Racial and Ethnic Disparities in Pain Management for Nursing Home Residents: A Scoping Review

Abstract Within nursing homes, residents commonly experience pain that unfortunately goes underrecognized and undertreated, having a dramatic negative impact on residents' quality of life. Nursing homes are becoming more racially and ethnically diverse, and there is concerning evidence documenting disparities in the quality of nursing home care. In other healthcare settings, people of diverse race groups often receive less optimal pain management, but the evidence regarding racial disparities has not been synthesized for nursing homes. Thus, the purpose of this review was to investigate what is known about racial disparities related to pain management (e.g. assessment, treatment, preferences) in US nursing homes. We completed a scoping literature review using PRISMA-ScR guidelines and searching PubMed, CINHAL, and Scopus for peer-reviewed, empirical studies. Most studies were older large retrospective cohort studies of administrative data documenting that White residents were more likely than residents of diverse race groups to have pain documented and treated. Only a few studies looked at possible reasons to explain the disparities; differences were not found to be related to nursing staff racial bias nor differences in pain-related diagnoses. However, there was evidence of racial differences in resident behavior and attitudes related to pain management. None of the studies examined systemic factors related to differences among nursing homes, which has been implicated in studies looking at other outcomes including COVID-19. More research is needed which examines the causal mechanisms behind the documented racial disparities in pain management so that gaps in care can be reduced.

Sleep quality declines in old age and is particularly poor for long-term care (LTC) residents with dementia.Compromised sleep quality is associated with severe cognitive and neuropsychiatric symptoms, agitation, aggressiveness, and poor quality of life.Based on the premise that stressors can have a cumulative effect on people with dementia throughout the day that contributes to negative consequences later in the day, we examined if daytime activity, mood, and unit tumult were associated with sleep quality.A convenience sample of 53 LTC residents with dementia participated in this correlational study.Objective sleep quality and activity variables were measured using Actigraphy, and mood was measured by the Observed Emotion Rating Scale.Unit tumult was defined as events in the residents living area that are deviations from the typical day (i.e., census changes, being cared for by a certified nursing assistant from a temporary staffing agency, and lower than usual staffing level).Comorbid illness and level of dementia were control variables.Half of the sample had a sleep efficiency that was less than .85and were awake for more than 90 minutes at night.Comorbid illness, negative mood at bedtime, and daytime activity level accounted for 26.1% of the variance in total sleep minutes.Census changes and the use of temporary agency staff were associated with poor total sleep time and sleep efficiency.Findings suggest that daytime activity, mood at bedtime, and unit tumult should be considered when designing and testing interventions to improve sleep quality among LTC residents with dementia.

FACTORS INFLUENCING RETENTION INTENTION OF NURSES AT LONG-TERM CARE HOSPITALS IN KOREA
So Young Shin, 1 and Joo Hee Kim, 2 1. Global Brain Health Institute, University of California, San Francisco / Inje University, Busan, Pusan-jikhalsi, Republic of Korea,2. Busan Hangun Hospital,Busan,Republic of Korea Purpose: This study aimed to investigate the levels and correlations of role conflict, nursing professionalism, nursing work environment and retention intention, and the factors influencing retention intention of nurses at long-term care hospitals.Methods: The subjects included 183 nurses at nine long-term care hospitals in one metropolitan city in Korea.A set of self-reported questionnaires was administered to assess general characteristics, role conflict, nursing professionalism, nursing work environment, and retention intention of the subjects.Collected data was analyzed using descriptive statistics, t-tests, one-way ANOVA, Pearson correlation coefficients, and multiple linear regression.Results: 183 subjects with a mean (±SD) age of 41.66 (±12.29) years were included in the final analyses.Retention intention had a significant positive correlation with nursing professionalism (r=.39, p<.001) and nursing work environment (r=.51, p<.001).Nursing work environment had a significant negative correlation with role conflict (r=-.30,p<.001) and a significant positive correlation with nursing professionalism (r=.48, p<.001).In the final multiple regression analysis, the factors influencing retention intention of subjects were number of beds (β=-.15p<.026), nursing professionalism (β=.19, p=.007) and nursing work environment (β=.36, p<.001).The explanatory power of number of beds, nursing professionalism and nursing work environment on retention intention was 34.0% (F=16.66,p<.001).Conclusion: Improving nursing professionalism and nursing work environment of nurses at long-term care hospitals will ultimately enhance their retention intention and positively impact on the quality of gerontological nursing service.

FAILURE TO THRIVE: NURSING HOME STAFF EXPERIENCES IN CARING FOR RESIDENTS DURING THE COVID-19 PANDEMIC
Yu-Ping Chang, 1 Audrieanna Raciti, 2 Cristina de Rosa, 1 Margaret Doerzbacher, 1 Yanjun ZHou, 1 Chia-Hui Chen, 1 and Amy Lyons, 1 1.University at Buffalo, Buffalo, New York, United States, 2. University at Buffalo, 7168292015, New York, United States Nursing home residents and staff have accounted for roughly 40% of Coronavirus-related deaths in the U.S. The burden of caring for vulnerable residents coupled with isolation policies has taken a significant emotional toll among direct health care staff in long term care facilities.This study explores nursing home staff's experiences in caring for residents during the COVID-19 pandemic.A qualitative descriptive approach with a semi-structured guide was used to conduct individual interviews.We recruited nursing home staff employed during the COVID-19 pandemic in long term care facilities located in New York State.Interviews were recorded, transcribed verbatim, and then analyzed using Braun and Clarke's Reflexive Thematic analysis.Twelve nursing home staff were interviewed.Participants consistently refer to failure-to-thrive as an extremely concerning problem because many residents demonstrate decreased appetite and poor nutrition, inactivity, and depressive symptoms due to social isolation.They also often feel frustrated and overwhelmed due to uncertainty and shortages of staff.Five main themes were identified, including doing their best to manage residents' failure-to-thrive, working as a team, keeping family members informed and connected, struggling to balance competing personal and professional demands, and needing support to reduce stress and build strength.Our study findings indicate that nursing home staff experienced a high level of stress and identified failure-to-thrive caused by isolation and loneliness as a common phenomenon among nursing home residents during the COVID-19 pandemic.Interventions are urgently needed to reduce isolation and loneness in nursing home residents and to provide support for staff.Employing Foreign Educated Nurses (FENs) helps address Registered Nurse (RN) shortages in long-term care (LTC) in the United States (US).However, examination of factors explaining differences in their employment outcomes relative to US Educated Nurses (USENs) is limited.This study uses 2018 National Sample Survey of Registered Nurses data to compare income, work hours, job satisfaction, and human capital, defined as personal characteristics (knowledge, work experience) and behaviors (job mobility), of FENS and USENs working full-time in LTC.A human capital score, consisting of highest nursing education, skill certifications, state licensures, years of experience, multi-state employment history, and multi-lingual status was constructed.Covariates included nurse demographics, direct care role, and ability to practice to full scope.Covariate-adjusted group differences in employment outcomes and human capital were compared using ANCOVA and logistic regression.Mediation analyses explored whether human capital explained FEN vs USEN differences.FENs earned higher hourly wages (p=0.0169),worked fewer hours annually (p=0.0163), and reported greater human capital (p<.0001) compared to USENs.FENs and USENs, however, had similar annual salaries (p=0.3101) and job satisfaction (p=0.1674).Human capital mediated FEN vs USEN effects on hourly wages but not annual work hours.FENs' higher levels of human capital partially account for FEN vs USEN differences in hourly wages.Application of the human capital concept advanced our ability to examine differences in employment outcomes and highlight aspects of the value that FENs contribute to LTC settings.(n=4,427).A 10% sample of Veterans without indications of EM was selected for comparison (n=530,535).Logistic regression compared EM+ Veterans to the comparison sample and assessed overall demographic and clinical differences as well as differences by age, i.e. 50-64 versus 65 and older.Overall, female gender (OR=5.3,95% CI=4.3-6.5),non-white race/ethnicity (OR=1.7,CI=1.5-1.9),dementia (OR=3.0,CI=2.6-3.5),PTSD (OR=2.0,CI=1.6-2.5),anxiety (OR=1.3,CI=1.0-1.5),military service connected disability status (OR=1.3,CI=1.1-1.5), and higher Elixhauser medical morbidity scores (OR=1.1,CI=1.1-1.1) were associated with EM.Prior year ER visits (OR=28.0,CI=23.6-33.4),inpatient stays (OR=14.0,CI=11.5-17.0), and mental health visits (OR=26.1,CI=22.2-30.6)also predicted EM+ status.Fortysix percent of VHA Veterans with indicators of EM were aged 50-64.For these Veterans, female gender, PTSD, service connection, and mental health visits were associated with increased risk of EM compared to Veterans 65+.Findings highlight clinical correlates of EMs among Veterans in VHA care.Increased awareness of EM risk factors is warranted and may inform VHA efforts for EM prevention, detection and intervention.

LIVING IN THE NEW NORMAL: EFFECT OF RESIDENTIAL SETTING ON PERCEPTION OF A MEANINGFUL LIFE AMONG OLDER WOMEN
Judith Scott, 1 Helen Graham, 1 Ann Mayo, 2 and Melissa Benton, 1 1.University of Colorado Colorado Springs,Colorado Springs,Colorado,United States,2. University of San Diego,San Diego,California,United States Perception of a meaningful life is related to depression, anxiety, and general well-being.The sense that one's life is meaningful influences overall quality of life, which influences aging well.It is not clear whether differences in residential setting influence perception of a meaningful life.This study evaluated the effect of residential setting (community versus assisted living) on perception of a meaningful life in 48 older (79.7 ± 1.0 years) women living in the community (n=24) or assisted living (n=24) who were pair matched by age.They completed a one-time questionnaire regarding self-rated health and whether life has meaning.Both questions were scored on a 5-point scale with 0 indicating poor health or no life meaning and 4 indicating excellent health or strong life meaning.There were no significant differences in age between women in community living (CL) and assisted living (AL) (78.0 ± 09 vs. 81.5 ± 1.6 years, respectively; p=0.7).Both groups also reported similar self-rated health scores (CL: 2.4 ± 0.2; AL: 2.2 ± 0.2; p=0.4), indicating good-very good health.However, there were significant differences between groups in their perception of a meaningful life.Women in CL reported significantly lower scores compared to women in AL (2.9 ± 0.2 vs. 3.6 ± 0.1; p=0.006), indicating that women in CL perceived a less meaningful life.Based on our findings, it appears that the supportive infrastructure provided by AL residential settings may promote quality of life and successful aging by enhancing the perception of a more meaningful life.

NURSING HOME FACTORS AND THEIR IMPACT ON COVID-19 CASES: A STUDY OF WISCONSIN STATE
Mohammed Abahussain, 1 Priya Nambisan, 2 Colleen Galambos, 2 Bo Zhang, 2 and Elizabeth Bukowy, 3 1.University of Wisconsin-Milwaukee, Wauwatosa, Wisconsin, United States, 2. University of Milwaukee,Wisconsin,United States,3. Medical College of Wisconsin,Wauwatosa,Wisconsin,United States COVID-19 has been devastating for Nursing Homes (NHs).The concentration of older adults with underlying chronic conditions inevitably made the setting highly vulnerable leading to high rates of mortality for residents.However, some nursing homes fared better than others.This study examines several quality measures and organizational factors to understand whether these factors are associated with COVID-19 cases in Wisconsin.We combined three datasets from Centers for Medicare & Medicaid Services (CMS) -the Star Rating dataset, Provider Information dataset and COVID-19 Nursing Home dataset.Data used Jenefer Jedele, 1 Cameron Griffin, 2 and Julie Weitlauf, 3 1.