Abstract
Staffing has emerged as a key focus of quality of care in various residential long-term care settings. The search for the ideal staff to resident ratio has led to several recommendations, and there is general agreement that turnover among direct care workers, registered nurses, or managerial professionals (directors of nursing, facility social workers, administrators/directors) is disruptive to the function and quality of care delivered in residential settings (N. J. Zhang, Unruh, Liu, & Wan, 2006). A number of efforts, ranging from enhancing staff training to systemic “culture change” initiatives, have arisen in response to the many challenges staff and residents face in nursing homes or other residential environments (Koren, 2010).
The Journal of Applied Gerontology has had an ongoing interest in issues related to staffing in nursing homes or other long-term care services (Castle, 2008; Donoghue, 2010; Kash, Naufal, Cortés, & Johnson, 2010), and the articles of this issue represent stellar emergent work in this area. The first article examines correlates of intention to leave one’s position in a large sample of nursing home staff (Zhang, Punnett, Gore, & The CPH-NEW Research Team, 2014). Zhang and colleagues demonstrate the key role of healthy workplace conditions (as measured by four variables: coworker support, supervisor support, respect received at work, and decision authority) in determining whether certified nurse assistants or similar direct care workers intend to leave their current positions in the next 2 years. In addition to the very impressive sample size, I was struck by how Zhang and colleagues effectively honed in on four key indicators that could shape the assessment of working conditions in future initiatives to reduce staff turnover. The next two articles in this issue focus on staffing and quality of care issues (Castle, Wagner, Ferguson, & Handler, 2014; Hunt, Corazzini, & Anderson, 2014). Castle and colleagues examine a unique aspect of quality of care: hand hygiene in nursing home staff. Again, using a large, representative data source, Castle et al. (2014) demonstrate that low staffing levels in nursing homes were associated with more frequent facility deficiency citations during routine state survey visits. This article is one of the first to examine the issue of hand hygiene in nursing homes and shed light on what could be a crucial, emerging issue in quality of care in nursing homes. In other innovative contribution, Hunt and colleagues conduct a longitudinal case analysis that used multiple sources of data, including interviews, observations, and document review. These various data sources yielded rich insights into how turnover at the upper levels of management in nursing homes (this particular facility experienced 400% turnover during the 9-month study period) was detrimental to resident safety. Hunt et al. illustrate, quite powerfully, how turnover at the director and other upper management positions can destabilize the quality of care delivered in nursing homes.
The final two articles selected for this issue help to apply the results of the prior articles to consider how to move the literature forward (Lopez, White, & Carder, 2014; Shield et al., 2014). Lopez et al. (2014) present results of a work-based learning program for direct care workers called Jobs to Careers. Focus group data interpreted through the lens of symbolic interactionism identified three pathways by which the Jobs to Careers program positively influenced direct care workers’ employment experiences: relational aspects of work, worker identity, and finding time. The article by Renée Shield and colleagues (2014) proposes a new conceptual model (the Medical Staff Involvement Model) to examine how medical staff involvement in nursing homes is influenced by a number of proposed factors. Using a mixed methods design that incorporated qualitative and quantitative data from multiple sources, the study by Shield et al. (2014) illustrates how medical staff can influence key care processes in nursing homes and sets the stage for a future research agenda. The analysis also served to highlight one of the ongoing initiatives in the Journal of Applied Gerontology: the use of mixed methods to better understand key topics of interest in applied gerontology.
This excellent collection of studies epitomizes the continuum of scholarship often on display in the Journal of Applied Gerontology: from a strong description of a given issue, to evaluations of clinical, systems-level, or policy interventions to address said issue, to the development and refinement of conceptual and theoretical models to more effectively frame future applied research on the issue. Given the urgency of staffing and quality of care in residential environments for older persons and their families, the work featured in this issue is timely and essential.