Communication in the nursing home: a grounded theory of nurse-CNA communication

Quality nursing home care is a national health concern. Projections of increasing residency rates are coupled with growing concern about nursing home staff capacity and ability to provide quality care. The Institute of Medicine Committee of the Future Health Care Workforce for Older Americans suggests that efforts are needed toward improving nursing home workforce skill. Nurses and certified nursing assistants (CNAs) comprise the majority of the nursing home workforce; CNAs provide 80% of resident care. Despite their significant role as direct caregivers, little is known about nurse-CNA interactional processes, including how they communicate. This relative lack of existing information suggested a need for better understanding of even fundamental communication processes from nurse and CNA perspectives. A grounded theory approach guided this study to gain understanding of nurse-CNA communication processes and factors that influence the processes from the perspective of nurses and CNAs when providing direct care to nursing home residents. Goffman's dramaturgical concept of front- and back-stages, supported by the premises of symbolic interactionism, provided an analytical framework for exploring nurse-CNA communication processes in the complex context of the nursing home setting. Data were obtained from observation, shadowing, and interviews of nurses and CNAs on two ~ 40-bed long-term care units in a nursing home. Systematic procedures 13 for inductive data analysis suggested that nurse-CNA communication processes were guided by four "rules of performance": (1) maintaining information flow, (2) following procedure, (3) fostering collegiality, and (4) showing respect. Nurses and CNAs communicated as opportunity arose in the midst of resident care and described their communication processes in relation to efficiency of care that was affected by the presence or absence of cooperation, initiative, and reciprocity. Role ambiguity stemmed from nurse-CNA hierarchical position associated with delegation and supervision; contextual ambiguity resulted from the dual purpose of the nursing home as a health care institution and the resident's "home." The interplay of "rules of performance" on the front- and back-stages of direct care should be considered in the development of contextually applicable policy and practice strategies that are relevant to nurses and CNAs providing care to nursing home residents.