title: Top nurse-management staffing collapse and care quality in nursing homes.
abstract: Director of nursing turnover is linked to staff turnover and poor quality of care in nursing homes; however the mechanisms of these relationships are unknown. Using a complexity science framework, we examined how nurse management turnover impacts system capacity to produce high quality care. This study is a longitudinal case analysis of a nursing home (n = 97 staff) with 400% director of nursing turnover during the study time period. Data included 100 interviews, observations and documents collected over 9 months and were analyzed using immersion and content analysis. Turnover events at all staff levels were nonlinear, socially mediated and contributed to dramatic care deficits. Federal mandated, quality assurance mechanisms failed to ensure resident safety. High multilevel turnover should be elevated to a sentinel event for regulators. Suggestions to magnify positive emergence in extreme conditions and to improve quality are provided.
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: Selina R
authors.initials: SR
authors.lastname: Hunt
authors.forename: Kirsten
authors.initials: K
authors.lastname: Corazzini
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Anderson
mesh_terms: D006801:Humans; D008137:Longitudinal Studies; D009718:Nurse Administrators / Q000706:statistics & numerical data; D009735:Nursing Homes / Q000458:organization & administration* / Q000592:standards*; D009740:Nursing Staff; D010563:Personnel Turnover / Q000706:statistics & numerical data; D011787:Quality of Health Care; D000078329:Workforce
keywords: director of nursing; nursing home; outcomes; quality; top management; turnover