The objective of this study was to determine whether nurse staffing levels and modifiable characteristics of the nursing practice environment are associated with important quality indicators represented by the percentage of residents with pressure ulcers and numbers of deficiency citations in nursing homes. A cross-sectional design linked nurse survey data, aggregated to the facility level, with Nursing Home Compare, a publicly available federal database containing nursing home–level measures of quality. The facility sample consisted of 63 Medicare- and Medicaid-certified nursing homes in New Jersey, and the nurse survey sample comprised 340 registered nurses providing direct resident care. Characteristics of the practice environment were measured using the Practice Environment Scale of the Nursing Work Index, included in the nurse survey. The total number of deficiency citations, the percentage of residents with pressure ulcers, nurse staffing levels, and facility characteristics were extracted from the Nursing Home Compare database. Results indicated that a supportive practice environment was inversely associated with the percentage of residents with pressure ulcers and fully mediated the effect of profit status on this important outcome. The nursing practice environment and facility size explained 25% of the variance in quality deficiencies. There were no associations between staffing levels and quality indicators. Findings indicate that administrative initiatives to create environments that support nursing practice may hold promise for improving quality indicators in nursing homes.
nursing homes; nursing practice environment; quality
Computerized decision support systems (CDSSs) have the potential to significantly improve the quality of nursing care of older people by enhancing the decision making of nursing personnel. Despite this potential, health care organizations have been slow to incorporate CDSSs into nursing home practices.
This study describes facilitators and barriers that impact the ability of nursing personnel to effectively use a clinical CDSS for planning and treating pressure ulcers (PUs) and malnutrition and for following the suggested risk assessment guidelines for the care of nursing home residents.
We employed a qualitative descriptive design using varied methods, including structured group interviews, cognitive walkthrough observations and a graphical user interface (GUI) usability evaluation. Group interviews were conducted with 25 nursing personnel from four nursing homes in southern Norway. Five nursing personnel participated in cognitive walkthrough observations and the GUI usability evaluation. Text transcripts were analyzed using qualitative content analysis.
Group interview participants reported that ease of use, usefulness and a supportive work environment were key facilitators of CDSS use. The barriers identified were lack of training, resistance to using computers and limited integration of the CDSS with the facility’s electronic health record (EHR) system. Key findings from the usability evaluation also identified the difficulty of using the CDSS within the EHR and the poorly designed GUI integration as barriers.
Overall, we found disconnect between two types of nursing personnel. Those who were comfortable with computer technology reported positive feedback about the CDSS, while others expressed resistance to using the CDSS for various reasons. This study revealed that organizations must invest more resources in educating nursing personnel on the seriousness of PUs and poor nutrition in the elderly, providing specialized CDSS training and ensuring that nursing personnel have time in the workday to use the CDSS.
Computerized; decision support system; graphical user interface evaluation; nursing homes; qualitative; content analysis
The purpose of this retrospective study was to evaluate nursing home quality measures (QMs) available in a national database called Nursing Home Compare. The aim was to determine whether differences in QM scores occurred with changing staffing-level mix.
All Missouri nursing home facilities were included for the analysis of the 14 QMs downloaded in February 2004.
Analyses of variance were used to examine differences in the dependent QM scores; the independent range of staffing levels for 3 disciplines, certified nurse assistant (CNA), licensed practical nurse (LPN), and registered nurse (RN), was analyzed on the basis of their number of hours per resident per day worked in the nursing home. Planned contrasts and post hoc Bonferroni adjustments were calculated to further evaluate significance levels. Finally, residents were used as a covariate to determine effects on significant analyses of variance.
Care is proportionate to the percentage of CNA/LPN/RN staffing-level mix, with 2 long-stay QMs (percentage of residents who lose bowel or bladder control and percentage of residents whose need for help with activities of daily living has increased) and 2 short-stay measures (percentage of residents who had moderate to severe pain and percentage of residents with pressure ulcers) revealed differences in mean quality scores when staffing levels changed.
nursing home; outcomes; quality measures; staffing
The Greenlandic Healthcare Reform (2010) required improved quality of services for health promotion, prevention of infectious and lifestyle diseases, family nursing and evidence-based clinical nursing.
To investigate current nursing practice in Greenland and to identify whether it meets the requirements of healthcare reform.
This ethnographic study utilised documentary analysis, participant observation and qualitative interviewing carried out in remote areas of Greenland during 2011–2012. Eight registered nurses, four women and four men, aged between 35 and 55, participated in this study. Four were working at healthcare centres in towns and four were working at nursing stations in villages. The nurses were educated in Greenland or a Nordic country and had been practicing nursing for at least 2 years in an Arctic region. They were observed for 1–5 days, and subsequently interviewed. Interviews included in-depth questioning, based on emerging outcomes from observation. Interviews were recorded and transcribed; they were analysed within a phenomenological–hermeneutic approach.
Nurses in rural and remote areas navigate their health promotion and preventive work with conflict between health strategies and everyday realities, where unpredictable tasks often lead to prioritisation of urgent, acute work. There is interaction between personal and professional skills. Everyday life is characterised by opportunities and challenges in the grey areas, namely nursing, medical and social work.
The nature of nursing practice in rural and remote Greenland is characterised by a high degree of variability and complexity, with a requirement for a wide range of knowledge and skills. Nurses need to be better prepared with regard to acute medical care, preventive care, social work, humanistic approaches and information technology to implement the ideology of health strategies.
Ethnographic study; Greenland; nursing practice; remote and rural areas
GPs often perceive home-visit requests as a time-consuming aspect of general practice. The new general medical services contract provides for practices to be relieved of responsibility for home-visits, although there is no model for the transfer of care. One such model could be to employ nurse practitioners to manage such requests. Nurse practitioners can effectively substitute for GPs in managing same-day in-hours emergency care in the surgery, but their role in managing all such requests, including those requiring home visits, has not been assessed.
To explore the feasibility and clinical management outcomes of nurse practitioner management of same-day care requests, including those requiring home visits, to inform a proposed randomised controlled trial.
Design of study
Non-randomised comparative trial.
One large general practice (14 600 patients) in south London.
Nurse practitioner assessment and management of all same-day care requests for 2 days per week was compared with normal GP management on another 2 days, over a 6-month period. Clinical management outcome data were collected from patient records and from data-collection forms completed by a nurse practitioner and GPs. Patient and staff satisfaction was assessed by questionnaire.
The nurse practitioner was more likely than GPs to assess patients in person, less likely to give advice alone, and more likely to issue a prescription. There was no significant difference between the nurse practitioner and GPs regarding any other clinical management outcomes or patient satisfaction; however, the response rate of the patient satisfaction questionnaire in this pilot study was poor.
Nurse practitioner management of acute in-hours care requests, including home visits, appears feasible in practice and merits further assessment.
house calls; nurse practitioners; primary health care
Urinary tract infections (UTIs, including upper and lower symptomatic) are the most common infections in nursing homes and prevention may reduce patient suffering, antibiotic use and resistance. The spectre of agents used in preventing UTIs in nursing homes is scarcely documented and the aim of this study was to explore which agents are prescribed for this purpose.
We conducted a one-day, point-prevalence study in 44 Norwegian nursing homes during April-May 2006. Nursing home residents prescribed any agent for UTI prophylaxis were included. Information recorded was type of agent and dose, patient age and gender, together with nursing home characteristics. Appropriateness of prophylactic prescribing was evaluated with references to evidence in the literature and current national guidelines.
The study included 1473 residents. 18% (n = 269) of the residents had at least one agent recorded as prophylaxis of UTI, varying between 0-50% among the nursing homes. Methenamine was used by 48% of residents prescribed prophylaxis, vitamin C by 32%, and cranberry products by 10%. Estrogens were used by 30% but only one third was for vaginal administration. Trimethoprim and nitrofurantoin were used as prophylaxis by 5% and 4%, respectively.
The agents frequently prescribed to prevent UTIs in Norwegian nursing homes lack documented efficacy including methenamine and vitamin C. Recommended agents like trimethoprim, nitrofurantoin and vaginal estrogens are infrequently used. We conclude that prescribing of prophylactic agents for UTIs in nursing homes is not evidence-based.
To examine the effects of electronic health information technology (HIT) on nursing home residents.
The study evaluated the impact of implementing a comprehensive HIT system on resident clinical, functional, and quality of care outcome indicators, as well as measures of resident awareness of and satisfaction with the technology. The study used a prospective, quasi-experimental design, directly assessing 761 nursing home residents in 10 urban and suburban nursing homes in the greater New York City area.
No statistically significant impact of the introduction of HIT on residents was found on any outcomes, with the exception of a significant negative effect on behavioral symptoms. Residents' subjective assessment of the HIT intervention were generally positive.
The absence of effects on most indicators is encouraging for the future development of HIT in nursing homes. The single negative finding suggests that further investigation is needed on possible impact on resident behavior.
Long-Term Care; Technology; Quality of Care
Admission to a nursing home is generally regarded as a stressful time for older people and their carers. Although the choice of home is significant in facilitating a more positive transition, few studies have explored this issue in detail, particularly in the context of rural communities. With a worldwide ageing population and an increasing demand for long-term care facilities, it is important to highlight the factors that can improve the experience of entry to long-term care and the role of nursing home staff in facilitating a more positive transition for older people and their families.
The overall aim of this qualitative study was to explore rural family carers’ experience of the nursing home placement of an older relative. Semi structured interviews were conducted with 29 relatives of nursing home residents. Participants were selected from a large health and social care trust in the United Kingdom. Data were analysed using grounded theory principles and procedures and NVivo software.
Rural family carers had a strong sense of familiarity with the nursing homes in their area and this appeared to permeate all aspects of their experience. Carers who reported a high degree of familiarity appeared to experience a more positive transition than others. This familiarity was influenced by the high degree of social capital that was present in the rural community where the study was conducted. This familiarity, in turn, influenced the choice of nursing home and the responses of family carers. The theory that emerged suggests that familiarity was the key factor influencing rural family carers’ experience of the nursing home placement of an older relative.
The population of the world is ageing and nursing homes are increasingly providing care to older people with multiple and complex needs. This study makes an important contribution to the ways in which the move to long term care can be managed more effectively by increasing awareness of the importance of familiarity, stability and social capital in the lives of older people and their carers.
Family carers; Nursing homes; Older people; Rural health care
To develop a broad understanding of nursing beliefs, knowledge and roles in feeding decisions for nursing home residents with advanced dementia.
Concern is growing about the common use of feeding tubes in nursing home residents with advanced dementia. Nurses can play an important role in providing information and guiding family members through difficult feeding decisions. Little is known about nurses' perspectives on feeding decisions.
In-depth semi-structured interviews of 11 licensed nurses who were experienced in caring for nursing home residents with dementia.
Analysis of the interview transcripts revealed three themes: insufficient empirical information, ambiguous role in feeding decisions and uncertainty about moral agency in decisions about the placement of feeding tubes.
Despite views that family members would benefit from guidance in decisions regarding the placement of feeding tubes, nurses were, nevertheless, reluctant to become involved in these difficult decisions.
Relevance to clinical practice
If nurses are to guide family members in decisions about the use of feeding tubes, they need more education about evidence-based practice as well as support in exercising their nursing responsibilities.
end-of-life decision-making; ethics; feeding tube; long-term care; qualitative study
This descriptively designed study examined sensitivity and specificity of staff nurses identification of behavior change in nursing home residents with dementia. Behavior changes and whether further physical assessment was indicated were described and compared to judgments made by one expert advanced practice nurse. The convenience sample included 155 residents and 38 staff nurses from eleven nursing homes. Verbal symptoms and body part cues were the most prevalent behaviors regardless of the assessor. Sensitivity, or probability of identifying a real behavior change, was generally low for the staff nurses, ranging between 35–65% for the different types of behaviors, while specificity was quite high at over 95%. Additional assessment was felt to be needed for 51% of residents by the staff nurse and for 73% of residents by the expert. This study found that staff nurses are under-identifying behavior changes and the need for additional physical assessment.
This manuscript describes a method for adjustment of nursing home quality indicators (QIs) defined using the Center for Medicaid & Medicare Services (CMS) nursing home resident assessment system, the Minimum Data Set (MDS). QIs are intended to characterize quality of care delivered in a facility. Threats to the validity of the measurement of presumed quality of care include baseline resident health and functional status, pattern of comorbidities, and facility case mix. The goal of obtaining a valid facility-level estimate of true quality of care should include adjustment for resident- and facility-level sources of variability.
We present a practical and efficient method to achieve risk adjustment using restriction and indirect and direct standardization. We present information on validity by comparing QIs estimated with the new algorithm to one currently used by CMS.
More than half of the new QIs achieved a "Moderate" validation level.
Given the comprehensive approach and the positive findings to date, research using the new quality indicators is warranted to provide further evidence of their validity and utility and to encourage their use in quality improvement activities.
The purpose of this research is twofold. The first purpose is to utilize a new methodology (Bayesian networks) for aggregating various quality indicators to measure the overall quality of care in nursing homes. The second is to provide new insight into the relationships that exist among various measures of quality and how such measures affect the overall quality of nursing home care as measured by the Observable Indicators of Nursing Home Care Quality Instrument. In contrast to many methods used for the same purpose, our method yields both qualitative and quantitative insight into nursing home care quality.
Design and Methods
We construct several Bayesian networks to study the influences among factors associated with the quality of nursing home care; we compare and measure their accuracy against other predictive models.
We find the best Bayesian network to perform better than other commonly used methods. We also identify key factors, including number of certified nurse assistant hours, prevalence of bedfast residents, and prevalence of daily physical restraints, that significantly affect the quality of nursing home care. Furthermore, the results of our analysis identify their probabilistic relationships.
The findings of this research indicate that nursing home care quality is most accurately represented through a mix of structural, process, and outcome measures of quality. We also observe that the factors affecting the quality of nursing home care collectively determine the overall quality. Hence, focusing on only key factors without addressing other related factors may not substantially improve the quality of nursing home care.
Bayesian networks; Nurse staffing; Nursing home quality; Occupancy rate; Quality indicators
The quality of care in nursing homes is weakly defined, and has traditionally focused on quantify nursing homes outputs and on comparison of nursing homes’ resources. Rarely the point of view of clients has been taken into account. The aim of this study was to ascertain what means “quality of care” for residents of nursing homes.
Grounded theory was used to design and analyze a qualitative study based on in-depth interviews with a theoretical sampling including 20 persons aged over 65 years with no cognitive impairment and eight proxy informants of residents with cognitive impairment, institutionalized at a public nursing home in Spain.
Our analysis revealed that participants perceived the quality of care in two ways, as aspects related to the persons providing care and as institutional aspects of the care’s process. All participants agreed that aspects related to the persons providing care was a pillar of quality, something that, in turn, embodied a series of emotional and technical professional competences. Regarding the institutional aspects of the care’s process, participants laid emphasis on round-the-clock access to health care services and on professional’s job stability.
This paper includes perspectives of the nursing homes residents, which are largely absent. Incorporating residents’ standpoints as a complement to traditional institutional criteria would furnish health providers and funding agencies with key information when it came to designing action plans and interventions aimed at achieving excellence in health care.
Nursing Home; Qualitative Research; Quality of Health Care; Patient Satisfaction; Aged
Dissemination of research findings to practice and maintaining rigor and validity in qualitative research is a continuing challenge for nurse researchers. Using three nursing home case studies as examples, we describe how exit interview-consultation was used as: (1) a validation strategy, and; (2) as a rapid research dissemination tool that is particularly useful for nursing systems research. Through an exit interview–consultation method, researchers validated inferences made from qualitative and quantitative data collected in three comprehensive nursing home case studies that examined nursing management practices. This exit interview-consultation strategy extends the traditional member check approach by providing confirmation at the individual and organizational level. We examined how using the exit interview-consultation strategy can potentially assist nursing home organizations to increase their capacity for improving operations. Benefits from research participation are often indirect; this study's results suggest that exit interview-consultation can provide direct and immediate benefits to organizations and individuals.
exit interview-consultation; member check; research dissemination; validity; nursing homes
To assist American families that will one day need to find a nursing home for a loved one, NLM is developing a “Web 2.0” interface to important evaluative information about nursing homes in the US. Currently in prototype form, our “Nursing Home Screener” locates homes on a Google Map. It allows nursing home quality, indicated by map icons, to be surveyed in any of four major categories: staffing, fire safety deficiencies, healthcare deficiencies, and quality of care inferred from residents’ health. Within each category, options can be tailored to user preferences. Furthermore, home attributes can be used to selectively hide home markers of less interest. The goal is to offer the public a timely, easy to use site for the rapid location and comparison of nursing homes, thus identifying those worth further review or a personal visit.
Heart failure is likely to be particularly prevalent in the nursing home population, but reliable data about the prevalence of heart failure in nursing homes are lacking. Therefore the aims of this study are to investigate (a) the prevalence and management of heart failure in nursing home residents and (b) the relation between heart failure and care dependency as well as heart failure and quality of life in nursing home residents.
Nursing home residents in the southern part of the Netherlands, aged over 65 years and receiving long-term somatic or psychogeriatric care will be included in the study. A panel of two cardiologists and a geriatrician will diagnose heart failure based on data collected from actual clinical examinations (including history, physical examination, ECG, cardiac markers and echocardiography), patient records and questionnaires. Care dependency will be measured using the Care Dependency Scale. To measure the quality of life of the participating residents, the Qualidem will be used for psychogeriatric residents and the SF-12 and VAS for somatic residents.
The study will provide an insight into the actual prevalence and management of heart failure in nursing home residents as well as their quality of life and care dependency.
Dutch trial register NTR2663
Registered nurses make measurable contributions to the health and wellness of persons living in nursing homes. However, most nursing homes do not employ adequate numbers of professional nurses with specialized training in the nursing care of older adults to positively impact resident outcomes. As a result, many people never receive excellent geriatric nursing while living in a long-term care facility. Nurses have introduced various professional practice models into health care institutions as tools for leading nursing practice, improving client outcomes, and achieving organizational goals. Problematically, few professional practice models have been implemented in nursing homes. This article introduces an evidence-based framework for professional nursing practice in long-term care. The Everyday Excellence framework is based upon eight guiding principles: Valuing, Envisioning, Peopling, Securing, Learning, Empowering, Leading, and Advancing Excellence. Future research will evaluate the usefulness of this framework for professional nursing practice.
The use of information and communication technology has increased in the society, and can be useful in nursing care. The aim of this study was to describe district nurses’ attitudes regarding the implementation of information and communication technology in home nursing. The first and third authors performed five focus group discussions with 19 district nurses’ from five primary healthcare centres in northern Sweden. During the focus group discussions, the following topics were discussed: the current and future use of information and communication technology in home nursing; expectations, advantages, disadvantages and hindrances in the use of information and communication technology in home nursing; and the use of information and communication technology from an ethical perspective. The transcribed focus group discussions were analysed using qualitative content analysis. The results showed that district nurses’ attitudes were positive regarding the use of information and communication technology in their work. They also asked for possibilities to influence the design and its introduction. However, the use of information and communication technology in home nursing can be described as a complement to communication that could not replace human physical encounters. Improvements and risks, as well as the importance of physical presence in home nursing were considered vital. The results revealed that the use of information and communication technology requires changes in the district nurses’ work situation.
District nursing; focus groups; information and communication technology (ICT); attitudes; qualitative content analysis.
National estimates are provided, for the first time, of the number of hospitalizations in a year for elderly persons who also experience some nursing home use, and patterns for this interaction are described. In 1987, 816,000 persons were transferred from nursing homes to hospitals, constituting 8.5 percent of all Medicare hospital admissions for persons ages 65 and older. Another 347,000 hospital stays involved people admitted from the community and discharged to a nursing home. The reporting of discharge destination on Medicare hospital bill data in 1987 also is analyzed. It was found that these data may have underreported a nursing home as the destination by between 15 and 20 percent. The magnitude of hospitalizations of nursing home residents suggests that programs aimed at improving nursing home care might have an important impact on total days of hospital care, and that it is important to learn more about the optimal use of expensive hospital care.
Nursing homes are a common site of death, but older residents receive variable
quality of end-of-life care. We used a mixed methods design to identify external
influences on the quality of end-of-life care in nursing homes. Two qualitative
case studies were conducted and a postal survey of 180 nursing homes surrounding
the case study sites. In the case studies, qualitative interviews were held with
seven members of nursing home staff and 10 external staff. Problems in accessing
support for end-of-life care reported in the survey included variable support by
general practitioners (GPs), reluctance among GPs to prescribe appropriate
medication, lack of support from other agencies, lack of out of hours support,
cost of syringe drivers and lack of access to training. Most care homes were
implementing a care pathway. Those that were not rated their end-of-life care as
in need of improvement or as average. The case studies suggest that critical
factors in improving end-of-life care in nursing homes include developing
clinical leadership, developing relationships with GPs, the support of
‘key’ external advocates and leverage of additional
resources by adoption of care pathway tools.
Case studies; end-of-life care; mixed methods; nursing homes; older people; survey
The traditional means of communication between nurses and physicians is through paging. This method is disruptive to the workflow of both professions and is too non-specific to be used for all types of messages.
We undertook a quality improvement project to streamline communication between nurses and trainees for urgent and non-urgent matters. We assessed user uptake and satisfaction with the new method.
A General Internal Medicine teaching unit in a tertiary care academic centre.
Through collaborative techniques, we developed a novel communication method that sends non-urgent messages to a Web-based task list and urgent messages to an alphanumeric pager. We implemented this new technology using a collaborative process between nurses and physicians to address all concerns.
Post-implementation surveillance indicated a high degree of uptake of the new practice. User surveys and focus groups showed a high level of satisfaction and a perceived decrease in interruptions to the workflow of both nurses and physicians with the new system. Usage data indicated that the new system may increase overall non-urgent communication.
A Web-based system to triage urgent and non-urgent messages between nurses and physicians was developed collaboratively and implemented successfully to improve workflow for both groups.
Care home residents are vulnerable to the adverse effects of prescribing but there is limited monitoring in the UK.
To compare prescribing quality in care homes in England and Wales with the community and with US nursing homes.
Design and setting
Cross-sectional analysis of a UK primary care database and comparison with the US National Nursing Home Survey including 326 general practices in 2008–2009 in England and Wales, with 10 387 care home and 403 259 community residents aged 65 to 104 years.
Comparison of age- and sex-standardised use of ‘concern’ and common drug groups in the last 90 days and potentially inappropriate prescribing based on a consensus list of medications best avoided in older people (Beers criteria).
Compared to the community, care home residents were more likely to receive ‘concern’ drugs, including benzodiazepines (relative risk (RR) = 2.05, 95% confidence interval (CI) = 1.90 to 2.22), anticholinergic antihistamines (RR = 2.78, 95% CI = 2.38 to 3.23), loop diuretics (RR = 1.47, 95% CI = 1.41 to 1.53), and antipsychotics (RR = 22.7, 95% CI = 20.6 to 24.9). Use of several common drug groups, including laxatives, antidepressants, and antibiotics, was higher, but use of cardiovascular medication was lower. Thirty-three per cent (95% CI = 31.7% to 34.3%) of care home residents in England and Wales received potentially inappropriate medication, compared to 21.4% (95% CI = 20.9% to 21.8%) in the community. The potentially inappropriate prescribing rate in US nursing homes was similar to England and Wales.
Care home prescribing has the potential for improvement. High use of anticholinergic and psychotropic medication may contribute to functional and cognitive decline. The targeting and effectiveness of medication reviews in care homes needs to be improved.
community; inappropriate prescribing; nursing homes; prescribing patterns; primary care
The caring relationship between the nurse and the person in need of nursing care has been described as a key concept in nursing and could facilitate health and healing by involving the person’s genuine needs. The aim of this study was to explore registered nurses’ experiences of their relationships with persons in need of home-based nursing care. Individual interviews with nurses (n=13 registered nurses and 11 district nurses) working in home-based nursing care were performed. A thematic content analysis was used to analyze the transcribed interviews and resulted in the main theme Good nursing care is built on trusting relationship and five sub-themes, Establishing the relationship in home-based nursing care, Conscious efforts maintains the relationship, Reciprocity is a requirement in the relationship, Working in different levels of relationships and Limitations and boundaries in the relationship. A trusting relationship between the nurse and the person in need of healthcare is a prerequisite for good home-based nursing care whether it is based on face-to-face encounters or remote encounters through distance-spanning technology. A trusting relationship could reduce the asymmetry of the caring relationship which could strengthen the person’s position. The relationship requires conscious efforts from the nurse and a choice of level of the relationship. The trusting relationship was reciprocal and meant that the nurse had to communicate something about themself as the person needs to know who is entering the home and who is communicating through distance-spanning technology.
Relationship; home-based nursing care; registered nurses; experiences; distance-spanning technology; interviews; thematic content analysis.
The emigration of skilled nurses from the Philippines is an ongoing phenomenon that has impacted the quality and quantity of the nursing workforce, while strengthening the domestic economy through remittances. This study examines how the development of brain drain-responsive policies is driven by the effects of nurse migration and how such efforts aim to achieve mind-shifts among nurses, governing and regulatory bodies, and public and private institutions in the Philippines and worldwide.
Interviews and focus group discussions were conducted to elicit exploratory perspectives on the policy response to nurse brain drain. Interviews with key informants from the nursing, labour and immigration sectors explored key themes behind the development of policies and programmes that respond to nurse migration. Focus group discussions were held with practising nurses to understand policy recipients’ perspectives on nurse migration and policy.
Using the qualitative data, a thematic framework was created to conceptualize participants’ perceptions of how nurse migration has driven the policy development process. The framework demonstrates that policymakers have recognised the complexity of the brain drain phenomenon and are crafting dynamic policies and programmes that work to shift domestic and global mindsets on nurse training, employment and recruitment.
Development of responsive policy to Filipino nurse brain drain offers a glimpse into a domestic response to an increasingly prominent global issue. As a major source of professionals migrating abroad for employment, the Philippines has formalised efforts to manage nurse migration. Accordingly, the Philippine paradigm, summarised by the thematic framework presented in this paper, may act as an example for other countries that are experiencing similar shifts in healthcare worker employment due to migration.
Nurse migration; Brain drain; Brain circulation; Human resources for health; Filipino nurses; Philippines
To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs).
Four randomly selected community nursing homes.
NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs).
Interviews (n = 35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers’ Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description.
None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were ‘‘checklists’’ to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities.
Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.
clinical practice guidelines; nursing facilities; qualitative research