Connection, regulation, and care plan innovation: a case study of four nursing homes

Abstract

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.

FIGURE 1

Conceptual Model of how System Parameters Impact Care planning Process

FIGURE 2

Connection Maps for the four Study Facilities. “Other Disciplines” Includes Rehabilitation, Dietary, Social Work, and Activities Staff. “Medical Team” Includes Attending Physicians, Psychiatrists, and Nurse Practitioners. “Care Plan Team” Includes MDS Nurses and any Other Team Members Assigned in That Facility, Often Social Work and Activities. “Frontline Nursing Staff” Includes floor Nurses (Generally LPNs) And CNAs. Arrows Between Boxes Indicate Connection, Information Flow, and Cognitive Diversity Between Group Members