Feature ArticleRules of performance in the nursing home: A grounded theory of nurse–CNA communication
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.
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