title: 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.
authors.affiliation: Department of Medicine, Division of Geriatrics, and The Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA. colon001@mc.duke.edu
authors.forename: Cathleen S
authors.initials: CS
authors.lastname: Colón-Emeric
authors.forename: Deborah
authors.initials: D
authors.lastname: Lekan-Rutledge
authors.forename: Queen
authors.initials: Q
authors.lastname: Utley-Smith
authors.forename: Natalie
authors.initials: N
authors.lastname: Ammarell
authors.forename: Donald
authors.initials: D
authors.lastname: Bailey
authors.forename: Mary L
authors.initials: ML
authors.lastname: Piven
authors.forename: Kirsten
authors.initials: K
authors.lastname: Corazzini
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Anderson
mesh_terms: D004059:Diffusion of Innovation; D005260:Female; D033161:Government Regulation; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D009657:North Carolina; D009735:Nursing Homes / Q000458:organization & administration*; D019982:Organizational Case Studies; D010346:Patient Care Management / Q000458:organization & administration*