Outcomes of Nursing Management Practice in Nursing Homes (NMP)

Although clinical trials have identified interventions that reduce adverse outcomes such as falls in nursing home (NH) residents, attempts to translate those interventions into practice using current standard of care quality improvement (QI) techniques have not been successful. Using a complexity science framework, our previous RO1 has shown that low connection, information flow, and cognitive diversity among NH staff explains much of the poor quality of care delivered for complex problems such as falls. Our pilot work of "CONNECT", a multi-component intervention that encourages staff to engage in network-building and use simple strategies to make new connections with others, enhance information flow, and use cognitive diversity, suggests that staff can learn to improve the density and quality of their interactions. We hypothesize that higher levels of connection, information flow and cognitive diversity are necessary before any QI intervention for a complex geriatric problem such as falls can be successful.

This 5-year study will use a prospective, cluster-randomized, outcome assessment blinded design, with NHs (n=16) randomized to either CONNECT and a standard falls QI program (CONNECT + FALLS) or FALLS alone. We estimate that 560 residents and 576 staff members will participate. Specific aims are (1) Aim 1 (primary): Compare the impact of the CONNECT intervention plus a falls reduction QI intervention (CONNECT+FALLS) to the falls reduction QI intervention alone (FALLS) on fall-related process measures in nursing home residents; (2) Aim 2 (exploratory): Compare the impact of CONNECT+FALLS to FALLS alone on fall-related outcome measures in nursing home residents, and determine whether these are mediated by the change in fall-related process measures; (3) Aim 3 (exploratory): Compare the impact of CONNECT+FALLS to FALLS alone on staff interaction measures as reported by NH staff, and determine whether these mediate the impact on fall-related process measures and fall-related outcome measures. Cross-sectional, repeated measures of staff interaction are taken prior to first intervention, at 3 months and at 6 months. Longitudinal resident fall-related process and outcomes are measured for the 6 months prior to the FALLS intervention, and the 6 months after the FALLS intervention is completed. Fall-related process measures are the primary outcome. Exploratory outcome measures include fall-related outcome measures and staff interaction measures (communication; participation, group-to-group interaction, psychological safety, and safety culture). Analysis will use a 3-level mixed model to account for the complex nesting of patients and staff within homes, and control for covariates associated with fall risk, including baseline facility fall rates and staff turnover rates.