Background
Guiding framework
Parameter | Definition |
---|---|
Interconnections | Networks of interconnection develop when staff members interact to complete work [23]. Interconnections create social networks and feedback loops through which tacit knowledge develops and grows; local changes in behavior can give rise to system-wide change [24], influencing the extent to which the organization is capable of new behaviors. |
Rate of new information flow | Staff members share information with each other about patients and work processes. The rate with which staff in a system share new information will influence generation of new behaviors [22]. |
Diversity of cognitive schema | Cognitive schemas arise from social, educational, or cultural backgrounds, organizational roles, and age [25]. They are mental models by which people evaluate and make sense of information [26]. Diversity of cognitive schema refers to the variety of mental models available with which to expand possibilities for understanding and acting in novel ways. |
Methods
Ethics and consent
Sample
Data collection procedures
Facility (Case Number) | Case 1 | Case 2 | Case 3 | Case 4 |
---|---|---|---|---|
Number of staff: total for facility
| 104 | 119 | 97 | 86 |
Total number of transcripts or documents coded
| 142 | 155 | 100 | 119 |
Staff participant characteristics
| ||||
% female | 84% | 81% | 78% | 74% |
Race/Ethnicity | ||||
Caucasian | 46% | 60% | 25% | 38% |
African American | 44% | 35% | 59% | 56% |
Other (Asian, Hispanic or unknown) | 10% | 5% | 16% | 6% |
Age group (years) | ||||
20-24 | 7% | 11% | 18% | 8% |
25-34 | 22% | 32% | 27% | 20% |
35-44 | 26% | 32% | 28% | 25% |
45-54 | 22% | 14% | 21% | 18% |
55+ | 23% | 11% | 6% | 29% |
Tenure in years: mean (SD) | ||||
Tenure in facility | 7.6 (9.4) | 3.0 (3.0) | 1.6 (2.6) | 7.9 (9.5) |
Tenure in position | 6.8 (8.1) | 2.6 (3.0) | 1.4 (2.4) | 6.0 (7.0) |
Facility staff by position involved in observation and/or informal interview
| ||||
Nursing home administrator | 1 | 1 | 3 | 1 |
Director of nursing | 1 | 1 | 3 | 1 |
Assistant director of nursing | 0 | 1 | 2 | 0 |
Quality assurance registered nurse (RN) | 1 | 0 | 0 | 0 |
RN supervisor | 2 | 2 | 1 | 1 |
Licensed practical nurse supervisor | 0 | 0 | 0 | 1 |
MDS nurse (RN) | 2 | 2 | 2 | 1 |
Staff development coordinator (RN) | 1 | 0 | 0 | 2 |
Staff development nurse (RN) | 0 | 2 | 0 | 0 |
Rehabilitation director (or speech therapist) | 0 | 1 | 2 | 1 |
Rehabilitation/Restorative Staff | 2 | 10 | 3 | 7 |
Staff RN | 9 | 6 | 3 | 2 |
Staff LPN | 5 | 12 | 13 | 11 |
Agency LPN | 1 | 0 | 5 | 0 |
Nursing assistants (including Medication techs) | 36 | 36 | 26 | 21 |
Sitter | 1 | 0 | 0 | 0 |
Medical doctor | 1 | 2 | 2 | 1 |
Nurse practitioner | 1 | 1 | 0 | 0 |
Psychiatrist | 0 | 1 | 0 | 1 |
Podiatrist | 0 | 1 | 0 | 0 |
Lab tech (contract) | 0 | 0 | 0 | 1 |
Dietician | 0 | 1 | 0 | 0 |
Dietary manager | 1 | 1 | 3 | 1 |
Dietary staff/aides | 10 | 4 | 0 | 4 |
Activities director | 1 | 1 | 1 | 2 |
Activities assistants | 2 | 1 | 1 | 1 |
Environmental services manager | 1 | 4 | 1 | 1 |
Environmental services staff | 8 | 6 | 5 | 5 |
Social worker | 0 | 0 | 0 | 1 |
Social services staff | 2 | 2 | 2 | 0 |
Administrative support staff | 14 | 13 | 11 | 10 |
Corporate staff | 1 | 7 | 8 | 5 |
Total # staff
|
104
|
119
|
97
|
82
|
Other observations
| ||||
Shadowed (in-depth observation) | 14 | 26 | 18 | 14 |
Depth interviews | 32 | 39 | 24 | 31 |
Documents reviewed | 42 | 39 | 20 | 44 |
Analysis
Within-case analysis
Cross-case analysis
Results and discussion
Local Interaction Strategies
“A lot of people will say, ‘Well, the receptionist just answers the phone.’ She observes a WHOLE LOT. And I’ll ask for her opinion on certain residents and how they’re acting… Housekeeping [will tell you] any complaints a patient may have…the food, the service, that kind of stuff…because the resident can pick anybody to talk to… [and] might tell them something that they would not tell anybody else.”
The common pattern of local interaction
…they’re not that much help…Say you’re in the room with a resident who’s an accident waiting to happen. You don’t feel comfortable leaving him… And then, there is another lady who’s accident-prone…and her alarm goes off. Instead of the nurse answering it, they just sit there listening to it and then they’ll come [tell us] to take them to the bathroom. That’s why I don’t even bother now [to ask the nurses for help]… You get in the habit of…getting another nurse aide.
CNA: If I could change something around here I would start with the front office…How are we going to work together when they don’t?Interviewer: So do you get much contact with anyone in the front office?CNA: When they get ready to come out here and chew somebody out about something, I see them then.Interviewer: …Do you have meetings?CNA: No…But that is what it boils down to, no communication. …we come in and work blind. That is how it is here.
The positive pattern of local interaction
Local interaction Strategy/ Definition | Exemplar quotation | Outcome described |
---|---|---|
Connection: Local interactions strategies that help individuals make and keep good relationships with co-workers and foster good teamwork; these lay the foundation for effective information exchange and problem solving about resident problems. | ||
• Be approachable--Be open, listen, and respond to what people say | A rehabilitation therapist said, “If I have a positive relationship before a situation comes up, then I’m more likely to get a positive response from [the nursing assistants] out on the floor, too… They will stop me and they’ll tell me about issues. | Respect |
Better care planning | ||
Early detection of problems | ||
• Pitch-in-- Go beyond regular duties to help others | I [nursing assistant] had one total care person and the rest just need some assistance which made my assignment easier. So I went down and gave a couple of showers and made a couple of beds for the other girls…They did not ask me, I just went ahead and did it.” | Teamwork |
Staff well being | ||
• Seek assistance-- Request help | An employee performance standard (employee handbook), “They are willing to ask for help and do not think they can handle every situation on their own. If they can’t get the needed result they will find someone else who can. They are primarily concerned about getting the right result for a resident.” | Patient safety/earlier detection of problems |
• Reciprocate-- Give and take with others in a way that generates goodwill | A business manager says, “I give [my assistant] a lot of my work to help me out – AND we work together. She does things for me. I just don’t like telling her what to do. I said, ‘These are the things that have to be done, let’s work on it together.’ And I do that kind of thing. I think its being a team player and not just unloading everything on one person. … She had to leave early one day and I said, ‘Well, go, I’ll finish up.’ And I made her leave. You know, I believe you should be able to take the load over.” | Teamwork |
Staff well being | ||
• Show appreciation-- Express a positive opinion of other peoples’ actions | “If I [administrator] see things that are right…we write you up for that in a positive way…we try to focus on what you are doing right.” | Motivating |
Empowering | ||
Staff well being | ||
Confidence | ||
Satisfaction | ||
• Give respect--Let others know you value them and their opinion | An administrator says that “to develop employees to their fullest potential and allow them to see the difference that THEY can make in people’s lives….by viewing every [resident] as an individual, whether [or not] they are capable of communicating with us to treat them with the dignity and respect that THEY deserve and to – to try to give them the best quality of life. I feel like if we treat our employees right, they’ll treat the residents right. But, we have to model the behavior that we want them to have. And, uh, so – and I think that starts with - with EVERYONE, but certainly with me. And so I do everything I can to encourage that behavior.” | Respect |
Staff well being | ||
Patient quality of life | ||
• Say thank you-- Express gratitude, pleasure and satisfaction | “Staff like to be recognized…when [the administrator] goes in there one-on-one and says, ‘thank you for the hard work that you do’ and ‘can’t even pay you enough for the hard work that you do. We really appreciate it.’ The staff like that.” | Staff well being |
Respect | ||
• Give praise-- Let others know you admire the work they do | “It makes me [nurse] feel good when I do something good for a resident, like if something happens to them and I end up having to send them out…and someone will come to me and say, ‘You did a really good job. You knew to call 911, you knew to do this. You knew to do that.’” | Respect |
Motivating Empowering | ||
Staff well being | ||
Satisfaction | ||
• Coach/Mentor-- Guide, instruct, or train others; form trusting relationships | “I [nurse] use to get the worse nursing assistants. But what I would do was to…work with their strengths and whatever weaknesses. I would teach them. ‘You don't leave up a rail’…I will go back and check behind them. Before long they will pick up on these things” | Valuing Confidence |
Better resident care | ||
Patient safety | ||
New Information Exchange: Local Interaction Strategies that help individuals give and get new information about residents to and from the right people, in a way that ensures everyone understands. | ||
• Listen-- Hear with thoughtful attention | A nurse manager said, “Just let people know that they’re important [said with emphasis] and that what they have to say is important… Whether you can do anything or not, at least you’re listening! You know that you’ve heard what they’ve had to say.” | Staff feel respected |
Valuing | ||
• Give information-- Share information; give a report | After a CNA described how she solved a resident behavior problem, a researcher asked, “Did you share your strategy with anybody else?” The CNA said, “I did with another nursing assistant. She had [the resident] the next day and I told her what I did… she said okay and she tried the same thing and it worked.” | Teamwork |
More consistency in resident care | ||
• Receive information-- Graciously accept information | An LPN explained, “If you’ve got concerns or complaints, being able to go to someone and say, you know, ‘This is bothering me,’ or ‘I’m concerned about this.’ And, them at least addressing your concerns—that’s important. They may not do anything about it THEN, but then at least they LISTEN to you. I think that important.” | Potentially pick up resident issue |
Staff feels respected | ||
Staff well being | ||
Valuing | ||
• Explain-- Give more details to clarify what you mean | A housekeeping director said, “If you just say, ‘This is wrong you know, you better change this, it is not good,’ they [housekeeping staff] will just end up hating you…I explain to them, ‘This is what you need to do. Bring the trash can; put a lining on that trash can, so when you take off the diaper, drop it directly in…I give them several examples like that and that way they understand.’” | Staff well-being and efficacy |
Better job performance | ||
• Verify Meaning-- Make sure you understand information shared by others. | A nursing home administrator relayed a conversation with an employee who said, “I don’t understand why I’m submitting a doctor’s bill.” I said, “Prospective Payment System…” and I went through the scenario. She said “Now I understand.” That’s what I try to … I’ll look in your eyes; if I’m comfortable you got it, we move on with business. If not, I want you to think about it for a minute… | Delegated tasks more likely to be done properly |
Cognitive Diversity: Strategies that help individuals notice changes in residents’ conditions and that they act on what they see and discuss multiple opinions to make good sense of the problem and ensure shared meaning of events. | ||
• Pay attention-- Make a conscious effort to stop, watch and act. | “In the wheelchair…in front of the nursing station, one male resident had been snoring very loudly. A certified nursing assistant moved him and another resident in a geri-chair around and reclined both so they can sleep more comfortably. She then picked up a couple of paper towels that had fallen on the floor and went into a bathroom to throw them out and wash her hands.” | Better quality |
Patient safety | ||
Earlier detection | ||
• Ask questions-- Ask for explanation when you feel uneasy about something and when you feel you were not heard. | A nursing assistant said, “I would…look at the chart. But…for me to really, really understand the resident - since that nurse knows that resident, I would rather go to [the nurse] and say, ‘Well, how about so and so, what kind of person is he?’ You know, ‘can he stand, can he sit?’ | Patient safety |
Better care | ||
• Give feedback-- Provide others with useful opinions or reactions to their work | A physical therapist said, “If I hear of problems, I try to pull people in. For instance, we’re having issues with some restraint situations…And so, we’ve opened up some lines of communication.” | Patient safety |
Better care | ||
• Receive feedback-- Graciously accept others’ opinions about, or responses to, your work | A Minimum Dataset Nurse explained, “I have a particular resident who…filled my ears full yesterday and, you know, I explained to him that I’ll be coming to him every day that I’m here - sitting down and talking with him and, you know, I’m going to help him, you know, try to resolve anything that I can. And he was very responsive to it.” | Quality improvement |
Resident quality of life | ||
• Suggest alternatives-- Give different options for others to consider before taking action | A Nurse stated, “I looked in on a patient, but, she’s been in the bed for the last few days…So, I asked [the charge nurse], ‘Why is she in the bed?’ And they said, ‘Oh she just hasn’t been feeling well.’ So, I tell the charge nurse, ‘You might want to look for a UTI, because she has a history of having UTIs.” | Earlier detection of problems |
Better care outcomes. | ||
• Sensemaking-- Talk with other people to ask, “what does this mean?” Together make sense of confusing information or situations | An Activities Director said, “There was an issue with [a resident] trying to sneak food. And he, at the time, couldn’t take anything by mouth. We had a lot of conversations…everyone could come with their ideas and really try to think about how to make it work for the resident and the family…It was great. It was a lot of conversation and really coming together for the resident’s best interest.” | Better care planning and decision-making |
Better care outcomes |
“Today I was very disturbed. [Resident name] had diarrhea… I tried everything. I even let her get it all out, thought she was finished, came back, dried her up again, come back, she did it again. I said, “Oh, God, am I ever going to get out of this room… I was mad because it was slowing me down. I had four more people that needed to be up.”
“I went and got [name of another CNA], and let her handle it. I asked her to help me out. So, she took over!….Every day we have a routine. We work together. …In the morning we’re on our own unless we need help, but in the afternoons, we do our rounds together. She’s there, helps me catch up. She’s my buddy…It gets a whole lot of work done faster.”
“Uh huh, all the time…it’s all about teamwork…it works excellent too. [In the past] you go home tired and worn out - don’t have any energy left to play with your kids… [Now] when you go home, you’re not all drained out and tired.”
“[I tried] to be very patient whenever I tried to get [nursing] to do [a new task/skill]… Oftentimes, they would not follow through and I tried not to lose my temper or yell, because I know everybody has a learning curve…I try to interact with nursing staff in a way that facilitates good dialogue [so] they feel that they can approach me with patient problems, so that we can solve things together. I listen to what they have to say, and their way of doing things, and try to see if that’s the best way to meet the patients’ needs.”
“ADON: I don’t get upset very often - but when a patient passed away - one of the family members had come down the hall … and overheard a CNA say, ‘Yeah, you know, when, a family member’s dying, the family comes out of the walls like vultures.’ [In a tone of incredulity] I said, ‘How could anybody do that?’ I said, ‘Put yourself in their place. How would you feel if your mother had just died and you heard somebody say that?’”
“Staff Development Director: If I see something wrong, …I explain to them why. Because if you just say, ‘This is wrong, you better change this’ , there is no good effect. They will just end up hating you. But, if you say, for example, ‘You know that the soiled diaper that you lay down on the floor is dirty and contains different microorganisms that …will make you all sick…I explain to them and so they learn…that way they understand and they comply.’”
“If I hear of problems, I try to pull people in. For instance …the way restraints are handled…is very heavy on [physical therapist]. She’s really carried the burden for YEARS… And so, we’ve opened up communication …. Pulling us all into the same room to be able to hash out what needs to be done [going] forward. It’s a multi-disciplinary approach versus a physical therapy approach - It shouldn’t fall to one person; what if she’s not here? Having a multi-disciplinary approach is the biggest key. It’s not just one person LEADING THE CHARGE….[It] means change. Change is often hard.”