps between the actual staffing and the appropriate nursing staffing levels based on resident acuity. Data sources and specific methodologies are analyzed, compared, and recommended. The goal is to assist nursing home nurses and administrators to ensure adequate nursing home staffing levels that protect resident health, safety, and well-being., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Background and Objectives: This article describes nursing home (NH) leaders' involvement in quality improvement (QI) decisions, with an emphasis on the concept of alignment in QI decisions across leaders., Research Design and Methods: We used a qualitative approach and semistructured interviews to collect data from a convenience sample of 39 NH leaders, including corporate/executive-level leaders and facility-level leaders. Thematic analysis was used to inductively capture key patterns in data., Results: Variations in alignment emerged as a major theme to describe the interface and interaction among facility- and corporate/executive-level leaders around QI decision making and implementation of QI decisions. For this study, alignment refers to the extent of shared understanding, beliefs, motivations, and implied or explicit agreement among leaders in regards to: (a) goals, values, priorities, and expectations for quality or QI (and/or applicable resources); and (b) expectations for leaders to carry out QI decisions made by other leaders., Discussion and Implications: This study offers new insights into the complexities associated with leadership alignment toward improving NH quality. The findings provide a glimpse into leaders' involvement in QI based on their position on the facility's organizational chart and extend our understanding of the centrality of the concept of alignment in promoting QI. These findings may inform future research on facility- and corporate/executive-level leader interactions and how these interactions impact quality outcomes.

Nursing homes use team nursing, with minimal RN presence, leaving the majority of direct care to licensed practical/vocational nurses (LPNs/LVNs) and unlicensed assistive personnel (UAP), including medication aides. The current article describes challenges faced by nursing home directors of nursing (DONs) leading and managing a team nursing approach, including consideration of scope of practice, delegation and supervision regulations, and related policy implications. A secondary data analysis was performed of qualitative data from a study to develop and test DON guidelines for delegation in nursing home practice. A convenience sample (N = 29) of current or previous DONs and other nursing home leaders with knowledge and expertise in the DON role participated in in-depth, guided interviews. The findings highlight a core concern to nursing licensure policy and regulation: knowledge and practice gaps related to scope of practice and delegation and supervision among DONs, RNs, and LPNs/LVNs, as well as administrators, and the role of nursing leaders in supporting appropriate delegation practices. The findings offer directions for research and practice in addressing challenges in aligning team nursing practices with regulatory standards as well as the related gaps in knowledge among DONs, administrators, and nursing staff. [Journal of Gerontological Nursing, 44(6), 10-14.]., (Copyright 2018, SLACK Incorporated.)

Background: Nursing home (NH) quality improvement (QI) is challenging. The critical role of NH leaders in successful QI is well established; however, current options for assessing the QI capabilities of leaders such as the licensed NH administrator are limited., Purpose: This article presents the development and preliminary validation of an instrument to measure NH administrator self-efficacy in QI., Methodology/approach: We used a mixed-methods cross-sectional design to develop and test the measure. For item generation, 39 NH leaders participated in qualitative interviews. Item reduction and content validity were established with a sample of eight subject matter experts. A random sample of 211 administrators from NHs with the lowest and highest Centers for Medicare and Medicaid Services Five-Star Quality ratings completed the measure. We conducted exploratory and confirmatory factor analyses and tested the measure for internal reliability and convergent, discriminant, and known group validity., Findings: The final measure included five subscales and 32 items. Confirmatory factor analysis reaffirmed the factorial structure with good fit indices. The new measure's subscales correlated with valid measures of self-efficacy and locus of control, supporting the measure's convergent and discriminant validity. Significant differences in most of the subscales were found between the objective (Centers for Medicare and Medicaid Services Five-Star Quality rating) and subjective (Self-Rated Facility QI Index) quality outcomes, supporting the measure's known group validity., Practice Implications: The instrument has usefulness to both NH organizations and individual NH administrators as a diagnostic tool to identify administrators with higher/lower chances of successfully implementing QI. Organizations and individuals can use this diagnostic to identify the administrator's professional development needs for QI, in general, and specific to the instrument's five subscales, informing directions for in-house training, mentoring, and outside professional development. Attending to NH administrators' QI professional development needs prior to implementing QI holds promise to enhance the chances for successful implementation of QI, which is urgently needed in many NHs.

Background: Ineffective assessment and management of pain is a significant problem. A gap in prelicensure health science program pain content has been identified for the improvement of pain care in the United States., Method: Through consensus processes, an expert panel of nurses, who participated in the interdisciplinary development of core competencies in pain management for prelicensure health professional education, developed recommendations to address the gap in nursing curricula., Results: Challenges and incentives for implementation of pain competencies in nursing education are discussed, and specific recommendations for how to incorporate the competencies into entry-level nursing curricula are provided., Conclusion: Embedding pain management core competencies into prelicensure nursing education is crucial to ensure that nurses have the essential knowledge and skills to effectively manage pain and to serve as a foundation on which clinical practice skills can be later honed. [J Nurs Educ. 2015;54(6):317-327.]., (Copyright 2015, SLACK Incorporated.)

Pain in older adults is a prevalent problem that affects quality of life and challenges nurses, particularly those caring for older adults living in long term care settings. Despite the national priority of pain management, insufficient knowledge of nurses about geriatric pain is a documented barrier to effective geriatric pain management in all long term care settings. To address this knowledge gap, a website (GeriatricPain.org) was developed by the National Geriatric Pain Collaborative with a grant from the MayDay Fund to provide a single site for evidenced-based, easy-to-use, downloadable resources on pain management. This paper describes the development of the most recent addition to the website, a set of evidence-based core geriatric pain management competencies and a geriatric pain knowledge assessment, and discusses their potential uses in improving pain care for older adults., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Nursing was not a part of the coalition of multiple nursing home stakeholders at the roll out of the Advancing Excellence Campaign (AEC). In January 2007, several nurse organizations proactively approached the AEC leadership, were welcomed and immediately began to volunteer for leadership positions such as committee chairs and conference coordinators. This paper presents an exemplar of how a proactive stance, even when not initially included, allowed nurses to secure chairs at the decision making table of this quality campaign and contribute to improved resident outcomes., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The benefits of interprofessional education (IPE) amongst health professionals are well documented, however, the implementation of interprofessional initiatives across the USA is inconsistent. This report describes the development and content of a number of IPE initiatives that are in the early stages of development and implementation at the University of California, Davis, USA. The article describes several important factors that were found to be necessary for the initial implementation of these IPE initiatives. Evaluation data from these initiatives, which is providing a range of positive outcomes, are also presented and discussed in relation to the wider IPE literature.

Looking forward to the Quality Assurance Performance Improvement (QAPI) program to be implemented and required in 2014, and as nursing home staff provide care for residents with increasingly complex health issues, knowledge of how to implement quality improvement (QI) is imperative. The nursing home administrator and director of nursing (DON) provide overall leadership, but it is the primary responsibility of the DON and other registered nurse staff to implement and manage the day to day QI process. This article describes potential roles of nursing leaders and key components of a QI project using a pressure ulcer case study exemplar to illustrate a quality improvement process. The authors suggest specific methods that RN leaders can employ using the Advancing Excellence Campaign Circle of Success as an organizing framework along with evidence-based resources. Nursing home leaders could use this article as a guideline for implementing any clinical quality improvement process., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: The objective of this project was to develop core competencies in pain assessment and management for prelicensure health professional education. Such core pain competencies common to all prelicensure health professionals have not been previously reported., Methods: An interprofessional executive committee led a consensus-building process to develop the core competencies. An in-depth literature review was conducted followed by engagement of an interprofessional Competency Advisory Committee to critique competencies through an iterative process. A 2-day summit was held so that consensus could be reached., Results: The consensus-derived competencies were categorized within four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management. These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models. A set of values and guiding principles are embedded within each domain., Conclusions: These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of learning activities across health professions designed to advance care that effectively responds to pain., (Wiley Periodicals, Inc.)

The purpose of this research was to examine factors associated with the use of advanced practice nurse and physician assistant (APN/PA) visits to nursing home (NH) patients compared with those by primary care physicians (PCPs). This was a secondary analysis using Medicare claims data. General estimation equations were used to determine the odds of NH residents receiving APN/PA visits. Ordinary least squares analyses were used to examine factors associated with these visits. A total of 5,436 APN/PAs provided care to 27% of 129,812 residents and were responsible for 16% of the 1.1 million Medicare NH fee-for-service visits in 2004. APN/PAs made an average of 33 visits annually compared with PCPs (21 visits). Neuropsychiatric and acute diagnoses and patients with a long-stay status were associated with more APN/PA visits. APN/PAs provide a substantial amount of care, but regional variations occur, and Medicare regulations constrain the ability of APN/PAs to substitute for physician visits., (Copyright 2012, SLACK Incorporated.)

The lack of a systematic and comprehensive pain management program is a common quality problem in nursing homes. The purpose of this article is to address the business case for effective pain management in this setting, including the conceptual domains and processes that should be considered in improving quality and reducing costs. Unfortunately, the literature contains very little to inform those working to implement effective and efficient pain management programs in nursing homes. This article suggests several strategies for establishing an internal business case to support the implementation of a comprehensive pain management program in a nursing home setting., (Copyright 2012, SLACK Incorporated.)

Purpose: Advancing Excellence (AE) is a coalition-based campaign concerned with how society cares for its elderly and disabled citizens. The purpose of this project was to work with a small group of volunteer nursing homes and with local quality improvement networks called LANEs (Local Area Networks for Excellence) in 6 states in a learning collaborative. The purpose of the collaborative was to determine effective ways for LANEs to address and mitigate perceived barriers to nursing home data entry in the national Advancing Excellence campaign and to test methods by which local quality improvement networks could support nursing homes as they enter data on the AE Web site., Design and Methods: A semistructured telephone survey of nursing homes was conducted in 6 states. Participants included LANEs from California, Georgia, Massachusetts, Michigan, Oklahoma, and Washington. Facility characteristics were obtained from a series of questions during the telephone interview. Three states (GA, MA, OK) piloted a new spreadsheet and process for entering data on staff turnover, and 3 states (CA, MI, WA) piloted a new spreadsheet and process for entering data on consistent assignment., Results: Many of the nursing homes we contacted had not entered data for organizational goals on the national Web site, but all were able to do so with telephone assistance from the LANE. Eighty-five percent of nursing homes said they would be able to collect information on advance directives if tools (eg, spreadsheets) were provided. Over 40% of nursing homes, including for-profit homes, were willing to have staff and residents/families enter satisfaction data directly on an independent Web site. Nursing homes were able to convey concerns and questions about the process of goal entry, and offer suggestions to the LANEs during semistructured telephone interviews. The 6 LANEs discussed nursing home responses on their regularly scheduled calls, and useful strategies were shared across states. Nursing homes reported that they are using Advancing Excellence target setting and goal entry to improve care, and that they would use new tools such as those for measuring satisfaction, consistent assignment, and advance directives., Implications: Having LANE members contact nursing homes directly by telephone engaged the nursing homes in providing valuable feedback on new Advancing Excellence goals and data entry. It also provided an opportunity to clarify issues related to the campaign and ongoing quality improvement efforts, including culture change., (Published by Elsevier Inc.)