1. 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

3. Faculty Disclosures: Dr. Bonner has disclosed that she has no relevant financial relationships.

4. 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

5. Acknowledgement This study was supported by an American Medical Director’s Association Foundation/Pfizer Quality Improvement Award

6. 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

7. 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

8. Original 12 Domains Hospital 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

9. Selecting the Topic: CNAs’ 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

10. The Research Question 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

11. 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.

12. 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)

13. 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)

14. 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

15. 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

16. 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

17. 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)

18. 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

19. Risk Adjustment Based on available data Falls –cognitive impairment, Alzheimer’s disease, behaviors, ADL status, average number of medications, facility characteristics Daily use of physical restraints –cognitive impairment, behaviors, number of medications, ADL status, Alzheimer’s disease, facility characteristics Pressure ulcers –cognitive impairment, Alzheimer’s 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

20. RESULTS

21. Demographic Data for 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

22. Demographic Data for 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%

23. Demographic Data for 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)

24. CNA PSC and Falls Rates Poisson Regression (N=74 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 Alzheimer’s disease in the facility (B=.011; p=.017) –lower proportion of Medicare residents in the facility (B=-.013; p=.000).

25. CNA PSC and Restraint Rates Multinomial Logistic Regression (N=74) 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)

26. CNA PSC and Pressure Ulcer Rates Poisson Regression (N=74 facilities) Average CNA total PSC scores did not have a statistically significant association with pressure ulcer rates (B=-0.001; p=0.807)

27. CNA PSC and CNA Turnover Linear Regression (N=74) 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 (B=1.446; p=.001) Lower CNA turnover was associated with higher facility occupancy (B=-.188; p=.000) Adjusted R square for this model was.639.

28. VariableBSEP-Value CNA staffing-0.5550.3530.116 LPN staffing-0.9380.295 0.002** RN staffing0.5400.4470.227 CNA turnover-2.3901.094 0.029** LPN turnover-0.1731.3860.901 RN turnover0.8421.3730.540 GEE Model for Staffing, Turnover and Total PSC (N=1761) Dependent Variable: Total CNA Patient Safety Culture Score **p<.05

29. VariableBSEP-Value Gender Female4.8683.2540.135 Male0a0a Education High School Degree2.0401.7630.247 Associates Degree-3.1673.0620.301 Bachelors Degree or Higher0a0a Age-0.0870.039 0.025** GEE Model for CNA Demographic Characteristics (N=1761) Dependent Variable: Total CNA Patient Safety Culture Score a. Set to zero because this parameter is redundant. **p<.05

30. VariableBSEP-Value Not for profit-1.7711.7550.313 Profit0a0a Non-chain member-1.5241.6450.354 Chain member0a0a Non-rural location-1.5372.6840.567 Rural location0a0a High School Degree1.9631.7690.267 Associate Degree-3.5762.9500.225 Bachelors Degree or higher0a0a CNA turnover-1.3370.515 0.009** Age-0.0490.0680.469 Tenure as a CNA-0.0580.1000.559 Tenure in the facility0.0090.1350.946 County unemployment rate1.2970.8380.122 Number of nursing homes in the county-0.0520.0910.571 Average facility occupancy-0.0100.2170.964 Average facility private pay occupancy-0.0060.1620.970 Bed size-0.0200.0140.134 LPN staffing-0.8010.211 0.000** Combined GEE Model for Facility level and CNA Demographic Characteristics (N=1761) Dependent Variable: Total CNA Patient Safety Culture Score a Set to zero because this parameter is redundant. **p<.01

31. DISCUSSION

32. CNA PSC and Falls Rates Poisson 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

33. CNA PSC and Restraint Rates Multinomial 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

34. CNA PSC and Pressure Ulcer Rates Poisson Regression Average CNA total PSC scores did not have a statistically significant association with pressure ulcer rates (B=-0.001; p=0.807). 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)

35. VariableBSEP-Value CNA staffing-0.5550.3530.116 LPN staffing-0.9380.295 0.002** RN staffing0.5400.4470.227 CNA turnover-2.3901.094 0.029** LPN turnover-0.1731.3860.901 RN turnover0.8421.3730.540 GEE Model for Staffing, Turnover and Total PSC (N=1761) Dependent Variable: Total CNA Patient Safety Culture Score **p<.05

36. VariableBSEP-Value Gender Female4.8683.2540.135 Male0a0a Education High School Degree2.0401.7630.247 Associates Degree-3.1673.0620.301 Bachelors Degree or Higher0a0a Age-0.0870.039 0.025** GEE Model for CNA Demographic Characteristics (N=1761) Dependent Variable: Total CNA Patient Safety Culture Score a. Set to zero because this parameter is redundant. **p<.05

37. VariableBSEP-Value Not for profit-1.7711.7550.313 Profit0a0a Non-chain member-1.5241.6450.354 Chain member0a0a Non-rural location-1.5372.6840.567 Rural location0a0a High School Degree1.9631.7690.267 Associate Degree-3.5762.9500.225 Bachelors Degree or higher0a0a CNA turnover-1.3370.515 0.009** Age-0.0490.0680.469 Tenure as a CNA-0.0580.1000.559 Tenure in the facility0.0090.1350.946 County unemployment rate1.2970.8380.122 Number of nursing homes in the county-0.0520.0910.571 Average facility occupancy-0.0100.2170.964 Average facility private pay occupancy-0.0060.1620.970 Bed size-0.0200.0140.134 LPN staffing-0.8010.211 0.000** Combined GEE Model for Facility level and CNA Demographic Characteristics (N=1761) Dependent Variable: Total CNA Patient Safety Culture Score a Set to zero because this parameter is redundant. **p<.01

38. 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. F urther 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

39. 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

40. 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

41. Policy and Practice Implications 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’ 9 th SOW includes recommendations to include the nursing home culture survey in comprehensive resident safety programs

42. 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

43. 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