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Purpose: This study was designed to collect and compare nurse staffing standards and staffing levels in six counties: the United States, Canada, England, Germany, Norway, and Sweden. Design: The study used descriptive information on staffing regulations and policies as well as actual staffing levels for registered nurses, licensed nurses, and nursing assistants across states, provinces, regions, and countries. Methods: Data were collected from Internet searches of staffing regulations and policies along with statistical data on actual staffing from reports and documents. Staffing data were converted to hours per resident day to facilitate comparisons across countries. Findings: We found wide variations in both nurse staffing standards and actual staffing levels within and across countries, although comparisons were difficult to make due to differences in measuring staffing, the vagueness of standards, and limited availability of actual staffing data. Both the standards and levels in most countries (except Norway and Sweden) were lower than the recommended levels by experts. Conclusions: Our findings demonstrate the need for further attention to nurse staffing standards and levels in order to assure the quality of nursing home care. Clinical Relevance: A high quality of nursing home care requires adequate levels of nurse staffing, and nurse staffing standards have been shown to improve staffing levels. Journal of Nursing Scholarship, 2011; XX:X, XXX–XXX. ©2011 Sigma Theta Tau International.

Assistive personnel are the primary caregivers in long-term residential care (LTRC) in industrialized countries. Our goal is to describe and compare the work-related characteristics of assistive personnel in LTRC in five countries (Canada, Germany, Norway, U.K., and U.S), which may reflect how various societies view their responsibility to aging populations and the workers who care for them. OECD and national statistical databases are used to assess and compare the work context for assistive personnel. Analysis of the statistical data is informed by on-site observations in nursing homes with reputations for high quality, close readings of these organizations’ documents and records, and interviews with LTRC staff. Pay is generally low and the work required of assistive personnel is often demanding in all countries studied. While most assistive personnel have completed high school, formal certification requirements vary considerably. Professionalization is increasing in Norway with its high school major in eldercare, and in Germany, which has a 2-year certificate program. Financial compensation for assistive personnel in Norway and Canada is greater than in the other countries. Union membership for assistive personnel ranges from very high in Canada to negligible in the U.S. Some countries studied have training programs of only a few months duration to prepare assistive personnel for highly demanding jobs. However, in Germany and Norway, training aims to professionalize the work of assistive personnel for the benefit of workers, employers, and residents. There are high rates of part-time and/or casual work among assistive personnel, associated with reduced employment-related benefits, except in Germany and Norway, where these benefits are statutory for all. Data suggest that unionization is protective for assistive personnel, however union coverage data were not available for all countries. The need to improve the qualifications and training of assistive personnel was observed to be a national priority everywhere except in the U.S. Compensation is relatively low in the U.K., the U.S. and Germany, despite the important jobs performed by assistive personnel. Finally, to improve future research, statistical mapping of this critical component of the labour force in LTRC should be a greater priority across high-income countries.

This paper examines the tension between macro level regulation and the rule breaking and rule following that happens at the workplace level. Using a comparative study of Canada, Norway, and Germany, the paper documents how long-term residential care work is regulated and organized differently depending on country, regional, and organizational contexts. We ask where each jurisdiction's staffing regulations fall on a prescription-interpretation continuum; we define prescription as a regulatory tendency to identify what to do and when and how to do it, and interpretation as a tendency to delineate what to do but not when and how to do it. In examining frontline care workers' strategies for accomplishing everyday social, health, and dining care tasks we explore how a policy-level prescriptive or interpretive regulatory approach affects the potential for promising practices to emerge on the frontlines of care work. Overall, we note the following associations: prescriptive regulatory environments tend to be accompanied by a lower ratio of professional to non-professional staff, a higher concentration of for-profit providers, a lower ratio of staff to residents and a sharper division of labour. Interpretive regulatory environments tend to have higher numbers of professionals relative to non-professionals, more limited for-profit provision, a higher ratio of staff to residents, and a more relational division of labour that enables the work to be more fluid and responsive. The implication of a prescriptive environment, such as is found in Ontario, Canada, is that frontline care workers possess less autonomy to be creative in meeting residents' needs, a tendency towards more task-oriented care and less job autonomy. The paper reveals that what matters is the type of regulation as well as the regulatory tendency towards controlling frontline care workers decision-making and decision-latitude. Cet article examine la tension entre le règlement du niveau macro et la rupture de la règle et la règle suivante qui se passe au niveau du lieu de travail. En utilisant une étude comparative entre le Canada, la Norvège et l'Allemagne, l'article expose à grands traits comment le travail de soins à domicile à long terme est réglementé et organisé différemment selon le pays, les régions et les contextes organisationnels. Nous demandons l'endroit où la dotation en personnel de chaque pays tombe dans un continuum d'ordonnance-interprétation; nous définissons l'ordonnance comme une tendance réglementaire pour identifier ce qu'il faut faire et quand et comment le faire, et l'interprétation comme une tendance à définir ce qu'il faut faire, mais pas quand et comment le faire. En examinant les stratégies des travailleurs de soins de première ligne dans l'accomplissement de leurs tâches quotidiennes sociales et médicales, nous explorons la façon dont une approche réglementaire prescriptive ou interprétative au niveau politique touche le potentiel de pratiques prometteuses d'émerger sur le front du travail de soins. Dans l'ensemble, nous notons les associations suivantes : les environnements réglementaires normatifs ont tendance à être accompagnés d'une baisse du ratio du personnel professionnel par rapport au personnel amateur, une concentration plus élevée de prestataires à but lucratif, un ratio plus faible du personnel pour les résidents et une division plus aiguë du travail. Les environnements réglementaires d'interprétation ont tendance à avoir un plus grand nombre de personnel professionnel par rapport au personnel amateur, une disposition plus limitée à but lucratif, un ratio plus élevé de personnel pour les résidents, et une division plus relationnelle du travail qui permet le travail à être plus fluide et réactif. L'implication d'un environnement normatif, comme on en trouve en Ontario, au Canada, est que les travailleurs de première ligne possèdent moins d'autonomie à être créatifs pour répondre aux besoins des résidents, une tendance vers plus de soins axés sur les tâches que sur l'autonomie de travail. L'article révèle que ce qui importe est le type de règlement ainsi que la tendance réglementaire vers le contrôle des travailleurs de première ligne par la prise de décision.

International quality concerns regarding long-term residential care, home to many of the most vulnerable among us, prompted our examination of the audit and inspection processes in six different countries. Drawing on Donabedian’s ( Evaluation & Health Professions , 6 (3), 363–375, 1983 ) categorization of quality criteria into structural, process and outcome indicators, this paper compares how quality is understood and regulated in six countries occupying different categories according to Esping Andersen’s ( 1990 ) typology: Canada, England, and the United States (liberal welfare regimes); Germany (conservative welfare regime); Norway, and Sweden (social democratic welfare regimes). In general, our review finds that countries with higher rates of privatization (mostly the liberal welfare regimes) have more standardized, complex and deterrence-based regulatory approaches. We identify that even countries with the lowest rates of for profit ownership and more compliance-based regulatory approaches (Norway and Sweden) are witnessing an increased involvement of for-profit agencies in managing care in this sector. Our analysis suggests there is widespread concern about the incursion of market forces and logic into this sector, and about the persistent failure to regulate structural quality indicators, which in turn have important implications for process and outcome quality indicators.

Assistive personnel are the primary caregivers in long term residential care (LTRC) and their job autonomy is a major social determinant of health. Our goal is to explore experiences of assistive personnel in six industrialized countries (Canada, Germany, Norway, Sweden, England, and the U.S.), and consider innovations in the LTRC setting that might influence their job autonomy. The methodology is based on on-site observations at nursing homes and interviews with assistive personnel and other relevant LTRC staff in selected nursing homes in all six countries. Previously published statistical material from the study on staff characteristics like pay, formal education, unionization, employment-related benefits and extent of part-time work is employed as relevant context for discussing job autonomy. Our results show that assistive personnel are highly supportive of job autonomy though they interpret autonomy differently and report widely varying levels of job autonomy. Those LTRC organizations that have a reputation for encouraging autonomy of assistive personal, report recruiting is far easier even where there is a shortage. In some countries we were told that “resident-centered” (“person-centered”) care and a leveling of the division of labor, understood as more equal and horizontal division of labor, was on the rise and this could affect autonomy. Job autonomy is welcomed by assistive personnel. The wide variation in job autonomy across nursing homes and across countries is surprising. Within nursing homes variation may reflect imperfect or incomplete implementation of autonomy policies, or differential application of policies. The resident-centered philosophy and the leveling of the division of labor could make for greater autonomy for assistive personnel. These workplace innovations are not universal in all countries and they could be more difficult to apply where resources and commitment are lacking. The increasingly frail population of LTRC facilities and the general trend toward growth of specialized medical treatment within LTRC in some of the countries may support an argument for some limitations to job autonomy in assistive personnel. Autonomy is favored by assistive personnel though not all have it. The workplace innovations of resident-centered care and a leveling of the division of labor in LTRC, could make for a greater degree of autonomy for assistive personnel in the future, while increased demand for highly skilled care could work in the other direction.

Central line-associated bloodstream infections (CLABSI) represent a serious patient safety issue. To prevent these infections, bundled interventions are increasingly recommended. We examine the extent of adoption of Central Line (CL) Bundle elements throughout US intensive care units (ICU) and determine their effectiveness in preventing CLABSIs. In this cross-sectional study, National Healthcare Safety Network (NHSN) hospitals provided the following: ICU-specific NHSN-reported rates of CLABSI/1,000 central line days; policies and compliance rates regarding bundle components; and other setting characteristics. In 250 hospitals the mean CLABSI rate was 2.1 per 1000 central line days and 49% reported having a written CL Bundle policy. However, of those that monitored compliance, only 38% reported very high compliance with the CL Bundle. Only when an ICU had a policy, monitored compliance, and had ≥ 95% compliance did CLABSI rates decrease. Complying with any one of three CL Bundle elements resulted in decreased CLABSI rates (β = -1.029, p = 0.015). If an ICU without good bundle compliance achieved high compliance with any one bundle element, we estimated that its CLABSI rate would decrease by 38%. In NHSN hospitals across the US, the CL Bundle is associated with lower infection rates only when compliance is high. Hospitals must target improving bundle implementation and compliance as opposed to simply instituting policies.

There are only a few cytogenetic analysis (CA) studies that directly compare the novel cultivation technique using immunostimulatory CpG-oligonucleotide DSP30/interleukin-2 (DSP30/IL2) with other culture methods. Therefore, parallel cultures of peripheral blood of 129 chronic lymphocytic leukemia (CLL) patients were set up in unstimulated cultures, in the presence of pokeweed medium (PWM), and with DSP30/IL2. Furthermore, CA results were compared with data obtained by FISH. Clonal aberrations were observed by CA in 6% of the cases in unstimulated cultures, in 27% of the cases with PWM, and in 40% of the cases with DSP30/IL2. Some clonal aberrations were detected by CA only with one culture method. Using 3 different culture methods, clonal aberrations were detected in 41% of the cases by CA and in 71% of the cases by FISH. Altogether, 78% of the cases exhibited clonal aberrations discovered by CA and FISH. Also, CA detected clonal aberrations not targeted by FISH in 7% of the cases, and FISH identified clonal aberrations not detected by CA in 36% of the cases. Our study demonstrates that the combined use of CA with different culture methods together with FISH increases our knowledge of the genetic complexity and heterogeneity in CLL pathogenesis.