2.50
Hdl Handle:
http://hdl.handle.net/10755/157234
Type:
Presentation
Title:
Direct Observation of RN Care Processes in Two VA-Affiliated Nursing Homes
Abstract:
Direct Observation of RN Care Processes in Two VA-Affiliated Nursing Homes
Conference Sponsor:Western Institute of Nursing
Conference Year:2009
Author:Dellefield, Mary E., PhD, RN
P.I. Institution Name:VA San Diego Medical Center, Research
Title:Researcher
Contact Address:3350 La Jolla Village Drive, San Diego, CA, 92161, USA
Contact Telephone:858-552-8585 x2686
Co-Authors:Claudia Der-Martirosian, PhD, Statistical Consultant; Charlene Harrington, PhD, RN, FAAN, Professor; Martha Shively, PhD, RN, Associate Chief Research
Purposes/Aims: The study purpose was the development and implementation of a PDA-based tool used to directly observe registered nurse (RN) care practices related to five pressure ulcer (PU) risk factors, including immobility, incontinence, nutrition, pain, and PU treatment. Percentages of direct care (assessment, treatment, medications) and indirect care (supervision, management, documentation) practices and any associations with total nursing and RN staffing levels were described. Rationale/Conceptual Basis/Background: Concerns about the quality of nursing homes (NHs) persist. Within Donabedian's quality framework, RN time is a structural measure of quality and RN care practices are process measures of quality. Relatively few RNs work in NHs and are responsible for providing professional supervision, management, and oversight of clinical assessments to a largely para-professional nursing staff. In 2007, the American Health Care Association (AHCA) reported that by skill level CNAs provided 2.3 hours per resident day (HPRD); .32 HPRD for RNs; and .78 HPRD for LVNs/LPNs. Methods: An exploratory descriptive study using industrial engineering work-sampling methodology and RN convenience samples in 2 VA-affiliated NHs (40-bed Nursing Home Care Unit [NHCU] currently a Community Living Center [CLC] and 174-bed VA-contract Community NH [CNH]). CLC nursing skill mix included RNs and licensed vocational nurses. Two-hundred fifty-eight RN care practices categorized by PU risk factors were used. The practices were identified and defined based on clinical practice guidelines for PU prevention, NH regulation, and an expert panel. Results: Observations were collected at a confidence level of 95%. 2,855 (CLC) and 4,476 (CNH) discrete care activities for 7 RNs (51% RNs at CLC) and 7 RNs (50% RNs at CNH) were obtained. Data collectors achieved a range of 90% - 100% inter-rater reliability during training and at study sites. CLC RN activities included: 46% direct, 41% indirect care, and 12% unproductive activities. CNH RN activities included:  31% direct, 59% indirect, and 10% unproductive activities. RNs spent 29% (CLC) and 45% (CNH) reading and writing in charts. At both sites, percentages of RN direct vs. indirect care varied by clinical domains but not by RN or total nurse staffing levels. Case mix indexes (32 CLC; 28 CNH) were similar. Supervisory and managerial activities occupied 12% (CLC) and 23% (CNH) of their total work time. RNs rarely provided supervision and management to CNAs (CNH), focusing on other RNs and LVNs instead. Implications: The percentages of total RN care practices associated with five clinical risk factor for PU prevention differed by nursing skill mix at each facility. Documentation comprised a majority of indirect care; the clinical domains reflected in RN documentation could not be determined by direct observation. Although inaccuracies in NH documentation have been reported, the use of the chart and RN self-report will enhance the measurement of RN care practices associated with PU prevention. A PDA-based method of measuring RN clinical practice is ideal for measurement of direct care activities. This method may provide real-time performance feedback to RNs in the clinical setting. Increased performance of RN activities related to supervision and management of CNAs is recommended.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Western Institute of Nursing

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleDirect Observation of RN Care Processes in Two VA-Affiliated Nursing Homesen_GB
dc.identifier.urihttp://hdl.handle.net/10755/157234-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Direct Observation of RN Care Processes in Two VA-Affiliated Nursing Homes</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Western Institute of Nursing</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2009</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Dellefield, Mary E., PhD, RN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">VA San Diego Medical Center, Research</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Researcher</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">3350 La Jolla Village Drive, San Diego, CA, 92161, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">858-552-8585 x2686</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">mary.dellefield@va.gov</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Claudia Der-Martirosian, PhD, Statistical Consultant; Charlene Harrington, PhD, RN, FAAN, Professor; Martha Shively, PhD, RN, Associate Chief Research</td></tr><tr><td colspan="2" class="item-abstract">Purposes/Aims: The study purpose was the development and implementation of a PDA-based tool used to directly observe registered nurse (RN) care practices related to five pressure ulcer (PU) risk factors, including immobility, incontinence, nutrition, pain, and PU treatment. Percentages of direct care (assessment, treatment, medications) and indirect care (supervision, management, documentation) practices and any associations with total nursing and RN staffing levels were described. Rationale/Conceptual Basis/Background: Concerns about the quality of nursing homes (NHs) persist. Within Donabedian's quality framework, RN time is a structural measure of quality and RN care practices are process measures of quality. Relatively few RNs work in NHs and are responsible for providing professional supervision, management, and oversight of clinical assessments to a largely para-professional nursing staff. In 2007, the American Health Care Association (AHCA) reported that by skill level CNAs provided 2.3 hours per resident day (HPRD); .32 HPRD for RNs; and .78 HPRD for LVNs/LPNs. Methods: An exploratory descriptive study using industrial engineering work-sampling methodology and RN convenience samples in 2 VA-affiliated NHs (40-bed Nursing Home Care Unit [NHCU] currently a Community Living Center [CLC] and 174-bed VA-contract Community NH [CNH]). CLC nursing skill mix included RNs and licensed vocational nurses. Two-hundred fifty-eight RN care practices categorized by PU risk factors were used. The practices were identified and defined based on clinical practice guidelines for PU prevention, NH regulation, and an expert panel. Results: Observations were collected at a confidence level of 95%. 2,855 (CLC) and 4,476 (CNH) discrete care activities for 7 RNs (51% RNs at CLC) and 7 RNs (50% RNs at CNH) were obtained. Data collectors achieved a range of 90% - 100% inter-rater reliability during training and at study sites. CLC RN activities included: 46% direct, 41% indirect care, and 12% unproductive activities. CNH RN activities included:&nbsp; 31% direct, 59% indirect, and 10% unproductive activities. RNs spent 29% (CLC) and 45% (CNH) reading and writing in charts. At both sites, percentages of RN direct vs. indirect care varied by clinical domains but not by RN or total nurse staffing levels. Case mix indexes (32 CLC; 28 CNH) were similar. Supervisory and managerial activities occupied 12% (CLC) and 23% (CNH) of their total work time. RNs rarely provided supervision and management to CNAs (CNH), focusing on other RNs and LVNs instead. Implications: The percentages of total RN care practices associated with five clinical risk factor for PU prevention differed by nursing skill mix at each facility. Documentation comprised a majority of indirect care; the clinical domains reflected in RN documentation could not be determined by direct observation. Although inaccuracies in NH documentation have been reported, the use of the chart and RN self-report will enhance the measurement of RN care practices associated with PU prevention. A PDA-based method of measuring RN clinical practice is ideal for measurement of direct care activities. This method may provide real-time performance feedback to RNs in the clinical setting. Increased performance of RN activities related to supervision and management of CNAs is recommended.</td></tr></table>en_GB
dc.date.available2011-10-26T19:41:14Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T19:41:14Z-
dc.description.sponsorshipWestern Institute of Nursingen_GB
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