Evaluation of the relationships among structure, process, and outcome in the changing nursing home environment

The purpose of this study was to examine the relationships among structure, process, and outcome in the changing nursing home environment. The selection of variables to measure structural characteristics (resident, unit, and nursing home) was guided by the conceptual framework for the evaluation of quality of care described by Donabedian (1980). Demographic resident characteristics included age, gender and race. Resident characteristics included comorbidities, advanced directives, and length of stay. Staffing characteristics included agency staffing, non-licensed staffing, nursing hours per resident, and therapy. Unit characteristics included census and case-mix. Unit process was measured by turbulence on the unit. Nursing home process included the extent of technology, extent of support, and perceived environmental uncertainty. Resident outcomes included functional decline and pressure ulcer rate. Unit outcomes included emergency room use, hospitalization, mortality, fall rate, and discharge to home. Adverse drug event was the nursing home level outcome. The setting was three nursing homes in the southeastern region of the United States. Two-hundred three residents with functional status time 1 and time 2 at the time of medical record review were included in the study. The review of medical records was used to collect information on resident demographics, resident characteristics, and the outcomes of functional decline and pressure ulcer rate. Sixty-eight nurses completed surveys on the extent of technology, extent of support, and perceived environmental uncertainty. Nursing home administrative records were reviewed to obtain data on the unit level and nursing home level structures, processes, and outcomes.;Cross-tabulation and chi-square test of independence showed highly significant differences between nursing units and nursing homes for gender, race and advance directives. Analysis of variance demonstrated significant differences at the unit level for comorbidity, functional status at time 2, and length of stay. There were significant within nursing home unit differences for 2 of the 3 nursing homes for comorbidity and functional status time 2. Analysis of variance by nursing home for all variables aggregated to the unit level showed significant differences for gender, advance directives, mean agency staffing, mean turbulence, mean emergency room use, mean hospitalization, and mean fall rate. (Abstract shortened by UMI.).