Running head: AN INTEGRATIVE REVIEW 1

An Integrative Review

Raven L. Stokes

Bon Secours Memorial College of Nursing

Nursing Research- 4122

I Pledge
AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this paper, is to provide an integrative review that evaluates the literature

regarding the association of registered nurses (RN) in long term care facilities (LTC) and its

relationship to the quality of care being provided to residents. Most LTC facilities utilize license

practical nurses (LPN) to manage the care of its residents. However, being that LPNs scope of

practice is limited, and LTC facilities are now taking on a higher acuity of patients, that leaves a

potential gap in the quality of care that residents are receiving. Registered nurses are better

prepared to manage chronically ill patients, so it would be appropriate to relate a LTC facilitys

quality of care to its employment of RNs. The literature for this integrative review was located

through the use of the electronic database PUBMED. A total of five articles were selected to be

analyzed for this integrative review. The findings from the five articles revealed that having RNs

involved in the direct care role, in LTC facilities did improve the facilitys overall quality of care.
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An Integrative Review

It is a known fact, that there is a shortage of RNs that work in long term care (LTC)

facilities. The reasons facilitating the lack of RNs in LTC facilities varies. Due to this shortage,

LPNs are now carrying out tasks that would be better suited for the skill set of a RN. Federal law

requires that LTC facilities have an RN on duty for eight hours each day, seven days a week. This

minimum level of RN staffing is concerning for multiple reasons, because in some LTC facilities

the only RN is the Director of Nursing (DON) who is an administrative role and does not

perform direct patient care. Then as stated earlier, LPNs scope of practice is limited and varies

from state, so in some states they are unable to perform certain tasks such as comprehensive

assessments or be in supervisory roles. Due to the lack of clarity regarding the role of LPNs it is

only natural to assume that patient care is lacking which impacts a LTC facilitys quality of care.

This confusion regarding LPNs roles is why it important to have more regularly staffed RNs in

direct patient care roles. RNs are overall better qualified to manage patients and there is very

little questioning regarding their scope of practice which means that LTC patients would be

receiving a level of care that LPNs cannot provide. Through this integrative review, this paper

will aim to investigate the researchers PICOT question, Do LTC facilities that are regularly

staffed with RNs, provide better quality of care, when compared to LTC facilities that are not?

During the research process of locating literature that addressed this topic, the researcher found

that there was a lack of studies that assessed the overall impact of RNs working in LTC and

quality of care. The results obtained during the research process mainly compared how RNs and

LPNs completed tasks and its impact on patient care. This topic is of interest to the researcher

because she has been working in LTC for the past five years and noticed a difference in how RNs

and LPNs provide patient care.

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Design and Search Methods

This integrative review will be based on five research articles that are related to the topic

of interest that was mention earlier. In order to locate these articles, the researcher utilized the

database PubMed. In order to access the most relevant studies, the key terms of Registered

Nurses, Nursing home quality, RN, and LPN were used. To make sure the literature was the

most current pertaining to the topic the search was filtered to only include articles from 2011-

2016. This review will be based on two cross-sectional studies, one qualitative descriptive study,

one comparative, multiple case study, and one sequential explanatory mixed-methods study.

Finding/Results

Once the five articles that were selected for review were analyzed, the researcher was

able to conclude that having RNs in LTC facilities does indeed improve the quality of care being

provided to the facilities residents (Lee, Blegen, & Harrington, 2014; Gray-Miceli, de Cordova,

Crane, Quigley, & Ratcliffe, 2016; Vogelsmeier, Scott- Cawiezell, & Pepper, 2011; Corazzini et

al., 2013; and Corazzini, Anderson, Mueller, Thorpe, & McConnell, 2013). Located in Table 1, is

the summary of all five articles discussed in this review. The review is organized by the

following categories: RN staffing hours, RNs and LPNs knowledge of the causes of falls,

medication reconciliation, pain management, and nurses scope of practice. The reasoning for the

choice of categories is due to the fact that there is a lack of studies that pertains to RNs impact to

nursing homes quality. The categories represents quality measures and tasks that impact patient

care.

RN Staffing Hours
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In the cross-sectional study done by Lee, Blegen, and Harrington (2014), it was found

that LTC facilities with high RN staffing had a positive effect in the reduction of pressure ulcers

(PU) among residents. This is very significant information because facilities that receive

Medicaid will not get reimbursed for facility acquired pressures ulcers, which can become costly

to manage. According the article, there was an 11.3% drop in facility acquired PUs, in LTC

facilities that had high RN staffing hours. (p. 414). The study also evaluated the relationship

among RN staffing hours on other quality indicators such as catheter usage, weight loss, UTIs

and use of antipsychotic drugs. However, it was found that Medicaid reimbursement impacted

those outcomes. This study was conducted on 195 nursing homes located in CO and utilized

secondary data from a total of five administrative databases. The databases used include the

following: Online Survey Certification and Reporting (OSCAR), Minimum Data Set 2.0 (MDS),

quarterly staffing data from the CO state inspections, state Medicaid reimbursement data, and the

Area Resources File (ARF). (p. 414). Data analysis was conducted through multiple methods

such as separate regression analyses, 2-staged least squares regressions in Stata 10.0, along with

the Durbin-Wu- Hausman test. The researchers also utilized Strata cluster procedure were used in

the regression models.

RNs and LPNs Knowledge on the Causes of Falls

In the cross-sectional study conducted by Gray-Miceli et al., (2016) that evaluated the

knowledge of RNs and LPNs on fall prevention, it was found that both group were in need of

further education in regards to fall prevention. Although RNs had the best score overall, no one

in the study scored 100% on the questionnaire. This study was conducted on 47 RNs and LPNs

from three different nursing homes. All the participants in the group provided direct patient care

and had various work schedules. This study excluded nurses who were in a management
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position. The nurses knowledge on fall prevention, was assessed through the use of eight fall

clinical vignettes (scenarios) and a questionnaire referring to the clinical vignettes. Data analysis

for the study was conducted through use of standard descriptive statistics, logistic regression, and

analysis of variance, all of which were though the R statistical package.

The drive behind this study is due to the fact, That yearly one-half to three-fourths of the

1.4 million residents of nursing homes fall. (p.153). Within that occurrence, 30% of those falls

are considered to be preventable. (p.154). RNs and LPNs both manage patient care, so it is

imperative that both are knowledgeable on fall prevention. LTC facilities are supposed to provide

continue education to its staff on various topic such as fall prevention. The results from this study

shows a possible flaw in the education being provided on this topic. Since RNs performed best

overall, it shows how having more RNs working impacts a nursing homes quality of care.

Medication Reconciliation

This qualitative descriptive study that was conducted by Vogelsmeier et al., (2011)

addresses the differences between how medication reconciliation is performed by RNs and

LPNs. This 18 month study involved RNs and LPNs from eight Midwestern nursing homes and

was conducted through the use of informal interviews and onsite observations. Data analysis for

this study was done through use of the qualitative content analysis approach. To ensure that the

data was credible, dependable, and confirmable, an audit trail was maintained along with

participant feedback. The results from the study showed that there was a major difference in how

RNs and LPNs approach medication reconciliation. The results revealed that RNs viewed the

responsibility as a clinical process compared to LPNs who saw it as task to be completed. (p. 59-

60). These differences in approaches played a role in the amount of discrepancies identified by

each group. The study clearly implied that RNs are better qualified to complete medication
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reconciliation and if LPNs are going to be completing this practice their education needs to be

enhanced.

Pain Management

Corazzini et al. (2013) conducted a comparative, multiple case study that evaluated how

pain management was conducted among RNs and LPNs. The study sample, consisted of ten

nursing homes located in Minnesota and North Carolina, the Director of Nursing (DON) of these

facilities were then interviewed about the role of RNs and LPNs in regards to pain management

in their facility. The interviews transcripts were then analyzed through Atlas.ti, version 6.0.

(p.42). Data analysis was conducted through open coding and three themes were identified,

which included pain detection, pain assessment, and appropriateness of medication given. (p.43).

The article goes on to discuss how high RN-to-LPN ratios in nursing homes have a greater

capacity to manage pain in a timely manner. Pain management requires a level of critical

thinking that is only within the scope of practice of RNs because LPNs are not able to perform

comprehensive assessment.

Nurses Scope of Practice

The purpose of this study, was to Describe the differences of LPNs scope of practice

throughout the country and how it relates to the quality of care in nursing homes. (p.316). This

sequential explanatory mixed-methods study consisted of both quantitative and qualitative

components obtain from all fifty states. Data analysis for the qualitative portion was done by

putting the nurse practice acts (NPA) in one of the following four domains: assessment, care

planning, delegation, and supervision. Data analysis for the quantitative portion was done

through cross-sectional, quantitative analysis of fully specified, hierarchical linear models.

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(p.316-317). The sample of this study consisted of 12,698 facilities and 51 NPAs. The results of

this study showed that the limitation to LPNs scope of practice can negatively impact patient

care. The study made several finding such as, states that allow LPNs to conduct focus

assessments, had a higher usage of restraints. It was also revealed that patient management based

off the LPNs focus assessment, without the RN expertise, can lead to detrimental care. The study

also revealed, that LPNs assessments were found to lead to better patient outcome when used in

conjunction with a RNs assessment.

Discussion/Implications

All five articles selected for this review clearly shows the positive relationship between

having RNs and their impact on the quality of care in LTC facilities. Due to the fact, that LPNs

are limited by their scope of practice (Carazzini et al., 2013) along with LTC facilities taking on

a higher acuity of patients, federal law should be implemented to address this need. The literature

supports, that the quality of care provided in LTC facilities was greater when there was a high

RN-to-LPN ratio. (Carazzini et al., 2013; Lee et al., 2014). A major implication that resulted

from reviewing this literature, is that more studies need to be done that looks at the direct impact

RNs have on the overall quality of care in LTC facilities.

Research also revealed that the scope of practice for LPNs need to be defined more

clearly and be uniformed throughout the country. The reason why the LPNs scope of practice

was included in this study, is because they are the nursing staff that is providing majority of the

nursing care in LTC. It is important to look at how LPNs functions in their role, so that the

proper adjustments can be made in order to ensure residents are receiving the best care. There are

so many limitations in how LPNs function, which why major changes need to be made in LTC.

One has to wonder why there is such a stigma associated with LTC facilities. If the reason is
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related to the quality of care being provided, then why is the issue not being addressed? It is only

natural to assume that having more RNs working in LTC will lead to better patient outcomes.

Having RNs in the management role is not enough to address this issue because most of the time

they become aware of preventable poor patient outcomes after that fact.

This literature review has showed that LTC resident benefit from having more RNs

involved in their direct care. The literature utilized for this review satisfied the researchers

PICOT question stated earlier. All of the categories discussed in this review pertained to

components that impacts quality of care and the studies that were selected all showed how RNs

had a positive impact on quality of care being provided in LTC facilities.

Limitations/Conclusion

A major limitation to this integrative review is the lack of studies that evaluates the

overall impact RNs have on LTC facilities quality of care. Another limitation that needs to be

taken into consideration is that the researcher has no prior experience constructing an integrative

review. Some of the studies in this review were conducted on small samples, which could also be

considered as limitation. Since the LPNs scope of practice varies, the lack of clarity regarding

their role, may also impose limitations.

To conclude this paper, after reviewing the available literature that pertains to the

researchers PICOT question, it was revealed that RNs play a major role in nursing home quality

of care. Even though more research is needed to fully see the benefits that RNs bring to nursing

homes, the articles selected for this review shows how important it is to have nursing staff with

the RNs level of critical thinking. There needs to be research that looks into the shortage of RNs

in LTC because it is clearly indicated that they are needed. The LTC industry need to make major
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changes in order to ensure patients are receiving quality care. The business aspect of medical

care, plays a major role in why there is slow progression in making the necessary changes in

order ensure patient safely. It cost less to hire a LPN compared to an RN, but what is not taken

into account is the long term benefits that come from having more RNs, which would possibly

save money in the long run. Hopefully research will further reveal why RNs are needed and

interventions can be put into place to improve LTC facilities quality of care.
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Reference

Corazzini, K.N., Anderson, R.A., Mueller, C., Thorpe, J.M., & McConnell, E.S. (2013). Licensed

practical nurse scope of practice and quality of nursing home care. Nursing Research,

62(5), 315-324.

Corazzini, K.N., Mueller, C., Anderson, R.A., Day, L., Hunt-McKinney, S., & Porter, K. (2013).

Pain management in nursing homes and nursing scope of practice. Journal of

Gerontological Nursing, 39(4), 40-46.

Gray-Miceli, D., de Cordova, P.B., Crane, G., Quigley, P., & Ratcliffe, S.J. (2016). Nursing home

registered nurses and licensed practical nurses knowledge of causes of falls. Journal of

Nursing Care Quality, 31(2), 153-160.

Lee, H.Y., Blegen, M.A., & Harrington, C. (2014). The effects of rn staffing on nursing home

quality: A two-stage model. International Journal of Nursing Studies, 51, 409-417.

Vogelsmeier, A. A., Scott-Cawiezell, J.R., & Pepper, G. A. (2011). Medication reconciliation in

nursing homes. Journal of Gerontological Nursing, 37(12), 56-63.

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Table 1- Qualitative and Quantitative Article Evaluation Table

First Author Lee, H.Y. (2014)

(Year)/Qualifications College of Nursing, Eulji University , South Korea
Background/Problem Poor quality of care in nursing homes has been a problem
Statement for many years.
Study examines the question whether RN staffing level
would be associated with quality indicators in nursing
homes, as found in other studies.

Conceptual/theoretical Measures were based on literature review that showed the

Framework quality indicators selected were important because they
were expected to be related staffing levels
Design/ Cross-sectional design use to describe the relationship
Method/Philosophical between staffing, and the facility, and market
Underpinnings characteristics with three outcome quality indicators and
two process indicators
Secondary data was collected from five administrative
data bases: Online Survey Certification and Reporting
(OSCAR), Minimum Data Set 2.0 (MDS), quarterly
staffing data from the CO state inspections, state
Medicaid reimbursement data, and the Area Resources
File (ARF)
Quality indicators were selected from MDS data: Use of
antipsychotic drugs, use of indwelling catheters, risk of
pressures ulcers, urinary tract infections, weight loss
Staffing were measured by evaluating staffing hours per
resident day.
Facility characteristics were measured by the number of
beds in the facility
Resident casemx was measured through the ADL
dependency score calculated through OSCAR
Sample/ Setting/Ethical 195 nursing homes located in CO
Considerations Ethical Considerations: to prevent bias Stats cluster
procedures were used in all regression models. Ethical
approval given by UCSF Human Subject Protection
Program.
Major Variables Studied RN staffing levels
(and their definition), if Pressure ulcers occurrences
appropriate UTIs
Weight loss
Antipsychotic drug usage
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Measurement Tool/Data
Collection Method
Data Analysis
Catheter use
Secondary data was collected from five administrative
data bases: Online Survey Certification and Reporting
(OSCAR), Minimum Data Set 2.0 (MDS), quarterly
staffing data from the CO state inspections, state
Medicaid reimbursement data, and the Area Resources
File (ARF)
Descriptive statistics utilized
Pearson correlation coefficients used
Regression analyses used for each quality indicator
Durbin-Wu-Hausman endogeneity test

Findings/Discussion High RN staffing was associated with lower rates of Pus

Medicaid/Medicare reimbursement rates were associated
with percent of catheter usage.
RN staffing did not impact other quality indicators
The lack of relationship to the other quality indicators
maybe relate to small sample size
Appraisal/Worth to Study show RN staffing importance in PUs prevention.
practice

First Author Gray-Miceli, D. (2016)

(Year)/Qualifications School of Nursing, Rutgers The State University of New
Jersey; Institute for Health, Health Care Policy and Aging
Research, New Brunswick, New Jersey
Background/Problem To determine the difference in knowledge among RNs
Statement versus LPNs as it relates to 8 causes of fall among
nursing homes residents
Evidence shows that 30% of falls that occur in NHs are
preventable.
Conceptual/theoretical Not stated
Framework

Design/ Cross-sectional study that used randomized viewing of

Method/Philosophical validated fall clinical vignettes by nurse participants.
Underpinnings Each of the vignettes followed a predetermined
randomization sequence to minimize an order effect that
may have existed.
Clinical vignettes were analyzed by two fall experts, who
determined their appropriateness of the study.
Participants were recruited by research assistants
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The questionnaires were constructed by randomized

Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
block design.
Surveys were given after hour to prevent fatigue
Questionnaires were blindly reviewed for correctness
The correct answer for each vignette was predetermined
47 RNs and LPNs from 3 different facilities
Nursing administration was not included
Study was approved by IRB
RN
LPN
Clinical vignettes

Measurement Tool/Data Descriptive statistics used to summarized the educational

Collection Method experience of the participants both objectively and
subjectively

Data Analysis Logistic regression was used to test for separate

differences of the vignettes because they each tested a
different concept
ANOVA was used to test the relationship between RNs,
LPNs, education level, and nursing home site.
ANOVA was also used to average the scores between the
RNs and LPNs.
All analyses were conducted through the R statistical
package.

Findings/Discussion It was found that RNs did better on the questionnaires

about fall prevention
No one score 100% on the questionnaire
The nursing homes education program on fall
prevention needs to be re-examined

Appraisal/Worth to RNs are more knowledgeable on fall prevention.

practice However, this study showed the facilities need to address
their education being provided on fall prevention.

First Author Vogelsmeier, A.A. (2012)

(Year)/Qualifications Assistant Professor at University of Missouri-Columbia,
Sinclair School of Nursing, Columbia, Missouri and 2009-
2011 John A. Hartford Foundation Claire M. Fagin Fellow
Background/Problem To explore the involvement of nursing staff in the process of
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Statement medication reconciliation.

Conceptual/theoretical Not stated

Framework

Design/ Qualitative descriptive study used because this topic has

Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
not been well studied and descriptions of phenomena are
the goal.
Study lasted 18 months
Included 46 onsite observations and informal interviews
8 Midwestern nursing homes
Study had IRB approval
Analytical strategies were utilized to ensure data was
credible, dependable, and confirmable
RNs level of critical thinking
LPNs level off critical thinking

Measurement Tool/Data data was collected through observation and informal

Collection Method interviews

Data Analysis Data was analyzed through qualitative content analysis

approach
Participants validated their interpretations to ensure
accuracy
Data was reviewed a total of three times, after saturation
was complete, the finding were summarized into distinct
differences between the two groups.

Findings/Discussion RNs viewed medication reconciliations as clinical

process
LPNs viewed medication reconciliation as a tasks
RNs identified more discrepancies than LPNs

Appraisal/Worth to RNs are better suited to performed this tasks

practice If LPNs are going to being completing this tasks their
education need to meets the level of critical thinking
required for this tasks.

First Author Corazzini, K.N. (2013)

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(Year)/Qualifications Assistant Professor Duke University School of Nursing
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
16
Inadequate pain management in nursing homes continues
to be a challenge
How management is occurs with specific attention to
scope of practice differences between RNs and LPNs
Not stated
Comparative, multiple case study
Random sampling used to select nursing homes
DON for each nursing homes was contacted
Then two additional nurses were recruited to distribute
the study materials.
DONs were questioned about assessment, care planning,
delegation, and supervision
DONs were also questioned about strategies used to
guide their nurses practices
DONs were asked to provide examples on how a patient
in their facility pain was managed.
8 nursing homes in NC
2 nursing homes in MN
Study had IRB approval
Participants interviews were verified for accuracy
RN scope of practice
LPN scope of practice
Management of residents pain level
Data collected through telephone interviews with DONs
and nursing staff
Involved two steps
First step consisted of reviewing data to identify
difference between RNs and LPNs scope of practice
Open coding was used to describe the practices within
each domain
Each case summary was reviewed by the whole research
team
Data referring to pain management was organized in the
three themes identified from step one
Data analysis addressed the rigor, credibility,
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Findings/Discussion
Appraisal/Worth to
practice
First Author Corazzini, K.N. (2013)/ Associate Professor of Nursing
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
17
confirmability, and dependability.
Lack of RNs in nursing homes cause dependence on staff
who are unable to provide RN level pain management.
RNs and LPNs need to have open communications
among each other
This study shows how RNs impact pain management in
nursing homes
LPNs are providing most of the nursing care in nursing
homes.
LPNS practice, and RN direction of practice, follows in
part from NPAs
Not mentioned
Sequential explanatory mixed-methods design
To describe the differences in the regulation of LPNs
throughout the country
12, 698 nursing homes in 50 states
Utilized two coders from each state to reduce biases and
improve confirmability
Scope of practice for LPNs
NPAs
Qualitative interpretive paradigm
Mixed methods
Quantitative strand, cross-sectional, quantitative analyses
of fully specified, hierarchical linear models
Several strategies were used to ensure rigor, credibility,
confirmability, and dependability
Executives from two state boards of nursing reviewed all
summary matrices
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Bonferroni correction

Findings/Discussion LPNs scope of practice varies from state to state

States need to be more clearer on the role of LPNs
Appraisal/Worth to This studies shows how the LPN role varies from state to
practice state. Which can possibly leave a gap in patient care.
RNs scope of practice is more defined and embodies the
components needed to ensure patients are receiving
quality care.