Using Research to Enhance Knowledge of Nursing Home Quality and Safety

Nicholas G. Castle, Ph.D., M.H.A.

Chair and Professor

Department of Health Policy, Management, and Leadership

West Virginia University, Morgantown

“AHRQ’s funding opened doors and allowed me to take a comprehensive approach when analyzing quality of care in the nursing home setting. The research has benefited facilities and supported policy makers with empirical evidence about the importance of quality and safety in nursing homes.”

AHRQ grantee Nicholas G. Castle, Ph.D., M.H.A., has dedicated his career to the study of improving safety and quality in long-term care settings, including nursing homes and assisted living facilities. His research has examined the many factors that impact the quality of care, including staffing, resident satisfaction, and adverse event reporting.

Dr. Castle, who is chair and professor of the Department of Health Policy, Management, and Leadership at West Virginia University in Morgantown, started his AHRQ research in 2004 with funding to study outcomes related to use of physical restraints to prevent falls in nursing homes. Physical restraints include, but are not limited to, waist belts, hand mitts, and full-length bed rails. Rather than protecting residents from adverse events, research eventually showed that restraints were contributing to them. Dr. Castle’s 2008 study in The Gerontologist journal also showed a connection between the use of restraints and mental health decline in nursing home residents.

Resident satisfaction is an important element of care, according to Dr. Castle, who noted that measuring and reporting satisfaction with nursing home care can help facilities improve some aspects of quality. In 2010, shortly after AHRQ released its Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Nursing Home Survey, Dr. Castle’s AHRQ-funded research was instrumental in testing one of the survey modules developed to measure the satisfaction and experiences of short-stay nursing home residents who were discharged home or to other facilities.

At that time, many nursing homes were not using surveys at all or were using surveys developed in house that lacked benchmarks. The CAHPS discharged resident survey (PDF, 624 KB) “provides perspective from the resident’s angle and is an important tool to help seniors and their families choose a nursing home,” said Dr. Castle. “Satisfied residents are likely to have better health outcomes,” he added.

Dr. Castle’s work started with small grants and evolved into larger projects that focused on the effects of staffing characteristics on quality of care. The projects demonstrated that staffing levels, turnover, and consistent staff assignments directly impact the quality of care in nursing homes. One of his grants on this topic focused on the increased use of private agencies to provide temporary staff for nursing homes. “The surge and dependency in outsourcing the nursing home workforce remedied the high turnover and helped facilities maintained optimum staff levels, but at the same time it had a dangerous impact on the quality of care provided to residents,” he said.

Dr. Castle continued to assess the benefits and harms of the healthcare delivery system to inform decisionmaking. In 2013, he received a career enhancement grant from AHRQ to use the Patient-Centered Outcomes Research (PCOR) framework to examine the effects of consistent assignment of nurse aides in nursing homes to improve care.

To increase knowledge about adverse incident reporting practices and the role of health information technology (IT) in improving processes to measure quality, Dr. Castle surveyed nursing home administrators across the country. His research revealed inconsistencies in the processes used for reporting incidents that had caused or had the potential to cause harm to patients and unveiled multiple barriers in the use of health IT. “Facilities not only lacked the IT equipment, but also indicated that fear of reporting was also a barrier,” said Dr. Castle. This research underscored the importance of implementing standardized adverse event reporting systems to ensure the safety of nursing home residents.

Currently, Dr. Castle is a co-principal investigator on an AHRQ-funded study to evaluate strategies that nursing homes use to prevent adverse safety events affecting obese residents. Results from this work will be available in 2024.

Dr. Castle is the Editor for International Research for The Gerontologist. He also serves on the editorial boards of The Gerontologist, Research in Gerontological Nursing, the Journal of Post-Acute and Long-Term Care Medicine, and the Journal of Applied Gerontology. He is a Fellow of the Gerontological Society of America and a member of the Association of Health Services Research.

Principal Investigator: Nicholas G. Castle, Ph.D., M.H.A.
Institution: West Virginia University, Department of Health Policy, Management, and Leadership
Grantee Since: 2004
Type of Grant: Various