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The purpose of this article is to present issues scientists must consider to design effective experimental interventions. The efforts of nurse-researchers to test diverse interventions are consistent with the central role of interventions for the nursing discipline. Despite the importance of interventions, limited literature has addressed the actual design of these interventions. Many experimental interventions lack content validity, and others are inadequate to affect outcomes. Eight issues to consider in the development of interventions are discussed, including the conceptual basis of the intervention, descriptive research linking key concepts to the proposed outcome, previous intervention literature testing similar or related interventions, the intervention target, intervention specificity/generality, single or bundled interventions, intervention delivery, and intervention dose. Strategies are recommended for designing effective experimental interventions.

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PURPOSE: The purpose of the study was to determine if simply providing nursing facilities with comparative quality performance information and education about quality improvement would improve clinical practices and subsequently improve resident outcomes, or if a stronger intervention, expert clinical consultation with nursing facility staff, is needed. DESIGN AND METHODS: Nursing facilities (n = 113) were randomly assigned to one of three groups: workshop and feedback reports only, workshop and feedback reports with clinical consultation, and control. Minimum Data Set (MDS) Quality Indicator (QI) feedback reports were prepared and sent quarterly to each facility in intervention groups for a year. Clinical consultation by a gerontological clinical nurse specialist (GCNS) was offered to those in the second group. RESULTS: With the exception of MDS QI 27 (little or no activity), no significant differences in resident assessment measures were detected between the groups of facilities. However, outcomes of residents in nursing homes that actually took advantage of the clinical consultation of the GCNS demonstrated trends in improvements in QIs measuring falls, behavioral symptoms, little or no activity, and pressure ulcers (overall and for low-risk residents). IMPLICATIONS: Simply providing comparative performance feedback is not enough to improve resident outcomes. It appears that only those nursing homes that sought the additional intensive support of the GCNS were able to effect enough change in clinical practice to improve resident outcomes significantly.

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High rates of turnover among nursing home staff are well documented, especially among nursing assistants who provide 80 percent to 90 percent of the direct care to residents. High staff turnover significantly and negatively impacts a nursing home's ability to provide high-quality care. Current organizational theory and empirical evidence suggest that a supportive workplace promotes satisfaction and retention of workers. A model of staff support in the nursing home is proposed that conceptualizes the nursing home as a supportive social system in which the needs of both staff and residents can be better met.

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OBJECTIVE: To describe the prevalence, incidence, management, and predictors of venous ulcers in residents of certified long-term-care facilities using the Minimum Data Set. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: 32,221 residents admitted to long-term-care facilities in Missouri between January 1, 1996, and October 30, 1998. MAIN OUTCOME MEASURES: Version 2.0 of the Minimum Data Set was utilized. Assessment items included selected measures from background information, disease diagnoses, physical functioning and structural problems, health conditions, oral/nutritional status, and skin condition. MAIN RESULTS: Venous ulcer prevalence on admission was 2.5%. The incidence of venous ulcer development for long-term-care residents admitted without an ulcer at 90, 180, 270, and 365 days after admission was 1.0%, 1.3%, 1.8%, and 2.2%, respectively. The most frequent skin treatments for residents with a venous ulcer were ulcer care, dressings, and ointments. Factors associated with venous ulcer development within a year of admission were diabetes mellitus, peripheral vascular disease, and edema. CONCLUSION: Venous ulcer prevalence and incidence are greater in the long-term-care population than in the community at-large. Residents with a venous ulcer are likely to have comorbid conditions such as diabetes mellitus, peripheral vascular disease, congestive heart failure, edema, wound infection, and pain. Based on these data, risk factors such as history of leg ulcers, recent edema, diabetes mellitus, congestive heart failure, or peripheral vascular disease should prompt clinicians to carefully plan care that will manage a resident's risk for venous ulcer development.

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It is expected that at least 40 percent of the population over 75 will need extensive health care services late in their lives. The public has a negative view of nursing home placement that has, to some extent, been confirmed by research finding that the health of a frail older person deteriorates each time he or she is moved. The Aging in Place model of care for the elderly offers care coordination (case management) and health care services to older adults so they will not have to move from one level of care delivery to another as their health care needs increase. University Nurses Senior Care (UNSC) is the service entity of this project and provides as its core service care coordination with a variety of service options. These options include care packages or services at an hourly rate to meet individual client needs. The Aging in Place project will be evaluated by comparing project clients to residents of similar acuity in nursing homes and to similar clients receiving standard community support services. Data from this project will be important to consumers, researchers, providers, insurers, and policy makers.

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This article provides an overview of family involvement in care intervention and its implementation with African American and Caucasian family members of persons with dementia in nursing home settings.

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The "Observable Indicators of Nursing Home Care Quality" instrument was developed as a new measure of nursing home care quality. The instrument is based on a theoretical model of quality nursing home care grounded in data from provider and consumer focus groups. The instrument was piloted in 10 Missouri nursing homes. Subsequent versions were tested in 109 Missouri and 11 Icelandic nursing homes. Content validity was established using experts. Concurrent and known groups validity was evaluated using Minimum Data Set quality indicators, survey citations, and a process of care measure. Interrater and test-retest reliabilities were calculated as well as coefficient alpha. The "Observable Indicators of Nursing Home Care Quality" instrument is a new measure that can be used by researchers, and potentially by regulators, consumers, or providers, to observe and score specific indicators of quality care following a 20- to 30-minute inspection of a nursing home.

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BACKGROUND: Determining meaningful thresholds to reinforce excellent performance and flag potential problem areas in nursing home care is critical for preparing reports for nursing homes to use in their quality improvement programs. This article builds on the work of an earlier panel of experts that set thresholds for quality indicators (QIs) derived from Minimum Data Set (MDS) assessment data. Thresholds were now set for the revised MDS 2.0 two-page quarterly form and Resource Utilization Groups III (RUGS III) quarterly instrument. SETTING THRESHOLDS: In a day-long session in October 1998, panel members individually determined lower (good) and upper (poor) threshold scores for each QI, reviewed statewide distributions of MDS QIs, and completed a follow-up Delphi of the final results. REPORTING MDS QIS FOR QUALITY IMPROVEMENT: The QI reports compiled longitudinal data for all residents in the nursing home during each quarter and cumulatively displayed data for five quarters for each QI. A resident roster was provided to the nursing home so that the quality improvement team could identify the specific residents who developed the problems defined by each QI during the last quarter. Quality improvement teams found the reports helpful and easy to interpret. SUMMARY AND CONCLUSIONS: As promised in an earlier report, to ensure that thresholds reflect current practice, research using experts in a panel to set thresholds was repeated as needed. As the MDS instrument or recommended calculations for the MDS QIs change, thresholds will be reestablished to ensure a fit with the instrument and data.

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Consumers want a range of services and care available for them if and when they may need them. They want long-term care that addresses six areas of concern: community-based services, continuity, coordination, caring, convenience, and cost. To develop new perspectives and new ways of providing the needed long-term services, it is time for health care leaders to work cooperatively with consumers to redesign long-term care, both community-based and institutional. Consumers and consumer advocates, working cooperatively with health care leaders, could reinvent home health care, nursing home care, and other long-term services such as "aging in place" for older people.

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It is becoming increasingly common for nursing facilities to use Quality Indicators (QI) derived from Minimum Data Set (MDS) data for quality improvement initiatives within their facilities. It is not known how much support facilities need to effectively review QI reports, investigate problems areas, and implement practice changes to improve care. In Missouri, the University of Missouri-Columbia MDS and Nursing Home Quality Research Team has undertaken a Quality Improvement Intervention Study using a gerontological clinical nurse specialist (GCNS) to support quality improvement activities in nursing homes. Nursing facilities have responded positively to the availability of a GCNS to assist them in improving nursing facility care quality.

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Regulating and standardizing the assessment of residents was envisioned by the 1986 Committee on Nursing Home Reform to have many advantages for facility management, government regulatory agencies, and clinical staff to evaluate changes in resident status and adjust the care plans accordingly. Standardized assessment data was viewed as a source of management information to be used to track case mix (i.e., acuity) of residents, allocate resources such as staff, and evaluate care quality. The Resident Assessment Instrument is a clinically relevant assessment process that can facilitate effective care planning, interventions, and quality improvement. It is a clinically complex process requiring care delivery systems developed by RNs to support the implementation of individualized care.

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This exploratory study was undertaken to discover the defining dimensions of nursing home care quality from the viewpoint of consumers of nursing home care. Eleven focus groups were conducted in five Missouri communities. The seven dimensions of the consumer multidimensional model of nursing home care quality are: staff, care, family involvement, communication, environment, home, and cost. The views of consumers and families are compared with the results of a previous study of providers of nursing home services. An integrated, multidimensional theoretical model is presented for testing and evaluation. An instrument based on the model is being tested to observe and score the dimensions of nursing home care quality.

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This exploratory study was undertaken to discover the defining dimensions of nursing home care quality and to propose a conceptual model to guide nursing home quality research and the development of instruments to measure nursing home care quality. Three focus groups were conducted in three central Missouri communities. A naturalistic inductive analysis of the transcribed content was completed. Two core variables (interaction and odor) and several related concepts emerged from the data. Using the core variables, related concepts, and detailed descriptions from participants, three models of nursing home care quality emerged from the analysis: (1) a model of a nursing home with good quality care; (2) a model of a nursing home with poor quality care; and (3) a multidimensional model of nursing home care quality. The seven dimensions of the multidimensional model of nursing home care quality are: central focus, interaction, milieu, environment, individualized care, staff, and safety. To pursue quality, the many dimensions must be of primary concern to nursing homes. We are testing an instrument based on the model to observe and score the dimensions of nursing home care quality.

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Researchers, providers and government agencies have devoted time and resources to the development of a set of Quality Indicators derived from Minimum Data Set (MDS) data. Little effort has been directed toward verifying that Quality Indicators derived from MDS data accurately measure nursing home quality. Researchers at the University of Missouri-Columbia have independently verified the accuracy of QI derived from MDS data using four different methods; 1) structured participative observation, 2) QI Observation Scoring Instrument, 3) Independent Observable Indicators of Quality Instrument, and 4) survey citations. Our team was able to determine that QIs derived from MDS data did differentiate nursing homes of good quality from those of poorer quality.

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In 1994 12.7% of the population was 65 and over, while 10.6% were 85 and over. Expenditures for nursing homes reached $72.3 billion in 1994 (much of which is tax-supported) accounting for 8.7% of all personal health money spent. Data from the 1993 Missouri Medicaid cost reports for 403 nursing homes were reviewed to determine differences in costs per resident day (PRD) and discover which factors most influenced these differences. Mid-sized facilities with 60-120 beds reported the lowest resident-related PRD costs. PRD expenses for aides and orderlies were higher in tax-exempt facilities, which was thought to be related to their "more altruistic" mission. Investor-owned facilities showed significantly greater administrative costs PRD, which may relate to higher administrative salaries and fancier offices. The authors suggest further study that would incorporate location, occupancy rate, quality of care, case mix, and payer mix data.

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BACKGROUND: Determining meaningful thresholds to reinforce excellent performance and flag potential problem areas is critical for quality improvement reports. Without thresholds, an organization may interpret its performance as superior to others because it is "better than average" and falsely assume it does not have care problems in certain areas. SETTING THRESHOLDS: The Minimum Data Set (MDS) assessment instrument is mandated for use nationwide in all nursing homes participating in Medicaid or Medicare programs. Since 1993 a research team at the University of Missouri-Columbia has been developing and testing quality indicators (QIs) derived from MDS data as a foundation for quality improvement activities. In July 1996, a cross-section of 13 clinical care personnel from nursing homes participated on an expert panel for threshold setting for QIs derived from MDS assessment data. Panel members individually determined good and poor threshold scores for each QI, reviewed statewide distributions of MDS QIs, and, two weeks later, completed a follow-up Delphi round. Three members of the research team reviewed the results of the expert panel and set the final thresholds. With thresholds established for good and poor scores, MDS QI scores are reported to a sample of Missouri nursing homes using the thresholds. CONCLUSIONS: To ensure that thresholds reflect current practice, threshold setting with another panel of experts will be repeated as needed, but at least biannually. The report format will be revised on the basis of user input, and a statewide study testing different educational support methods for quality improvement using MDS QIs is now underway.

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This study examines perspectives of a broad group of nursing home employees, regulators, advocates, and professional associations to describe progress made since the 1990 implementation of the Nursing Home Reform legislation (OBRA '87) and to determine whether the legislation is perceived as effecting positive change for nursing home residents. Interviews were conducted with 132 professional and non-professional staff in six states and 56 residents. Important issues about nursing home staffing and quality of care are explored. In general, OBRA '87 is viewed as positive, with all groups of respondents indicating that nursing staff or quality have not deteriorated; administrators, licensed nurses, and certified nursing assistants indicate the quality of nursing care provided and the nursing staff levels have improved since OBRA '87 implementation. Regulators agree that quality of nursing care has improved, but nursing home advocates, regulators, and professional association staff indicate mostly no change or no opinion. There is a danger in interpreting that quality and staffing are adequate from these results. While both may have improved, they may not be adequate.

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In conclusion, redesigning the senior leadership management theory course in our undergraduate baccalaureate nursing program to incorporate new concepts of managed care, case management, critical paths, and multidisciplinary collaborations was successful. Providing students with a "real world" project developing critical paths provided an opportunity for them to make a contribution to an organization while learning verbal and written collaborative skills that may prove crucial to their future in nursing. Critical path development projects will be pursued until those specific needs of the organization have been met. Other opportunities will become obvious for class projects as new challenges are presented for organizations to address in this ever-changing health care delivery system.

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This study examines perspectives of a broad group of nursing home employees, regulators, advocates, and professional associations to describe progress made since the 1990 implementation of the Nursing Home Reform legislation (OBRA '87) and to determine whether the legislation is perceived as affecting positive change for nursing home residents. Interviews were conducted with 59 residents and 132 professional and non-professional staff in six states. Important quality of care issues of resident rights, resident dignity, restraint use, resident assessment, as well as perspectives of residents themselves are explored. In general, OBRA '87 is viewed as positive, with all groups of respondents indicating that residents have benefited from it. They identify the focus on resident rights as the most important accomplishment. Empowerment of residents through involvement in care decisions is noted by many as an important achievement. Many conclude that quality of care has improved and restraint use has decreased. The MDS is a useful tool from the standpoint of nursing home staff and regulators. This appraisal sharply contrasts their opinions about the Preadmission Screening and Resident Review (PASARR) screening tool. We believe that PASARR should be reexamined and that changes should be made in the process and/or implementation of the tool.

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