Organizational Context and Facilitation Interactions on Delirium Risk in Long-Term Care: A Cross-Sectional Study

Katharina Choroschun; Carole A Estabrooks; Yinfei Duan; Stephanie Chamberlain; Shovana Shrestha; Greta G Cummings; Alba Iaconi; Peter G Norton; Yuting Song; Matthias Hoben

doi:10.1016/j.jamda.2024.03.111

Organizational Context and Facilitation Interactions on Delirium Risk in Long-Term Care: A Cross-Sectional Study

J Am Med Dir Assoc. 2024 Apr 22:S1525-8610(24)00342-6. doi: 10.1016/j.jamda.2024.03.111. Online ahead of print.

Affiliations

¹ School of Public Health, Bielefeld University, Bielefeld, Germany. Electronic address: k.choroschun@uni-bielefeld.de.
² Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada.
³ Institute of Health Policy, Health, Management and Evaluation, School of Public Health, University of Toronto, Toronto, Ontario, Canada.
⁴ School of Nursing, Qingdao University, Qingdao, China.
⁵ School of Health Policy and Management, Faculty of Health, York University, Toronto, Ontario, Canada.

PMID: 38663451
DOI: 10.1016/j.jamda.2024.03.111

Abstract

Objectives: Organizational context (eg, leadership) and facilitation (eg, coaching behaviors) are thought to interact and influence staff best practices in long-term care (LTC), including the management of delirium. Our objective was to assess if organizational context and facilitation-individually, and their interactions-were associated with delirium in LTC.

Design: Retrospective cross-sectional analysis of secondary data.

Setting and participants: We included 8755 residents from 281 care units in 86 LTC facilities in 3 Canadian provinces.

Methods: Delirium (present/absent) was assessed using the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS 2.0). The Alberta Context Tool (ACT) measured 10 modifiable features of care unit organizational context. We measured the care unit's total care hours per resident day and the proportion of care hours that care aides contributed (staffing mix). Facilitation included the facility manager's perception of RAI-MDS reports' adequacy and pharmacist availability. We included unit managers' change-oriented organizational citizenship behavior (OCB) and an item reflecting how often care aides recommended policy changes. Associations of organizational context, facilitation, and their interactions with delirium were analyzed using mixed-effects logistic regressions, controlling for covariates.

Results: Delirium symptoms were prevalent in 17.4% of residents (n = 1527). Manager-perceived adequacy of RAI-MDS reports was linked to reduced delirium symptoms (odds ratio [OR] = 0.63). Higher care hours per resident day (OR = 1.2) and an available pharmacist in the facility (OR = 1.5) were associated with increased delirium symptoms. ACT elements showed no direct association with delirium. However, on care units with low social capital scores (context), increased unit managers' OCB decreased delirium symptoms. On care units with high vs low evaluation scores (context), increased staffing mix reduces delirium symptoms more substantially.

Conclusions and implications: Unit-level interactions between organizational context and facilitation call for targeted quality improvement interventions based on specific contextual factors, as effectiveness may vary across contexts.

Keywords: Organizational context; health care research; nurse staffing; quality improvement interventions; quality in long-term care.