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Health Services Research & Development

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2009 HSR&D National Meeting Abstract

National Meeting 2009

3020 — Direct Observation of RN Care Practices in Two VA-Affiliated Nursing Homes

Dellefield ME (VASDHS), Shively M (VASDHS), Harrington C (UCSF)

The study objective was the development and implementation of a PDA-based method to directly observe RN care practices related to five pressure ulcer (PU) risk factors, including immobility, incontinence, pain, PU treatment, and weight loss. Percentages of direct- (e.g., assessment, treatment, medications) and indirect-care practices (e.g., supervision, management, documentation), and any associations with total nursing and RN staffing levels were described.

An exploratory descriptive study using industrial engineering work-sampling methodology and RN convenience samples in two VA-affiliated nursing homes [NHs] (40-bed Nursing Home Care Unit [NHCU] currently a Community Living Center [CLC] and 174-bed VA-contract Community NH [CNH]). CLC nursing skill mix included RNs and licensed vocational nurses. 251 RN care practices categorized by PU risk factors were used.

Observations collected at ± 5% level of accuracy totaled 2,855 (CLC) and 4,476 (CNH) discrete care activities for seven RNs (51% RNs at CLC); and seven RNs (50% RNs at CNH) as study subjects. Data collectors achieved a range of 90% - 100% inter-rater reliability during training and at study sites. RNs performed 47% direct care, 41% indirect care (70% related to documentation), and 12% unproductive activities (CNH); 31% direct care, 59% indirect care (75% related to documentation), and 10% unproductive activities (CNH). At both sites, percentages of RN direct vs. indirect time varied by clinical domains but not by RN or total nurse staffing levels. Case mix indexes (32 CMI -CLC; 28 CMI-CNH) were similar.

How RN time was spent related to five clinical risk factor domains at two NHs differed by nursing skill mix. Documentation comprised a majority of indirect care practice; direct observation was not useful in accurately attributing clinical domains to documentation. Although inaccuracies in NH medical record documentation have been reported, the use of chart reviews and RN self-report may enhance the measurement of RN care practices when a majority of RN time is spent on documentation. A PDA-based method of measuring RN clinical practice is feasible for measurement of direct-care activities.

A PDA-based measurement of RN clinical practice is feasible when measuring direct-care activities. This method of measuring RN direct-care practices may provide real-time performance feedback. This method may be useful in observing the direct-care practice of other clinical providers in a variety of healthcare settings.

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