Elsevier

Geriatric Nursing

Volume 38, Issue 5, September–October 2017, Pages 378-384
Geriatric Nursing

Feature Article
Rules of performance in the nursing home: A grounded theory of nurse–CNA communication

https://doi.org/10.1016/j.gerinurse.2016.12.013Get rights and content

Abstract

This study offers an initial theoretical understanding of nurse–CNA communication processes from the perspectives of nurses and CNAs who are providing direct care to residents in nursing homes. A grounded theory approach provided an understanding of nurse–CNA communication process within the complexities of the nursing home setting. Four themes (maintaining information flow, following procedure, fostering collegiality, and showing respect) describe the “rules of performance” that intertwine in nuanced relationships to guide nurse–CNA communication processes. Understanding how these rules of performance guide nurse–CNA communication processes, and how they are positively and negatively influenced, suggests that nurse–CNA communication during direct care of nursing home residents could be improved through policy and education that is specifically designed to be relevant and applicable to direct care providers in the nursing home environment.

Section snippets

Background

People 85 years of age and older are the second fastest growing age group in the US, and account for over half of the nursing home population.1 Residency rates are projected to increase 57% by 2030, as 8000 baby boomers turn age 70 every day.2, 3 Concern about adequacy of the nursing home workforce has heightened concern regarding nursing home staff capacity to provide quality of care.4, 5

Nurses (registered nurses, licensed practical nurses, licensed vocational nurses) and Certified Nursing

Theoretical framework

Concepts of symbolic interactionism provide the framework for understanding communication processes from the perspectives of nurses and CNAs in the context of the nursing home. Symbolic interactionism suggests that individuals act toward things based on meaning constructed through interaction and modified through an interpretative process.15 The use of a grounded theory approach is supported by the symbolic interactionist paradigm that nurse–CNA communication consists of socially constructed

Study design and participants

This grounded theory study used observation, shadowing, and semi-structured interviews for data collection. Approval to conduct the study in a 120+ bed for-profit nursing home in the Mountain West was granted by the nursing home administrator. Ethics approval was received from the Institutional Review Board.

Nurses and CNAs were recruited who were employed full or part time as direct care staff on either of two long-term care units in the nursing home, and employed long enough to be through new

Results

Nurses on average were older than CNAs, had been in their current positions longer, and had more years of healthcare experience. Most nurses had an associate degree and were registered nurses; one nurse had vocational training and was a practical nurse. Three CNAs had some college credit; two were currently enrolled in college. For one nurse and two CNAs, this was their first healthcare position. Most participants had previous nursing home experience except for one CNA who was previously a home

Discussion

A study aimed at improving coordination of the 24-h care of residents identified that very little is known about communication processes in the nursing home.22 However, ineffective communication is frequently associated with high rates of direct care staff turnover, increased error risk, and a subsequent negative impact on quality of resident care.8, 11 Most studies of communication processes in the nursing home focus on interactions between nurses, physicians, residents, and families.23 Few

Limitations and recommendations for future research

Results from a small sample of nurses and CNAs from one nursing home in the Mountain West may not be generalizable to other areas. Further, nurses and CNAs also engaged in communication about residents with staff members in other disciplines. Important perspectives about nursing home culture may be gained by further study determining if the rules of performance hold true for interactions with other nursing home staff in other job functions.

Future exploration of the rules of performance in

Acknowledgements

The author wishes to thank the University Of Utah College Of Nursing and the University of Utah College of Nursing Hartford Center for Geriatric Nursing excellence for supporting this research. A special acknowledgement is given to Dr. Margaret Clayton for her encouraging support and wisdom.

References (34)

  • L.M. Wagner et al.

    Barriers and facilitators to communicating nursing errors in long-term care settings

    J Patient Saf

    (2013)
  • N.G. Castle et al.

    Measuring administrators' and direct care workers' perceptions of the safety culture in assisted living facilities

    Jt Comm J Qual Patient Saf

    (2012)
  • C.S. Colón-Emeric et al.

    Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science

    Qual Health Res

    (2006)
  • K.G. Scandrett et al.

    Patient safety in the nursing home: how nursing staff assess and communicate about change in condition

    J Gerontol Nurs

    (2012)
  • E.A. Miller

    The affordable care act and long-term care: comprehensive reform or just tinkering around the edges?

    J Aging Soc Policy

    (2012)
  • A. Vogelsmeier et al.

    Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork

    J Nurs Care Qual

    (2011)
  • R.M. Werner et al.

    Quality improvement under nursing home compare: the association between changes in process and outcome measures

    Med Care

    (2013)
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