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.