Certified Nursing Assistants

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Certified Nursing Assistants Perceptions of
Nursing Home Patient Safety Culture Is There a
Relationship to Clinical or Workforce Outcomes?

• Alice F. Bonner, PhD, RN
• Graduate School of Nursing
• University of Massachusetts, Worcester
• March 7, 2008

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(No Transcript)
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Faculty Disclosures

• Dr. Bonner has disclosed that she has no relevant
  financial relationships.

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Learning Objectives

• By the end of the session, participants will be
  able to
• Discuss the importance of patient safety culture
  in long term care
• List at least two clinical outcomes and one
  workforce outcome relevant to the study of
  patient safety culture
• Consider future research opportunities related to
  the study of patient safety culture in long term
  care

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Acknowledgement

• This study was supported by an American Medical
  Directors Association Foundation/Pfizer Quality
  Improvement Award

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Consultants and Coauthors

• Nicholas Castle, PhD
• Associate Professor, Graduate School of Public
  Health
• Aiju Men, MS
• Analyst
• Steven Handler, MD, MS
• Assistant Professor, School of Medicine
• University of Pittsburgh
• Pittsburgh, Pennsylvania

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Background and Significance

• The significance of medical error
• 2000 Institute of Medicine (IOM) report, To Err
  is Human
• Definition of patient safety culture
• Development of instruments to measure PSC
• Several hospital studies
• At least six nursing home studies to date

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Original 12 DomainsHospital Survey of Patient
Safety Culture(HSOPSC)

• Overall Perceptions
• Frequency of events reported
• Management expectations and actions
• Organizational learning
• Teamwork within units
• Communication openness
• Feedback and communication about errors
• Non-punitive response to error
• Staffing
• Management support for resident safety
  (attitudes)
• Teamwork across units
• Handoffs and transitions

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Selecting the TopicCNAs Perceptions of Nursing
Home Patient Safety Culture

• Certified nursing assistants (CNAs) the heart of
  the interdisciplinary team (IDT)
• CNAs provide 80-90 of the direct care in nursing
  homes
• CNAs are on the frontlines and are often the
  first line of defense against accidents or injury

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The Research Question

• Is there a relationship between CNAs values,
  perceptions and attitudes about patient safety
  and clinical outcomes (rates of falls, daily
  restraint use, and pressure ulcers)?
• Is there a relationship between CNAs values,
  perceptions and attitudes about patient safety
  and a workforce outcome (nursing staff
  turnover)?
• Significance to date, no study has been
  published that examines the relationship between
  patient safety culture (PSC) scores and actual
  clinical or workforce outcomes in nursing homes

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Conceptual Framework
Denotes concept or relationship examined in this
study. Adapted from Stone, P. et al. (2005).
Organizational Climate of Staff Working
Conditions and Safety - An Integrative Model.
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Specific Aim 1

• Hypothesis
• Nursing homes with higher CNA PSC total scores
  and domain subscores will have lower rates of
  falls, daily restraint use, and pressure ulcers,
  and lower staff turnover (RN/LPN/CNA)

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Specific Aim 2

• Hypothesis
• Nursing homes with higher CNA total PSC scores
  and domain subscores will have higher staffing
  levels (RN/LPN/CNA) and lower turnover
  (RN/LPN/CNA)

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Specific Aim 3

• Hypothesis
• CNAs with more total years of education (in
  addition to CNA training), more years of
  experience and longer tenure in the nursing home
  will have higher average PSC scores than less
  educated, less experienced CNAs

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Specific Aim 4

• Hypothesis
• Nursing homes with higher CNA PSC scores will be
  located in non-rural counties, have higher bed
  occupancy, have lower bed size, have higher
  private pay occupancy and will have either
  not-for-profit status or will be members of a
  chain

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Parent Study Methods

• Castle, N.G. (2006). Nurse Aides ratings of the
  resident safety culture in nursing homes.
  International Journal for Quality in Health Care,
  18(5), 370-376.
• Sample
• 5 randomly selected states
• 10 random sample (240 homes)
• 72 nursing homes (30 response rate)
• 1579 CNAs (55 response rate)
• Procedures
• Human subjects
• Measures
• Data collection

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Dissertation Study Methods

• Secondary data analysis
• Hospital Survey on Patient Safety Culture
  (HSOPSC)
• Matched with data from the Minimum Data Set
  (MDS), Online Survey Certification and Reporting
  (OSCAR) System, and Area Resource File (ARF)
• Procedures
• Approval obtained from both the University of
  Massachusetts and University of Pittsburgh IRB
  (exempt status)
• Power analysis
• Data analysis
• Exploratory factor analysis
• Poisson, linear and multinomial logistic
  regression
• Generalized Estimating Equations (GEE)

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Selected Outcome Variables

• Falls
• Use of physical restraints
• Pressure ulcers
• Nursing staff turnover
• Based on work by Teigland, Capezuti, Rubenstein,
  Berlowitz, Schnelle, Sullivan-Marx, Strumpf,
  Castle, Engberg, Mor, Morris, Harrington, Rantz,
  Scott-Cawiezell and others

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Risk AdjustmentBased on available data

• Falls
• cognitive impairment, Alzheimers disease,
  behaviors, ADL status, average number of
  medications, facility characteristics
• Daily use of physical restraints
• cognitive impairment, behaviors, number of
  medications, ADL status, Alzheimers disease,
  facility characteristics
• Pressure ulcers
• cognitive impairment, Alzheimers disease,
  behaviors, ADL status, average number of
  medications, facility characteristics. Sample
  facilities had very small numbers of low risk
  residents, therefore categories were combined
• Turnover
• facility characteristics such as staffing, profit
  or chain, bed size, county unemployment rate,
  facility occupancy

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RESULTS
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Demographic Datafor CNAs

• 82.7 were Caucasian
• 91.9 of CNAs had a high school degree
• 98.1 were female
• Average age was 30 years
• Average tenure in the facility was 4.6 years
• Average tenure as a CNA was 7.8 years

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Demographic Datafor Nursing Homes

• 82.4 were non-rural
• 58 were non-profit
• 37.8 were chain members
• Average facility bed size was 102.5
• Average facility fall rate was 12.3
• Average facility pressure ulcer rate was 8.2
• Average facility restraint rate was 6.7

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Demographic Datafor Nursing Homes

• Average CNA turnover rate was 33.6
• Average LPN turnover rate was 28
• Average RN turnover rate was 24
• Average CNA staffing 29 FTE/100 residents
• Average LPN staffing 9 FTE/100 residents
• Average RN staffing 11 FTE/100 residents
  (includes administrative RN staff)

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CNA PSC and Falls RatesPoisson Regression (N74
facilities)

• A higher average CNA total PSC score was
  associated with a higher rate of falls (B.015
  p.000). In addition, a higher rate of falls was
  associated with
• fewer beds (B-.001 p.028)
• higher cognitive performance scale (CPS) scores
  (more cognitively impaired residents) (B.182
  p.003)
• lower activities of daily living (ADL) scores
  (less functionally dependent residents) (B-.182
  p.006)
• higher rate of Alzheimers disease in the
  facility (B.011 p.017)
• lower proportion of Medicare residents in the
  facility (B-.013 p.000).

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CNA PSC and Restraint RatesMultinomial Logistic
Regression (N74)

• Facilities with higher average CNA total PSC
  scores were more likely to report moderate
  restraint use, whereas facilities with lower
  average CNA total PSC scores were more likely to
  report high restraint use (B.172 p.017). In
  addition
• Facilities reporting moderate restraints had more
  medications per resident than those reporting
  high restraints (B.895 p.023)
• Facilities reporting moderate restraints had
  slightly lower ADL scores (more functionally
  independent) than facilities reporting high
  restraints (B-.003 p.028)

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CNA PSC and Pressure Ulcer RatesPoisson
Regression (N74 facilities)

• Average CNA total PSC scores did not have a
  statistically significant association with
  pressure ulcer rates (B-0.001 p0.807)

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CNA PSC and CNA TurnoverLinear Regression (N74)

• Higher CNA PSC scores were associated with lower
  CNA turnover (B-.052 p.030). In addition
• Lower CNA turnover was associated with not for
  profit status (B1.446 p.001)
• Lower CNA turnover was associated with higher
  facility occupancy (B-.188 p.000)
• Adjusted R square for this model was .639.

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GEE Model for Staffing, Turnover and Total PSC
(N1761)
Variable B SE P-Value
CNA staffing -0.555 0.353 0.116
LPN staffing -0.938 0.295 0.002
RN staffing 0.540 0.447 0.227
CNA turnover -2.390 1.094 0.029
LPN turnover -0.173 1.386 0.901
RN turnover 0.842 1.373 0.540
Dependent Variable Total CNA Patient Safety
Culture Score plt.05
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GEE Model for CNA Demographic Characteristics
(N1761)
Variable B SE P-Value
Gender
Female 4.868 3.254 0.135
Male 0a
Education
High School Degree 2.040 1.763 0.247
Associates Degree -3.167 3.062 0.301
Bachelors Degree or Higher 0a
Age -0.087 0.039 0.025
Dependent Variable Total CNA Patient Safety
Culture Score a. Set to zero because this
parameter is redundant. plt.05
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Combined GEE Model for Facility level and CNA
Demographic Characteristics (N1761)
Variable B SE P-Value
Not for profit -1.771 1.755 0.313
Profit 0a
Non-chain member -1.524 1.645 0.354
Chain member 0a
Non-rural location -1.537 2.684 0.567
Rural location 0a
High School Degree 1.963 1.769 0.267
Associate Degree -3.576 2.950 0.225
Bachelors Degree or higher 0a
CNA turnover -1.337 0.515 0.009
Age -0.049 0.068 0.469
Tenure as a CNA -0.058 0.100 0.559
Tenure in the facility 0.009 0.135 0.946
County unemployment rate 1.297 0.838 0.122
Number of nursing homes in the county -0.052 0.091 0.571
Average facility occupancy -0.010 0.217 0.964
Average facility private pay occupancy -0.006 0.162 0.970
Bed size -0.020 0.014 0.134
LPN staffing -0.801 0.211 0.000
Dependent Variable Total CNA Patient Safety
Culture Score a Set to zero because this
parameter is redundant. plt.01
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DISCUSSION
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CNA PSC and Falls RatesPoisson Regression

• A higher average CNA total PSC score was
  associated with a higher rate of falls (B.015
  p.000). Why?
• Ascertainment bias in MDS measure
• Comprehensive fall prevention programs include
  more effective reporting and documentation
  strategies
• Resident selection (higher percentage of
  dementia, more functional independence)
• Unmeasured confounding factors

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CNA PSC and Restraint RatesMultinomial Logistic
Regression

• Facilities with higher average CNA total PSC
  scores were more likely to report moderate
  restraint use, whereas facilities with lower
  average CNA total PSC scores were more likely to
  report high restraint use (B.172 p.017)
• Facilities with a less developed PSC are more
  likely to use restraints
• In homes with zero or very low restraints, CNAs
  may perceive this as a lack of safety for
  residents

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CNA PSC and Pressure Ulcer RatesPoisson
Regression

• Average CNA total PSC scores did not have a
  statistically significant association with
  pressure ulcer rates (B-0.001 p0.807). Why
  not?
• Are pressure ulcers a quality or a safety
  measure?
• Do some staff consider pressure ulcers
  inevitable?
• Failure to detect differences (study only powered
  to detect moderate to large effect)

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GEE Model for Staffing, Turnover and Total PSC
(N1761)
Variable B SE P-Value
CNA staffing -0.555 0.353 0.116
LPN staffing -0.938 0.295 0.002
RN staffing 0.540 0.447 0.227
CNA turnover -2.390 1.094 0.029
LPN turnover -0.173 1.386 0.901
RN turnover 0.842 1.373 0.540
Dependent Variable Total CNA Patient Safety
Culture Score plt.05
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GEE Model for CNA Demographic Characteristics
(N1761)
Variable B SE P-Value
Gender
Female 4.868 3.254 0.135
Male 0a
Education
High School Degree 2.040 1.763 0.247
Associates Degree -3.167 3.062 0.301
Bachelors Degree or Higher 0a
Age -0.087 0.039 0.025
Dependent Variable Total CNA Patient Safety
Culture Score a. Set to zero because this
parameter is redundant. plt.05
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Combined GEE Model for Facility level and CNA
Demographic Characteristics (N1761)
Variable B SE P-Value
Not for profit -1.771 1.755 0.313
Profit 0a
Non-chain member -1.524 1.645 0.354
Chain member 0a
Non-rural location -1.537 2.684 0.567
Rural location 0a
High School Degree 1.963 1.769 0.267
Associate Degree -3.576 2.950 0.225
Bachelors Degree or higher 0a
CNA turnover -1.337 0.515 0.009
Age -0.049 0.068 0.469
Tenure as a CNA -0.058 0.100 0.559
Tenure in the facility 0.009 0.135 0.946
County unemployment rate 1.297 0.838 0.122
Number of nursing homes in the county -0.052 0.091 0.571
Average facility occupancy -0.010 0.217 0.964
Average facility private pay occupancy -0.006 0.162 0.970
Bed size -0.020 0.014 0.134
LPN staffing -0.801 0.211 0.000
Dependent Variable Total CNA Patient Safety
Culture Score a Set to zero because this
parameter is redundant. plt.01
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Discussion

• CNA PSC scores were associated with some (falls,
  restraints), but not all (pressure ulcers)
  clinical outcomes
• Few PSC subscore associations were noted in the
  data, possibly related to sample size. Further
  work on subscales/domains is needed
• Associations were noted between CNA PSC scores,
  CNA turnover and LPN staffing, suggesting the
  importance of staff mix and nursing staff models

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Discussion

• Factor Analysis
• The factor structure was similar, but some
  differences were noted, suggesting that further
  work on adapting the HSOPSC to nursing homes and
  CNA populations may improve the validity of the
  instrument

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Strengths and Limitations

• Strengths
• National, randomly selected sample
• HSOPSC has previously reported reliability,
  validity
• Focus on CNAs, critical to NH PSC
• Limitations
• Reliability and validity of MDS, OSCAR data
• Different clinical indicators and variables for
  risk adjustment may need to be examined
• Sample size may have had limited ability to
  detect some significant results

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Policy and PracticeImplications

• Interventions that improve CNA PSC may influence
  clinical outcomes, such as falls and restraint
  use
• Efforts to reduce CNA turnover should include a
  focus on nursing management and staff models, and
  enhancing PSC (Advancing Excellence goals include
  reducing nursing staff turnover)
• The QIOs 9th SOW includes recommendations to
  include the nursing home culture survey in
  comprehensive resident safety programs

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Implications and Future Research

• Future studies should consider fall-related
  injuries as well as falls rates, and other
  clinical indicators
• Future studies should build on our knowledge of
  CNA PSC and include other members of the IDT
• Review of the literature in nursing homes in
  press and targeted for April issue of Annals of
  Long Term Care (co-authors Castle, Perera,
  Handler)
• Original Study submitted to JAMDA and currently
  under review

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Conclusions

• Measuring patient safety culture may be helpful
  in working with your IDT on specific areas such
  as communication, teamwork, handoffs
• Interventions that improve CNA PSC may influence
  clinical outcomes, such as falls and restraint
  use
• Revised NH Culture survey should be available on
  the AHRQ website after May 2008