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Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.

Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.

ObjectivesIn the emergency department (ED), health care providers miss delirium approximately 75% of the time, because they do not routinely screen for this syndrome. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a brief (

Background: Among patients in skilled nursing facilities for post-acute care, increased registered nurse, total licensed staff, and nurse assistant staffing is associated with a decreased rate of hospital transfer for selected diagnoses. However, the cost-effectiveness of increasing staffing to recommended levels is unknown. Methods: Using a Markov cohort simulation, we estimated the incremental cost-effectiveness of recommended staffing versus median staffing in patients admitted to skilled nursing facilities for post-acute care. The outcomes of interest were life expectancy, quality-adjusted life expectancy, and incremental cost-effectiveness. Results: The incremental cost-effectiveness of recommended staffing versus median staffing was $321,000 per discounted quality-adjusted life year gained. One-way sensitivity analyses demonstrated that the cost-effectiveness ratio was most sensitive to the likelihood of acute hospitalization from the nursing home. The cost-effectiveness ratio was also sensitive to the rapidity with which patients in the recommended staffing scenario recovered health-related quality of life as compared to the median staffing scenario. The cost-effectiveness ratio was not sensitive to other parameters. Conclusion: Adopting recommended nurse staffing for short-stay nursing home patients cannot be justified on the basis of decreased hospital transfer rates alone, except in facilities with high baseline hospital transfer rates. Increasing nurse staffing would be justified if health-related quality of life of nursing home patients improved substantially from greater nurse and nurse assistant presence.

Purpose: A gap between research and practice in many nursing home (NH) care areas persists despite efforts by researchers, policy makers, advocacy groups, and NHs themselves to close it. The reasons are many, but two factors that have received scant attention are the dissemination process itself and the work of the disseminators or change agents. This review article examines these two elements through the conceptual lens of Roger's innovation dissemination model. Design and Methods: The application of general principles of innovation dissemination suggests that NHs are characteristically slow to innovate and thus may need more time as well as more contact with outside change agents to adopt improved practices. Results: A review of the translation strategies used by NH change agents to promote adoption of evidence-based practice in NHs suggests that their strategies inconsistently reflect lessons learned from the broader dissemination literature. Implications: NH-related research, policy, and practice recommendations for improving dissemination strategies are presented. If we can make better use of the resources currently devoted to disseminating best practices to NHs, we may be able to speed NHs' adoption of these practices.

Purpose: This article describes a distance learning model designed to help nursing homes implement incontinence management best practices. A basic premise is that translating research into practice requires both a feasible intervention and a dissemination strategy responsive to the target audience's needs. Design and Methods: Over 8 months, nurse supervisors from 14 nursing homes in nine states learned how to implement prompted voiding during monthly 60- to 90-min teleconferences. Supervisors completed field assignments that required them to implement prompted voiding. Descriptive evaluation data were collected using a resident data form, pre- and posttraining quizzes, and a project evaluation survey. Results: Nursing home staff attended an average of 6.5 teleconferences; on average, three staff members typically attended each teleconference. Eighty-nine percent of all survey respondents (N = 28) reported that they (a) would participate in a similar project and (b) would recommend the course to colleagues. Average scores on the quiz increased 16% (p less than 0.05) from pre- to posttraining. Collectively, participating facilities assessed a total of 261 incontinent residents and reported maintaining 117 (44.8%) on prompted voiding, for an average of 10 residents per facility. Implications: The intervention implementation results were promising for a management strategy often described as challenging to maintain. The distance learning model worked as expected. Given its strengths and relatively few weaknesses, it appears to be a feasible, effective, and low-cost strategy for translating research into nursing home practice.

Purpose: To describe a standardized observation protocol to determine if nursing home (NH) staff offer choice to residents during 3 morning activities of daily living (ADL) and compare the observational data with deficiency statements cited by state survey staff. Design and Methods: Morning ADL care was observed in 20 NHs in 5 states by research staff using a standardized observation protocol. The number of observations in which choice was not offered was documented for 3 morning ADL care activities and compared with deficiency statements made by surveyors. Results: Staff failed to offer choice during morning ADL care delivery for at least 1 of 3 ADL care activities in all 20 NHs. Observational data showed residents were not offered choice about when to get out of bed (11%), what to wear (25%), and breakfast dining location (39%). In comparison, survey staff issued only 2 deficiencies in all 20 NHs relevant to choice in the targeted ADL care activities, and neither deficiency was based on observational data. Implications: Survey interpretative guidelines instruct surveyors to observe if residents are offered choice during daily care provision, but standardized observation protocols are not provided to surveyors to make this determination. The use of a standardized observation protocol in the survey process similar to that used by research staff in this study would improve the accuracy and transparency of the survey process.

This article uses a retrospective approach to critique the research base underlying the nursing home culture-change movement--an effort to radically transform the nation's nursing homes by delivering resident-directed care and empowering staff. The article traces the development of the movement from its inception 10 years ago to 2005, when the Centers for Medicare and Medicaid Services implemented its own initiative to support the movement, thus giving it new momentum, to the present day. This historical overview provides context for a proposed research agenda aimed at strengthening the movement's empirical base, thereby facilitating culture-change interventions as well as helping the movement navigate the next step in its evolution.

Purpose: The purpose of this study was to evaluate the sensitivity of family members' responses to open-ended interview questions about an intervention to improve incontinence and mobility care for their relative in a nursing home. Design and Methods: The study was a randomized, controlled intervention trial with incontinent nursing home residents (N = 145), wherein research staff provided toileting and walking assistance of sufficient intensity to significantly improve continence and mobility outcomes in the treatment group. Interviewers posed open-ended interview questions to family members after 8 weeks of intervention to assess if they noticed a difference in care. Results: Family responses to open-ended questions showed that, compared to the control group, the intervention group noticed significant overall improvement in incontinence and mobility care and in residents' outcomes in mobility. Implications: Families' responses to open-ended questions were sensitive to improvements in incontinence and mobility care and may provide evidence for important care quality differences that would be missed if only direct satisfaction and discrepancy-based closed-ended questions were asked.

Nursing home medical-record documentation of daily-care occurrence may be inaccurate, and information is not documented about important quality-of-life domains. The inadequacy of medical record data creates a barrier to improving care quality, because it supports an illusion of care consistent with regulations, which reduces the motivation and ability of providers to identify areas for improvement. Observational protocols designed for use by survey and quality-assurance staff can provide the independent information necessary for improving both medical record accuracy and residents' quality of life. Unfortunately, observational protocols currently used in survey and quality-assurance activities are not designed in a manner that is consistent with the scientific principles that guide observational measurement. The purpose of this article is to describe the steps to develop a standardized and scientifically defensible observational system to assess nursing home care quality.

Purpose: This study investigated whether the use of restraining devices and related measures of care quality are different in nursing homes that score in the upper and lower quartiles on the Minimum Data Set (MDS) "prevalence of restraint" quality indicator, which assesses daily use of restraining devices when residents are out of bed. Design and Methods: The study was a cross-sectional study, with 413 residents in 14 nursing facilities. Eight homes scored in the lower quartile (25th percentile; low prevalence, 0-5%) on the MDS restraint prevalence quality indicator, and six homes scored in the upper quartile (75th percentile; high prevalence, 28-48%). Eight care processes related to the management of restraints and gait and balance problems were defined and operationalized into clinical indicators. Research staff conducted direct observations during three 12-hr days (7 a.m.-7 p.m.) to determine the prevalence of restraining devices and identify resident and staff behaviors that may be affected by restraint use. Results: Residents in high-restraint homes were in bed during the day on more observations than residents in low-restraint homes (44% vs. 33%; p < .001), were more frequently observed with bed rails in use (74% of residents vs. 64% of residents; p < .03), and received less feeding assistance during meals (2.7 min vs. 4.1 min; p<.001). There were no differences between homes in the use of out-of-bed restraints, nor were there any differences on any care process measure related to the management of restraints, gait and balance problems, or measures of physical or social activity. Implications: A home's score on the MDS-generated prevalence of restraint quality indicator was not associated with differences in the use of restraints, physical activity, or any care process measure when residents were out of bed. However, there were differences in the use of in-bed restraining devices, and residents in high-restraint homes were in bed more often during the day. These differences were associated with poor feeding assistance and reflect important differences in quality of care between homes, even though these differences are not what the restraint prevalence quality indicator purports to measure. Methods to monitor and improve the quality of care related to exercise, in-bed times, and resident freedom of movement are discussed.

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

Purpose: The Minimum Data Set (MDS) Activities of Daily Living (ADL) bed-mobility item, which rates the staff-assistance level necessary for bed movement, is used to target scheduled repositioning interventions and to identify physical function changes in nursing home residents; however, accuracy of the item is uncertain. The purpose of this study was to evaluate the accuracy of the MDS ADL bed-mobility item as completed by nursing home nurses with independent performance assessments conducted by research staff. Design and Methods: A convenience sample of 197 long-stay residents from 26 California nursing homes participating in a larger project was used in this cross-sectional study to compare independent research-staff performance assessments (using graduated assistance protocols of residents' ability to move in bed) and nursing home nurse MDS bed-mobility ratings. Participants also wore movement monitors to verify performance assessments. Results: Poor agreement existed between the nursing home nurse MDS bed-mobility ratings and the research-staff performance assessments across all assistance levels (kappa range, [kappa] = 0.007, p = .918 to [kappa] = 0.484, p < .001), with better agreement seen in totally dependent participants and with fewer elapsed days between MDS ratings and performance assessments. The odds of nursing home nurse errors (underestimating or overestimating dependency) on the MDS bed-mobility item were 2.1 times higher for participants judged independent by research staff compared with participants judged as requiring physical assistance by research staff (95% confidence interval, 1.14-4.03) when adjusted for number of days between nurse MDS ratings and research-staff performance assessments. Implications: Nursing home nurses overestimated resident dependency in bed mobility. The systematic inaccuracies in MDS bed-mobility ratings have implications for their use as a basis for targeting residents for repositioning programs and determining changes in residents' physical function. Performance assessments utilizing graduated assistance protocols are recommended as a method of improving the accuracy of MDS bed-mobility ratings. Key Words: Activities of daily living assessment, Bed mobility, Minimum data set accuracy, Physical performance assessments

Objectives. This study's objective was to refine a method for coding nursing home (NH) residents' comments about their perceptions of care into unmet needs specific to the manner and frequency of care delivery. Methods. NH residents (N = 69) were interviewed with both closed ended (i.e., forced-choice) and open-ended (i.e., residents' own words) questions about their perceptions of care across eight care domains. Unmet needs included comments indicating that residents desired a change in staff- and non-staff-related care. Staff-related unmet needs were further coded into unmet emotional support (i.e., emotional support or manner of care delivery) and instrumental (i.e., instrumental support or frequency of care) needs. Results. Of 66 residents who commented, 66%, expressed at least one unmet need across eight care domains. Among these 44 residents, 52% and 84% had unmet emotional support and instrumental support needs, respectively ([kappa] = .68 and .92). An additional 18% expressed both unmet emotional support and instrumental support needs. Discussion. The refined method offers a systematic way to code residents' comments about their care into unmet needs related to the manner and frequency of care delivery. The findings have direct implications for the identification of care areas in need of improvement from the resident's perspective and the evaluation of improvement efforts.

Background. Recommendations have been made to increase the number of nursing home (NH) staff available to provide feeding assistance during meals and to individualize care for residents. However, there are few data reflecting the number of residents responsive to feeding assistance during meals and what alternative interventions might be appropriate for other residents. The purpose of this study was to evaluate the effects and staffing requirements of two individualized feeding assistance interventions to improve oral food and fluid intake in NH residents. Methods. Skilled nursing participants (n = 134) in 3 NHs received a 2-day trial of one on-one feeding assistance daring 6 meals. 68 participants who did not increase their oral intake in response to feeding assistance during meals received a 2-day intervention trial during which snacks were offered between meals 3 times daily. As part of both interventions. research staff provided adequate feeding assistance that enhanced the resident's self-feeding ability, social stimulation throughout the meal or snack period, and availability of choices for foods and fluids. Results. 46% significantly increased their oral intake in response to one-on-one mealtime feeding assistance, and the staff time required to implement this intervention was 35 ([plus or minus] 8) minutes/meal per resident compared with usual NH care, which averaged 6 ([plus or minus] 9) minutes. 44% of the participants significantly increased their oral intake in response to the between-meal snack intervention, which required 12 ([plus or minus] 6) minutes of staff time per snack/resident compared with usual NH care (1 [plus or minus] 4 minutes). Conclusions. Most participants (90%) significantly increased their daily oral food and fluid intake in response to one of two individualized interventions. The staff time necessary to implement each intervention was significantly greater than the staff time currently being spent on feeding assistance care delivery. Suggestions are made to increase the efficiency of staff time when delivering feeding assistance.

Background. A new prevalence of pain quality indicator' based on the Minimum Data Set (MDS) has been developed for the purpose of providing nursing home (NH) consumers with information that would allow them to compare the quality of pain care between facilities. The purpose of this study was to compare pain-related care processes between NHs that scored in the lower 25th percentile (low pain prevalence) or upper 75th percentile (high pain prevalence) based on this indicator. Methods. Care processes related to pain assessment, documentation, and treatment were independently evaluated using standardized resident interview and medical record review protocols for 255 residents in 16 NHs that reported MDS pain prevalence of less than 15% (8 NHs in lower 25th percentile) or greater than 30% (8 NHs in upper 75th percentile). Results. A significantly greater proportion of participants in the high pain prevalence NHs reported symptoms indicative of chronic pain during interview. The standard zed pain interview revealed a significantly higher prevalence of pain among participants in the lowest quartile NH group compared to the MDS pain prevalence quality indicator, but the pain prevalence according to both MDS and interview were comparable in the higher quartile NHs. Medical record review showed that a significantly greater proportion of participants in upper quartile NHs had pain assessments documented by licensed nurses and physicians, received pain medication, and had documentation of treatment response. Conclusions. An MDS pain quality indicator accurately discriminates prevalence of pain between facilities. However, interpretation of the pain indicator requires caution. Rather than reflecting poor quality, a high prevalence of pain according to the MDS was associated with better pain assessment and treatment care processes.

Background. Aging is associated with decline in both cell-mediated and humoral immunity and may contribute to increased incidence and severity of infections in frail elderly. Exercise, depending on intensity, has significant effects on the immune system. We conducted a randomized, controlled clinical trial of a 32-week functionally oriented exercise program in frail elderly living in nursing homes and determined whether the exercise intervention was associated with a change in immune parameters in this frail elderly nursing home population. Methods. Nursing home residents were randomly assigned to an intervention (n = 94) and control group (n = 96). The intervention consisted of a functionally oriented endurance and resistance exercise training that was provided every 2 hours from 8:00 AM to 4:00 PM for 5 days a week for 8 months. Lymphocyte subpopulations, including activation markers (CD28, CD25, HLA-DR), in vitro proliferation, and soluble products of cytokine activity (neopterin and sTNF-RII) in serum were measured by taking blood samples at baseline and after 8 weeks and 32 weeks of the intervention. Results. Exercise training did not induce changes in lymphocyte subpopulations, activation markers (CD28, CD25, HLA-DR), in vitro proliferation, and soluble products of cytokine activity (neopterin and sTNF-RII) in serum. Conclusions. A 32-week exercise intervention did not bring about beneficial or detrimental effects on immune parameters in the frail elderly nursing home population and may explain why the intervention was not associated with a change in the incidence of infections in the intervention group compared with the control group.

Purpose: This article presents a rationale and conceptual framework for making comprehensive consumer information about nursing facilities available. Such information can meet the needs of various stakeholder groups, including consumers, family/ friends, health professionals, providers, advocates, ombudsman, payers, and policy makers. Design and Methods: The rationale and framework are based on a research literature review of key quality indicators for nursing facilities. Results: The findings show six key areas for information: (a) facility characteristics and ownership; (b) resident characteristics; (c) staffing indicators; (d) clinical quality indicators; (e) deficiencies, complaints, and enforcement actions; and (f) financial indicators. This information can assist in selecting, monitoring, and contracting with nursing facilities. Implications: Model information systems can be designed using existing public information, but the information needs to be enhanced with improved data.

Background. Direct observation of care is an important data source for nursing home (NH) quality assessment, especially in light of evidence that chart information is inaccurate or incomplete for many daily care areas. The purpose of this study was to describe a standardized feeding assistance observational protocol that is designed for routine use by external (survey teams) and internal (licensed NH staff) quality assurance personnel to (i) maximize the amount of useful information gained from relatively brief observational periods; (ii) provide specific rules of measurement, which allow for replication and valid comparisons between NHs; and (iii) provide specific scoring rules that allow defensible categorical statements to be made about feeding assistance care quality within the NH. Methods. Four feeding assistance care quality indicators (QIs) were defined and operationalized in this study for 302 long-term residents in 10 skilled NHs: (i) Staff ability to accurately identify residents with clinically significant low oral food and fluid intake during mealtime; (ii) Staff ability to provide feeding assistance to at-risk residents during mealtime; (iii) Staff ability to provide feeding assistance to residents identified by the Minimum Data Set as requiting staff assistance to eat; and (iv) Staff ability to provide a verbal prompt to residents who receive physical assistance at mealtimes. Results. There were significant differences between facilities for three of the four QIs. The proportion of participants in each facility where staff 'failed' the QIs ranged as follows: (Quality Indicator i) 42% to 91%; (ii) 25% to 73%; (iii) 11% to 82%; and (iv) 0% to 100%. Conclusions. A standardized observational protocol can be used to accurately measure the quality of feeding assistance care in NHs. This protocol is replicable and shows significant differences between facilities with respect to accuracy of oral intake documentation and the adequacy and quality of feeding assistance during mealtimes.