Deborah Lekan-Rutledge

Patterns of Medical and Nursing Staff Communication in Nursing Homes: Implications and Insights From Complexity Science

Complexity science teaches that relationships among health care providers are key to our understanding of how quality care emerges. The authors sought to compare the effects of differing patterns of medicine-nursing communication on the quality of information flow, cognitive diversity, self-organization, and innovation in nursing homes. Two facilities participated in 6-month case studies using field observations, shadowing, and depth interviews. In one facility, the dominant pattern of communication was a vertical “chain of command” between care providers, characterized by thin connections and limited information exchange. This pattern limited cognitive diversity and innovation in clinical problem solving. The second facility used an open communication pattern between medical and frontline staff. The authors saw higher levels of information flow, cognitive diversity, innovation, and self-organization, although tempered by staff turnover. The patterns of communication between care providers in nursing facilities have an important impact on their ability to provide quality, innovative care.

The Power of Relationship for High Quality Long Term Care

In an effort to ensure quality, nursing homes are among the most highly regulated and rule-driven health care organizations. With such attention to quality, why do industry assessments1 continue to report poor quality? Traditional models for organizing care are derived from longstanding Newtonian beliefs about the world and have led to a reliance on regulation and rules as a primary means of control.2 Complexity science, however, offers a new way to understand organizational dynamics3 and thus provides insights about why nursing homes may struggle to provide high quality care and suggests new targets for improvement. In particular, complexity science reveals that the capacity of a human system to change and improve is shaped by the quality of relationships among its members.4 Consider the following scenario. A certified nurse assistant (Katie CNA) discusses her assignment with the nurse. Katie CNA learns that she should first get Mrs. Jones up because this resident must be upright to eat due to choking risk; second bathe and dress Mrs. Smith who is incontinent and at risk for decubitus; and last care for Mrs. Lee because she is not incontinent and doesn’t mind sleeping later. Before beginning her assignment, however, Katie CNA hears from Mary CNA that Mrs. Lee’s daughter is on her way into the building. The nurses and CNAs all know that this daughter complains and is demanding when she finds her mother in bed past 7:30 am; these complaints have been discussed in recent unit meetings. Using this new information, Katie CNA adjusts her plans and takes care of Mrs. Lee first instead of following the nurse’s instructions. Remembering what she learned from the nurse, however, Katie CNA asks Mary CNA to get Mrs. Jones and Mrs. Smith out of bed right away. Mary CNA agrees but only after she secures Katie CNA’s promise to help with her heavy care residents later in the day. Meanwhile the nurse notices the daughter’s arrival, observes the adjustments made by Katie CNA and delays the daughter at the nurse’s station to allow Katie CNA time to prepare Mrs. Lee. This scenario describes a process of self-organization.5 Each individual began with a set of plans for her work. However, each quickly adjusted her actions based on new information that came through interaction with each other and observation of events. The outcome was good and appropriate care for those involved. Self-organization is a property of all social systems—referred to in complexity science as complex adaptive systems.3 Self-organization occurs when people are free to interact, exchange information, and adjust behavior to meet the immediate demands of the environment.5 In this scenario, three critical system parameters6 for effective self-organization were apparent in this small complex adaptive system. These system parameters, which are imbedded in the relationships among the members of the system, are: Appropriate information flow. Katie CNA received a clear assignment from the nurse and was open to additional new information from Mary CNA that made her aware of the need to adjust her plans. In addition, a unit meeting provided information to all staff members and allowed for discussion of the daughter’s history of complaints. Good connections among its members. Mary CNA had open communication with Katie CNA such that Katie trusted the information received. A unit meeting about Mrs. Lee’s daughter and her complaints is more evidence of good connection. In addition, the nurse was connected to the care setting such that she observed emerging events and thus was able to adjust her own behavior in response. Finally, Mary CNA trusted that Katie CNA would reciprocate and assist Mary with the heavy care residents. This trust was another sign of good connections among staff. There was sufficient cognitive diversity. Cognitive diversity refers the variety of people in a system in terms of characteristics such as roles or positions, education levels and background, or cultural orientations. Cognitive diversity means that the system will have more “new” information available to it. For example, people holding similar education, roles, and positions, are not as likely to learn something new from each other as would people who hold different education, roles and positions. In this scenario, the nurse and CNA, being cognitively diverse, interacted in a way that ensured a better understanding of events. Specifically, the nurse, using clinical knowledge, discussed information with Katie CNA in such a way that Katie understood that the care instructions were not meaningless rules to be followed. Because she learned the clinical basis for the care assignment, Katie CNA did not delay the care of Mrs. Jones and Smith when other demands arose; instead, she asked Mary CNA to substitute for her. Even this simplistic scenario suggests that a fairly complex set of behaviors were required for effective care. One would need a fairly long list of rules to specify the behaviors necessary to achieve this outcome, which occurred spontaneously and relatively effortlessly through self-organization. Such self-organization was possible only because of the nature of the relationships among the people on this unit. Currently, the authors are conducting a series of case studies in nursing homes in part to examine relationship patterns necessary for self-organization. To date, we have completed three, six-month case studies and found that in general, the relationship patterns in these nursing homes do not create a level of interaction needed to support truly effective self-organization. Some dominant patterns appeared across these three cases that are likely to exist in many other nursing homes as well. These dominant patterns, described below, suggest a restriction in information flow, poor connections among staff, and lack of interaction among people with cognitive diversity. Thus, the system parameters described above were restricted rather than enhanced. In these nursing homes, RNs were in supervisory or administrative roles and interacted with other nursing staff mainly over staffing problems and staff conflict issues. RNs engaged in interdisciplinary care planning but had minimal interaction with front line, LPN and CNA, staff. Sometimes RNs asked LPNs and CNAs for information, but little information was returned to them. LPNs were tied to medication and treatment carts, covering up to 30 or more residents. Thus, they interacted little with anyone else in their rush to medicate and treat residents on time. CNAs mainly interacted with other CNAs. If teamwork existed, it was in small cliques with conflict and lack of cooperation between cliques. CNAs were rewarded for completing individual assignments not for teamwork. There was heavy reliance on rules and rule enforcement. This meant that managers frequently interacted with staff to correct them on what they were doing wrong. In one example, a manager was observed correcting a CNA for placing a shampoo bottle in a laundry basket but the manager never knew, and thus did not acknowledge, that the CNA used her own money to buy the shampoo for a resident who had none. Not surprisingly, staff members in these nursing homes felt unappreciated. In sum, little attention was paid to the nature and quality of staff relationships. Something better is possible however! By recognizing that self-organization is a naturally occurring characteristic of all work units, managers have some new tools for facilitating a higher quality of care. Key to this capacity is fostering relationship patterns that appropriately alter the system parameters of information flow, connection, and cognitive diversity. Prior research studies have demonstrated a link between better resident outcomes, lower staff turnover and specific management practices that facilitate the system parameters. Some evidence-based management practices are: Reduce reliance on rules and on rule enforcement.4 Facilitate open communication where staff say what they believe without fear.4 In combination with communication openness, create a climate of clear expectations, appropriate rewards and attention to staff concerns.7 Facilitate participation in decision making (PDM) by nurses.4, 8 Facilitate CNA PDM along with high interaction between RNs and CNAs.9 Facilitate leadership behaviors that are relationship-oriented.4 Encourage staff not to wait for managers but to take initiative to raise issues and take advantage of chance encounters with managers to problem solve.10 Use every means for connecting staff, including formal and informal meetings, planned and unplanned encounters in the hallways.10 Foster frequent conversations among RNs, LPNs, and CNAs.11 Understanding that relationships are truly the basis for high quality care, we need to quickly learn to do things differently in long-term care. Over-reliance on rules is not working. This article suggests some effective management practices that bring people together, improve information flow, and increase cognitive diversity. Importantly good teamwork must be accompanied by good information flow between teams and levels in the organization. Let’s talk more not less.

Connection, Regulation, and Care Plan Innovation: A Case Study of Four Nursing Homes

We describe how connections among nursing home staff impact the care planning process using a complexity science framework. We completed six-month case studies of four nursing homes. Field observations (n = 274), shadowing encounters (n = 69), and in-depth interviews (n = 122) of 390 staff at all levels were conducted. Qualitative analysis produced a conceptual/thematic description and complexity science concepts were used to produce conceptual insights. We observed that greater levels of staff connection were associated with higher care plan specificity and innovation. Connection of the frontline nursing staff was crucial for (1) implementation of the formal care plan and (2) spontaneous informal care planning responsive to changing resident needs. Although regulations could theoretically improve cognitive diversity and information flow in care planning, we observed instances of regulatory oversight resulting in less specific care plans and abandonment of an effective care planning process. Interventions which improve staff connectedness may improve resident outcomes.

Complexity Theory: A Long-Term Care Specialty Practice Exemplar for the Education of Advanced Practice Nurses

This clinical exemplar highlights how an academic clinical practice supported gerontological nursing students as they learned evidence-based approaches to managing complex geriatric syndromes in long-term care. Urinary incontinence (UI), which occurs in more than two thirds of nursing home residents, was the focus of the faculty practice. Advanced practice nursing skills developed by students included advanced physical assessment and diagnostic reasoning techniques, critical appraisal of the scientific evidence for UI management, and the ability to teach evidence-based approaches to UI care to bedside nursing staff. Outcomes of the practice for the facilities included improved detection of urinary retention, reduced wetness rates, and strengthened systems of care for UI. Student outcomes included an increased sense of self-efficacy in management of UI and other complex geriatric problems. Complexity theory guides a discussion of how curriculum design and research-based practices can be implemented to enhance both student and facility outcomes.

Assessment of urinary incontinence.

1. In the past, nursing practice toward incontinence has focused on urine containment and skin protection rather than on proactive treatment-oriented therapeutic care. 2. Accurate assessment and diagnosis of urinary incontinence determine the success of treatment. 3. Efforts directed at early identification, appropriate assessment and treatment, and linkage to community agencies should be initiated by the nurse.

Exit interview-consultation for research validation and dissemination

Dissemination of research findings to practice and maintenance of rigor and validity in qualitative research are continuing challenges for nurse researchers. Using three nursing home case studies as examples, this article describes how exit interview-consultation was used as (a) a validation strategy and (b) a rapid research dissemination tool that is particularly useful for nursing systems research. Through an exit interview-consultation method, researchers validated inferences made from qualitative and quantitative data collected in three comprehensive nursing home case studies that examined nursing management practices. This exit interview-consultation strategy extends the traditional member-check approach by providing confirmation at the individual and organizational level. The study examined how using the exit interview-consultation strategy can potentially assist nursing home organizations to increase their capacity for improving operations. Benefits from research participation are often indirect; this studys results suggest that exit interview-consultation can provide direct and immediate benefits to organizations and individuals.

Bladder management in adult care homes. Review of a program in North Carolina.

In North Carolina there are approximately 34,000 residents in adult care homes (ACHs). Approximately 40% of these residents have urinary incontinence, and others require assistance with toileting. High prevalence of cognitive impairment, few licensed staff, and low staff-to-resident ratios in ACHs make behavioral techniques used in community-dwelling populations and toileting programs used in nursing homes inappropriate for these residents. This program was implemented using a two-level approach (facility and individual resident) and uses an education consultation approach for implementation.

Drug Prescribing by Telephone: A Potential Cause of Polypharmacy in Nursing Homes

Prior experience with Centers of Excellence such as cancer centers and diabetes centers, has been excellent, and establishment of these programs did not demoralize those growing fields; rather, it had longterm beneficial effects on manpower development. Augmented financial resources in public/private sector collaboration are critical ingredients for the development of geriatric medicine, as identified in the 1977 and 1987 IOM reports and by Drs Bloom and Hamerman. The field is developing at a time when possible funding is limited. How different it was in the mid 1960s, when there was a war on heart disease, stroke and cancer with billions of dollars eventually channeled in those areas. A subspecialty developing in that era could use many more paths for developing its academic leaders; good examples are medical cardiology and medical oncology. We thank Dr Bloom and Dr Hamerman for their excellent ideas and their assistance in bringing the need for resources to an audience of policy makers.