Staff-resident interaction in the nursing home: An ethnographic study of socio-economic disparities and community contexts

In recent years, nursing home (NH) researchers have paid increasing attention to socio-economic and racial/ethnic disparities in quality of care. Although there is growing evidence of disparities in resident health outcomes, less is known about the ways in which these differences manifest in care processes from a qualitative perspective. This paper addresses this gap by comparing staff-resident interactions in two urban, non-profit NHs, including roughly 50 staff participants in each facility. The researcher conducted ethnographic observation in one facility serving a white, middle class community and another serving low-income Black and Hispanic clients from an underserved neighborhood. Grounded theory methods generated three categories of interaction—activating, relating, and attending—which were performed differently in the two NHs. In the more affluent facility, staff interacted with residents in a dynamic fashion, adapting to residents’ responses, and they were relatively well equipped with resident-specific information when responding to individual concerns. In the safety-net facility, staff interacted with residents in a one-directional, “didactic” fashion, providing instruction without a mechanism for adapting to residents’ responses, and they were not as well equipped with resident-specific information. These differences reflected disparities between the two facilities in staff communication skills, underscoring the importance of workforce development to enhance the quality of staff-resident interaction and promote resident-centered care. This study raises further questions about the role of neighborhood contexts in shaping organizational processes that influence quality of life for NH residents. Moreover, the study offers a unique contribution to the NH literature by generating a typology of styles of interaction that can be used to develop a conceptual framework for understanding staff-resident interaction in the nursing home. Such a framework can inform efforts to improve residents’ quality of life.     

The missing family: Staff perspectives on and responses to familial noninvolvement in two diverse nursing homes

Although the continuum of familial involvement with nursing home residents includes those who are deeply engaged and those who are totally absent, little is known about how staff perceive and react to family noninvolvement. This article explores staff perspectives on and responses to family absence. Semistructured interviews were conducted with 52 employees and 18 residents from two NHs, one an urban facility with a largely chronic mentally ill population and the other a rural, tribally owned facility with a predominately cognitively impaired American Indian clientele. Medical record reviews were also conducted. Staff theories of family absence were informed primarily by dominant American and American Indian cultural values regarding kinship, psychiatric disorders, and institutionalization. In each facility, metaphoric kinship relationships between staff and residents compensated somewhat, but not entirely, for perceived family noninvolvement. This research highlights the cultural variability of staff perspectives on family absence but also points to similar strategies for coping with it.     

Personal Trauma and Risk Behaviors Among Youth Entering Residential Treatment

The focus of this study was to determine the prevalence and types of traumas experienced by adolescents prior to admission to long term mental health residential care and the impact of these traumas on their risk behaviors. The research was conducted at a state-supported residential mental health treatment facility functioning under the authority of the Department of State Health Services. Client level data was extracted from social assessment forms (N = 457) in case records of clients. Results confirmed that exposure to trauma was pervasive among adolescents admitted to the facility. Findings also revealed a link between trauma and risk behaviors among youth entering residential treatment facilities. Increased trauma exposure significantly impacted the risk behaviors of youths entering the residential treatment facility. The results indicate that the total number of traumas experienced was a greater predictor of risk behaviors among these youth than the specific traumas experienced. Internalizing behaviors such as self-harm and suicide attempts also increased with the number of traumas experienced by the adolescent. The study demonstrates the need for further exploration of the complex relationship between personal trauma, mental health, and social development in adolescents.     

Medicare and Medicaid Reimbursement Rates for Nursing Homes Motivate Select Culture Change Practices But Not Comprehensive Culture Change

Components of nursing home (NH) culture change include resident-centeredness, empowerment, and home likeness, but practices reflective of these components may be found in both traditional and “culture change” NHs. We use mixed methods to examine the presence of culture change practices in the context of an NH’s payer sources. Qualitative data show how higher pay from Medicare versus Medicaid influences implementation of select culture change practices, and quantitative data show NHs with higher proportions of Medicare residents have significantly higher (measured) environmental culture change implementation. Findings indicate that heightened coordination of Medicare and Medicaid could influence NH implementation of reform practices.     

Support for Waste Facility Siting: Differences between Community Leaders and Residents

Abstract Decisions regarding hazardous waste facility siting are now open to extensive public debate. Efforts on the part of public officials and private companies to site waste management facilities have been thwarted by public opposition. Using survey data from leaders and residents in communities which are hosting or siting facilities, this study examines their sociodemographic characteristics, knowledge, levels of trust, perceptions of risk, perceptions of economic impacts, perceptions of equity issues and the differential effects of these factors on acceptance of local waste facility siting. Leaders in these communities were more supportive of local waste facility siting than were other community residents. The major determinant of leaders' acceptance of waste siting was their perceptions of the economic benefits of a facility to the community. Although this was also important to residents, perceptions of health, safety, and environmental contamination risks had larger effects on their acceptance of such facilities.     

Does Nursing Home Ownership Change Affect Family Ratings on Experience with Care?

Person-centeredness may suffer in nursing homes (NHs) with recent ownership changes. This study identifies associations between ownership change and reported care experiences, important measures of person-centered care for long-term residents in Maryland NHs. Care experience measures and ownership change data were collected from Maryland Health Care Commission reports, which reported data on 220 Maryland NHs from 2011 and 2012. Facility and market covariates were obtained from 2011 NH Compare and Area Health Resource Files. Linear regression was used to examine whether ownership change in 2011 was associated with lower care experience ratings reported during April to June 2012. Dependent variables were overall care rating (scale 1–10), percentage of respondents answering that they would recommend the NH, and assessments of five care and resident life domains (scale 1–4). Care experiences reported in 2012 were high; however, after controlling for covariates, ownership change was associated with significant decreases in 6 out of 7 measures, including a 0.39-point decrease in overall care rating (p = .001). NH managers and policy makers should consider strategies to improve patient-centeredness after ownership change.     

Architectural Space in Respite and Intermediate Care: An Actor-Network Theory Analysis

This article presents an analysis of 2 short-term care facilities using actor-network theory with the aim of revealing performative processes in different networks in the buildings in use. The 2 facilities differed in architectural design, which was expected to influence their care model and organization. One facility was larger and accommodated 4 patients/residents in double rooms as well as permanent residents who stayed in single rooms. The other facility was smaller and accommodated only short-term care patients in single rooms. The study revealed that the latter facility received more care-demanding people than the other. The size and the type of patients/residents influenced the social environment. The larger facility was more busy and lively than the smaller one. However, the analysis did not show any difference in quality of care or ambiance. Both facilities were valued as either good or bad by different residents or staff members. The study concludes that therapeutic values and outcomes are defined and redefined in the ongoing performances of everyday interactions.     

Chapter 3 Residential Care Facilities for the Elderly

Abstract

Residential Care Facilities for the Elderly (RCFEs), known as board and care homes, are licensed in California and many other states for non-medical care in the community. RCFEs are examined here to provide illustrative issues in the definition of types of long-term residential care. The research examines physical functioning, social supports, and course of residential placement for 109 RCFE residents (mean age 84 years). A significant portion of the residents had personal assistance needs not usually provided at the RCFE level (75% assistance with medication, 52% used walking aids, 29% assistance in bathing). Additionally, a third of the residents had restricted social supports and social activity. Residents report declines in functioning and support as reasons for moving to residential care. Length of residence in the facility (range less than a year to 15 years) was not related to physical functioning or social activity. These findings do not support “aging in place,” within the facility, as the rationale for increased need for assistance in residential care. Implications include the need to maintain the social model of residential care ample for the majority of residents while assuring the availability of a higher need for assistance of a significant portion of the residential care population.     

Becoming institutional bodies: Socialization into a long-term care home

This paper reports the findings from a phenomenological study examining the lived experience of moving to a long-term care facility and the process of socialization for new residents into the nursing home culture and environment. Three residents were followed over the first six months after moving to a long-term care facility using a series of in depth interviews and participant observation with residents themselves, staff members and family members. This paper focuses on the five institutional level processes related to socialization into the long-term care environment as they were experienced by the new residents. These included: placing the body, defining the body, focusing on the body, managing the body, and relating to the body. The findings point to the importance of place in the construction of institutional bodies in the long-term care context.     

The influence of financial incentives and racial status on the use of post-hospital care

This study examines the influence of financial incentives and the racial status of the patient on the use of extended care following an episode of hospitalization. Post-hospital care (PHC) is defined as the services provided by a skilled nursing facility (SNF) or intermediate care facility (ICF) following discharge. The focus of the analysis is on the use or nonuse of PHC, the presence or absence of a delay in transfer to an ICF or SNF and, limited to those who experienced a postponement, the length of the delayed discharge. After controlling for multiple factors, the results indicate that Medicare beneficiaries were more likely to use PHC, less likely to experience a delay in discharge, and used fewer days of prolonged care. Medicaid recipients and uninsured patients experienced reduced access to PHC. The results also indicated that the access of Native Americans and Americans to PHC was impeded.     

Communicating risk to parents and those living in areas with a disaster history

This study explored how publics respond to risk communication in high probability but time-indeterminate natural disaster situations when parts of the area have been involved in a similar disaster before. An impending rockslide is expected to produce a tsunami in the fjord around Åknes in Norway. Waves may run up above sea level as high as 82 m or 269 ft. All residents (18 and older) of the four most threatened communities received a questionnaire to determine what they perceived to be useful risk information. Three hundred and eighty-two (43.6% of 875) responded. Results indicated that parents of children living within the tsunami risk zones perceived the risk information to be the most useful. Those who lived in communities that experienced a similar disaster in 1934 reported public meetings less useful than written or mediated information. Publics who lived in communities with such disaster history and those who were not parents posed special challenges in risk communication because they perceived information from the government agencies as lacking in usefulness. Therefore, committing the resources necessary to foster dialogues with a diversity of publics exposed to risk would be well served to fully understand the nature of risk communication responses, and to be able to save human lives.     

Constructing Deservingness

Abstract

This study examines the influence of financial incentives and the racial status of the patient on the use of extended care following an episode of hospitalization. Post-hospital care (PHC) is defined as the services provided by a skilled nursing facility (SNF) or intermediate care facility (ICF) following discharge. The focus of the analysis is on the use or nonuse of PHC, the presence or absence of a delay in transfer to an ICF or SNF and, limited to those who experienced a postponement, the length of the delayed discharge. After controlling for multiple factors, the results indicate that Medicare beneficiaries were more likely to use PHC, less likely to experience a delay in discharge, and used fewer days of prolonged care. Medicaid recipients and uninsured patients experienced reduced access to PHC. The results also indicated that the access of Native Americans and Americans to PHC was impeded.     

Risk and Recovery: Understanding Flood Risk Perceptions in a Postdisaster City—The Case of New Orleans

Flood hazards are a serious and growing threat to the health and welfare of residents in cities and rural areas around the world. This cross-sectional study uses a sample of 383 residents living in seven New Orleans, Louisiana, neighborhoods to examine the effect of experiential, sociodemographic, and socioeconomic factors on flood risk perceptions. Findings suggest that respondents judge the level of flood risk to be lower than other types of risk. Results from ordinal logistic regression analyses show that flood risk perception is influenced by flood experience, income, race, gender, homeownership status, and years residing in New Orleans. Our findings support extant scholarship showing that African Americans tend to have higher perceptions of risk than whites and that low-income people and women have higher risk perceptions than higher income residents and men. Finally, we discuss the implications of our findings for risk management planning in coastal cities like New Orleans that face omnipresent flood threats associated with climate-change-driven sea level rise and increased frequency and destructiveness of storms.     

Community Support for a Gold Cyanide Process Mine: Resident and Leader Differences in Rural Montana*

Abstract Previous studies have established that community residents and leaders differ in their support for hazardous waste facility siting in rural areas (Spies et al. 1998). We examine whether these same differences exist in rural communities that face other high‐risk development decisions by analyzing resident and leader support for a proposed gold cyanide process (GCP) mine in Montana. Compared to proposed hazardous waste facilities, a much stronger predictor of both resident and leader support in the GCP mine context is recreancy, or distrust in institutions and outside interveners. However, perceived economic benefits remain key differences between residents and leaders in both the GCP mine and hazardous waste facility cases.     

On the edge: Balancing health, participation, and autonomy to maintain active independent living in two retirement facilities

This study examines how independent living residents in Continuing Care Retirement Communities (CCRCs) work to maintain a healthy, active community. Specifically, this paper elucidates how independent living residents, who have high status in CCRCs but also face transitions to more advanced care, manage their daily lives to build a positive sense of community against the backdrop of potential health and social declines. The researcher supplemented four years of observation in one CCRC and two years of observation in another with qualitative interviews with thirty residents from both facilities. Results indicated that shared sentiments contrasting the active social world in independent living with other living units, norms of mutual support balanced with autonomy, social participation as a source of belonging (or isolation), and definitions of deviance surrounding functional health and manners framed residents' understandings of daily life by reaffirming independent living residents' privileged status in each facility.     

Moving teenagers out of high-risk neighborhoods: how girls fare better than boys

Moving to Opportunity (MTO) offered public housing residents the opportunity to move to low-poverty neighborhoods. Several years later, boys in the experimental group fared no better on measures of risk behavior than their control group counterparts, whereas girls in the experimental group engaged in lower-risk behavior than control group girls. The authors explore these differences by analyzing data from in-depth interviews conducted with 86 teens in Baltimore and Chicago. They find that daily routines, fitting in with neighborhood norms, neighborhood navigation strategies, interactions with peers, friendship making, and distance from father figures may contribute to how girls who moved via MTO benefited more than boys.     

Facility Ownership and Resident Satisfaction with Assisted Living

Abstract

Although the majority of assisted living facilities operate as for-profit organizations and serve increasingly frail elderly populations, little is known about the impact of ownership on the quality of care in assisted living. This study examines the relationship between facility ownership and the quality of care in assisted living, using resident satisfaction as a quality indicator. The assessed aspects of satisfaction include health care, housekeeping, physical environment, relationships with staff, and social life/activities. The relationship of facility ownership to resident satisfaction is examined controlling for resident psychological well-being, functional ability, facility size, and staff resources. Data were collected in personal interviews with 156 residents, including 96 residents in eight for-profit facilities and 60 residents in five nonprofit facilities in Maryland. Residents in the sampled nonprofit facilities were more satisfied with assisted living than were residents in the for-profit facilities. In particular, residents in nonprofit facilities were more satisfied with health care, physical environment, and social life/activities in the facility. Better understanding of the relationship between facility ownership and resident satisfaction can help administrators create environments that maximize resident satisfaction in both nonprofit and for-profit facilities.     

The relationship between organizational factors and resident satisfaction with nursing home care and life

We examined the relationships between nursing home (NH) resident satisfaction and NH organizational characteristics, while controlling for the effect of resident characteristics within facilities. We used a stratified, random sample of NHs (N = 72) from two states and a prescreened and randomized sample of 1496 residents. Data sources included resident interviews, an administrator survey, the Minimum Data Set (MDS), and the Online Survey, Certification and Reporting System (OSCAR). Using Hierarchical Linear Modeling (HLM) techniques, we found that non-chain affiliation, certified nursing assistant staffing, and provision of a family council had significant positive effects on total resident satisfaction. The presence of a special care unit was associated with lower levels of satisfaction.     

Childless Elders in Assisted Living: Findings from the Maryland Assisted Living Study

We compared data drawn from a random sample of 399 current assisted living residents and a subsample of 222 newly admitted residents for two groups: childless residents and residents with children. The percentage of childless residents (26%) in our study was slightly higher than U.S. population estimates of childless individuals aged 65 years and older (20%). In the overall sample, the two groups differed significantly by age, race, and women's years of education. The childless group was slightly younger, had a higher percentage of African American residents, and had more years of education than the group with children. In the subsample, we looked at demographic, functional, financial, and social characteristics and found that childless residents reported fewer diagnoses of dementia and fewer visits from a relative but more reported paying less money per month for assisted living and having private insurance than residents with children. As childlessness among older adults continues to increase, it will become increasingly important to understand how child status affects the need for and experience of long-term care.