Introduction
Nursing homes are established to provide care services to older adults and individuals with disabilities who cannot be cared for at home but do not require hospital care. Similar to other healthcare sectors, nursing homes emphasize patient dignity and care quality and implement measures to promote a culture of patient safety. However, a range of serious care quality issues, including the risks of staff violence, injuries resulting from patient falls, and care mistakes are recognized by modern researchers (Kuk et al., 2017; Mills et al., 2019). Negative health outcomes of nursing home patients can stem from different sources. To minimize care quality concerns, researchers in the field must single out the factors that pose a challenge to proper nursing care in this type of facility. This paper is aimed at reviewing and appraising two up-to-date studies to answer the following question: what are the challenges and barriers to providing high-quality nursing care in the nursing home?
Literature Search Strategy
The research question introduced above refers to the state of scientific research regarding practical challenges and barriers that make negative contributions to the quality of care in nursing homes. The literature search was conducted with the help of two tools – PubMed and Google Scholar. The first tool allows accessing the Medline database of scientific studies in the field of biology and medicine, whereas the second one helps to search for studies across all scientific disciplines. The basic keyword helping to search was “nursing home,” and it was used in different combinations with other terms, including “care quality,” “barriers,” “barriers to quality,” and “challenges in care.” All keywords were selected based on their relevance to the research question and the identified facility type, as well as the ability to yield sufficient search results. Some synonymous keywords were evaluated concerning the frequency of occurrence in all online texts. For instance, in Google, the phrase “barriers to quality” yields eight times as many results as “obstacles to quality,” so the first option was considered a better choice.
In PubMed, the applied filters included the date of publication (not older than five years) and source type (all types apart from books and documents). The settings regarding the language of publications were not available, but the search did not yield results in languages other than English. The filters used in Google Scholar were the publication date (since 2016), sorting the results by relevance, and the exclusion of patent citations. The number of citations retrieved using PubMed exceeded 150, and approximately the same number of results was retrieved with the help of Google Scholar. The best matches were then evaluated manually to select the most relevant articles that would focus specifically on nursing care and be published in peer-reviewed journals.
Critical Appraisal of the Articles
Being able to provide care services that cause positive health outcomes for clients without involving safety risks is of great importance when it comes to the work of nursing homes, which explains the selection of the research question. Understanding that barriers to the provision of high-quality care can be multifaceted, modern researchers approach this clinical question from different angles and highlight diverse aspects of care. The studies by Mills et al. (2019) and Kuk et al. (2017) selected for the critical appraisal demonstrate more specific aspects of the topic of care quality, such as interactions with residents and the success of strategies to promote functional activities.
In their qualitative study, Mills et al. (2019) research the factors that pose threats to care quality improvement in nursing homes by conducting semi-structured interviews with nursing home staff members, the majority of which are the nursing staff. In their quantitative cross-sectional study, Kuk et al. (2017) use a questionnaire to explore the factors that the nursing staff in nursing homes perceives as obstacles to effective care and health promotion among residents. Mills et al. (2019) focus more on the empathy component of nursing care (resident-nurse interactions) and barriers to it. Kuk et al. (2017) emphasize caring and the effectiveness of nurses’ strategies to promote physical activity among residents. Thus, both of the studies touch upon some negative factors that predict care quality, but the difference between them is the degree of specificity.
The two studies explore the topic of barriers to care quality improvement using different types of research perspectives and approaches. In their study used for descriptive purposes, Mills et al. (2019) have conducted qualitative semi-structured interviews with 68 nursing staff members and 10 specialists in other fields, including nursing home physicians. Each interviewee was supposed to answer eight open-ended questions about the LOCK quality improvement project and their positive and negative experiences with it. A qualitative perspective seems appropriate in this case since it allows all interviewees to share specific details of their individual experiences, thus shedding light on new, previously unexplored obstacles to high-quality care. Differently from that, in their descriptive cross-sectional study, Kuk et al. (2017) approach the topic and explore nurse-perceived barriers to high-quality care with the help of a quantitative tool. It is the 33-item MAINtAIN inventory that explores barriers and behaviors. In this case, the selection of a quantitative perspective also has certain advantages, such as the opportunity to get more generalizable and reliable results due to a larger sample (more than 360 nurses).
The research groups conducting the selected studies have chosen different sampling techniques. Mills et al. (2019) have applied snowball (participants recruit other participants) and emergent (researchers make sampling decisions) sampling techniques to recruit 78 participants from 6 U.S. nursing homes. As for Kuk et al. (2017), the researchers have drawn random samples from nursing homes in each of the five regions selected for the study. On the one hand, random sampling allows eliminating sampling bias and describing a specific population as a whole, whereas the approaches used by Mills et al. (2019) do not guarantee representativeness. On the other hand, the choice of these specific sampling methods seems appropriate for the selected topics. For instance, Mills et al. (2019) explore the implementation of a specific quality improvement initiative that is not nationwide, so the use of probabilistic sampling would presumably take too much time.
Data collection/analysis methods also deserve attention since they help to single out the studies’ potential drawbacks. Mills et al. (2019) used in-person semi-structured interviews as the key data collection method and then conducted a thematic analysis manually. The method’s main advantage is that it provides certain uniformity since the interview structure is predetermined, but the questions are broad enough to let the participants share any relevant experiences. Regarding the analysis method, thematic analysis is a common choice for interview transcripts, but its flexibility also creates obstacles to coherence and consistency. In Kuk et al. (2017), the MAINtAIN inventory developed to measure nurse-perceived barriers to caring for those in nursing homes acts as the data collection tool, which allows getting specific results. They used data analysis methods include the calculation of descriptive statistics and hierarchical linear regression tests in SPSS. These methods facilitate the interpretation of large data sets and offer accuracy, which makes them a good choice.
The studies’ limitations vary greatly due to design-related differences. The study by Mills et al. (2019), focuses on the Veterans Health Administration (VHA) nursing homes, so it is not clear whether the results are generalizable. To continue, the researchers cannot contextualize the staff members’ experiences due to having no information about the actual outcomes of program implementation at specific facilities. Speaking about the second study, its potential weaknesses include the inability to establish cause-effect relationships in terms of barriers to high-quality care – it is because the study is not longitudinal (Kuk et al., 2017). Additionally, participants’ sincerity is a common issue peculiar to the use of self-report tools – conceivably, the respondents could have distorted some facts or overestimated the positive outcomes of their resident care activities.
In terms of themes and issues, differences between the two studies are evident. The recurring thought in the study by Mills et al. (2019) is that barriers to quality improvement (QI) initiatives in nursing homes remain relatively unknown. In contrast, Kuk et al. (2017) are convinced that the frequency of the already known barriers is a research issue that requires much attention. It is not possible to say which research group is correct given the difference between the research objects and the fact that the two groups explore different types of nursing homes.
Both studies contain interesting arguments regarding the implications of the findings. In Mills et al. (2019), the identified barriers to care improvement in VHA nursing homes include issues when interpreting data reports, lack of experience in using observation tools, and misconceptions about quality improvement goals. The researchers argue that these results can also guide the implementation of the LOCK framework to improve resident outcomes in community nursing homes (Mills et al., 2019). It is probably true given that the LOCK approach is broad and mainly covers the philosophy of QI. As per Kuk et al. (2017), the main nurse-perceived barriers to effective functional activity promotion include inadequate staffing levels, physical limitations affecting residents, resource availability, and issues in team communication. Interestingly, based on statistical analysis, Kuk et al. (2017) suppose that obstacles to proper care that nurses emphasize do not necessarily affect behaviors more than other, less frequently cited barriers to care quality. This idea suggests that nurses’ opinions should not be the only source of information when studying factors that negatively affect the quality of nursing home care, which sounds logical.
The quantitative study adds to the current knowledge regarding constraints affecting care quality in the nursing home. Kuk et al. (2017) demonstrate that widely known issues in the organization of care, such as having enough staff and resources and interprofessional communication, continue to affect care quality. Such findings can be found in the related literature and similar studies covering the topic; for instance, the evidence for staffing levels as a critical barrier to high-quality services in the nursing home is abundant. It has been reported by Dyck and Kim (2018), Fosse et al. (2017), Hartmann et al. (2016), Jun, Kovner, and Stimpfel (2016), Lavallée et al. (2018), Li et al. (2020), and White et al. (2020). Similarly to Kuk et al. (2017), Ali and Li (2019), Iaboni et al. (2020), and Ree, Johannessen, and Wiig (2019) mention financial and time constraints as barriers to injury prevention in nursing homes.
The results of the qualitative study also find partial reflection in the related literature addressing barriers to quality and nursing homes. Mills et al. (2019) highlight that the nursing staff sometimes simply lacks substantial training regarding the use of QI tools and needs more coherent teamwork. These factors and their influences on nursing home care are recognized worldwide, including the studies by Al-Jumaili and Doucette (2017), Chen et al. (2020), Gil (2018), Smythe et al. (2017), and Vikström and Johansson (2019). Similarly to Mills et al. (2019), Ginsburg et al. (2018) and Müller et al. (2018) report ineffective communication between the members of nursing home teams as a separate barrier to care and an issue in QI. However, the conclusions reported by Mills et al. (2019) are unique since they refer to an innovative theoretical framework first proposed in another article by Mills et al. (2018).
The reviewed studies contain ideas that demonstrate persistent knowledge gaps to be addressed in the nearest future. For instance, Mills et al. (2019) suggest that barriers to proper care in the nursing home are also related to motivation for improvement, which is why QI initiatives with employee motivation components might be effective. However, not much is known about such interventions and whether an emphasis on motivation changes care quality drastically. Also, the extent to which nurse-reported barriers to care provision in nursing homes reflects their actual behaviors and challenges remains another research gap (Kuk et al., 2017). It is possible that the use of non-self-report methods, for instance, observation, will help to address it.
Conclusion
Both articles add to the current knowledge regarding barriers to effective nursing care in nursing homes. Using the interview method, thematic analysis, and non-probabilistic sampling, Mills et al. (2019) demonstrate that the implementation of QI initiatives in VHA nursing homes is complicated by nurses’ misconceptions and the need for continuous training. In their cross-sectional study, Kuk et al. (2017) explore the experiences of a larger sample using random sampling, the quantitative MAINtAIN inventory, and time-honored statistical analysis techniques. Their research sheds light on broader issues, such as staffing, limited resources, residents’ capabilities, and poor team communication as nurse-perceived obstacles to high-quality care.
From a clinical perspective, the results suggest that strategies to enhance residents’ capabilities (reduce the fear of falling) are needed to improve quality in terms of nurse-initiated health promotion activities. In terms of management and education, to propel care quality to the next level, it is essential to consider team communication training and avoid saving on nurse training when introducing any new QI tools. From a research perspective, establishing the accuracy of nurse-perceived negative contributions to quality is still critical. Thus, new studies to compare care providers’ perspectives to the results of observations will further promote knowledge development.
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