Nursing Home Patient Safety Culture Perceptions Among Licensed Practical Nurses

Abstract

Background: 

Licensed practical nurses (LPNs) working in nursing homes are the primary licensed nurses providing care and ensuring patient safety in New Jersey. As such, it is important to understand LPNs' perception of patient safety culture (PSC) and job satisfaction, which may impact resident safety.

Purpose: 

To describe the relationship between LPNs' perception of PSC in nursing homes and job satisfaction.

Methods: 

A cross-sectional study design was used to survey LPNs in New Jersey.

Results: 

LPNs working in nursing homes were less satisfied than LPNs working in other settings, and their perception of PSC was lower than that in 2019 national data report.

Conclusion: 

LPNs in nursing homes indicated that PSC needs improvement. Now is an opportune time to implement initiatives to foster a culture of safety in nursing homes.

Patient safety is a nationwide concern, particularly for the 1.16 million residents living in one of the 15 183 United States (US) nursing homes.¹ As the primary licensed nurse providing direct care to residents in nursing homes, licensed practical nurses (LPNs) are instrumental to ensuring resident safety. With the aging population in the United States, the 901 660 US LPNs are essential to the nursing workforce for those needing care in the nursing home settings.² The primary employment setting for LPNs in the US (27.5%) and in New Jersey (NJ) (34%) is nursing home/extended care.^3,4 Thus, their perception of how to maintain safety for residents can provide insight into how to improve the quality of care for vulnerable patients in nursing homes.

The National Academies of Sciences, Engineering, and Medicine (NASEM) National Imperative to Improve Nursing Home Quality report provided recommendations to improve the quality of care in nursing homes.⁵ This report recognized care in nursing homes is provided by registered nurses (RNs) and LPNs; however, RNs and LPNs have different scopes of practice and are used interchangeably. Furthermore, evidence indicates LPNs are functioning at higher levels because of the unavailability of RNs in the nursing home setting.^6,7

PATIENT SAFETY

In 2000, the NASEM, formerly the Institute of Medicine (IOM), To Err Is Human: Building a Safer Health System report identified the need to protect patients from harm because adverse events from medical errors were occurring in health care settings.⁸ Recommendations included that health care organizations should make patient safety an organizational priority.⁸ Patient safety was also the focus of the IOM Crossing the Quality Chasm: A New Health System for the 21st Century report, recognizing that hospital culture must change when errors occur from blaming to examining the incident and recommending areas for improvement.⁹ The IOM identified the keys to patient safety culture (PSC) as (1) a shared belief that health care can be designed to prevent harm; (2) an organizational commitment to investigate patient injuries and near misses; and (3) an environment that balances the need for reporting of events and the need to take disciplinary action.¹⁰ These recommendations are particularly important to nursing homes, as residents often represent vulnerable populations that are prone to safety concerns.

Existing evidence supports that nurses perceive PSC in nursing homes as worse than that in hospitals.^11–14 In the 5 PSC dimensions of nonpunitive response to error, teamwork within units, communication openness, feedback and communication about error, and organizational learning, nursing homes scored significantly lower in each of these dimensions than did hospitals.¹³ Furthermore, many nurses report that nursing homes have a “blame and shame” culture.^15,16

Higher ratings of PSC were associated with improved patient safety and health care quality in nursing homes, specifically lower fall rates and use of physical restraints and higher Centers for Medicare & Medicaid Services Nursing Home Compare Five-Star quality ratings.^17–19 One quality indicator consistently associated with better resident safety is the level of nurse staffing.²⁰ Studies support that higher RN staffing levels are associated with higher safety culture scores and Nursing Home Compare Quality staffing ratings, a rating system that allows comparison of nursing homes.^11,12,21 A recent study with Medicaid-certified long-term care (LTC) facilities found as the total numbers of licensed staff (RNs and LPNs) per resident per day increased, the fall rate decreased; yet, as the number of LPN hours per resident increased, the fall rate increased.¹⁷ Considering there are more LPNs than RNs working in nursing homes, it is important to conduct additional research on LPN staffing and patient outcomes to better understand this finding.¹⁷

Nursing home staff who have previously been surveyed regarding PSC are typically identified as RNs, nurse managers, nursing assistants, and nursing home administrators.^11,12,22 Nursing home administrators and managers report a more positive PSC than staff.^14,22 Information specific to LPNs' perception of PSC is lacking, as their responses are often included with nurses or licensed staff.^15,22 Thus, this research focused on the perceptions of LPNs who are the primary licensed nurse providing direct care to residents in nursing homes.

JOB SATISFACTION

Although researchers have examined job satisfaction in the acute care setting, little has been done for examining job satisfaction in nursing homes.^23,24 Autonomy, work stress, work exhaustion, excessive workload, poor working conditions, and inadequate staffing are related to job satisfaction in nursing homes.^25,26 Furthermore, job satisfaction is related to the work environment, relationship with the residents, manager support, and feeling valued and empowered to work to the full extent of their license.^25,26 Nurses who were satisfied with their jobs were more likely to report a higher safety climate.²⁷ During the COVID-19 pandemic, high job stress and fear of getting COVID-19 were significantly related to decreased job satisfaction of nurses caring for patients with COVID-19.^28,29

With the growing elderly population, it is essential to investigate LPNs' perception of PSC and job satisfaction. The research questions were as follows:

1. How do LPNs' perception of PSC compare with the responses in the Nursing Home Survey on Patient Safety Culture (NHSPSC) 2019 User Database Report?
2. What is the relationship between LPNs' perception of PSC and job satisfaction?
3. Is there a difference in job satisfaction between LPNs working in nursing homes and those working in other settings?

METHODS

The aim of this descriptive, cross-sectional study was to describe and examine the relationship between LPNs' perception of PSC in nursing homes and job satisfaction. Approval was obtained from the university's institutional review board. An online survey was sent to a purposive sample of 20 773 LPNs who had email addresses listed with the NJ Board of Nursing. To be included in the analysis, respondents were required to have an active LPN license and work in an NJ nursing home. The survey was emailed in October 2020, between the first and second waves of the COVID-19 pandemic. LPNs were encouraged to participate, with reminder emails sent on the based on the Dillman method, which has an established survey implementation sequence for reminder emails.³⁰ As a token of appreciation for completing the survey, 8 LPN participants were randomly selected to receive a $100 gift card at the conclusion of the survey period.

Measures

Three instruments were used to determine LPNs' perception of PSC, job satisfaction, and demographic characteristics. An Agency for Healthcare Research and Quality (AHRQ) survey, the NHSPSC, was used, which is psychometrically reliable and validated instrument.³¹ Researchers at AHRQ developed the NHSPSC to determine perceptions of nursing home staff, inclusive of LPNs, about the PSC at the nursing home in which they work.³¹ The NHSPSC has 42 items with 12 PSC composite measures, which can be found in Supplemental Digital Content Table (available at: https://links.lww.com/JNCQ/B64). Response options follow a 6-point Likert format scale: strongly disagree or never (1) to strongly agree or always (6). The NHSPSC has 2 additional questions: (1) whether the respondent would tell friends this is a safe nursing home for their family, and (2) asking respondents to provide an overall rating on resident safety on a scale from poor (1) to excellent (5). The Cronbach α for the 12 composites ranged from 0.62 to 0.86.¹⁴ Job satisfaction was measured with 2 items: (1) “How satisfied are you with your job?” and (2) “How satisfied are you with being an LPN?” Response options for both items follow a 6-point Likert format scale ranging from very dissatisfied (1) to very satisfied (6). A demographic data questionnaire was used to describe the characteristics of the sample including gender, age, ethnicity, race, and employment setting.

Data analysis

Descriptive statistics were used to describe the demographics. We then calculated a mean average of the percentage of positive responses (strongly agree and agree) on the items within each 12 PSC composites according to AHRQ's methodology.³² We compared our sample scores to the scores of US-wide respondents in the NHSPSC 2019 User Database Report.³² Job satisfaction items were analyzed using descriptive statistics and the test of proportions to determine whether job satisfaction was different among LPNs in nursing homes versus other settings. Pearson correlation, adjusted for multiple comparisons, was used to assess the association between PSC and job satisfaction, with a significance level of α = .05. R statistical software was used in data analysis (The R Foundation, Vienna, Austria).

RESULTS

Of the 20 773 LPNs who were emailed the survey, 804 (3.9%) responded that they had an active LPN license and worked in NJ. Of those 804 LPNs, 258 (32%) worked in a nursing home. The majority of LPN respondents (n = 132; 74%) worked in for-profit facilities. On average, LPNs were 48 years old and reported working in their current position for 10 years (Table 1). The majority of LPNs obtained their practical nursing education at a vocational technical school (n = 190; 84%), and 49% (n = 111) reported they intend to leave their position in 5 years. In addition, 24% (n = 54) were enrolled in a RN education program. There was a significant difference in age of 1.4 years (P = .049) when comparing LPNs in this study with the LPN respondents in the NJ license renewal survey; however, this difference was not clinically significant.⁴

Table 1. - LPN Demographics^a

Category	LPNs (n = 258) Mean (SD), Range	NJCCN LPN Nursing Home Workforce Data (n = 5466) Mean (SD), Range	P
Age	48 (11.1), 24-72	46.6 (11.9), 23-87	.049b
	n (%)	n (%)
Gender
Male	22 (10)	642 (14)	.923
Female	197 (86)	4055 (86)
Transgender/prefer not to answer	10 (4)	1 (0)
Ethnicity
Hispanic/Latino	21 (8)	344 (8)	.975
Race
American Indian or Alaskan Native	1 (0)	4 (0)	.999
Asian	12 (5)	504 (13)
Black/African American	54 (22)	1493 (37)
Native Hawaiian or other Pacific Islander	3 (1)	40 (1)
White/Caucasian	101 (41)	1317 (33)
Other	56 (23)	313 (8)
Multiple positions
1	142 (63)	3672 (83)	.954
2	74 (33)	674 (15)
3	10 (4)	55 (1)
Job status
Full-time	166 (73)	3439 (79)	.999
Part-time	34 (15)	445 (10)
Per diem	25 (11)	340 (8)
Other	3 (1)	138 (3)

Abbreviations: LPN, licensed practical nurse; NJCCN, New Jersey Collaborating Center for Nursing.

^aParticipants may have skipped questions, causing data in this table to add up to less than the total number of participants.

^bP < .05.

The NHSPSC positive responses are provided in Supplemental Digital Content Table (available at: https://links.lww.com/JNCQ/B64). The lowest positive responses were for the following Staffing composite: “Staff have to hurry because they have too much work to do” (15%, reverse coded) and “We have enough staff to handle the workload” (16%); and the following Organizational learning composite: “This nursing home lets the same mistakes happen again and again” (24%). The highest positive responses were in the Feedback and Communication about Incidents composite: “Staff tell someone if they see something that might harm a resident” (82%) and “When staff report something that could harm a resident, someone takes care of it” (75%). When asked to rate the safety of the nursing home, 48% indicated they would advise their friends this is a safe nursing home and 33% provided an overall rating on resident safety as either excellent or very good (Figure 1).

Figure 1.: Overall rating on resident safety and willingness to recommend nursing home; LPNs in New Jersey and 2019 User Database Report. LPN indicates licensed practical nurse; NJ, New Jersey; NHSPSC, Nursing Home Survey on Patient Safety Culture.

All composite and item-level results in this study were lower than those listed in the 2019 User Database Report (Figure 2; see Supplemental Digital Content Table, available at: https://links.lww.com/JNCQ/B64). Although the top 3 composite results for LPNs working in nursing homes were similar in trend to the NHSPSC 2019 User Database Report, all 3 composite results were lower than the national average. In addition, the lowest 3 composite results were also similar, yet all 3 were lower than the national average.

Figure 2.: NHSPSC composite-level average percent positive response LPNs in New Jersey and 2019 User Database Report. NHSPSC indicates Nursing Home Survey on Patient Safety Culture; LPN, licensed practical nurse; NJ, New Jersey.

Overall, the LPNs were somewhat to very satisfied (n = 179; 69%) with their jobs. However, when compared with LPNs working in other settings (n = 437), LPNs working in nursing homes (n = 258) were less satisfied (P < .0001). Regarding the relationship between LPNs' perception of PSC and job satisfaction, a significant positive correlation, yet weak at under 0.4, was found between all PSC composites and job satisfaction, indicating the higher an LPN's job satisfaction, the higher their perception of PSC (Table 2).

Table 2. - Correlations: NHSPSC Composites and Job Satisfaction

NHSPSC Composites	Correlation Coefficient (r): Job Satisfaction
Teamwork	0.357a
Staffing	0.395a
Compliance with procedures	0.285a
Training and skills	0.317a
Nonpunitive response to mistakes	0.345a
Handoffs	0.214a
Feedback and communication about incidents	0.176
Communication openness	0.298a
Supervisor expectations and actions promoting resident safety	0.282a
Overall perception of resident safety	0.312a
Management support for resident safety	0.369a
Organizational learning	0.241a

Abbreviation: NHSPSC, Nursing Home Survey on Patient Safety Culture.

^aCorrelation significant at .05.

DISCUSSION

The LPN perception of patient safety in nursing homes needs improvement, particularly focusing on nurse workload and staffing. Higher levels of staffing are needed to handle the workload and strategies need to be implemented to prevent mistakes from reoccurring. It is unfortunate that less than 50% of the LPNs surveyed felt the nursing home in which they work was safe. This is compared with the almost 75% recommendation for the national sample of LPNs and 82% recommendation of staff at 5 LTC facilities in Kentucky.¹⁷ These findings, however, warrant further investigation in NJ nursing homes due to the difference between our results and the national average.

A possible explanation of these perceived unsafe PSC results may be because LPNs did not believe they had enough staffing to manage the workload. Furthermore, given the extensive evidence that staffing is related to resident outcomes and job satisfaction, it is not surprising that the perception of LPNs on resident safety is lacking.^33,34 With lack of staffing, LPNs may also have perceived that residents' needs were not met. In our previous qualitative study, LPNs working in NJ nursing homes often “prayed they would make it through the shift” because of the heavy workload and the number of residents they were assigned in the nursing home.⁶ The issue of heavy workload is especially troubling for those LPNs working at night. The number of residents assigned to LPNs is greater than that in acute care, with an average of 25 residents per LPN on the day shift and 50 residents per LPN at night.²¹

Considering our study was conducted between the first and second waves of the COVID-19 pandemic, COVID-19 may have impacted the lower levels of PSC. The COVID-19 pandemic did bring new attention to inadequate staffing that existed in NJ nursing homes prior to the pandemic. Thus, the Governor sought a rapid review of NJ nursing homes. Recommendations included establishing and fostering a culture of safety and quality inclusive of adequate staffing levels by skill level.³⁵ Subsequent to this report, new ratios of direct care staff to adult residents in nursing homes were legislated and specify: 1 certified nursing assistant (CNA) for 8 residents on the day shift, and 1 direct care staff member (RN, LPN, or CNA) for every 10 residents on the evening shift and 14 residents on the night shift.³⁶ Although this legislation does not address the LPN or RN ratios, it can be viewed as a first step to demonstrate a need to improve the workload level in nursing homes. Considering the NJ standards for LTC facilities to only require 1 RN to be present on the day shift and be present or on call on the evening and night shifts, it is not yet known whether these new ratios will have an impact on PSC.³⁷

When examining the NHSPSC composite-level averages, the results aligned with the trend of the national average, but the overall percent positives for NJ LPNs were lower for each of the 12 composites. Feedback and Communication about Incidents was the category with the highest rating, indicating that LPNs are informing management of when safety incidents occur, which was also found in a study with licensed nurses.¹⁴ In a study conducted in 2016 with staff working in 9 NJ nursing homes, the NHSPSC results also aligned with our data.³⁸ Despite the consistent results there has been no improvement since 2016 with staffing, nonpunitive responses to mistakes, and communication openness remaining the lowest.³⁸ Our findings also suggest that LPNs feel threatened to report mistakes, as indicated by the nonpunitive response to mistakes sitting only slightly above the perception of safe staffing. These findings are in alignment with a study of 26 nursing homes in Ohio, in which 1 in 5 nurses reported feeling punished by management and 2 in 5 nurses reported that reporting of errors was seen as a personal attack.¹⁵ LPNs should feel empowered by management to address concerns of resident safety and report errors without the fear of being reprimanded unjustly. A just culture needs to be fostered in nursing homes in which all staff members know that reporting mistakes or errors will result in quality improvement initiatives and learning opportunities.

Overall, there were direct correlations on all 12 PSC composites with job satisfaction; however, the correlations were relatively week (r = 0.176-0.395). It is not surprising, however, that the highest correlation was between staffing and job satisfaction. Evidence suggests that nurses' job satisfaction predicts staff turnover, which adversely affects resident outcomes.²⁵ In a systematic review on job satisfaction, researchers found that organizational factors, including staffing, were identified as equivocal or not important to job satisfaction.²⁵ This may explain why the correlation between staffing and job satisfaction remained under 0.4, implying there is a direct, but weak association.

Implications

The first step to improve staffing in NJ nursing homes was accomplished with the implementation of ratios of direct care staff to residents; however, research needs to be conducted to determine whether this has impacted resident outcomes. The next step is to increase RN and LPN staffing in nursing homes. The recommendations from the NASEM report, The National Imperative to Improve Nursing Home Quality, include changing the federal requirement to have 1 RN to be present on all shifts, 7 days a week, in addition to the director of nursing, and have additional RNs based on resident census and needs.⁵ Nursing home leaders also need to commit to a positive PSC and not a culture of blame and shame. Once workload is addressed, management should focus on improving the work environment that encompasses resident safety. Nursing home leaders can then educate all staff members on just culture and demonstrate the organization's commitment to a positive PSC when mistakes or errors occur.

Limitations

A limitation of this study was the participants were a small convenience sample of LPNs in NJ and may not reflect the perceptions of LPNs working in nursing homes in other states. In addition, the NHSPSC was utilized to obtain the perception of PSC of LPNs who work in NJ nursing homes, whereas it was designed to measure the PSC at a single nursing home. In addition, the respondents in the NHSPSC 2019 User Database Report had varied job titles from nursing assistant and licensed nurse to administrator/manager and physician and thus may have rated the PSC higher or differently than our LPN respondents did.

CONCLUSION

LPNs working in NJ nursing homes indicated that PSC needs improvement. With the COVID-19 pandemic putting a spotlight on the issues in nursing homes, it is an opportune time to implement initiatives to foster a culture of safety in nursing homes. Improving nurse staffing and PSC will enhance quality of care in nursing homes and benefit our most vulnerable residents.