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Proportion of U.S. nursing homes operating under their state training hour requirements by facility size and ownership, 2010 (n = 15,508).
Source publication
Purpose of the study:
To examine the relationship between certified nursing assistant (CNA) training requirements and resident outcomes in U.S. nursing homes (NHs). The number and type of training hours vary by state since many U.S. states have chosen to require additional hours over the federal minimums, presumably to keep pace with the increasin...
Contexts in source publication
Context 1
... examined associations of state-level training hour regulations (i.e., clinical hours, in- service hours, total initial training hours, and ratio of clini- cal to didactic hours) on resident outcomes (QIs) with and without adjustment for case-mix, ownership status, percent- age of Medicaid-certified beds, and urban-rural status. Appendix 1). ...
Context 2
... more states in 2010 required additional train- ing hours compared with 2004, we also investigated how this translated down to actual NHs within states. Slightly more than half of all U.S. NHs (59%) were required to employ CNAs with training hours over federal minimums; clinical and in-service training hour requirements did not vary across facility size (Figure 1). There was no statistical ...
Citations
... In addition, there may need to be focused modules on specific presentations, such as personality disorders and hoarding. Further, implementation and dissemination of trainings continues to be a challenge, especially when factoring the high burden of postlicensure training requirements for NH staff (Trinkoff et al., 2017). ...
... The skills development period varies substantially ▪ More time spent on induction, training, and supervision [42,51,54,59] ▪ Pressure to delegate due to staff shortage [76] ▪ Resistance, resentment, and scepticism by qualified staff [27,48,77] ▪ Nurses' unwillingness to shift some tasks [27,48,77] ▪ Variability role assignments limits nurses' ability to effectively delegate and supervise [27,48,77] ▪ Some assistants have reading and writing difficulties [75] ▪ Unclear accountability lines for actions [42,54,78] across all the countries reviewed. For instance, the minimum in-service (on-the-job) training duration ranged between 1 and 48 h [61,66,70], whereas the maximum in-service training period was undertaken between 126 and 672 days [26,51,91]. ...
Background
A 15 million health workforce shortage is still experienced globally leading to a sub-optimal healthcare worker-to-population ratio in most countries. The use of low-skilled care assistants has been suggested as a cost-saving human resource for health strategy that can significantly reduce the risks of rationed, delayed, or missed care. However, the characterisation, role assignment, regulation, and clinical governance mechanisms for unlicensed assistive workforce remain unclear or inconsistent. The purpose of this study was to map and collate evidence of how care assistants are labelled, utilised, regulated, and managed in formal hospital settings as well as their impact on patient care.
Methods
We conducted a scoping review of literature from PUBMED, CINAHL, PsychINFO, EMBASE, Web of Science, Scopus, and Google Scholar. Searches and eligibility screening were conducted using the Participants–Context–Concepts framework. Thematic content analysis guided the synthesis of the findings.
Results
73 records from a total of 15 countries were included in the final full-text review and synthesis. A majority (78%) of these sources were from high-income countries. Many titles are used to describe care assistants, and these vary within and across countries. On ascribed roles, care assistants perform direct patient care, housekeeping, clerical and documentation, portering, patient flow management, ordering of laboratory tests, emergency response and first aid duties. Additional extended roles that require higher competency levels exist in the United States, Australia, and Canada. There is a mixture of both positive and negative sentiments on their impact on patient care or nurses’ perception and experiences. Clinical and organisational governance mechanisms vary substantially across the 15 countries. Licensure, regulatory mechanisms, and task-shifting policies are largely absent or not reported in these countries.
Conclusions
The nomenclature used to describe care assistants and the tasks they perform vary substantially within countries and across healthcare systems. There is, therefore, a need to review and update the international and national classification of occupations for clarity and more meaningful nomenclature for care assistants. In addition, the association between care assistants and care outcomes or nurses’ experience remains unclear. Furthermore, there is a dearth of empirical evidence on this topic from low- and middle-income countries.
... 22 Most studies are limited to linking data at the facility level, limiting their abilities to consider withinfacility variations across care units. 43 Our study had several limitations: (1) Researchers have documented that rates of resident pain using the RAI-MDS 2.0 might be under-reported. 12,39 (2) Because our resident data and nursing assistant data are linkable only at the care unit level, we were not able to identify dyads of nursing assistant and the residents they care for, and even if we had this capacity, care is not a single or even multiple dyadic process in nursing homes. ...
Background:
Inadequate pain management persists in nursing homes. Nursing assistants provide the most direct care in nursing homes, and significantly improving the quality of care requires their adoption of best care practices informed by the best available evidence. We assessed the association between nursing assistants' use of best practices and residents' pain levels.
Methods:
We performed a cross-sectional analysis of data collected between September 2019 and February 2020 from a stratified random sample of 87 urban nursing homes in western Canada. We linked administrative data (the Resident Assessment Instrument-Minimum Data Set [RAI-MDS], 2.0) for 10,093 residents and survey data for 3547 nursing assistants (response rate: 74.2%) at the care unit level. Outcome of interest was residents' pain level, measured by the pain scale derived from RAI-MDS, 2.0. The exposure variable was nursing assistants' use of best practices, measured with validated self-report scales and aggregated to the unit level. Two-level random-intercept multinomial logistic regression accounted for the clustering effect of residents within care units. Covariates included resident demographics and clinical characteristics and characteristics of nursing assistants, unit, and nursing home.
Results:
Of the residents, 3305 (30.3%) were identified as having pain. On resident care units with higher levels of best practice use among nursing assistants, residents had 32% higher odds of having mild pain (odds ratio, 1.32; 95% confidence interval, 1.01-1.71; p = 0.040), compared with residents on care units with lower levels of best practice use among nursing assistants. The care units did not differ in reported moderate or severe pain among residents.
Conclusions:
We observed that higher unit-level best practice use among nursing assistants was associated with mild resident pain. This association warrants further research to identify key individual and organizational factors that promote effective pain assessment and management.
... As the complexity of the demand for nursing care increases, more well-trained certified nurse assistants (CNA), nurses and professionals from other professions (including medical and allied healthcare professionals) should be added to the skill mix to maintain high-quality care. For example, a study in the US shows that adding well-trained CNA's (with increased requirements for CNA training) are able to improve the quality of long-term care [43]. However, adding welltrained professionals to a team is challenging. ...
Background
Healthcare professionals in nursing homes face complex care demands and nursing staff shortages. As a result, nursing homes are transforming into home-like personalised facilities that deliver person-centred care. These challenges and changes require an interprofessional learning culture in nursing homes, but there is little understanding of the facilitators that contribute to developing such a culture. This scoping review aims to identify those facilitators.
Methods
A scoping review was performed in accordance with the JBI Manual for Evidence Synthesis (2020). The search was carried out in 2020–2021 in seven international databases (PubMed, Cochrane Library, CINAHL, Medline, Embase, PsycINFO and Web of Science). Two researchers independently extracted reported facilitators that contribute to an interprofessional learning culture in nursing homes. Then the researchers inductively clustered the extracted facilitators into categories.
Results
In total, 5,747 studies were identified. After removing duplicates and screening titles, abstracts and full texts, 13 studies that matched the inclusion criteria were included in this scoping review. We identified 40 facilitators and clustered them into eight categories: (1) shared language, (2) shared goals, (3) clear tasks and responsibilities, (4) learning and sharing knowledge, (5) work approaches, (6) facilitating and supporting change and creativity by the frontline manager, (7) an open attitude, and (8) a safe, respectful and transparent environment.
Conclusion
We found facilitators that could be used to discuss the current interprofessional learning culture in nursing homes and identify where improvements are required. Further research is needed to discover how to operationalise facilitators that develop an interprofessional learning culture in nursing homes and to gain insights into what works, for whom, to what extent and in what context.
... Importantly, training programs and nursing homes should retain in-person training as it remains the best practice and industry standard for direct care occupations (Trinkoff et al., 2017). Blended or hybrid training models can also be utilized as they augment in-person instruction and hands-on learning opportunities with classroom-based technologies. ...
... These modes of training delivery are preferable to fully online learning methods for certified nursing assistant training programs (Ochylski et al., 2017). Other modes of training delivery can include group demonstrations, paired work, call-and-response, role play activities, hands-on learning activities, job previews, and field practice (Trinkoff et al., 2017). The federal government (CMS), as recommended by the Committee, should reimburse entry-level training costs so that nursing homes can provide training to nursing assistants free of charge. ...
... This myriad of stressors stems from poor media coverage, lack of recognition as key or frontline workers, and lack of training opportunities to name only a few (Oliver, 2020;Trinkoff et al., 2017;Han et al., 2014;Eldh et al., 2016). At the end of the MHLLSP participants rated their own quality of life as better than the baseline and this item had the largest shift amongst all the questionnaires statements aligned to factors. ...
... Case studies of high-quality NH training would be informative. Prior work demonstrates that greater NH state training requirements (i.e., total hours, clinical hours) are associated with better resident care (Drake, 2020;PHI, 2004PHI, , 2016Trinkoff et al., 2017). Yet few studies have examined CNA outcomes like job satisfaction or retention in relation to training features or programs. ...
Background and Objectives
This study examined the relationship between nursing home (NH) quality using consumer complaints and certified nursing assistant (CNA) annual retention rates among Ohio freestanding NHs (n = 691).
Research Design and Methods
Core variables came from the 2017 Ohio Biennial Survey of Long-term Care Facilities and CMS Automated Survey Processing Environment Complaints/Incidents Tracking System. To compare NHs, four quartiles of CNA retention rates were created: low (0-48%), medium (49-60%), high (61-72%), and very high retention (73-100%). Negative binomial regressions were estimated on total, substantiated, and unsubstantiated allegations and complaints. All regressions controlled for facility and county-level factors and clustered facilities by county.
Results
NHs in the top 50% (high and very high) of retention received 1.92 fewer allegations than those in the bottom 50%, representing a 19% difference; this trend was significant and negative across all outcomes. Using quartiles revealed a non-linear pattern: high retention NHs received the fewest number of allegations and complaints. The differences between high and low retention on allegations, substantiated, and unsubstantied allegations were 33% (3.73 fewer), 34% (0.51 fewer), and 32% (3.12 fewer) respectively. Unexpectedly, very high retention NHs received more unsubstantiated allegations than high retention NHs.
Discussion and Implications
While higher retention should result in fewer complaints, our results indicate that some turnover may be desirable because the very high retention NHs performed slightly worse than those with high retention. Among the remaining facilities, fewer complaints may be achieved by improving CNA retention through higher wages, career advancement, and better training.
... The level of analysis will be the individual nursing home resident nested within nursing home corporations, with each nursing home serving as its own control and nursing homes stratified by corporation. Data available from the pre-baseline, baseline, postintervention, and sustainment measurements (See Fig. 2 and Table 1) will enable estimation of (a) within individual variation over time (pre-baseline [week 1] through sustainment [week 22]), (b) between individual variation incorporating individual characteristics (e.g., demographics, dementia severity level), and (c) facility level variation incorporating nursing home characteristics (e.g., corporate membership, facility bed-size, and staffing) [107,108]. ...
Background
Disturbed sleep places older adults at higher risk for frailty, morbidity, and even mortality. Yet, nursing home routines frequently disturb residents’ sleep through use of noise, light, or efforts to reduce incontinence. Nursing home residents with Alzheimer’s disease and or related dementias—almost two-thirds of long-stay nursing home residents—are likely to be particularly affected by sleep disturbance. Addressing these issues, this study protocol implements an evidence-based intervention to improve sleep: a nursing home frontline staff huddling program known as LOCK. The LOCK program is derived from evidence supporting strengths-based learning, systematic observation, relationship-based teamwork, and efficiency.
Methods
This study protocol outlines a NIH Stage III, real-world hybrid efficacy-effectiveness pragmatic trial of the LOCK sleep intervention. Over two phases, in a total of 27 non-VA nursing homes from 3 corporations, the study will (1) refine the LOCK program to focus on sleep for residents with dementia, (2) test the impact of the LOCK sleep intervention for nursing home residents with dementia, and (3) evaluate the intervention’s sustainability. Phase 1 (1 year; n = 3 nursing homes; 1 per corporation) will refine the intervention and train-the-trainer protocol and pilot-tests all study methods. Phase 2 (4 years; n = 24 nursing homes; 8 per corporation) will use the refined intervention to conduct a wedge-design randomized, controlled, clinical trial. Phase 2 results will measure the LOCK sleep intervention’s impact on sleep (primary outcome) and on psychotropic medication use, pain and analgesic medication use, and activities of daily living decline (secondary outcomes). Findings will point to inter-facility variation in the program’s implementation and sustainability.
Discussion
This is the first study to our knowledge that applies a dementia sleep intervention to systematically address known barriers to nursing home quality improvement efforts. This innovative study has future potential to address clinical issues beyond sleep (safety, infection control) and expand to other settings (assisted living, inpatient mental health). The study’s strong team, careful consideration of design challenges, and resulting rigorous, pragmatic approach will ensure success of this promising intervention for nursing home residents with dementia.
Trial registration
NCT04533815, ClinicalTrials.gov, August 20, 2020.
... The models controlled for patient characteristics and a fixed effect for state to account for differences in state regulations that may affect nursing home quality. 36,37 Thus, our results represent the SNF-level risk-adjusted scores for the average change per 10 days and the percentage of patients who had any improvement in the total scores for the 4 outcome measures. Consistent with previous studies, 20,27,38 the models included an indicator variable that equaled 0 for the period before (January 1, 2015-June 30, 2016) and 1 for the period after (July 1, 2016-December 31, 2017) the improvement in function quality measure was added to the 5-star rating system in July 2016. ...
Objective
To determine if patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016.
Design
Pre (1/1/2015–6/30/2016) versus post (7/1/2016–12/31/2017) design.
Setting
Skilled Nursing Facilities (n=12,829).
Participants
Medicare fee-for-service beneficiaries discharged from acute hospitals to SNF following hip replacement between 01/01/2015 and 12/31/2017 (N=106,832).
Main Outcome Measures
The 5-day and 14-day Minimum Data Set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10-days and any improvement between the 5-day and 14-day assessments.
Results
The average adjusted changer per 10-days for the quality measure total score for patients admitted before July 2016 and after July 2016 were 1.00 points (standard error [SE]=0010) and 1.06 points (SE=0.010), respectively (p<0.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (SE=0.06) had any improvement in the quality measure total score compared to 45.5% (SE=0.23) of patients admitted after July 2016 (p<0.01). This was a relative increase of 2.5%. The adjusted change per 10-days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016.
Conclusions
Patients admitted to a SNF following a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.
... However as of 2010, 31 states or districts required additional training hours above the federal minimum due to the increasing complexity of care which NF residents require. 55 Many states require CNAs to attend a state approved nursing assistant training programs, and many training programs' curriculum include oral hygiene education, but the length and quality of oral hygiene education is not specified. Hoben et al completed a systematic review and meta-analysis and found that 24% (7%-47%) of care providers reported lack of knowledge, education, or training in providing oral care as a barrier to providing care for residents. ...
Aims
The purpose of this study was to determine if the number of certified nursing assistants (CNAs) trained with the Mouth Care Matters (MCM) oral health educational program had an impact on nursing facility (NF) resident oral health.
Materials and methods
Three NFs participated in a cluster randomized control trial. In NF‐A: all CNAs were offered the MCM program, NF‐B: 3 CNAs were offered the MCM program, and NF‐C: Control (no CNAs were offered the MCM program). Demographic information, systemic health data, and oral health data at baseline, 3‐month, and 6‐month intervals were collected and analyzed using Kruskal‐Wallis, Wilcoxon signed‐rank and Wilcoxon rank‐sum tests. A total of 24 dentate residents participated in this study. Plaque control record scores for NF‐A were significantly reduced compared to NF‐B and NF‐C (P < .001 and P = .002 respectively) and gingival bleeding index for NF‐A were significantly reduced compared to NF‐B and NF‐C (P = .002 and P < .001 respectively).
Conclusion
Increasing the number of CNA's trained in the Mouth Care Matters educational program positively impacted NF residents’ oral hygiene.
