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In 2017, 352 refugees were relocated to the Kansas City, Kansas area. As part of the relocation process, newly arrived refugees receive physical and mental health screenings. This study is a retrospective analysis of the results of 92 Refugee Health Screener-15 (RHS-15) surveys collected from February to December 2017 and interviews with the healthcare providers who administered the surveys in a primary care clinic.The most commonly reported mental health symptoms included the following: too much thinking or too many thoughts; muscle, bone, or joint pain; and crying easily. Thirty-seven refugee surveys (40%) indicated the need for follow-up mental health screening. A significant small correlation (r = .22, p = .03) was found between female gender and the depression subscale of mental health symptoms. Provider interviews revealed challenges associated with conducting mental health screening of newly arrived refugees in a primary care setting.

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OBJECTIVE: The aim of this study was to understand how nurses in a 25-bed critical-access hospital (CAH) led change to become the 1st to achieve Magnet®. BACKGROUND: Approximately 21% of the US population lives in rural areas served by CAHs. Rural nurse executives are particularly challenged with limited resources. METHODS: Staff nurses, nurse managers, interprofessional care providers, the chief nursing officer, and board of directors (n = 27) were interviewed. Observations of hospital units and administrative meetings were done, and hospital reports were analyzed. RESULTS: Nine themes emerged to support a conceptual model of leading change. The CAH spent 3 years of its 6-year journey establishing organizational readiness. Nurses overcame complex challenges by balancing operational support and fostering relationships. The Magnet journey led to significantly improved nurse and patient outcomes. A new organizational culture centered on shared governance, evidence-based practice, and higher education emerged. CONCLUSIONS: The journey to Magnet leads to improved nurse, patient, and organization outcomes.

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CONTEXT: Persons with Alzheimer's disease and other dementias experience behavioral symptoms that frequently result in nursing home (NH) placement. Managing behavioral symptoms in the NH increases staff time required to complete care, and adds to staff stress and turnover, with estimated cost increases of 30%. The Changing Talk to Reduce Resistivenes to Dementia Care (CHAT) study found that an intervention that improved staff communication by reducing elderspeak led to reduced behavioral symptoms of dementia or resistiveness to care (RTC). OBJECTIVE: This analysis evaluates the cost-effectiveness of the CHAT intervention to reduce elderspeak communication by staff and RTC behaviors of NH residents with dementia. DESIGN: Costs to provide the intervention were determined in eleven NHs that participated in the CHAT study during 2011-2013 using process-based costing. Each NH provided data on staff wages for the quarter before and for two quarters after the CHAT intervention. An incremental cost-effectiveness analysis was completed. ANALYSIS: An average cost per participant was calculated based on the number and type of staff attending the CHAT training, plus materials and interventionist time. Regression estimates from the parent study then were applied to determine costs per unit reduction in staff elderspeak communication and resident RTC. RESULTS: A one percentage point reduction in elderspeak costs $6.75 per staff member with average baseline elderspeak usage. Assuming that each staff cares for 2 residents with RTC, a one percentage point reduction in RTC costs $4.31 per resident using average baseline RTC. CONCLUSIONS: Costs to reduce elderspeak and RTC depend on baseline levels of elderspeak and RTC, as well as the number of staff participating in CHAT training and numbers of residents with dementia-related behaviors. Overall, the 3-session CHAT training program is a cost-effective intervention for reducing RTC behaviors in dementia care.

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Item response theory (IRT) models provide an appropriate alternative to the classical ordinal confirmatory factor analysis (CFA) during the development of patient-reported outcome measures (PROMs). Current literature has identified the assessment of IRT model fit as both challenging and underdeveloped (Sinharay & Johnson, 2003; Sinharay, Johnson, & Stern, 2006). This study evaluates the performance of Ordinal Bayesian Instrument Development (OBID), a Bayesian IRT model with a probit link function approach, through applications in two breast cancer-related instrument development studies. The primary focus is to investigate an appropriate method for comparing Bayesian IRT models in PROMs development. An exact Bayesian leave-one-out cross-validation (LOO-CV) approach (Vehtari & Lampinen, 2002) is implemented to assess prior selection for the item discrimination parameter in the IRT model and subject content experts' bias (in a statistical sense and not to be confused with psychometric bias as in differential item functioning) toward the estimation of item-to-domain correlations. Results support the utilization of content subject experts' information in establishing evidence for construct validity when sample size is small. However, the incorporation of subject experts' content information in the OBID approach can be sensitive to the level of expertise of the recruited experts. More stringent efforts need to be invested in the appropriate selection of subject experts to efficiently use the OBID approach and reduce potential bias during PROMs development.

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Communication with residents and their families is important to ensure that the end-of-life experience is in accordance with resident's wishes. A secondary analysis was conducted to determine: (a) who should communicate with the resident/family about death and dying; (b) when communication should occur around death and dying, obtaining a "DNR" order, and obtaining a hospice referral; and (c) what differences exist in communication about death and dying between Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and unlicensed staff. Greater than 90% of staff (N=2,191) reported that the physician or social worker should communicate about death and dying with residents/families, but only 53% thought that direct care staff should talk with them. Weighted scores for "When communication should occur about death and dying and obtaining a 'DNR' Order" revealed significantly (p < .01) lower scores for unlicensed staff than RNs and LPNS (i.e., licensed staff), indicating that licensed staff were more likely to initiate conversations on admission or at the care-planning meeting, or when the resident's family requested it. No differences were found between staff on communication about obtaining a hospice referral. The identified gaps in perception about who should be communicating can assist in developing appropriate interventions that need future testing. The potential for training regarding communication strategies and techniques could lead to higher satisfaction with end-of-life care for residents and their families.

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The practice environment is important to nurse satisfaction and patient outcomes. Laschinger and Leiter posited causal relationships by development and testing of the Nursing Worklife Model (NWLM). Using a secondary analysis of unit-level data (N = 3,203; medical, surgical, medical-surgical, critical-care, and step-down units) from the 2011 National Database for Nursing Quality Indicators®, hypothesized pathways of the NWLM were tested using structural equation modeling. Practice Environment subscales developed by Lake were used to operationalize model variables with job enjoyment being the outcome variable. Positive pathways identified in the original causal model were supported. However, using an iterative process, additional pathways were identified that improved model fit (comparative fit index = 0.99; root mean square error of approximation = 0.06; standardized root mean square residual = 0.002). Nurse manager ability, leadership, and support had direct links to job enjoyment as well as other elements of the model. Development of nurse managers is important to the retention of clinical nurses in the hospital setting.

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BACKGROUND: Developing valid and reliable patient-reported outcome measures (PROMs) is a critical step in promoting patient-centered health care, a national priority in the U.S. Small populations or rare diseases often pose difficulties in developing PROMs using traditional methods due to small samples. METHODS: To overcome the small sample size challenge while maintaining psychometric soundness, we propose an innovative Ordinal Bayesian Instrument Development (OBID) method that seamlessly integrates expert and participant data in a Bayesian item response theory (IRT) with a probit link model framework. Prior distributions obtained from expert data are imposed on the IRT model parameters and are updated with participants' data. The efficiency of OBID is evaluated by comparing its performance to classical instrument development performance using actual and simulation data. RESULTS AND DISCUSSION : The overall performance of OBID (i.e., more reliable parameter estimates, smaller mean squared errors (MSEs) and higher predictive validity) is superior to that of classical approaches when the sample size is small (e.g. less than 100 subjects). Although OBID may exhibit larger bias, it reduces the MSEs by decreasing variances. Results also closely align with recommendations in the current literature that six subject experts will be sufficient for establishing content validity evidence. However, in the presence of highly biased experts, three experts will be adequate. CONCLUSIONS: This study successfully demonstrated that the OBID approach is more efficient than the classical approach when the sample size is small. OBID promises an efficient and reliable method for researchers and clinicians in future PROMs development for small populations or rare diseases.

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OBJECTIVE: The objective of this study is to identify the effects of unit collaboration and nursing leadership on nurse outcomes and quality of care. BACKGROUND: Along with the current healthcare reform, collaboration of care providers and nursing leadership has been underscored; however, empirical evidence of the impact on outcomes and quality of care has been limited. METHODS: Data from 29742 nurses in 1228 units of 200 acute care hospitals in 41 states were analyzed using multilevel linear regressions. Collaboration (nurse-nurse collaboration and nurse-physician collaboration) and nursing leadership were measured at the unit level. Outcomes included nurse job satisfaction, intent to leave, and nurse-reported quality of care. RESULTS: Nurses reported lower intent to leave, higher job satisfaction, and better quality of care in units with better collaboration and stronger nursing leadership. CONCLUSION: Creating a care environment of strong collaboration among care providers and nursing leadership can help hospitals maintain a competitive nursing workforce supporting high quality of care.

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Developing valid and reliable instruments is crucial but costly and time-consuming in health care research and evaluation. The Food and Drug Administration and the National Institutes of Health have set up guidelines for developing patient-reported outcome instruments. However, the guidelines are not applicable to cases of small sample sizes. Instead of using an exact estimation procedure to examine psychometric properties, our Bayesian Instrument Development (BID) method integrates expert data and participant data into a single seamless analysis. Using a novel set of priors, we use simulated data to compare BID to classical instrument development procedures and test the stability of BID. To display BID to non-statisticians, a graphical user interface based on R and WINBUGS is developed and demonstrated with data on a small sample of heart failure patients. Costs were saved by eliminating the need for unnecessary continuation of data collection for larger samples as required by the classical instrument development approach.

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BACKGROUND: Research on end-of-life care in nursing homes is hampered by challenges in retaining facilities in samples through study completion. Large-scale longitudinal studies in which data are collected on-site can be particularly challenging. OBJECTIVES: To compare characteristics of nursing homes that dropped from the study to those that completed the study. METHODS: One hundred two nursing homes in a large geographic 2-state area were enrolled in a prospective study of end-of-life care of residents who died in the facility. The focus of the study was the relationship of staff communication, teamwork, and palliative/end-of-life care practices to symptom distress and other care outcomes as perceived by family members. Data were collected from public data bases of nursing homes, clinical staff on site at each facility at 2 points in time, and from decedents' family members in a telephone interview. RESULTS: Seventeen of the 102 nursing homes dropped from the study before completion. These non-completer facilities had significantly more deficiencies and a higher rate of turnover of key personnel compared to completer facilities. A few facilities with a profile typical of non-completers actually did complete the study after an extraordinary investment of retention effort by the research team. CONCLUSION: Nursing homes with a high rate of deficiencies and turnover have much to contribute to the goal of improving end-of-life care, and their loss to study is a significant sampling challenge. Investigators should be prepared to invest extra resources to maximize retention.

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Nursing home staff turnover results in high cost--both economic and personal--and has a negative impact on the quality of care provided to residents at the end of life. Reducing staff turnover in nursing homes would benefit both the cost to the U.S. health care system, and, most importantly, the care residents receive in the vulnerable period leading to death. There is rising pressure on nursing homes to improve their palliative and end-of-life care practices and reduce transfers to hospital for situations and conditions that can be safely managed on site. Nursing care staff deserve an investment in the specific training necessary for them to give the highest quality care to dying residents. This training should be multifaceted and include the physiological, psychological, spiritual, interpersonal, and cultural (including ethnic) aspects of dying. Empowerment with these necessary knowledge, skills, and attitudes will not only result in better care for residents but likely also will reduce the burnout and frustration staff experience in caring for residents near death.

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BACKGROUND: Little is known about measuring equivalence between two rating scales. Measuring the equivalence between two rating scales requires a study design and analysis conducive to clear interpretation of actual equivalence with simple inferences. OBJECTIVE: The aim of this study was to show the use of bayesian methodology in determining equivalence within a simulated content validity study (to establish equivalence, not content validity). METHODS: Participants were randomized into two groups and responded to the items' perceived relevance or perceived correlation to a construct, job enjoyment. Items from the National Database of Nursing Quality Indicators were used. RESULTS: Eighty-seven nursing faculty members from various schools of nursing participated. Findings revealed in all items having a posterior probability of >95% that rating scales are equivalent using an informative prior whereas using a weak or flat prior led to a minimal decrease in posterior probability results. DISCUSSION: Prior and new information collected from this study was used to determine a posterior probability that a mean difference (±0.5 points) between the relevance and correlation group exists, thereby demonstrating equivalence between two rating scales.

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Little is known about the factors that contribute to symptoms in nursing home residents with cancer. We compared rates of symptoms in residents with (n = 1,022) and without cancer (n = 9,910) and examined physiologic, psychologic and situational factors potentially related to symptoms in residents with cancer. Pain, shortness of breath, vomiting, weight loss, and diarrhea were significantly (p < .05) more prevalent in residents with cancer. Cancer treatments, comorbid illnesses, and situational factors were not consistently correlated with symptoms. Improved symptom control was especially needed for the 30% of residents with cancer who clinically deteriorated within 3 months of admission; physical dependence and deteriorating clinical status were associated with pain, shortness of breath, and weight loss.

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OBJECTIVE: To examine the efficiency of the care planning process in nursing homes. METHODS: We collected detailed primary data about the care planning process for a stratified random sample of 107 nursing homes from Kansas and Missouri. We used these data to calculate the average direct cost per care plan and used data on selected deficiencies from the Online Survey Certification and Reporting System to measure the quality of care planning. We then analyzed the efficiency of the assessment process using corrected ordinary least squares (COLS) and data envelopment analysis (DEA). RESULTS: Both approaches suggested that there was considerable inefficiency in the care planning process. The average COLS score was 0.43; the average DEA score was 0.48. The correlation between the two sets of scores was quite high, and there was no indication that lower costs resulted in lower quality. For-profit facilities were significantly more efficient than not-for-profit facilities. CONCLUSIONS: Multiple studies of nursing homes have found evidence of inefficiency, but virtually all have had measurement problems that raise questions about the results. This analysis, which focuses on a process with much simpler measurement issues, finds evidence of inefficiency that is largely consistent with earlier studies. Making nursing homes more efficient merits closer attention as a strategy for improving care. Increasing efficiency by adopting well-designed, reliable processes can simultaneously reduce costs and improve quality.

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Nursing home residents living with cancer have unacceptably high percentages of unrelieved pain and other symptoms. However, residents with cancer have received relatively little attention in the literature to date. This article provides an overview of previous symptom research for residents with cancer, explores clinical and organizational factors that impede effective symptom management, and proposes an agenda for future research and clinical practice. Residents with cancer have numerous symptoms that tend to be different from the symptoms of other nursing home residents. Symptom management for residents with cancer is often complicated by cognitive impairment, declining physical functioning, and comorbid illnesses. Barriers to symptom management include underuse of analgesics and hospice, nursing home staffing patterns, and lack of resources. Additional research is necessary to provide a more comprehensive understanding of residents with cancer, explore how organizational factors affect the care of residents with cancer, and evaluate interventions for effective symptom assessment and management. Collaboration of oncology nurses with clinicians and researchers in nursing home settings is needed to improve care for residents with cancer.

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BACKGROUND: Although there is some evidence of improved quality in nursing home care after the implementation of the 1987 Omnibus Budget Reconciliation Act regulations, the nursing processes that contribute to that improvement are not well understood. Assumptions that the mandated tools for resident assessment and care planning account for the change remain uninvestigated. OBJECTIVES: To generate an empirically supported conceptual model of care planning integrity, incorporating five subconstructs: coordination, integration, interdisciplinary team, restorative perspective, and quality. METHODS: A correlational, model generation-model selection design guided the study. Using a random sample of 107 facilities, the research team combined primary data collected from care planning team members (n = 508) via a telephone survey, with variables extracted from the Medicaid Cost Reports and the Centers for Medicaid and Medicare Services Online Survey, Certification, and Reporting System (OSCAR) database. Primary and alternative models of care planning integrity were examined for fit to the data using structural equation modeling procedures. RESULTS: Using preliminary analyses, 18 observed indicators to represent the five latent subconstructs were identified. Fit indices for the primary model were borderline (comparative fit index =.892; root mean square error of approximation = .048), but were excellent for the alternative model (comparative fit index = .972; root mean square error of approximation = .026). Care planning integrity is demonstrated within nursing facilities through direct relationships with coordination, integration, and quality, and indirect relationships through integration with interdisciplinary team and restorative perspective. DISCUSSION: Care planning integrity captures differences in the way nursing facilities implement the care planning process, using the mandated standardized tools, that may make a difference in resident outcomes. Subsequent research is indicated to address those dynamics.

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The project reported here is the first in a series of cost analyses regarding the care planning process among 107 facilities. Process-based costing strategies and data envelopment analyses identified nursing facilities with efficient and less-efficient care planning processes. Having more people and more time devoted to the care planning process did not assure quality or efficiency. Efficiency varied across the nursing facilities and was not related to number of beds, profit status, or location; however, Medicare-certified facilities were less likely to be efficient.

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The study describes the design and implementation of an Internet-based, computed-assisted telephone survey about the care-planning process in 107 long-term care facilities in the Midwest. Two structured telephone surveys were developed to interview the care planning coordinators and their team members. Questionmark Perception Software Version 3 was used to develop the surveys in a wide range of formats. The responses were drawn into a database that was exported to a spreadsheet format and converted to a statistical format by the Information Technology team. Security of the database was protected. Training sessions were provided to project staff. The interviews were tape-recorded for the quality checks. The inter-rater reliabilities were above 95% to 100% agreement. Investigators should consider using Internet-based survey tools, especially for multisite studies that allow access to larger samples at less cost. Exploring multiple software systems for the best fit to the study requirements is essential.

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The valid measurement of nurses' job satisfaction is critical because job satisfaction is important for the retention of qualified nurses to provide patient care in hospitals. Two studies were conducted to adapt the Stamps Index of Work Satisfaction (1997b) to measure work satisfaction at the patient care unit level for use by the National Database of Nursing Quality Indicators (NDNQI). In Study 1 (n = 918 RNs) exploratory factor analysis of data obtained using the NDNQI-Adapted Index replicated the conceptual dimensions of the Stamps measure. Associations with scores on Job Enjoyment were evidence that the Index measured the intended construct. Using theta, the reliability of the composite subscales was .91. The adapted Work Satisfaction subscale scores explained 46% of the variance in Job Enjoyment, with each subscale contributing uniquely (p < .001). In Study 2 (n = 2277 RNs) confirmatory factor analysis using structural equation modeling supported the 7-subscale structure for the Adapted Index (CFI [719] = .88; RMR = .05). Replication of associations between scores on the Index subscales and Job Enjoyment provided further evidence regarding validity of the data, since the Work Satisfaction subscales explained 56% of the variance in Job Enjoyment. The feasibility of using an on-line version of the Adapted-Index for data collection was demonstrated. The findings from the two studies indicate that the adapted Index of Work Satisfaction has a structure similar to the original instrument and is a reliable and valid measure of work satisfaction at the patient care unit level.

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