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Purpose: This study introduces the first National Nursing Assistant Survey (NNAS), a major advance in the data available about certified nursing assistants (CNAs) and a rich resource for evidence-based policy, practice, and applied research initiatives. We highlight potential uses of this new survey using select population estimates as examples of how the NNAS can be used to inform new policy directions. Design and Methods: The NNAS is a nationally representative survey of 3,017 CNAs working in nursing homes, who were interviewed by phone in 2004-2005. Key survey components are recruitment; education; training and licensure; job history; family life; management and supervision; client relations; organizational commitment and job satisfaction; workplace environment; work-related injuries; and demographics. Results: One in three CNAs received some kind of means-tested public assistance. More than half of CNAs incurred at least 1 work-related injury within the past year and almost one quarter were unable to work for at least 1 day due to the injury. Forty-two percent of uninsured CNAs cite not participating in their employer-sponsored insurance plan because they could not afford the plan. Years of experience do not translate into higher wages; CNAs with 10 or more years of experience averaged just $2/hr more than aides who started working in the field less than 1 year ago. Implications: This survey can be used to understand CNA workforce issues and challenges and to plan for sustainable solutions to stabilize this workforce. The NNAS can be linked to other existing data sets to examine more comprehensive and complex relationships among CNA, facility, resident, and community characteristics thereby expanding its usefulness. Key Words: Certified nursing assistants Direct care workers, Long-term care workforce, Nursing homes, National Nursing Assistant Survey

Purpose: This research applies a stress and support conceptual model to investigate the effects of background characteristics, personal and job-related stressors, and workplace support on direct care workers' (DCW) job satisfaction. Design and Methods: Researchers collected survey data from 644 DCWs in 49 long-term care (LTC) organizations. The DCWs included nurse assistants in nursing homes, resident assistants in assisted living facilities, and home care aides in home health agencies. We examined the influence of components of the LTC stress and support model on DCW job satisfaction. Initially, we ran a multiple regression analysis by entering individual-level DCW predictors with job satisfaction as the outcome. Subsequently, we used hierarchical linear modeling to examine the influence of organizational factors on DCW job satisfaction after controlling for significant individual-level DCW variables. Results: Components of the model explained 51% of the variance in DCW job satisfaction. Background characteristics of DCWs were less important than personal stressors (e.g., depression), job-related stressors (e.g., continuing education), and social support (e.g., interactions with others) in predicting job satisfaction. Results from hierarchical linear modeling analysis showed that nursing homes compared to the two other types of LTC organizations had lower average DCW job satisfaction rates, as did organizations offering lower minimum hourly rates and those reporting turnover problems. Implications: Study findings underscore the importance of targeting both DCW-level and organizational-level factors to increase DCW job satisfaction. Key Words: Aides in nursing homes, Home health agencies, Assisted living

Purpose: This study examined issues related to using older workers in frontline jobs in long-term care from employers' and prospective employees' perspectives. Design and Methods: Telephone surveys were conducted with employers representing 615 nursing homes and 410 home health agencies, and 1,091 low-income participants aged 40+ in Operation ABLE employment and training organizations. A total of 696 of these participants were 55 years or older. Results: Low-income older workers were interested in paraprofessional careers in long-term care. More were interested in home health care jobs than working in nursing homes. Job titles that most interested these workers were infrequent in nursing homes. Many workers perceived their health status as sufficient for frontline work. The majority was interested in career advancement opportunities and went to senior centers and places of worship to seek employment. Industry employers had many positive perceptions of older direct care workers, but there were real and perceived deterrents to hiring older workers. The most prominent deterrents were employers' perceptions that older workers have higher health care costs and are less willing to use technology. Implications: Policy makers should target Title V funds toward training low-income older workers for long-term care jobs, particularly in using mechanical devices and long-term care technologies. Employment and training organizations should add coursework in long-term care technologies, learn about legal issues in targeting advertising to low income older workers, and educate employers about ways to reach these prospective employees. Older workers can use information about employers' perceptions when seeking employment. Key Words: Workforce, Low income, Title V, Nursing home, Home health care

Purpose: This article reports on a randomized, controlled intervention study designed to reduce employee turnover by creating a retention specialist position in nursing homes. Design and Methods: We collected data three times over a 1-year period in 30 nursing homes, sampled in stratified random manner from facilities in New York State and Connecticut and randomly assigned to treatment and control conditions. Staff outcomes were measured through certified nursing assistant interviews, and turnover rates were measured over the course of the year. In the intervention condition, a staff member was selected to be the facility retention specialist, who would advocate for and implement programs to improve staff retention and commitment throughout the facility. Retention specialists received an intensive 3-day training in retention leadership and in a number of evidence-based retention programs. Ongoing support was provided throughout the project. Results: Treatment facilities experienced significant declines in turnover rates compared to control facilities. As predicted, we found positive effects on certified nursing assistant assessments of the quality of retention efforts and of care provided in the facility; we did not find effects for job satisfaction or stress. Implications: The study provides evidence for the effectiveness of the retention specialist model. Findings from a detailed process evaluation suggest modifications of the program that may increase program effects. Key Words: Long-term care, Staff retention, Employee turnover, Certified nursing assistants, Nurses

Purpose: The purpose of this study was to evaluate WIN A STEP UP, a workforce development program for nursing assistants (NAs) in nursing homes (NHs) involving continuing education by onsite trainers, compensation for education modules, supervisory skills training of frontline supervisors, and short-term retention contracts for bonuses and/or wage increases upon completion. Design and Methods: We collected longitudinal semistructured interview and survey data from NAs, supervisors, and managers at 8 program NHs and 10 comparison NHs. To control for selection bias, we matched 77 NA program participants to 81 participating site and 135 comparison site controls using propensity scores in a quasi-experimental design supplemented by qualitative assessments. Results: Managers at seven of eight participating NHs wanted to repeat the program. At 3 months after baseline, participants differed from controls by having (a) more improved nursing care and supportive leadership scores, (b) greater improvement in team care, and (c) stronger ratings of career and financial rewards. Nurse supervisors participating in supervisory skills training reported positive changes in management practices for themselves and peers. Modest 3-month turnover reductions occurred in six settings where the program was fully implemented without incident. Implications: Managers', supervisors', and participating NAs' consistent perceptions of improved quality of care and job quality, along with a promise of increased retention, suggest that interventions like WIN A STEP UP are beneficial. Key Words: Direct care workers, Turnover, Nursing homes, Workforce development, Supervision, Retention

Purpose: The purpose of this study was to investigate (a) whether certified nursing assistants (CNAs) are more committed to nursing home jobs when they perceive their jobs as enhanced (greater autonomy, use of knowledge, teamwork), and (b) whether CNA job commitment affects resident satisfaction. Design and Methods: A qualitative exploration of management philosophy and practice and of CNAs' views of their jobs in 18 Massachusetts nursing homes formed the basis for a survey administered to 255 CNAs in 15 homes. A quality-of-life questionnaire was administered to 105 residents. Logistic regression accounting for clustering estimated the effect of personal characteristics, satisfaction with tangible job rewards, and aspects of job design on CNAs' intent to stay in current jobs. A general linear model estimated the effect of job commitment on residents' satisfaction with their relationship to nursing staff. Results: After we accounted for satisfaction with wages, benefits, and advancement opportunities, good basic supervision was most important in affecting CNAs' intent to stay in their jobs. Job enhancements were not significantly related to intent to stay. Residents were more satisfied with their relationships to nursing staff and their quality of life on units where a higher proportion of CNAs were committed to their jobs. Implications: The finding that greater job commitment of CNAs is associated with better quality of relationships and life for residents implies that better jobs lead to better care. Culture change transformation that increases CNA autonomy, knowledge input, and teamwork may not increase workers' commitment to jobs without improvements in basic supervision. Key Words: Workforce, Turnover, Frontline caregivers, High-performance management, Culture change

Purpose: Better Jobs Better Care (BJBC) was a long-term care workforce demonstration that sought to improve recruitment and retention of direct care workers by changing public policy and management practice. The purpose of this article is to document and assess BJBC's implementation, analyze factors affecting implementation, and draw lessons from it for other long-term care workforce initiatives. Design and Methods: We analyzed qualitative data from project work plans and progress reports, and notes from telephone and in-person interviews with project staff, coalition stakeholders, and state policy experts. We abstracted the data, categorized it, and summarized it by state in matrices for analysis. Results: The five BJBC projects did implement their demonstration plans. Factors that affected project implementation included having demonstration resources; strong, stable leadership; strong coalitions that included key stakeholders; a neutral lead agency; clear goals; effective process; and a favorable state history and context. Implications: BJBC demonstrated that recruitment and retention is a long-term care industry problem, not just a nursing home problem. Future initiatives should: recognize that workforce policy and management practice change is difficult and takes time, obtain funding, develop strategies specific to the state history and context, engage key stakeholders, and develop relationships among stakeholders. Key Words: Workforce, Aide, Nursing home, Home health, Assisted living, Long-term care

This is the first published account of state administrative code variations in nursing home social worker qualifications. It is important to review state codes because the majority of nursing homes in the U.S. have fewer than 121 beds and therefore are not required by the federal government to employ at least one full-time qualified social worker. States have the option of extending the federal regulations to homes with 120 or fewer beds, or strengthening the federal requirements in other ways. Findings indicate enormous variation in state requirements for qualifications of nursing home social workers, and even when states define a qualified nursing home social worker (not all do), they often exempt facilities from employing one. Seven states were found to be out of federal compliance. Research describing the qualifications of people employed in nursing home social services is called for, as well as research documenting effective psychosocial interventions, especially as they relate to resident quality of life. Ten recommendations for enhancing nursing home social work services are included. KEYWORDS. Nursing home, nursing facilities, long-term care, psychosocial, social work, social services

Objectives. High turnover rates among nursing assistants (NAs) in nursing homes have costly implications for facility operation and quality, and low rates of NA profession retention can deplete the stock of experienced staff. This study assessed the extent to which the same factors are associated with NAs' intent to leave a particular job versus the NA profession. Methods. We used data for 2,328 NAs from the 2004 National Nursing Assistant Survey to model (a) two measures of facility retention (whether NAs expected to leave their current job within 1 year and whether they were also searching for a new job); and (b) NA profession retention, measured by whether NAs did not expect their next job to be as an NA. Results. Substantially different factors affected facility versus profession retention. Facility characteristics (including supervisor qualities, training/safety, and benefits) primarily affected facility retention, whereas NA profession retention was negatively associated with income and education. Discussion. Facilities can implement specific actions to retain NAs, though such policies may have a limited effect on retention in the profession. Broader enhancements of career opportunities may be necessary for profession retention, though balance between retention and promotion may be important. Key Words: Long-term care--Intent to leave--Staffing--Turnover.

Data from a large sample of nursing homes were used to examine the cross-sectional association between use of agency staff, regular staff, and quality. Agency use data came from a survey conducted in 2003 (N = 1071 nursing homes). The agency and regular staff measures were for nurse aides, licensed practical nurses, and registered nurses. We used a single quality factor constructed from the 14 quality measures in Nursing Home Compare. More agency nurse aides resulted in a smaller increase in quality, compared to the use of an equivalent number of regular nurse aides. Agency registered nurse staff were associated with better quality factor scores, especially in the presence of high levels of regular licensed practical nurses. Our results have policy and practice implications, the most significant of which is that agency registered nurses may be beneficial in a wide variety of circumstances, whereas agency nurse aides and licensed practical nurses should be used with caution. KEYWORDS. Nurse aides, agency, agency staff, quality

Purpose: The purpose of this study was to determine the relationship between nursing home staffing level, care received by individual residents, and resident quality-related care processes and functional outcomes. Design and Methods: Nurses recorded resident care time for 5,314 residents on 156 units in 105 facilities in four states (Colorado, Indiana, Minnesota, and Mississippi). We linked residents' care times to their measures of health and functioning from Minimum Data Set assessments. Major variables were unit- and resident-specific minutes of care per day, process measures (physical restraints, range of motion, toileting program, and training in activities of daily living [ADLs]), outcome measures (ADL decline, mobility decline, and worsening behavior between the time study and 90-day follow-up), and covariates such as unit type and resident health status. We used multilevel analysis to examine staffing and quality relationships. Results: Residents with toileting programs, range of motion or ADL training, and restraints received significantly more care from unlicensed but not from licensed staff. However, functional outcomes were not significantly related to care received from licensed or unlicensed staff, except for ADL decline, which was greatest for residents receiving more unlicensed minutes of care. Unit staffing level (licensed and unlicensed) was unrelated to any of the care processes or outcome measures, although higher overall staffing was associated with more time devoted to direct resident care. Implications: Future research into nursing home quality should focus on organization and delivery rather than simply the amount of care available. Key Words: Nursing home, Quality, Nurse staffing, Outcomes, Multilevel model

Purpose: This study had two goals: (a) to assess the validity of the Online Survey Certification and Reporting (OSCAR) staffing data by comparing them to staffing measures from audited Medicaid Cost Reports and (b) to identify systematic differences between facilities that over-report or underreport staffing in the OSCAR. Design and Methods: We merged the 2002 Texas Nursing Facility Cost Report, the OSCAR for Texas facilities surveyed in 2002, and the 2003 Area Resource File. We eliminated outliers in the OSCAR using three decision rules, resulting in a final sample size of 941 of the total of 1,017 nonhospital-based facilities. We compared OSCAR and Medicaid Cost Report staffing measures for three staff types. We examined differences between facilities that over-reported or underreported staffing levels in the OSCAR by using logistic regression. Results: Average staffing levels were higher in the OSCAR than in the Medicaid Cost Report data. The two sets of measures exhibited correlations ranging between 0.5 and 0.6. For-profit and larger facilities consistently over-reported registered nurse staffing levels. Factors associated with increased odds of over-reporting licensed vocational nursing or certified nursing assistant staffing were lower Medicare or Medicaid censuses and less market competition. Facility characteristics associated with over-reporting were consistent across different levels of over-reporting. Underreporting was much less prevalent. Implications: Certain types of facilities consistently over-report staffing levels. These reporting errors will affect the validity of consumer information systems, regulatory activities, and health services research results, particularly research using OSCAR data to examine the relationship between staffing and quality. Results call for a more accurate reporting system. Key Words: Nursing home staffing, OSCAR, Medicaid Cost Reports, RN staffing levels

Purpose: The Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality sponsored a nationwide study to evaluate the federal paid feeding assistant (PFA) regulation that allows nursing homes to hire single-task workers to provide feeding assistance to nursing home residents. Organizers designed the PFA regulation to increase the number of staff available to provide assistance with eating and improve nutritional care process quality. Design and Methods: Trained research staff used standardized protocols to conduct direct observations during meals and face-to-face staff interviews in a convenience sample of seven facilities with PFA programs to evaluate care process quality. Results: Most (84%) of the trained PFAs in the seven site visit facilities were non-nursing staff within the facility; the quality of feeding assistance care provided by these workers was comparable to that provided by indigenous nurse aides. There were no reported changes in existing staffing levels (nurse aide or licensed nurses) following PFA program implementation, and the majority (> 90%) of indigenous staff at all levels reported positive benefits of the PFA program for both staff and residents. Implications: Findings from this preliminary study indicate that the PFA regulation may serve to increase the utilization of existing non-nursing staff to improve feeding assistance care during meals without having a negative impact on existing nurse aide and licensed nurse staffing levels. Key Words: Staffing, Nursing homes, Regulations, Centers for Medicare and Medicaid Services

Based on qualitative comparison of three nursing home facilities, the idea of organized emotional care is proposed as a complement to the concept of emotional labor for understanding care work. It is argued that emotional labor and organized emotional care are distinguished primarily by the presence or absence of organizational feeling rules and affective requirements. Care organizations can be plotted on a continuum with emotional labor at the coercive end and organized emotional care at the other. The proposed distinction restores a positive vision of organizational management of emotion to the sociology of work. Keywords: emotional labor, emotional care, care work, nursing homes

Purpose: In this study the levels of staff turnover reported in the nursing home literature (1990-2003) are reviewed, as well as the definitions of turnover used in these prior studies. With the use of primary data collected from 354 facilities, the study addresses the various degrees of bias that result, depending on how staff turnover is defined in nursing homes. Design and Methods: Data came from a survey mailed to administrators of 526 nursing homes during March 2003. Facilities were located in four states: Missouri, Texas, Connecticut, and New Jersey. Three hundred and fifty-four responses were received, giving a response rate of 67%. Results: The 1-year turnover rates identified in these facilities were 119%, 89%, 87%, 57%, and 48%, for nurse aides, licensed practical nurses, registered nurses, administrators, and directors of nursing, respectively. However, findings show that the definition of turnover used could influence the relative difference between these reported rates by as much as 47%. Implications: As a result of measurement error, turnover rates may be misrepresented in prior studies. On the basis of the results of this investigation, several recommendations are made for future data-collection initiatives that will eliminate some of this measurement error. Key Words: Measurement theory, Turnover, Nursing homes, Staff, Long-term care

The level of factor substitution in nursing homes is analyzed. Factor substitution is when organizations replace labor with machines because of rising labor costs.

Purpose: This study reviews staffing standards from the 50 states and the District of Columbia to determine if these standards are related to nursing home staffing levels. Design and Methods: Rules and regulations for states' nursing home staffing standards were obtained for the 50 states and the District of Columbia. Nurse staffing data were obtained from the Centers for Medicare and Medicaid Services On-Line Survey, Certification, and Reporting (known as OSCAR) database. The minimum hours per resident day (HPRD) staffing standards for each state were categorized according to the following: no state-specific HPRD standard (adheres only to federal staffing guidelines); low HPRD standard ([is less than or equal to] 2.5 HPRD); and high HPRD standard (> 2.5 HPRD). A series of hierarchical linear models examined the relationships between state staffing standards and actual facility staffing (total, licensed, and certified nurse aide HPRD), using a number of covariates. Results: The variance in facility staffing was much greater within than between states. Facilities in states with high staffing standards had somewhat higher staffing than states with no standards or low standards, whereas facility staffing in states with low standards was not significantly different from that in states with no standards. Other factors, such as resident acuity and average state Medicaid rate, also were related to staffing. Implications: State staffing standards may not be effective policy tools because they are only one of many factors that affect facility staffing levels. Setting a low minimum HPRD standard may fail to raise staffing, or it may even have a dampening effect on staffing rates in facilities. Key Words: Staffing levels, Quality of care, Nursing home, State standards, Policy

A study examines whether job characteristics, work environment, participation in quality improvement activities and facility quality improvement environment predicted employee commitment and job satisfaction in nursing homes and their intent to turnover. The results show that job and organizational factors predicted commitment and satisfaction while inturn predicted turnover intentions.

Purpose: This study examines the moderating effect of staff stability on the relationship between management practices used to empower nurse aides and resident outcomes in a multistate sample of nursing homes. An adaptation of Kanter's theory of structural power in organizations guided the framework for the model used in this study. Design and Methods: Management practices and nurse aide staff stability measures were taken from a survey of directors of nursing (n = 156) and day-shift charge nurses (n 430) in a stratified random sample of nursing facilities in Maine, Mississippi, New York, and Ohio (n = 156). Facility risk-adjusted pressure ulcer incidence rates and social engagement scores, taken from the Minimum Data Set, served as resident outcome measures. A hierarchical linear regression model was used to test the moderating effect of staff stability. Results: The situation in which higher numbers of rewards were given to nurse aide staff was associated with lower incidence of pressure ulcers, whereas the situation in which nurse aides had more influence in resident care decisions was associated with higher aggregate social engagement scores. The inclusion of nurse aide staff stability in the regression model provided additional explanatory information for the relationship between management practices and resident outcomes. Facilities experiencing low turnover and high retention were associated with lower pressure ulcer incidence, whereas facilities with high turnover and high retention were associated with higher social engagement scores. Implications: This study suggests that certain management practices used to empower nurse aides can influence resident outcomes. Further, effects of nurse aide staff stability vary with respect to the physical versus psychosocial nature of the outcome. Key Words: Managerial effectiveness, Long-term care, Nursing facility performance, Rosabeth Kanter

This purpose of this exploratory study is to describe the education, responsibilities, and knowledge of social service workers in skilled nursing facilities. The study used a stratified random sample for structured telephone interviews of 108 social service workers in Missouri. The data indicate that 16% of respondents have a graduate degree, 46% a bachelor's degree, and the remaining 38% have no college degree. Results show that 11% of facilities with more than 120 beds were out of compliance with OBRA requirements for a 'qualified' social service staff person, while the credentials of 35% of facilities with less than 120 beds exceeded the credential requirements. Social service staff report their responsibilities include facilitating the social and psychological well being of residents, discharge planning, the admission process, and care planning, The findings have implications for policy makers as consideration is given to the mental health needs of nursing home residents and for social work educators preparing students for gerontological practice. KEYWORDS. Nursing homes, social services, social workers, policy, practice, survey research, gerontology

Background. Recommendations have been made to increase the number of nursing home (NH) staff available to provide feeding assistance during mealtime. There are, however, no specific data related to two critical variables necessary to estimate mealtime staffing needs: (1) How many residents are responsive to feeding assistance? (2) How much staff time is required to provide feeding assistance to these residents? The purpose of this study was to collect preliminary data relevant to these two issues. Methods. Seventy-four residents in three NHs received a 2-day, or six-meal, trial of one-on-one feeding assistance. Total percentage (0% to 100%) of food and fluid consumed during mealtime was estimated across 3 days during usual NH care and 2 days during the intervention. The amount of time that staff spent providing assistance and type of assistance (i.e., frequency of verbal and physical prompts) was measured under each condition. Results. One half (50%) of the participants significantly increased their oral food and fluid intake during mealtime. The intervention required significantly more staff time to implement (average of 38 minutes per resident/meal vs 9 minutes rendered by NH staff). Conclusions. The time required to implement the feeding assistance intervention greatly exceeded the time the nursing staff spent assisting residents in usual mealtime care conditions. These data suggest that it will almost certainly be necessary to both increase staffing levels and to organize staff better to produce higher quality feeding assistance during mealtimes.