Do Work Environment Attributes Impact the Risk of Pressure Ulcers in Nursing Homes? Evidence from New York State

Studies suggest that work environment attributes (effectiveness, teamwork, primary assignment) influence nursing home (NH) quality, but few tested these relationships empirically. We examine the relationship between NH work environment and risk-adjusted pressure ulcers (PUs).

Data consists of: surveys from 7,418 workers in 162 NHs; the Minimum Data Set (MDS); and the OSCAR database. Using the MDS, long-term care (LTC) residents with high risk for PUs are identified.

The analytical sample includes 20,929 LTC residents at high risk for PUs. The dependent variable, PU presence/absence, is dichotomous. Independent variables of primary interest include facility-level measures of: work effectiveness (a 5-point Likert scale score); daily care team prevalence; and percent staff with primary assignment. Work effectiveness measure has been previously demonstrated as psychometrically reliable and valid. Other control variables include individual PU risk factors and facility characteristics.

We develop a risk adjustment model and test it using Hosmer-Lemeshow and C statistics. A GEE model with robust standard errors and probability weights is estimated.

Higher work effectiveness is associated with lower PU risk, after controlling for all factors. A high-risk resident in a facility with work effectiveness score of 4.5 is 46% less likely to have PUs compared to a similar resident in a facility with the score of 3.5 (OR=0.54, P<0.001). We detect a nonlinear relationship between team penetration and PUs.

Work environment attributes impact NH quality of care. These findings provide important insights into work processes that NH administrators and regulators should consider in improving quality of care for residents.