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a School of Rural Public Health, Texas A&M University System Health Science Center, College Station, TX
Correspondence: Charles D. Phillips, PhD, MPH, Public Health Policy and Management, School of Rural Public Health, 1266 TAMU, College Station, TX 77843-1266. E-mail: phillipscd{at}srph.tamu.edu.
Jared Diamond begins Guns, Germs, and Steel, his popular work on the effects of environmental features on the history of different cultures' material success, by recounting a conversation with Yali, a young New Guinean. Aware of the material wealth of Diamond's society and the comparative material scarcity surrounding him in his own, Yali asked Diamond the singularly obvious and important question (which I paraphrase here) "Why is it that you have so much cargo, while we have so little cargo?" (Diamond 1999
, p. 14; see A, Note 1).
Some gerontologists have stepped through the doors of nursing homes to be greeted by the odors of urine and feces and the sight of cognitively impaired residents in bedclothes arrayed in gerichairs in front of a television with no functioning vertical hold. These same individuals have also crossed the thresholds of nursing homes that embody all the environmental, interpersonal, and professional qualities considered most admirable in long-term care institutions. These latter institutions exhibit a plentitude of the treatment and caring so lacking in those other facilities. In such facilities, residents are members of a community and agents of action, not simply objects to be acted upon by staff. The care interactions in such settings are often filled with such affection and generosity of spirit that I, for one, am somewhat troubled that my own work seems too frequently to reduce these rich exchanges to a cold string of binary code incapable of capturing the fullness of these events. Such divergent experiences within different nursing homes leave us with a gerontologist's version of Yali's singularly obvious and important question, "Why are some nursing homes better than others?" (see A, Note 2).
This question immediately calls for an approach to studying nursing homes with the same genesis as the approach taken by Brannon and her colleagues in their contribution to this issue (Brannon, Zinn, Mor, and Davis 2002). She and her colleagues analyze nurse aide turnover as an organizational issue. Such an approach initially answers the more general question concerning nursing home quality with the statement: "Some nursing homes are better than others, because some nursing homes are more effective organizations than other nursing homes." In essence, some homes manufacture a better product than do others. However, when one asks the further question of why, or how, some homes produce a better product, the answers are somewhat less enlightening than one would hope.
Brannon and her colleagues attempt to clarify the nature of the potential relationship between nurse aide turnover and the organization's product (quality of life) by asking whether too little turnover may be as potentially troublesome as too much turnover (see A, Note 3). The authors then investigate what differentiates facilities with higher or lower turnover by developing a multivariate model that includes a variety of independent variables capturing environmental, organizational, and job characteristics in their sample of nursing homes (Brannon et al. 2002).
One of the impressive aspects of Brannon and colleagues 2002 work is the use of primary data in their analyses. In this research, the dependent variable and an array of independent variables derive from a primary data collection from directors of nursing. Historically, much of the work using an organizational approach has been restricted to the limited range of information available in administrative databases such as OSCAR, ARF, and statewide facility-level databases with a similar administrative focus (Banaszak-Holl, Zinn, and Mor 1996; Castle, Mor, and Banaszak-Holl 1997; Hughes, Lapane, and Mor 2000; Rosko, Chilingerian, Zinn, and Aronson 1995). These administrative data constituted a reasonable starting point for quantitative organizational studies of nursing homes. However, it is now clear that they offer a very limited set of options for evaluating quality of life, for improving thinking about nursing homes as organizations, and for understanding the dynamics of organizational behavior underlying the provision of care. In essence, they are of limited utility in developing a coherent answer to the gerontologist's version of Yali's question.
Brannon and colleagues' work (2002) focuses on nurse aide turnover, an important organizational characteristic. This measure is a step removed from the resident status and process quality measures usually considered an important part of our discussion of which facilities are better. However, the specific dimensions that these authors use in their model, although not necessarily the specific indicators, obviously rank high among the list of those factors that must be included in the development of models that more directly address the differences in quality of life across nursing homes.
One of the most difficult challenges to further progress in our efforts to answer this question seems to lay in the need to develop meaningful indicators that adequately represent the general dimensions of organizational performance and capability. Leadership, for example, is a crucial factor in quality management and improvement. But, how does one reliably and validly measure a facility leadership's commitment to quality and its openness to quality-related innovation? That is a more difficult characteristic to measure than span of control, but it is potentially more meaningful in determining the quality life in a facility (see A, Note 4).
In research efforts that involved site visits to higher quality nursing homes that operated at lower than average costs, one of the most interesting findings was that these facilities often used very different strategies to control their costs and maintain quality. But, they all shared a common commitment to quality and cost control. It was this commitment, not the specific strategy chosen to implement the commitment, that was considered crucial to these facilities' successful operations. In essence, the finding was that the "organizational culture or commitment," which could be implemented through a variety of organizational processes or structures, was a necessary condition for maintaining quality while controlling expenses (Phillips and Rose 2000; Rudder and Phillips 1998).
Such findings are somewhat troublesome to those gerontologists interested in pursuing an organizational approach to understanding nursing home quality. They are troublesome because they imply that what may be quite important in understanding why some facilities are better than others may be less determined by organizational structures or processes than one would hope. Different processes and structures may generate the same basic result, when a common commitment underlies these processes and structures. The same processes and structures may then generate different results when supported by different leadership commitments or organizational cultures.
This commentary is not in any way an attempt to discount the importance of such issues as workload, clinical resources, ownership, and market factors (Brannon et al. 2002) or the contribution of those researchers investigating these factors. However, it is a reminder that researchers' efforts to make the most of organizational analyses of nursing homes may require steps beyond the current measurement strategies, indicator development activities, and the current ways of thinking about nursing homes as organizations. Recent qualitative research provides indications that different types of nursing home residents interpret the same events differently because they define quality differently. At the resident-level, perceptions of quality seem to be an interaction between facility action and residents' expectations (Bowers, Fibich, and Jacobson 2001).
It seems unlikely that good models of organizational performance for nursing homes will be any less complex. Dr. Brannon (in this journal a decade ago, in an editorial on second-generation studies of nursing homes) indicated that progress in understanding nursing homes would "... require cross-disciplinary thinking, which results in studies of individual behavior framed in organizational context ... and studies of institutions attending to individual differences" (Brannon 1992, p. 293). That statement, which acknowledges the complexity inherent in building useful organizational models of nursing home performance, remains true today.
It is only appropriate then that gerontologists supplement their continuing quantitative work using organizational models and variables with complementary qualitative investigations. These qualitative studies should focus on developing a more finely grained picture of the interaction between organizational cultures, structures, and processes and the "products" produced by nursing homes. By investigating and understanding these interactions, then blending these qualitative findings with our quantitative models, gerontologists may, at some point, accumulate the knowledge necessary to provide a satisfying response to the question, "Why are some nursing homes better than others?"
The Forum
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). represents an interesting, but limited, variant on this theme in its look at workers' attitudes in facilities defined as poor or adequate, based on state survey results. |
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