Advertisement

Nurse staffing and adverse events in residential aged care: Retrospective multi-site analysis

  • Dorika Nhongo
    Affiliations
    CQUniversity, School of Nursing, Midwifery and Social Sciences, Bruce Highway, North Rockhampton, Qld, Australia
    Search for articles by this author
  • Annie Holt
    Affiliations
    School of Medicine, University of Notre Dame Australia, Fremantle, Australia
    Search for articles by this author
  • Tracy Flenady
    Affiliations
    CQUniversity, School of Nursing, Midwifery and Social Sciences, Bruce Highway, North Rockhampton, Qld, Australia

    Research Ready Grant Program (RRGP) Program Coordinator, School of Nursing, Midwifery and Social Sciences, Tertiary education division, B18 L1.32 Bruce Highway, North Rockhampton, QLD, 4701, Australia
    Search for articles by this author
  • Amanda Rebar
    Affiliations
    Motivation of Health Behaviours Lab, School of Health and Medical Sciences, Central Queensland University, 7/LG 15 North Rockhampton, QLD, 4702, Australia
    Search for articles by this author
  • Kasia Bail
    Correspondence
    Corresponding author.
    Affiliations
    CQUniversity, School of Nursing, Midwifery and Social Sciences, Bruce Highway, North Rockhampton, Qld, Australia

    Gerontological Nursing, Nursing, Faculty of Health and Ageing Research Group, University of Canberra, 11 Kirinari Street, Bruce, ACT, 2617, Australia

    Synergy Nursing and Midwifery Research Centre, ACT Health Directorate, 2-6 Bowes Street, Phillip, 2606, Australia
    Search for articles by this author
Published:October 19, 2022DOI:https://doi.org/10.1016/j.colegn.2022.09.017

      Summary of relevance

      • Issue: Quality of care is an ongoing issue in Australian residential aged care homes, with repeated reviews highlighting that workforce is a key aspect of neglect and poor resident outcomes.
      • What is already known: International residential aged care and Australian hospital evidence demonstrates more nurse staffing hours leads to lower rates of adverse events, but evidence specific to Australian aged care is lacking.
      • What this paper adds: Resident access to more registered nursing hours at night and on weekends decreased the chance of pressure injuries/skin tears or falls. Size of homes often determine nursing hours available.

      ABSTRACT

      Background

      People living in residential aged care homes are entitled to a safe environment 24 hours a day, 7 days a week. Unfortunately, past evidence tells us this is not always the case and that our most vulnerable population experience high rates of adverse events.

      Aim

      To determine whether after-hours shifts are associated with number of adverse events, independent of registered nurse staffing levels and residential aged care home size.

      Methods

      Retrospective cohort design with multilevel modelling. Adverse events, registered nurse staffing and facility size were collected via routine reporting from ten homes (1020 beds) in one Australian state for three months in 2017.

      Findings

      Residents records (n = 1560) of adverse events were collected from ten Residential Aged Care Homes with 1020 beds. An adverse event was reported, on average, every second shift per home. During afterhours shifts, there was an inverse association between nurse staffing and adverse events, such that lower nurse staffing was associated with higher rates of adverse events, specifically for falls and pressure injuries/skin tears. During day shifts, this effect was not seen.

      Discussion

      The findings support statements made at the Royal Commission into Aged Care Quality and Safety regarding the lack of adequacy of nurse staffing supervision during and after hours and may contribute to considerations of upcoming mandated registered nursing contact hours for 16 of the 24 hours in a day.

      Conclusion

      During after-hour shifts, but not day shifts, having fewer nurses is associated with more likelihood of adverse event occurrences in Australian residential aged care homes. More research, in more sites and across more organisations, with better granulation across day, evening, night and weekend/public holiday shifts will improve understanding and responsiveness to the phenomena. Future research examining falls should include staffing levels.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Collegian
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Andersson Frank, C.
        • Willman A.M.
        • Sandman P.
        • Hansebo G.
        Factors contributing to serious adverse events in nursing homes.
        Journal of Clinical Nursing. 2018; 27: e354-e362https://doi.org/10.1111/jocn.13914
      1. Aged Care Complaints Commission (2018). Annual report 20172018. Available from https://www.agedcarequality.gov.au/sites/default/files/media/Aged%20Care%20Complaints%20Commissioner%20%E2%80%93%20Annual%20Report%202017%E2%80%9318.pdf. [Accessed 13 October 2022].

      2. Australian Institute of Health and Welfare. Australia's health (2016). Canberra, Australia: Australian Available from: https://www.aihw.gov.au/reports/australias-health/australias-health-2016/contents/summary. [Accessed 13 October 2022].

      3. Australian Institute of Health and Welfare, (2022). Places in residential aged care by size of service and organisation type 2010-2021. GEN Aged Care Data. Available from: https://www.gen-agedcaredata.gov.au/Topics/Providers,-services-and-places-in-aged-care#Size%20of%20residential%20aged%20care%20services%20over%20time. [Accessed 13 October 2022].

      4. Australian Royal Commission into Aged Care Quality and Safety (2019). Interim report: neglect. Commonwealth of Australia.

      5. Australian Royal Commission into Aged Care Quality and Safety (2020). Counsel assisting's final submissions. Commonwealth of Australia. RCD.9999.0541.0001.

        • Bail K.
        • Gibson D.
        Put your data where your care is.
        MJA Insight+. 2021; 20 (Available from:) ([Accessed 07 June 2021])
        • Bail K.
        • Grealish L.
        'Failure to maintain': a theoretical proposition for a new quality indicator of nurse care rationing for complex older people in hospital.
        International Journal of Nursing Studies. 2016; 63: 146-161
      6. Ball, J., Barker, H., Griffiths, P., Jones, J., Lawless, J., Burton, C. R., et al. (2019). University of Southampton; Southampton: 2019. Implementation, Impact and Costs of Policies for Safe Staffing in Acute Trusts: Report to Funders.

        • Bates D.
        • Maechler M.
        • Bolker B.
        • Walker S.
        Fitting linear mixed-effects models using lme4.
        Journal of Statistical Software. 2015; 67: 1-48https://doi.org/10.18637/jss.v067.i01
        • Berger J.O.
        • Kotz S.
        • Balakrishnan N.
        • Read C.
        • Vidakovic B.
        • Johnson N.L.
        Encyclopedia of statistical sciences.
        Wiley, 2004
        • Blackman I.
        • Henderson J.
        • Weger K.
        • Willis E.
        Causal links associated with missed residential aged care.
        Journal of Nursing Management. 2020; 28: 1909-1917
        • Blackman I.
        • Henderson J.
        • Willis E.
        • Toffoli L.
        After hours nurse staffing, work intensity and quality of care-missed care study: New South Wales public and private sectors. Final report to the New South Wales Nurses and Midwives’ Association.
        Flinders University, Adelaide2015
        • Bonner A.F.
        • Castle N.G.
        • Perera S.
        • Handler S.M.
        • et al.
        Patient safety culture: a review of the nursing home literature and recommendations for practice.
        Ann Longterm Care. 2008; 16 (3. Rust TB): 18-22
        • Brauner D.
        • Werner R.M.
        • Shippee T.P.
        • Cursio J.
        • Sharma H.
        • Konetzka R.T.
        Does nursing home compare reflect patient safety in nursing homes.
        Health Affairs. 2018; 37: 1770-1778https://doi.org/10.1377/hlthaff.2018
        • Carle A.C.
        Fitting multilevel models in complex survey data with design weights: recommendations.
        BMC Medical Research Methodology. 2009; 9: 49-62
        • Caughey G.E.
        • Lang C.E.
        • Bray S.C.
        • Moldovan M.
        • Jorissen R.N.
        • Wesselingh S.
        • et al.
        International and national quality and safety indicators for aged care.
        Report for the Royal Commission into Aged Care Quality and Safety. South Australian Health and Medical Research Institute, Adelaide, South Australia2020
        • Choi S.
        • Cho E.
        • Kim E.
        • Lee K.
        • Chang S.J.
        Effects of registered nurse staffing levels, work environment, and education levels on adverse events in nursing homes.
        Scientific Reports. 2021; 11: 1-8
      7. Available from: https://www.R-project.org/. [Accessed 13 October 2022].
      8. Datta, R., Trentalange, M., Van Ness, P. H., McGloin, J. M., Guralnik, J. M., Miller, M. E., et al. (2017). Serious adverse events for older adults in nursing home and community intervention trials. Contemporary Clinical Trials Communications, 9, 77–80. https://doi.org/10.1016/j/conctc.2017.12.004.

        • Davidson P.M.
        • Elliott D.
        • Daly J.
        Clinical leadership in contemporary clinical practice: implications for nursing in Australia.
        J Nurs Manag. 2006; 14 (PMID: 16600005): 180-187https://doi.org/10.1111/j.1365-2934.2006.00555.x
        • Davis J.
        • Morgans A.
        • Birks M.
        • Browning C.
        The rhetoric and reality of nursing in aged care: views from the inside.
        Contemporary Nurse. 2016; 52: 191-203
      9. Department of Health (2021). Residential aged care services and sustainability (Pillar 2 of the Royal Commission response) – Mandatory care time standards and reporting. Australian Government. Available from: https://www.health.gov.au/sites/default/files/documents/2021/05/residential-aged-care-services-and-sustainability-pillar-2-of-the-royal-commission-response-mandatory-care-time-standards-and-reporting.pdf. [Accessed 13 October 2022].

        • Eagar K.
        • Westera A.
        • Kobel C.
        Australian residential aged care is understaffed.
        MJA. 2020; 212 (507-508.e1. 507-508)https://doi.org/10.5694/mja2.50615
      10. Available from: https://apo.org.au/node/263016. [Accessed 13 October 2022]
        • Fagerstrom L.
        • Kinnunen M.
        • Saarela J.
        Nursing workload, patient safety incidents and mortality: an observational study from Finland.
        BMJ Open. 2018; 8 (PMID: 29691240; PMCID: PMC5922465)e016367https://doi.org/10.1136/bmjopen-2017-016367
        • Griffiths P.
        • Ball J.
        • Bloor K.
        • Böhning D.
        • Briggs J.
        • Dall'Ora C.
        • et al.
        Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study.
        BMJ Quality & Safety. 2018; 28 (2019): 609-617
        • Harrington C.
        • Schnelle J.F.
        • McGregor M.
        • Simmons S.F.
        The need for minimum staffing standards in nursing homes.
        Health Serv Insigts. 2016; 9: 13-19
        • Havreng-Théry C.
        • Giner-Perot J.
        • Zawieja P.
        • Bertin-Hugault F.
        • Belmin J.
        • Rothan-Tondeur M.
        Expectations and needs of families in nursing homes: an integrative review.
        Medical Care Research and Review. 2020; 78: 311-325
        • Heath H.
        How to optimise the registered nurse contribution in care homes.
        Nurs Older People. 2012; 24: 23-28
        • Henderson J.
        • Willis E.
        Chapter twelve: the marketisation of aged care: the impact of aged care reform in Australia.
        Navigating private and public healthcare. Palgrave Macmillan, Singapore2020: 249-267
        • Henderson J.
        • Willis E.
        • Xiao D.
        • Blackman I.
        Missed care in residential aged care in Australia: an exploratory study.
        Collegian. 2017; 24: 411-416https://doi.org/10.1016/j.colegn.2016.09.001
        • Inacio M.C.
        • Moldovan M.
        • Whitehead C.
        • Sluggett J.K.
        • Crotty M.
        • Corlis M.
        • et al.
        The risk of fall-related hospitalisations at entry into permanent residential aged care.
        BMC Geriatrics. 2021; 21: 1-13https://doi.org/10.1186/s12877-021.02640-w
        • Jeon Y.-H.
        • Casey A.-N.
        • Vo K.
        • Rogers K.
        • Poole B.
        • Fethney J.
        Associations between clinical indicators of quality and aged-care residents’ needs and consumer and staff satisfaction: the first Australian study.
        Australian Health Review. 2018; 43: 133-141
        • Lee H.Y.
        • Blegen M.A.
        • Harrington C.
        The effects of RN staffing hours on nursing home quality: a two-stage model.
        International Journal of Nursing Studies. 2014; 51: 409-417https://doi.org/10.1016/j.ijnurstu.2013.10.007(2014)
        • Lee H.Y.
        • Shin J.H.
        Public reporting on the quality ratings of nursing homes in the Republic of Korea.
        Journal of Korean Academic Nursing. 2019; 49: 161-170https://doi.org/10.4040/jkan.2019.49.2.161
      11. Lenth, R. V. (2021). Estimated marginal means, aka least-squares means. R package version 1.6.0. Available from: https://CRAN.R-project.org/package=emmeans. [Accessed 13 October 2022].

        • Levinson D.R.
        Adverse events in skilled nursing facilities: national incidence among medicare beneficiaries.
        Department of Health Human Services, Washington DC2014
        • Little R.J.
        To model or not to model? Competing modes of inference for finite population sampling.
        Journal of American Statistical Association. 2004; 99: 546-556
        • Luyten H.
        • Sammons P.
        Multilevel modelling.
        Methodological advances in educational effectiveness research. Routledge, 2010: 260-290
        • McGilton K.S.
        • Profetto-McGrath J.
        • Robinson A.
        Implementing the supportive supervision intervention for registered nurses in a long- term care home: a feasibility study Katherine S.
        Worldviews on Evidence-Based Nursing. 2013; 10: 238-247
        • Nantsupawat A.
        • Poghosyan L.
        • Wichaikhum O.A.
        • Kunaviktikul W.
        • Fang Y.
        • Kueakomoldej S.
        • et al.
        Nurse staffing, missed care, quality of care and adverse events: A cross-sectional study.
        Journal of Nursing Management. 2021; 30 (Epub 2021 Nov 26): 447-454https://doi.org/10.1111/jonm.13501
        • Nhongo D.
        • Hendricks J.
        • Bradshaw J.
        • Bail K.
        Leadership and registered nurses (RNs) working after-hours in Residential Aged Care Facilities (RACFs): A structured literature review.
        Journal of Clinical Nursing. 2018; 27: 3872-3881https://doi.org/10.1111/jocn.14565
      12. NSW Nurses and Midwives’ Association. (2019). Why ratios matter. Hip fractures in residential aged care. NSW Nurses and Midwives’ Association Professional Issue 9.

        • OECD/European Commission
        A good life in old age? monitoring and improving quality in long-term Care.
        OECD Publishing, Paris2013
      13. [Doctoral Thesis]. Walden Dissertations and Doctoral Studies Collection Available from: https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=4605&context=dissertations. [Accessed 13 October 2022].
        • Patrician P.A.
        • Loan L.
        • McCarthy M.
        • Fridman M.
        • Donaldson N.
        • Bingham M.
        • et al.
        The association of shift-level nursing staffing with adverse patient events.
        The Journal of Nursing Administration. 2011; 41: 64-70https://doi.org/10.1097/NNA.0b013e31820594bf
        • Shin J.H.
        Why do we require registered nurses in nursing homes? Using longitudinal hierarchical linear modelling.
        Journal of Nursing Scholarship. 2018; 50: 705-713https://doi.org/10.1111/jnu.12412
        • St Clair B.
        • Jorgensen M.
        • Georgiou A.
        Incidence of adverse events in residential aged care.
        Australian Health Review. 2021; https://doi.org/10.1071/AH21090
        • Storch J.
        • Curry C.G.
        • Stevenson L.
        • Macdonald M.
        • Lang A.
        Ethics and safety in home care: perspectives on home support workers.
        Nurs Lead. (Toronto). 2014; 27: 76-96
        • Sutton N.
        • Ma N.
        • Yang J.S.
        • Rawlings-Way O.
        • Brown D.
        • McAllister G.
        • et al.
        Considering the new minimum staffing standards for Australian residential aged care.
        Aust Health Rev. 2022; 46 (PMID: 34607628): 391-397https://doi.org/10.1071/AH21160
        • Twigg D.E.
        • Whitehead L.
        • Doleman G.
        • El-Zaemey S.
        The impact of nurse staffing methodologies on nurse and patient outcomes: a systematic review.
        Journal of Advanced Nursing. 2021; 77: 4599-4611
        • Venturato L.
        • Drew L.
        Beyond ‘doing’: supporting clinical leadership and nursing practice in aged care through innovative models of care.
        Contemp Nurse. 2010; 35: 157-170
        • Wells Y.
        • Brooke E.
        • Solly K.N.
        Quality and safety in aged care virtual issue: what Australian research published in the Australasian Journal on Ageing tells us.
        Australasian Journal on Ageing. 2019; 38: E1-E6https://doi.org/10.1111/ajag.12638
        • Wolak .E.
        • Fairbairn .J.
        • Paulsen Y.R.
        Guidelines for estimating repeatability.
        Methods in Ecology and Evolution. 2012; 3: 129-137
        • Zhang L.
        • Zeng Y.
        • Weng C.
        • Yan J.
        • Fang Y.
        Epidemiological characteristics and factors influencing falls among elderly adults in long-term care facilities in Xiamen, China.
        Medicine. 2019; 98: E14375https://doi.org/10.1097/MD.0000000000014375
        • Zhang X.
        • Liu Y.
        A study of operational risks of elderly-care institutions based on stakeholder theory.
        J Shanghai Jiaotong Univ (Philos Soc Sci Ed). 2012; 20: 37-45