Threats to performing high-risk resident care activities in nursing homes: A work system analysis

Infections from multidrug-resistant organisms (MDROs) are a major concern for nursing home (NH) resident morbidity and mortality. Our goal was to identify threats to healthcare workers (HCWs) safely and efficiently performing resident care activities that contribute to MDRO transmission in NHs. Following focus group discussions with certified nursing assistants, we identified threats in terms of the Systems Engineering Initiative for Patient Safety work system model and then induced 24 broader themes. We then used Fuzzy Cognitive Mapping (FCM) to characterize how themes influence one another. FCM revealed two prominent themes that increase the amount of physical contact (transmission) between HCWs and residents and promote lapses in preventative practices during high-risk activities: 1) additional steps or tasks arising during these activities and 2) when these activities become otherwise prolonged. These themes were driven by themes related to the organization, residents, and residents' caregivers. To reduce MDRO transmission from these activities, the work systems of NHs must better support the capabilities, limitations, needs, and preferences of both the HCWs providing and the residents receiving care.