Association of Work Environment With Missed and Rushed Care Tasks Among Care Aides in Nursing Homes | Geriatrics | JAMA Network Open | JAMA Network
[Skip to Content]
[Skip to Content Landing]
Table 1.  Dependent, Independent, and Control Variables Measured
Dependent, Independent, and Control Variables Measured
Table 2.  Care Aide Characteristics
Care Aide Characteristics
Table 3.  Unit and Nursing Home Characteristics
Unit and Nursing Home Characteristics
Table 4.  Missed and Rushed Care Tasks Reported
Missed and Rushed Care Tasks Reported
Table 5.  Multivariable Analyses of Organizational Context With Missed Care and Rushed Carea
Multivariable Analyses of Organizational Context With Missed Care and Rushed Carea
1.
Hewko  SJ, Cooper  SL, Huynh  H,  et al.  Invisible no more: a scoping review of the health care aide workforce literature.  BMC Nurs. 2015;14(1):38. doi:10.1186/s12912-015-0090-xPubMedGoogle ScholarCrossref
2.
National Institute on Ageing.  Enabling the future provision of long-term care in Canada. https://static1.squarespace.com/static/5c2fa7b03917eed9b5a436d8/t/5d9de15a38dca21e46009548/1570627931078/Enabling+the+Future+Provision+of+Long-Term+Care+in+Canada.pdf. Accessed November 27, 2019.
3.
Chung  G.  Understanding nursing home worker conceptualizations about good care.  Gerontologist. 2013;53(2):246-254. doi:10.1093/geront/gns117PubMedGoogle ScholarCrossref
4.
Knopp-Sihota  JA, Niehaus  L, Squires  JE, Norton  PG, Estabrooks  CA.  Factors associated with rushed and missed resident care in western Canadian nursing homes: a cross-sectional survey of health care aides.  J Clin Nurs. 2015;24(19-20):2815-2825. doi:10.1111/jocn.12887PubMedGoogle ScholarCrossref
5.
Simmons  SF, Durkin  DW, Rahman  AN, Choi  L, Beuscher  L, Schnelle  JF.  Resident characteristics related to the lack of morning care provision in long-term care.  Gerontologist. 2013;53(1):151-161. doi:10.1093/geront/gns065PubMedGoogle ScholarCrossref
6.
Mallidou  AA, Cummings  GG, Schalm  C, Estabrooks  CA.  Health care aides use of time in a residential long-term care unit: a time and motion study.  Int J Nurs Stud. 2013;50(9):1229-1239. doi:10.1016/j.ijnurstu.2012.12.009PubMedGoogle ScholarCrossref
7.
Kaplan  HC, Brady  PW, Dritz  MC,  et al.  The influence of context on quality improvement success in health care: a systematic review of the literature.  Milbank Q. 2010;88(4):500-559. doi:10.1111/j.1468-0009.2010.00611.xPubMedGoogle ScholarCrossref
8.
Jones  TL, Hamilton  P, Murry  N.  Unfinished nursing care, missed care, and implicitly rationed care: state of the science review.  Int J Nurs Stud. 2015;52(6):1121-1137. doi:10.1016/j.ijnurstu.2015.02.012PubMedGoogle ScholarCrossref
9.
Kalisch  BJ, Tschannen  D, Lee  KH.  Missed nursing care, staffing, and patient falls.  J Nurs Care Qual. 2012;27(1):6-12. doi:10.1097/NCQ.0b013e318225aa23PubMedGoogle ScholarCrossref
10.
Ausserhofer  D, Zander  B, Busse  R,  et al; RN4CAST consortium.  Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study.  BMJ Qual Saf. 2014;23(2):126-135. doi:10.1136/bmjqs-2013-002318PubMedGoogle ScholarCrossref
11.
Ball  JE, Murrells  T, Rafferty  AM, Morrow  E, Griffiths  P.  ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care.  BMJ Qual Saf. 2014;23(2):116-125. doi:10.1136/bmjqs-2012-001767PubMedGoogle ScholarCrossref
12.
Estabrooks  CA, Squires  JE, Cummings  GG, Teare  GF, Norton  PG.  Study protocol for the translating research in elder care (TREC): building context—an organizational monitoring program in long-term care project (project one).  Implement Sci. 2009;4(1):52. doi:10.1186/1748-5908-4-52PubMedGoogle ScholarCrossref
13.
Chamberlain  SA, Hoben  M, Squires  JE, Cummings  GG, Norton  P, Estabrooks  CA.  Who is (still) looking after mom and dad: few improvements in care aides’ quality-of-work life.  Can J Aging. 2019;38(1):35-50. doi:10.1017/S0714980818000338PubMedGoogle ScholarCrossref
14.
Nelson  EC, Batalden  PB, Huber  TP,  et al; Learning from High-Performing Front-Line Clinical Units.  Microsystems in health care: part 1: learning from high-performing front-line clinical units.  Jt Comm J Qual Improv. 2002;28(9):472-493. doi:10.1016/S1070-3241(02)28051-7PubMedGoogle Scholar
15.
Estabrooks  CA, Morgan  DG, Squires  JE,  et al.  The care unit in nursing home research: evidence in support of a definition.  BMC Med Res Methodol. 2011;11(1):46. doi:10.1186/1471-2288-11-46PubMedGoogle ScholarCrossref
16.
Squires  JE, Hutchinson  AM, Bostrom  A-M,  et al.  A data quality control program for computer-assisted personal interviews.  Nurs Res Pract. 2012;2012:303816. doi:10.1155/2012/303816PubMedGoogle Scholar
17.
Estabrooks  CA, Squires  JE, Hayduk  LA, Cummings  GG, Norton  PG.  Advancing the argument for validity of the Alberta Context Tool with healthcare aides in residential long-term care.  BMC Med Res Methodol. 2011;11(1):107. doi:10.1186/1471-2288-11-107PubMedGoogle ScholarCrossref
18.
Milligan  GW, Cooper  MC.  An examination of procedures for determining the number of clusters in a data set.  Psychometrika. 1985;50(2):159-179. doi:10.1007/BF02294245Google ScholarCrossref
19.
Estabrooks  CA, Knopp-Sihota  JA, Cummings  GG, Norton  PG.  Making research results relevant and useable: presenting complex organizational context data to nonresearch stakeholders in the nursing home setting.  Worldviews Evid Based Nurs. 2016;13(4):270-276. doi:10.1111/wvn.12158PubMedGoogle ScholarCrossref
20.
Zúñiga  F, Ausserhofer  D, Hamers  JPH, Engberg  S, Simon  M, Schwendimann  R.  The relationship of staffing and work environment with implicit rationing of nursing care in Swiss nursing homes—a cross-sectional study.  Int J Nurs Stud. 2015;52(9):1463-1474. doi:10.1016/j.ijnurstu.2015.05.005PubMedGoogle ScholarCrossref
21.
Little  RJ.  A test of missing completely at random for multivariate data with missing values.  J Am Stat Assoc. 1988;83(404):1198-1202. doi:10.1080/01621459.1988.10478722Google ScholarCrossref
22.
Yamamoto-Mitani  N, Saito  Y, Takaoka  M, Takai  Y, Igarashi  A.  Nurses’ and care workers’ perception of care quality in Japanese long-term care wards: a qualitative descriptive study.  Glob Qual Nurs Res. 2018;5:2333393618812189. doi:10.1177/2333393618812189PubMedGoogle Scholar
23.
Henderson  J, Willis  E, Xiao  L, Blackman  I.  Missed care in residential aged care in Australia: an exploratory study.  Collegian. 2017;24(5):411-416. doi:10.1016/j.colegn.2016.09.001Google ScholarCrossref
24.
Recio-Saucedo  A, Dall’Ora  C, Maruotti  A,  et al.  What impact does nursing care left undone have on patient outcomes: review of the literature.  J Clin Nurs. 2018;27(11-12):2248-2259. doi:10.1111/jocn.14058PubMedGoogle ScholarCrossref
25.
Sochalski  J.  Is more better: the relationship between nurse staffing and the quality of nursing care in hospitals.  Med Care. 2004;42(2)(suppl):II67-II73. doi:10.1097/01.mlr.0000109127.76128.aaPubMedGoogle Scholar
26.
Carthon  JMB, Lasater  KB, Sloane  DM, Kutney-Lee  A.  The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals.  BMJ Qual Saf. 2015;24(4):255-263. doi:10.1136/bmjqs-2014-003346PubMedGoogle ScholarCrossref
27.
Ball  JE, Bruyneel  L, Aiken  LH,  et al; RN4Cast Consortium.  Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study.  Int J Nurs Stud. 2018;78:10-15. doi:10.1016/j.ijnurstu.2017.08.004PubMedGoogle ScholarCrossref
28.
Ball  J, Griffiths  P.  Missed nursing care: a key measure for patient safety.  Perspect Safety. March 2019. http://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety. Accessed December 11, 2019.Google Scholar
29.
Lillekroken  D, Hauge  S, Slettebø  Å.  The meaning of slow nursing in dementia care.  Dementia (London). 2017;16(7):930-947. doi:10.1177/1471301215625112PubMedGoogle ScholarCrossref
30.
Lohne  V, Høy  B, Lillestø  B,  et al.  Fostering dignity in the care of nursing home residents through slow caring.  Nurs Ethics. 2017;24(7):778-788. doi:10.1177/0969733015627297PubMedGoogle ScholarCrossref
31.
Zeller  A, Müller  M, Needham  I, Dassen  T, Kok  G, Halfens  RJ.  Dealing with aggressive behaviour in nursing homes: caregivers’ use of recommended measures.  J Clin Nurs. 2014;23(17-18):2542-2553. doi:10.1111/jocn.12468PubMedGoogle ScholarCrossref
32.
Musa  MK, Saga  S, Blekken  LE, Harris  R, Goodman  C, Norton  C.  The prevalence, incidence, and correlates of fecal incontinence among older people residing in care homes: a systematic review.  J Am Med Dir Assoc. 2019;20(8):956-962.e8. doi:10.1016/j.jamda.2019.03.033PubMedGoogle ScholarCrossref
33.
Lavallée  JF, Gray  TA, Dumville  J, Cullum  N.  Barriers and facilitators to preventing pressure ulcers in nursing home residents: a qualitative analysis informed by the Theoretical Domains Framework.  Int J Nurs Stud. 2018;82:79-89. doi:10.1016/j.ijnurstu.2017.12.015PubMedGoogle ScholarCrossref
34.
Van Tiggelen  H, Van Damme  N, Theys  S,  et al.  The prevalence and associated factors of skin tears in Belgian nursing homes: a cross-sectional observational study.  J Tissue Viability. 2019;28(2):100-106. doi:10.1016/j.jtv.2019.01.003PubMedGoogle ScholarCrossref
35.
Sfantou  DF, Laliotis  A, Patelarou  AE, Sifaki-Pistolla  D, Matalliotakis  M, Patelarou  E.  Importance of leadership style towards quality of care measures in healthcare settings: a systematic review.  Healthcare (Basel). 2017;5(4):E73. doi:10.3390/healthcare5040073PubMedGoogle Scholar
36.
Smith  SN, Almirall  D, Prenovost  K,  et al.  Organizational culture and climate as moderators of enhanced outreach for persons with serious mental illness: results from a cluster-randomized trial of adaptive implementation strategies.  Implement Sci. 2018;13(1):93. doi:10.1186/s13012-018-0787-9PubMedGoogle ScholarCrossref
37.
Kaplan  HC, Ballard  J.  Changing practice to improve patient safety and quality of care in perinatal medicine.  Am J Perinatol. 2012;29(1):35-42. doi:10.1055/s-0031-1285826PubMedGoogle ScholarCrossref
38.
Kuo  HT, Yin  TJC, Li  IC.  Relationship between organizational empowerment and job satisfaction perceived by nursing assistants at long-term care facilities.  J Clin Nurs. 2008;17(22):3059-3066. doi:10.1111/j.1365-2702.2007.02072.xPubMedGoogle ScholarCrossref
39.
Aarons  GA, Sawitzky  AC.  Organizational culture and climate and mental health provider attitudes toward evidence-based practice.  Psychol Serv. 2006;3(1):61-72. doi:10.1037/1541-1559.3.1.61PubMedGoogle ScholarCrossref
40.
Ruchlin  HS, Dubbs  NL, Callahan  MA.  The role of leadership in instilling a culture of safety: lessons from the literature.  J Healthc Manag. 2004;49(1):47-58. doi:10.1097/00115514-200401000-00009PubMedGoogle ScholarCrossref
41.
Grubaugh  ML, Flynn  L.  Relationships among nurse manager leadership skills, conflict management, and unit teamwork.  J Nurs Adm. 2018;48(7-8):383-388. doi:10.1097/NNA.0000000000000633PubMedGoogle ScholarCrossref
42.
Scott-Cawiezell  J, Schenkman  M, Moore  L,  et al.  Exploring nursing home staff’s perceptions of communication and leadership to facilitate quality improvement.  J Nurs Care Qual. 2004;19(3):242-252. doi:10.1097/00001786-200407000-00011PubMedGoogle ScholarCrossref
43.
Kitson  A, Harvey  G, McCormack  B.  Enabling the implementation of evidence based practice: a conceptual framework.  Qual Health Care. 1998;7(3):149-158. doi:10.1136/qshc.7.3.149PubMedGoogle ScholarCrossref
44.
Armijo-Olivo  S, Craig  R, Corabian  P, Guo  B, Souri  S, Tjosvold  L.  Nursing staff time and care quality in long-term care facilities: a systematic review [published online May 22, 2019].  Gerontologist. doi:10.1093/geront/gnz053PubMedGoogle Scholar
45.
Backhaus  R, Verbeek  H, van Rossum  E, Capezuti  E, Hamers  JP.  Nurse staffing impact on quality of care in nursing homes: a systematic review of longitudinal studies.  J Am Med Dir Assoc. 2014;15(6):383-393. doi:10.1016/j.jamda.2013.12.080PubMedGoogle ScholarCrossref
46.
Mark  BA, Salyer  J, Harless  DW.  What explains nurses’ perceptions of staffing adequacy?  J Nurs Adm. 2002;32(5):234-242. doi:10.1097/00005110-200205000-00003PubMedGoogle ScholarCrossref
47.
British Columbia Ministry of Health.  Residential care staffing review. https://www.health.gov.bc.ca/library/publications/year/2017/residential-care-staffing-review.pdf. Published 2017. Accessed November 27, 2019.
48.
Canadian Institute for Health Information.  Residential long-term care financial data tables 2013. https://www.cihi.ca/en/access-data-reports/results?f%5B0%5D=field_primary_theme%3A2051. Published 2015. Accessed November 27, 2019.
49.
Leonard  M, Graham  S, Bonacum  D.  The human factor: the critical importance of effective teamwork and communication in providing safe care.  Qual Saf Health Care. 2004;13(suppl 1):i85-i90. doi:10.1136/qshc.2004.010033PubMedGoogle ScholarCrossref
50.
Colón-Emeric  CS, Corazzini  K, McConnell  ES,  et al.  Effect of promoting high-quality staff interactions on fall prevention in nursing homes: a cluster-randomized trial.  JAMA Intern Med. 2017;177(11):1634-1641. doi:10.1001/jamainternmed.2017.5073PubMedGoogle ScholarCrossref
51.
Solon  G, Haider  SJ, Wooldridge  JM.  What are we weighting for?  J Hum Resour. 2015;50(2):301-316. doi:10.3368/jhr.50.2.301Google ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Geriatrics
    January 29, 2020

    养老院护理人员工作环境与遗漏和仓促护理任务之间的关系

    Author Affiliations
    • 1Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
    • 2Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
    JAMA Netw Open. 2020;3(1):e1920092. doi:10.1001/jamanetworkopen.2019.20092
    关键点 español English

    问题  工作环境是否与养老院护理人员未完成和匆忙完成基本护理任务有关?

    结果  在这项针对 93 家加拿大养老院 4016 名护理人员的横断面研究中,工作环境更好的养老院护理人员遗漏护理任务的可能性降低了 59%,匆忙完成护理任务的可能性降低了 66%。

    意义  这些调查结果表明,在工作环境更好的养老院里,遗漏或匆忙完成的基本护理任务更少。

    Abstract

    Importance  In Canada, approximately 81% of residents of nursing homes live with mild to severe cognitive impairment. Care needs of this population are increasingly complex, but resources, such as staffing, for nursing homes continue to be limited. Staff risk missing or rushing care tasks and interfering with quality of care and life.

    Objective  To assess the association of work environment with missing and rushing essential care tasks in nursing homes.

    Design, Setting, and Participants  This cross-sectional study used survey data collected from a random sample of 93 urban nursing homes in Western Canada, stratified by health region, owner-operator model, and facility size, between May and December 2017. All 5411 eligible care aides were invited to participate, and 4016 care aides agreed and completed structured, computer-assisted interviews in person. Analyses were conducted from July 4, 2018, to February 27, 2019.

    Main Outcomes and Measures  Self-reported number of essential care tasks missed (range, 0-8) or rushed (range, 0-7) in the most recent shift. Two-level random intercept hurdle regressions controlled for care aide, care unit, and nursing home characteristics.

    Results  Of 4016 care aides, 2757 (68.7%) were 40 years or older, 3574 (89.1%) were women, and 2663 (66.3%) spoke English as an additional language. For their most recent shift, 2306 care aides (57.4%) reported missing at least 1 essential care task and 2628 care aides (65.4%) reported rushing at least 1 essential care task. Care aides on units with more favorable work environments (eg, more effective leadership, better work culture, higher levels of buffering resources) were less likely to miss any care tasks (odds ratio, 1.59; 95% CI, 1.34-1.90; P < .001) and less likely to rush any care task (odds ratio, 1.66; 95% CI, 1.38-1.99; P < .001).

    Conclusions and Relevance  This study found that rates of missed and rushed essential care in Canadian nursing homes were high and were higher in units with less favorable work environments. This finding suggests that work environment should be added to the list of modifiable factors associated with improving nursing home care, as it may be an important pathway for improving quality of care. Further research is needed to understand associations of missed and rushed care and of improving work environments with outcomes among residents of nursing homes.

    Introduction

    Nursing homes care for people with complex medical and social care needs. More than 80% of direct care is performed by care aides (also called nursing assistants).1 Despite increasingly complex care needs of residents, nursing home funding remains limited,2 while workloads of care aides increase and become more complex. Care aides may rush and miss care tasks to meet tight schedules and task lists,3 although those tasks are essential to both quality of care and quality of life. Emerging research suggests that care aides frequently leave essential care undone4,5 and rush essential care.6

    Both quality of care and quality of life for residents likely diminish with missed and rushed care, but it is not fully understood why missed and rushed care happens. That knowledge is critical for interventions to reduce it. Kaplan et al7 identified optimized organizational context (ie, work environment) as important to successful interventions for quality improvement. In acute care, better organizational context is associated with less missed care.8-11 However, to our knowledge, there are no data for nursing homes.

    We examined how modifiable elements of organizational context are associated with missed and rushed care by care aides in nursing homes to inform the design of interventions that could reduce missed and rushed care. We hypothesized that care aides working on care units with more favorable organizational context would report fewer missed and rushed essential care tasks than those working on care units with less favorable context.

    Methods
    Study Design

    This study used cross-sectional survey data from the Translating Research in Elder Care (TREC) research program,12 which is a multilevel, longitudinal program of applied health services research to improve quality of care and quality of life for residents of nursing home and quality of work life for the staff who care for them. Since 2007, TREC has collected data from a cohort of 93 nursing homes across Western Canada. Variables used in this study were initially developed in 2012, piloted during data collection from 2014 to 2015, and first comprehensively collected from May to December 2017. This study is reported following Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Setting

    Canada’s health regions oversee most aspects of nursing homes, including quality of care and nursing home policies, with exceptions in some regions for for-profit operators.13 Health regions vary in oversight.13 Study facilities for TREC were randomly selected from lists stratified by health region (ie, British Columbia Fraser Health Authority, British Columbia Interior Health Authority, Alberta Health Edmonton Zone, Alberta Health Calgary Zone, or Winnipeg Regional Health Authority), owner-operator model (ie, public nonprofit, voluntary nonprofit, or private for-profit), and facility size (ie, small, defined as <80 beds; medium, 80-120 beds; or large, >120 beds). Specific sampling and data collection approaches are described in detail elsewhere.12 Care units (also known as clinical microsystems14,15) in this study were physical locations in nursing homes with a unit manager, a nurse overseeing shift-by-shift care, and dedicated teams of regular staff providing direct care. These clinical microsystems are essential foci for improvement programs.

    Ethics

    This study was approved by the University of Alberta research ethics board. For original TREC survey data collection, participating organizations gave operational approvals. Using multiple strategies, we informed potential survey participants about this study. Written informed consent was obtained from participants.

    Participants

    Care aides were eligible to participate if they had worked in a study facility for longer than 3 months, could identify a unit where they worked for at least 50% of their time during the data collection period, and worked on that unit for 6 or more shifts in the past month. Trained TREC data collectors went to each participating nursing home and invited all eligible care aides to participate.12 Care aides who agreed to participate completed computer-assisted, structured interviews in person16 between May and December 2017.

    Only care units with responses from at least 8 care aides were included in this study. This criterion reflects our finding that stable estimates of organizational context at the unit level are achieved when 8 or more individual responses are aggregated.15

    Measures
    Independent Variable

    Our independent variable was organizational context at the unit level, measured by the Alberta Context Tool (ACT). This validated instrument measures 10 modifiable elements of organizational context: leadership, culture, evaluation, formal interactions, informal interactions, structural and electronic resources, social capital, organizational slack in use of time, organizational slack in use of staff, and organizational slack in use of space.17 eTable 1 in the Supplement summarizes the psychometric properties of ACT. Each element has 2 to 9 items. Each element was aggregated within respondents by the mean or the count of items (Table 1). We used care aide responses to create unit-level scores for context because care aides are the only sufficiently large workforce group in nursing homes to support aggregate scores. Care aides also provide 80% or more of direct resident care1 and are most familiar with residents and conditions of work and resident life. They are well positioned to provide context scores that are closest to resident experiences. We aggregated to the unit level the 10 ACT elements from each care aide surveyed. Then, drawing on Milligan and Cooper’s clustering analysis approach18 (n of predetermined clusters = 2), we determined whether a unit had a more or less favorable organizational context.19

    Outcomes

    Our dependent variables were missed care and rushed care at the individual care aide level. Missed care and rushed care items were developed iteratively by engaging care aides in developing previous TREC surveys.4 Items followed the form, on your last shift, did you leave mouth care for residents undone because you did not have enough time? Care aides were asked yes or no for each missed and rushed task item. Yes responses were counted and summed separately for missed care and rushed care.

    Covariates

    For multivariable analysis, we adjusted for covariates related to care aide, unit, and nursing home characteristics (Table 1). Inclusion of these variables in final models was informed by previous research on missed care in acute settings and nursing homes.4,6,8,20 Care aides self-reported their demographic and work characteristics.12 Unit and facility characteristics were collected in short structured interviews with unit and facility managers. For missing data, we used listwise deletion. Less than 0.2% of data were missing for all variables, completely at random (Little missing completely at random test,21P = .84). eTable 2 in the Supplement shows characteristics of care aides with complete vs incomplete data.

    Statistical Analysis

    Analyses were conducted from July 4, 2018, to February 27, 2019, using SAS statistical software version 9.4 (SAS Institute). For descriptive analysis, variable categories were care aide demographic characteristics, care aide work characteristics, unit and facility characteristics, and health region. We calculated means and SDs for continuous variables and frequency counts and proportions for categorical and binary variables. We summed the number of times that care aides answered yes to missing or rushing each care task and calculated percentage of occurrence in the whole sample. We then ranked missed and rushed care tasks from highest to lowest percentage of occurrence in the whole sample. To inform inclusion of variables in subsequent multivariable analysis, we drew on previous literature on missed and rushed care in short- and long-term care settings. Multicollinearity was assessed, and 2 variables (ie, hours worked in 2 weeks and time worked as a care aide) were removed before multivariable analysis.

    For regression analyses, we ran 2 sets of analyses, one using ACT as a binary variable and the other with the 10 ACT elements individually. Hurdle Poisson regression models were used for both analyses. They account for excessive numbers of 0s using 2 components: logistic and Poisson regression models. The logistic model recodes the dependent variable (ie, missed care or rushed care) as a binary variable: 0 or 1. It models probability when the dependent variable is 0. The Poisson regression model only uses data with a non-0 dependent variable: 1 to 8 for missed care and 1 to 7 for rushed care. Odds ratios (ORs) with 95% CIs were generated for the logistic model. Relative rates (RRs) with 95% CIs were generated for the Poisson model. To control for the clustering effect of individual care aides within units, we added a random intercept parameter to each component. P values were 2-tailed, and statistical significance was set at P < .01.

    Results

    Of 5411 eligible care aides in 312 care units in 93 nursing homes, 4016 care aides (74.2%) responded to the survey invitation. Data to assess nonresponder characteristics were not available because data on nursing home care aides in Canada are not kept systematically.13 Characteristics of included care aides are presented in Table 2. Care aides were predominantly women (3574 care aides [89.1%]) 40 years or older (2757 care aides [68.7%]) who spoke English as an additional language (2663 care aides [66.3%]) (Table 2). Characteristics of care units and nursing homes are presented in Table 3.

    Missing and rushing care tasks were common in nursing homes. For their most recent shift, 2306 care aides (57.4%) reported missing at least 1 care task and 2628 care aides (65.4%) reported rushing at least 1 care task (Table 4). The most frequently missed task was taking residents for a walk, which 1492 care aides (37.2%) reported missing. The most frequently rushed task was talking with residents, which 1977 care aides (49.2%) reported rushing. Performing mouth care was missed by 567 care aides (14.1%) and rushed by 1580 care aides (39.3%). Other care tasks, such as toileting, preparing residents for sleep, bathing residents, feeding residents, and dressing residents, were each missed by less than 10% of care aides but were each rushed by more than 30% of care aides (Table 4).

    Compared with care aides who worked on units with less favorable organizational context, care aides who worked on units with more favorable organizational context were 59% less likely to miss any care task (OR, 1.59; 95% CI, 1.34-1.90; P < .001) and 66% less likely to rush any care task (OR, 1.66; 95% CI, 1.38-1.99; P < .001) (Table 5). Among care aides who reported rushing at least 1 task, those working on units with more favorable organizational context rushed 7% fewer care tasks (RR, 0.93; 95% CI, 0.88-0.98; P = .007) than care aides on units with less favorable organizational context (eTable 3 and eTable 4 in the Supplement).

    To understand which specific elements of organizational context were associated with missed and rushed care in our sample, we conducted further analyses with the 10 ACT elements. Missed care was associated with 4 elements: culture, organizational slack in use of staffing or use of time, and social capital (eTable 5 in the Supplement). With a 1-unit increase in care unit culture, care aides were 62% more likely to miss any care task (OR, 0.38; 95% CI, 0.19-0.73; P = .004). However, with a 1-unit increase in organizational slack in use of staff, care aides were 65% less likely to miss any care task (OR, 1.65; 95% CI, 1.32-2.05; P < .001). For organizational slack in use of time, care aides were 103% less likely to miss any care tasks (OR, 2.03; 95% CI, 1.44-2.86; P < .001). Among care aides who reported missing at least 1 care task, a 1-unit increase in social capital was associated with missing 49% fewer care tasks (RR, 0.51; 95% CI, 0.36-0.70; P < .001), and a 1-unit increase of organizational slack in use of staff was associated with missing 20% fewer care tasks (RR, 0.80; 95% CI, 0.71-0.90; P < .001) (eTable 5 in the Supplement).

    Rushed care was associated with 2 elements: organizational slack in use of staff and culture. With a 1-unit increase of organizational slack in use of staff on care units, care aides were 91% less likely to rush any care task (OR, 1.91; 95% CI, 1.51-2.42; P < .001). However, care aides who reported rushing at least 1 task rushed 34% more care tasks with a 1-unit increase in culture (RR, 1.34, 95% CI, 1.09-1.65; P = .006) (eTable 6 in the Supplement).

    Discussion

    In this cross-sectional study, high proportions of nursing home care aides reported missing and rushing essential care tasks—tasks that are important to quality of care and quality of resident life. Excessive staff busyness has been identified as a significant daily challenge in nursing homes in Europe,20 Canada,4 Japan,22 and Australia.23 Care aides’ work is frequently interrupted, with only 1- to 3-minute uninterrupted intervals provided for approximately half of care tasks, including feeding and bathing.6 In Switzerland, nurses and care aides reported missing 46% of activities of daily living at least once in the previous 7 days.20 In Japan, care workers have described only having time for minimum care (eg, bathing, changing diapers) and none for extra care, such as taking residents for a walk.22

    Research from acute settings supports that missing or rushing essential care interferes with quality and safety.8,24 Missed care explained 40% of variation in quality ratings of US-based acute care hospitals25 and 9.2% of variance in patient falls.9 In US and European acute care studies, missed care was associated with increased nosocomial infections, pressure ulcers, patient dissatisfaction, medication errors, readmission to hospitals, critical incidents, compromised patient safety, and increased mortality.8,9,26 A 2018 study across 9 European countries27 found that every 10% increase in missed care by nurses was associated with a 16% increase in odds of 30-day postoperative mortality. That study27 also found that missed care was associated with mediating the association of nurse staffing level with postoperative mortality rate. From these findings, Ball and Griffiths28 concluded that missed nursing care (ie, errors of omission) should be a key patient safety measure in hospitals alongside errors of commission. These reports suggest value in measuring and addressing missed care in nursing homes.

    Almost no research is available on rushed care, to our knowledge. However, evidence is emerging on the benefits of so-called slow care, the opposite of rushed care, for residents of nursing homes, especially those living with dementia.29 Staff who can give residents the time they need facilitate a sense of coherence and foster dignity.29,30 Unrushed care by staff has potential to decrease responsive behaviors of residents.31 These studies strongly suggest that there are potential harms for residents when staff rush care tasks.

    The 2 most frequently missed and rushed care tasks for nursing home care aides in our sample were walking and talking with residents. Talking is directly associated with preventing loneliness and boredom and with encouraging social engagement and creation of meaning. Walking is directly associated with mobility, a serious challenge in nursing homes.32 Immobility is associated with multiple adverse health and quality of life outcomes (eg, fecal incontinence, pressure ulcers, skin tears).32-34 Both talking and walking with residents are associated with care quality and quality of life.

    In our study, care aides working on care units with more favorable organizational context were less likely to miss or rush care tasks. Research has documented that modifiable features of organizational context (eg, leadership, culture, team communication) are associated with resident outcomes35-39 and that these features are interrelated.40-42 Each element of organizational context is modifiable and offers intervention possibilities. However, we propose that nursing home managers and researchers use organizational context as an omnibus construct, modifying multiple elements simultaneously instead of targeting single elements as they develop quality improvement interventions for resident outcomes. We adopted a validated measure of organizational context that draws on a conceptual framework43 and is operationalized through a rigorous process of cluster analysis18 with the 10 modifiable ACT elements. Our findings may provide potential directions for nursing home managers to reduce missed and rushed care by care aides through improved local organizational context.

    We found that units for which care aides perceived more organizational slack in use of staff and use of time had lower likelihoods or numbers of missed and rushed essential care tasks. Research has reported mixed evidence on the association of nursing staffing and resident outcomes, such as 2 systematic reviews in nursing homes that concluded that the evidence was inconsistent—higher staffing levels were associated with both better and worse resident outcomes.44,45 However, staff perceptions of staffing level may differ from actual levels. Perceptions are affected by care unit composition, staff composition, and resident composition.46 In our study, we identified variation in care aide perceptions of staffing and time across care units, although staffing levels for nursing homes (eg, number of care hours per resident day) are essentially constant across Western Canadian jurisdictions.2,47,48 While funding for nursing homes continues to be limited, our finding suggests opportunities for nursing home managers to improve care aides’ perceptions of staffing. Focus on organizational context and its various elements may reduce essential care tasks missed or rushed by care aides.

    We found that care aides on units with better work environment culture had higher likelihood or number of missed and rushed essential care tasks, opposite to our hypothesis. We do not yet understand why, but we urge further research on this association.

    We found that care aides on units with higher levels of social capital (eg, active connections through information sharing) missed fewer care tasks. Existing evidence is mixed on the association of work environment social capital with resident outcomes. Leonard et al49 have argued that effective communication is key to safe care; however, a randomized clinical trial by Colón-Emeric et al50 teaching nursing home staff to improve connections with coworkers reported improved staff communication but not an increased number of fall risk reduction activities. Our finding offers evidence for the association of social capital with less frequently missed care, providing a potential mechanism for the association of social capital in care units with resident outcomes.

    Strengths and Limitations

    Our study has some strengths, including that we controlled for the clustering effect of care aides within care units in our analyses14 and we used a large stratified random sample of nursing homes.12 Data collection used a rigorous in-person structured interview process with real-time data quality assessments. We included robust data and findings on both missed and rushed care, generating a more complete portrait of these phenomena in nursing homes than previous research has generated by studying only missed or rushed care.6,20

    Our study also has some limitations. We used survey data, which may be susceptible to self-report biases, although recall bias was reduced by asking aides to report on their most recent shift. The potential for misreporting, such as underreporting of missed and rushed care tasks, was reduced by our interview structure and data quality assessments. The study may have bias from omitted variables because we did not control for resident characteristics (eg, cognitive status, responsive behaviors) associated with missed and rushed care.5 We reduced bias by controlling for multiple proxy variables for these characteristics, such as unit type (eg, general long-term care, dementia care units) and the experiences of care aides of residents’ responsive behaviors. Also, the continuous part of the Hurdle Poisson regression models assumes that categories are equidistant. In addition, we did not include sampling weights in our models, as we were not interested in exact estimates of true population values but were interested in possible associations. For this purpose, sampling weights were less relevant.51 Furthermore, data were obtained from a stratified random sample of 93 of 524 facilities in the 3 provinces in Western Canada; thus, caution should be taken with wider generalizations.

    Conclusions

    This study’s findings suggest that rates of missed and rushed essential care are high, which may put residents of nursing homes at risk of adverse health outcomes and decreased quality of life. Researchers, policy makers, and health care system and nursing home managers should consider adding work environment to a list of modifiable factors to improve care and offer new intervention pathways for improving care quality.

    Back to top
    Article Information

    Accepted for Publication: December 3, 2019.

    Published: January 29, 2020. doi:10.1001/jamanetworkopen.2019.20092

    Correction: This article was corrected on April 3, 2020, to correct an error in the Abstract and in the Results. The number of care aides who spoke English as an additional language should have been 2663.

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Song Y et al. JAMA Network Open.

    Corresponding Author: Yuting Song, PhD, Faculty of Nursing, University of Alberta, 11405 87 Ave, 5-007D Edmonton Clinic Health Academy, Edmonton, AB T6G 1C9, Canada (yuting.song@ualberta.ca).

    Author Contributions: Dr Song had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: Song, Norton, Estabrooks.

    Drafting of the manuscript: Song, Hoben, Estabrooks.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Song.

    Obtained funding: Estabrooks.

    Supervision: Norton, Estabrooks.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Funding was provided by the Canadian Institutes of Health Research and partners in the Ministries of Health in British Columbia, Alberta, and Manitoba, Canada, as well as regional health authorities in participating British Columbia and Alberta regions.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Meeting Presentation: This article was presented at the Canadian Association for Health Services and Policy Research Conference; May 30, 2019; Halifax, Nova Scotia, Canada.

    Additional Contributions: The Translating Research in Elder Care 2.0 team contributed data to this study. The data were provided without compensation. Jayna Holroyd-Leduc, MD (Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada), and Sube Banerjee, MD (University of Plymouth, Plymouth, United Kingdom), provided constructive feedback on the manuscript. They did not receive compensation for the work. Cathy McPhalen, PhD (thINK Editing Inc), provided editorial support, which was funded by Carole Estabrooks’ Canada Research Chair, Ottawa, Ontario, Canada, in accordance with Good Publication Practice guidelines.

    References
    1.
    Hewko  SJ, Cooper  SL, Huynh  H,  et al.  Invisible no more: a scoping review of the health care aide workforce literature.  BMC Nurs. 2015;14(1):38. doi:10.1186/s12912-015-0090-xPubMedGoogle ScholarCrossref
    2.
    National Institute on Ageing.  Enabling the future provision of long-term care in Canada. https://static1.squarespace.com/static/5c2fa7b03917eed9b5a436d8/t/5d9de15a38dca21e46009548/1570627931078/Enabling+the+Future+Provision+of+Long-Term+Care+in+Canada.pdf. Accessed November 27, 2019.
    3.
    Chung  G.  Understanding nursing home worker conceptualizations about good care.  Gerontologist. 2013;53(2):246-254. doi:10.1093/geront/gns117PubMedGoogle ScholarCrossref
    4.
    Knopp-Sihota  JA, Niehaus  L, Squires  JE, Norton  PG, Estabrooks  CA.  Factors associated with rushed and missed resident care in western Canadian nursing homes: a cross-sectional survey of health care aides.  J Clin Nurs. 2015;24(19-20):2815-2825. doi:10.1111/jocn.12887PubMedGoogle ScholarCrossref
    5.
    Simmons  SF, Durkin  DW, Rahman  AN, Choi  L, Beuscher  L, Schnelle  JF.  Resident characteristics related to the lack of morning care provision in long-term care.  Gerontologist. 2013;53(1):151-161. doi:10.1093/geront/gns065PubMedGoogle ScholarCrossref
    6.
    Mallidou  AA, Cummings  GG, Schalm  C, Estabrooks  CA.  Health care aides use of time in a residential long-term care unit: a time and motion study.  Int J Nurs Stud. 2013;50(9):1229-1239. doi:10.1016/j.ijnurstu.2012.12.009PubMedGoogle ScholarCrossref
    7.
    Kaplan  HC, Brady  PW, Dritz  MC,  et al.  The influence of context on quality improvement success in health care: a systematic review of the literature.  Milbank Q. 2010;88(4):500-559. doi:10.1111/j.1468-0009.2010.00611.xPubMedGoogle ScholarCrossref
    8.
    Jones  TL, Hamilton  P, Murry  N.  Unfinished nursing care, missed care, and implicitly rationed care: state of the science review.  Int J Nurs Stud. 2015;52(6):1121-1137. doi:10.1016/j.ijnurstu.2015.02.012PubMedGoogle ScholarCrossref
    9.
    Kalisch  BJ, Tschannen  D, Lee  KH.  Missed nursing care, staffing, and patient falls.  J Nurs Care Qual. 2012;27(1):6-12. doi:10.1097/NCQ.0b013e318225aa23PubMedGoogle ScholarCrossref
    10.
    Ausserhofer  D, Zander  B, Busse  R,  et al; RN4CAST consortium.  Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study.  BMJ Qual Saf. 2014;23(2):126-135. doi:10.1136/bmjqs-2013-002318PubMedGoogle ScholarCrossref
    11.
    Ball  JE, Murrells  T, Rafferty  AM, Morrow  E, Griffiths  P.  ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care.  BMJ Qual Saf. 2014;23(2):116-125. doi:10.1136/bmjqs-2012-001767PubMedGoogle ScholarCrossref
    12.
    Estabrooks  CA, Squires  JE, Cummings  GG, Teare  GF, Norton  PG.  Study protocol for the translating research in elder care (TREC): building context—an organizational monitoring program in long-term care project (project one).  Implement Sci. 2009;4(1):52. doi:10.1186/1748-5908-4-52PubMedGoogle ScholarCrossref
    13.
    Chamberlain  SA, Hoben  M, Squires  JE, Cummings  GG, Norton  P, Estabrooks  CA.  Who is (still) looking after mom and dad: few improvements in care aides’ quality-of-work life.  Can J Aging. 2019;38(1):35-50. doi:10.1017/S0714980818000338PubMedGoogle ScholarCrossref
    14.
    Nelson  EC, Batalden  PB, Huber  TP,  et al; Learning from High-Performing Front-Line Clinical Units.  Microsystems in health care: part 1: learning from high-performing front-line clinical units.  Jt Comm J Qual Improv. 2002;28(9):472-493. doi:10.1016/S1070-3241(02)28051-7PubMedGoogle Scholar
    15.
    Estabrooks  CA, Morgan  DG, Squires  JE,  et al.  The care unit in nursing home research: evidence in support of a definition.  BMC Med Res Methodol. 2011;11(1):46. doi:10.1186/1471-2288-11-46PubMedGoogle ScholarCrossref
    16.
    Squires  JE, Hutchinson  AM, Bostrom  A-M,  et al.  A data quality control program for computer-assisted personal interviews.  Nurs Res Pract. 2012;2012:303816. doi:10.1155/2012/303816PubMedGoogle Scholar
    17.
    Estabrooks  CA, Squires  JE, Hayduk  LA, Cummings  GG, Norton  PG.  Advancing the argument for validity of the Alberta Context Tool with healthcare aides in residential long-term care.  BMC Med Res Methodol. 2011;11(1):107. doi:10.1186/1471-2288-11-107PubMedGoogle ScholarCrossref
    18.
    Milligan  GW, Cooper  MC.  An examination of procedures for determining the number of clusters in a data set.  Psychometrika. 1985;50(2):159-179. doi:10.1007/BF02294245Google ScholarCrossref
    19.
    Estabrooks  CA, Knopp-Sihota  JA, Cummings  GG, Norton  PG.  Making research results relevant and useable: presenting complex organizational context data to nonresearch stakeholders in the nursing home setting.  Worldviews Evid Based Nurs. 2016;13(4):270-276. doi:10.1111/wvn.12158PubMedGoogle ScholarCrossref
    20.
    Zúñiga  F, Ausserhofer  D, Hamers  JPH, Engberg  S, Simon  M, Schwendimann  R.  The relationship of staffing and work environment with implicit rationing of nursing care in Swiss nursing homes—a cross-sectional study.  Int J Nurs Stud. 2015;52(9):1463-1474. doi:10.1016/j.ijnurstu.2015.05.005PubMedGoogle ScholarCrossref
    21.
    Little  RJ.  A test of missing completely at random for multivariate data with missing values.  J Am Stat Assoc. 1988;83(404):1198-1202. doi:10.1080/01621459.1988.10478722Google ScholarCrossref
    22.
    Yamamoto-Mitani  N, Saito  Y, Takaoka  M, Takai  Y, Igarashi  A.  Nurses’ and care workers’ perception of care quality in Japanese long-term care wards: a qualitative descriptive study.  Glob Qual Nurs Res. 2018;5:2333393618812189. doi:10.1177/2333393618812189PubMedGoogle Scholar
    23.
    Henderson  J, Willis  E, Xiao  L, Blackman  I.  Missed care in residential aged care in Australia: an exploratory study.  Collegian. 2017;24(5):411-416. doi:10.1016/j.colegn.2016.09.001Google ScholarCrossref
    24.
    Recio-Saucedo  A, Dall’Ora  C, Maruotti  A,  et al.  What impact does nursing care left undone have on patient outcomes: review of the literature.  J Clin Nurs. 2018;27(11-12):2248-2259. doi:10.1111/jocn.14058PubMedGoogle ScholarCrossref
    25.
    Sochalski  J.  Is more better: the relationship between nurse staffing and the quality of nursing care in hospitals.  Med Care. 2004;42(2)(suppl):II67-II73. doi:10.1097/01.mlr.0000109127.76128.aaPubMedGoogle Scholar
    26.
    Carthon  JMB, Lasater  KB, Sloane  DM, Kutney-Lee  A.  The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals.  BMJ Qual Saf. 2015;24(4):255-263. doi:10.1136/bmjqs-2014-003346PubMedGoogle ScholarCrossref
    27.
    Ball  JE, Bruyneel  L, Aiken  LH,  et al; RN4Cast Consortium.  Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study.  Int J Nurs Stud. 2018;78:10-15. doi:10.1016/j.ijnurstu.2017.08.004PubMedGoogle ScholarCrossref
    28.
    Ball  J, Griffiths  P.  Missed nursing care: a key measure for patient safety.  Perspect Safety. March 2019. http://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety. Accessed December 11, 2019.Google Scholar
    29.
    Lillekroken  D, Hauge  S, Slettebø  Å.  The meaning of slow nursing in dementia care.  Dementia (London). 2017;16(7):930-947. doi:10.1177/1471301215625112PubMedGoogle ScholarCrossref
    30.
    Lohne  V, Høy  B, Lillestø  B,  et al.  Fostering dignity in the care of nursing home residents through slow caring.  Nurs Ethics. 2017;24(7):778-788. doi:10.1177/0969733015627297PubMedGoogle ScholarCrossref
    31.
    Zeller  A, Müller  M, Needham  I, Dassen  T, Kok  G, Halfens  RJ.  Dealing with aggressive behaviour in nursing homes: caregivers’ use of recommended measures.  J Clin Nurs. 2014;23(17-18):2542-2553. doi:10.1111/jocn.12468PubMedGoogle ScholarCrossref
    32.
    Musa  MK, Saga  S, Blekken  LE, Harris  R, Goodman  C, Norton  C.  The prevalence, incidence, and correlates of fecal incontinence among older people residing in care homes: a systematic review.  J Am Med Dir Assoc. 2019;20(8):956-962.e8. doi:10.1016/j.jamda.2019.03.033PubMedGoogle ScholarCrossref
    33.
    Lavallée  JF, Gray  TA, Dumville  J, Cullum  N.  Barriers and facilitators to preventing pressure ulcers in nursing home residents: a qualitative analysis informed by the Theoretical Domains Framework.  Int J Nurs Stud. 2018;82:79-89. doi:10.1016/j.ijnurstu.2017.12.015PubMedGoogle ScholarCrossref
    34.
    Van Tiggelen  H, Van Damme  N, Theys  S,  et al.  The prevalence and associated factors of skin tears in Belgian nursing homes: a cross-sectional observational study.  J Tissue Viability. 2019;28(2):100-106. doi:10.1016/j.jtv.2019.01.003PubMedGoogle ScholarCrossref
    35.
    Sfantou  DF, Laliotis  A, Patelarou  AE, Sifaki-Pistolla  D, Matalliotakis  M, Patelarou  E.  Importance of leadership style towards quality of care measures in healthcare settings: a systematic review.  Healthcare (Basel). 2017;5(4):E73. doi:10.3390/healthcare5040073PubMedGoogle Scholar
    36.
    Smith  SN, Almirall  D, Prenovost  K,  et al.  Organizational culture and climate as moderators of enhanced outreach for persons with serious mental illness: results from a cluster-randomized trial of adaptive implementation strategies.  Implement Sci. 2018;13(1):93. doi:10.1186/s13012-018-0787-9PubMedGoogle ScholarCrossref
    37.
    Kaplan  HC, Ballard  J.  Changing practice to improve patient safety and quality of care in perinatal medicine.  Am J Perinatol. 2012;29(1):35-42. doi:10.1055/s-0031-1285826PubMedGoogle ScholarCrossref
    38.
    Kuo  HT, Yin  TJC, Li  IC.  Relationship between organizational empowerment and job satisfaction perceived by nursing assistants at long-term care facilities.  J Clin Nurs. 2008;17(22):3059-3066. doi:10.1111/j.1365-2702.2007.02072.xPubMedGoogle ScholarCrossref
    39.
    Aarons  GA, Sawitzky  AC.  Organizational culture and climate and mental health provider attitudes toward evidence-based practice.  Psychol Serv. 2006;3(1):61-72. doi:10.1037/1541-1559.3.1.61PubMedGoogle ScholarCrossref
    40.
    Ruchlin  HS, Dubbs  NL, Callahan  MA.  The role of leadership in instilling a culture of safety: lessons from the literature.  J Healthc Manag. 2004;49(1):47-58. doi:10.1097/00115514-200401000-00009PubMedGoogle ScholarCrossref
    41.
    Grubaugh  ML, Flynn  L.  Relationships among nurse manager leadership skills, conflict management, and unit teamwork.  J Nurs Adm. 2018;48(7-8):383-388. doi:10.1097/NNA.0000000000000633PubMedGoogle ScholarCrossref
    42.
    Scott-Cawiezell  J, Schenkman  M, Moore  L,  et al.  Exploring nursing home staff’s perceptions of communication and leadership to facilitate quality improvement.  J Nurs Care Qual. 2004;19(3):242-252. doi:10.1097/00001786-200407000-00011PubMedGoogle ScholarCrossref
    43.
    Kitson  A, Harvey  G, McCormack  B.  Enabling the implementation of evidence based practice: a conceptual framework.  Qual Health Care. 1998;7(3):149-158. doi:10.1136/qshc.7.3.149PubMedGoogle ScholarCrossref
    44.
    Armijo-Olivo  S, Craig  R, Corabian  P, Guo  B, Souri  S, Tjosvold  L.  Nursing staff time and care quality in long-term care facilities: a systematic review [published online May 22, 2019].  Gerontologist. doi:10.1093/geront/gnz053PubMedGoogle Scholar
    45.
    Backhaus  R, Verbeek  H, van Rossum  E, Capezuti  E, Hamers  JP.  Nurse staffing impact on quality of care in nursing homes: a systematic review of longitudinal studies.  J Am Med Dir Assoc. 2014;15(6):383-393. doi:10.1016/j.jamda.2013.12.080PubMedGoogle ScholarCrossref
    46.
    Mark  BA, Salyer  J, Harless  DW.  What explains nurses’ perceptions of staffing adequacy?  J Nurs Adm. 2002;32(5):234-242. doi:10.1097/00005110-200205000-00003PubMedGoogle ScholarCrossref
    47.
    British Columbia Ministry of Health.  Residential care staffing review. https://www.health.gov.bc.ca/library/publications/year/2017/residential-care-staffing-review.pdf. Published 2017. Accessed November 27, 2019.
    48.
    Canadian Institute for Health Information.  Residential long-term care financial data tables 2013. https://www.cihi.ca/en/access-data-reports/results?f%5B0%5D=field_primary_theme%3A2051. Published 2015. Accessed November 27, 2019.
    49.
    Leonard  M, Graham  S, Bonacum  D.  The human factor: the critical importance of effective teamwork and communication in providing safe care.  Qual Saf Health Care. 2004;13(suppl 1):i85-i90. doi:10.1136/qshc.2004.010033PubMedGoogle ScholarCrossref
    50.
    Colón-Emeric  CS, Corazzini  K, McConnell  ES,  et al.  Effect of promoting high-quality staff interactions on fall prevention in nursing homes: a cluster-randomized trial.  JAMA Intern Med. 2017;177(11):1634-1641. doi:10.1001/jamainternmed.2017.5073PubMedGoogle ScholarCrossref
    51.
    Solon  G, Haider  SJ, Wooldridge  JM.  What are we weighting for?  J Hum Resour. 2015;50(2):301-316. doi:10.3368/jhr.50.2.301Google ScholarCrossref
    ×