Dr. Siegel is Assistant Professor, Betty Irene Moore School of Nursing at UC Davis, and Dr. Young is Associate Vice Chancellor for Nursing, UC Davis Health System, and Dean, Betty Irene Moore School of Nursing at UC Davis, Sacramento, California.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. Generous awards from the deTornyay Center for Healthy Aging at University of Washington School of Nursing and the John A. Hartford Foundation/Atlantic Philanthropies Claire M. Fagin Fellowship program provided funding to support this research, in part, and the preparation of this manuscript. Dr. Siegel is a John A. Hartford Foundation/Atlantic Philanthropies Claire M. Fagin Fellow. The authors acknowledge the guidance received from Dr. David Keepsnews and Dr. Martha Lentz during the data analysis and interpretation phases of this study. The authors also appreciate the support and participation of the nursing homes that provided data for this study.
Address correspondence to Elena O. Siegel, PhD, RN, Assistant Professor, Betty Irene Moore School of Nursing at UC Davis, UC Davis Health System, 4610 X Street, Suite 4202, Sacramento, CA 95817; e-mail: email@example.com.
Unlicensed assistive personnel (UAP) are vital members of the nursing home team, providing primary assistance with residents’ personal care, activities of daily living, and in some states, restorative care (i.e., range of motion, transfers), and/or administration of oral medications (Hansten & Jackson, 2004). UAP are authorized to perform these services under the direction and supervision of RNs. Licensed practical/vocational nurses (LPNs/LVNs) may also have responsibility for supervising UAP pursuant to each state’s nursing practice act (Hansten & Jackson, 2004). Effective and timely nurse-UAP communication is paramount to ensuring high-quality care (Scott-Cawiezell et al., 2004) and is an essential element of the nurse’s role in delegating and supervising UAP activities.
Gaps in nurse-UAP communication are reflected in reports of untimely information to UAP regarding resident care needs (Scott-Cawiezell et al., 2004), lack of routine change-of-shift reports (Anderson, Corazzini, & McDaniel, 2004; Mather & Bakas, 2002; Siegel, Young, Mitchell, & Shannon, 2008; Taunton, Swagerty, Smith, Lasseter, & Lee, 2004), limited opportunities for UAP to talk with nurses about their work demands (Castle, 2007), incomplete translation of information from care plans to UAP (Adams-Wendling, Piamjariyakul, Bott, & Taunton, 2008), and reports withheld by UAP regarding challenging workloads, unfinished tasks, or early indications of residents’ status changes (Bowers, Esmond, & Jacobson, 2000; Hartig, 1998). Communication gaps have been associated with obstacles to providing individualized care (Curry, Porter, Michalski, & Gruman, 2000; Walker, Porter, Gruman, & Michalski, 1999), appropriate nourishment (Crogan & Shultz, 2000), continence care (Resnick et al., 2006), and care associated with activities of daily living (Mather & Bakas, 2002).
While effective communication practices are inherent to the roles of both nurses and UAP, little is known about managements’ explicit expectations for nurse-UAP communication and the organizational infrastructure that promotes and reinforces these expectations. The purpose of this study was to identify and explore nursing home organizations’ written guidelines for nurse-UAP communication of residents’ health status and care needs. For this study, written guidelines included any information reflecting what, how, or when nurse-UAP communication should occur, as set forth in organizational documents. This study was guided by Donabedian’s (1980) structure-process-outcome model, suggesting that an organization’s written guidelines are a component of the organizational infrastructure that links management’s expectations for communication (structure) with actual employee communication practices (process), and ultimately, the level of quality care delivered (outcomes).
This descriptive, exploratory study involved a review of organizational documents provided by a convenience sample of nursing homes located in the Pacific Northwest. The study protocol was approved by the University’s Human Subjects Division.
Consistent with the exploratory nature of this study, 10 nursing homes were initially contacted regarding study participation, with the goal of recruiting a total of 6 sites diverse in ownership status and size. Upon obtaining signed consent, copies of specific organizational documents were requested from management at each site, including nurse and UAP job descriptions; organizational policies and procedures; employee handbooks and training manuals; blank forms, protocols, and flow sheets; blank documentation forms and instructions completed by UAP, as related to resident care needs, status, and activities; blank forms and instructions completed by nurses for purposes of informing UAP of resident care needs and health status; unit response protocols; and mission statements. In addition, an open request was made for any other documents reflecting expectations for nurse-UAP communication. Documents were self-selected by site representatives.
Organizational documents were analyzed using content analysis to identify and summarize the text reflecting expectations for nurse-UAP communication of resident health care needs, status, or changes in condition. Content analysis provided a systematic and uniform approach to identifying and coding text for themes and patterns (Burns & Grove, 2001). Decision rules for coding practices were documented, providing an audit trail of the data analysis process. Documents not containing any text associated with nurse-UAP communication, such as employee handbooks, were omitted from the analysis.
Six nursing homes participated in this study, including 2 sites owned by not-for-profit multisite nursing home chains, 3 sites owned by for-profit corporations, and 1 independently owned not-for-profit site. All facilities were Medicare/Medicaid certified. They ranged in size from 90 to more than 200 beds. A total of 81 documents were included in the study, ranging from 7 to 19 documents across sites.
Although the types of documents submitted for this study and the written guidelines for nurse-UAP communication identified in these documents varied across sites, two primary themes emerged. First, extensive and explicit communication guidelines for UAP were identified, in comparison to few corresponding guidelines for nurses. Second, written guidelines for UAP communication were identified in multiple documents, with variations across sites in the situations requiring communication, the level of detail, and the format for how UAP-to-nurse communication should occur (i.e., verbal, written).
Written Guidelines for UAP-to-Nurse Communication
Written guidelines for UAP communication were identified in the UAP job descriptions and resident-specific forms submitted by all 6 sites. Resident-specific forms included documents outlining care requirements, actual care provided, and assessment data. In addition, 3 sites submitted supplemental documents outlining UAP reporting/charting requirements. All UAP job descriptions included written guidelines for documentation of resident information/assessment data, with varying levels of specificity, ranging from explicit documentation requirements for “vital signs, I & O [intake and output], food & fluid intake” to generalized requirements for documentation of “resident response to plan of care accurately and in a timely manner.”
Written guidelines identified across all sites reflected a universal expectation for UAP to report changes in resident condition or status; these also had varying levels of specificity, including broad expectations for reporting general changes in resident condition (n = 4), a narrow expectation for reporting changes specific to eating habits (n = 1), and reference to a separate document for basic care procedures, including detailed and extensive situations requiring UAP report of changes (n = 1).
The majority of sites provided written guidelines for reporting/documenting skin assessments (n = 4), and/or intake and output, safety issues, changes in condition, and contributions to or assistance in the development of resident care plans (n = 5). Other written guidelines for UAP communication or the source documents reflecting these guidelines followed no discernable pattern across the sites. For example, written guidelines for UAP reporting of resident safety issues were identified in three different types of documents, such as UAP job descriptions (n = 3), supplemental reporting documents (n = 1), or resident-specific documents (n = 1).
Other than universal requirements for written documentation of vital signs, guidelines for how UAP should communicate information (i.e., verbal, written) varied across sites, with no discernable pattern. For example, skin assessment guidelines included verbal reporting (n = 1), written reporting (n = 2), and verbal and written reporting (n = 1). Other select reporting requirements identified in less than half of the UAP job descriptions included participation in daily (n = 1) or weekly (n = 1) reports, reporting tasks not completed (n = 2), asking for help as needed (n = 2), and reporting incidents or accidents (n = 1).
Written Guidelines for Nurse-UAP Communication
All 6 sites submitted job descriptions for licensed nurse positions, with separate job descriptions for RNs and LPNs (n = 4) and combined RN/LPN job descriptions (n = 2). Job descriptions from 3 sites provided the only source of explicit guidelines for nurse-UAP communication, with specific focus on reports or meeting requirements, including two job descriptions specifying reporting/meeting frequency (i.e., RN/LPN beginning-of-shift team report, RN weekly shift meetings), or more broadly, the overarching goal for “[RN/LPN] informational reports to [UAP]…so they can provide effective care to residents.” Two additional sites included written guidelines for nurses’ communication, in general terms, without reference to UAP, for example: “[RN/LPN] regular and ongoing communication with nursing staff.” The separate RN and LPN job descriptions from 1 site did not reflect any written guidelines for communication.
Considering nurse-UAP communication in a broader context of the nurse’s supervisory role, supervision was identified as a job requirement for nurses at all 6 sites, without explicit mention of communication as an element of the supervisory role. Rather, expectations for supervision referred indirectly to nurse-UAP communication, addressing the accuracy of charting/nursing care, compliance with policies, or in more comprehensive terms, “supporting efforts to give the best care possible to residents.” In addition, all nurses’ job descriptions reflected overarching roles and responsibilities associated with “planning, organizing, directing, and evaluating nursing services.” In contrast to written guidelines identified across all 6 sites for UAP to have knowledge and/or use of care plans, only 1 site provided a corresponding written guideline for LPNs to help UAP “understand and carry out their duties.” As such, UAP are presumably expected to draw from information that nurses communicate to them, in writing, via resident-specific forms.
This study identified and explored the written guidelines for what, how, and when nurses and UAP are expected to communicate regarding residents’ status and care needs. Overall, the findings do not offer a comprehensive understanding of expectations for nurse-UAP communication, given few explicit guidelines for nurses’ role in communication and the site-specific differences in guidelines for UAP. An inherent expectation for nurses, as professionals, to engage in communications with UAP, as part of their delegation and supervisory role, provides a plausible explanation for few guidelines explicating nurses’ specific role in communication. However, application of this rationale as a basis for documenting role expectations warrants consideration. A Centers for Medicare & Medicaid Services (CMS; 2001) report highlighted the value of providing explicit expectations for quality care, emphasizing the essential need for “clear guidelines and procedures, clear expectations regarding standards of care…and consistent enforcement of standards” (p. 13). CMS’ recommendation for clarity of expectations is especially pertinent to the discussions of communication as an element of the delegation/supervisory role, given nurses’ limited educational preparation in supervision (Eaton, 2001; Iowa CareGivers Association, 2000; Schirm, Albanese, Garland, Gipson, & Blackmon, 2000; Siegel et al., 2008) and the fundamental differences between RN and LPN preparation and scopes of practice. A lack of management’s clarity regarding role expectations for communication and the respective RN/LPN role distinctions may limit the extent to which licensed nurses fully understand and appropriately engage in effective communications with UAP.
The varied and fragmented guidelines for UAP communication identified in this study raise questions about the practical translation of these guidelines into daily activities. With limited training, numerous task demands, language barriers, and high rates of job turnover, it is unreasonable to assume that UAP, for the most part, possess a comprehensive understanding of resident needs and the requirements for communicating resident-specific health status, care needs, and changes in condition, given the varied and fragmented guidelines across sites. Sofie, Belza, and Young’s (2003) study of UAP perceptions of occupational health and safety risks revealed UAP difficulty in finding and interpreting information in resident charts and reported knowledge deficits regarding resident illnesses. Considering high UAP turnover, Adams-Wendling et al. (2008) pointed out UAP challenges in locating information across different documents when rotating through facilities. This challenge is heightened when communication expectations vary across settings, as revealed in this study, and supports findings from other studies that suggest UAP prefer informal verbal communication or shift reports over written communications (i.e., assignment sheets, care plans) (Mather & Bakas, 2002; Taunton et al., 2004). Although only half of the sites in the current study provided written guidelines for nurses’ formal verbal reports with UAP, further inquiry is needed to ascertain actual practices. Findings from other studies suggest that, in fact, some nurses do not use routine or formal shift reports to communicate with direct care workers (Anderson et al., 2004; Mather & Bakas, 2002; Siegel et al., 2008; Taunton et al., 2004).
The findings from this study may be restricted due to the reliance on site representatives to self-select documents for this study. In addition, the small sample precludes generalizability of the findings. Further research activities with larger, representative samples and multiple methods of data collection are needed to better understand the contribution of written guidelines to organizational infrastructures that support nurse-UAP communication.
Conclusion and Clinical Implications
This study raises concern regarding the underlying factors that influence management’s decisions to formalize expectations for nurse-UAP communication, the extent to which written guidelines support and reinforce RN and LPN scopes of practice, and the translation of UAP role expectations into actual practice. RNs have primary responsibility and accountability for ensuring appropriate delegation and supervisory practices (including the communication practices that support the delegation and supervisory roles), yet this distinction is blurred in combined RN/LPN job descriptions. The nursing home industry’s employment of greater numbers of LPNs than RNs, high turnover among all levels of nursing personnel (American Health Care Association, 2008), and limited RN and LPN preparation for the supervisory role collectively highlight the importance of written guidelines to explicate management’s expectations—and RN/LPN scopes of practice—for how, what, and when nurse-UAP communication should occur. In addition, attention is needed to organizational cultures that support translation of expectations into practice, given that UAP may be apprehensive or uneasy in approaching nurses (Crogan & Shultz, 2000); perceptions that some nurses do not appreciate, respect, or value UAP (Bowers et al., 2003; Crogan & Shultz, 2000; Jervis, 2002); and UAP perceptions that they have a better sense of the residents’ needs than the nurse (Jervis, 2002; Taunton et al., 2004). Further research relating to supportive human resource management and staffing practices that promote effective and efficient nurse-UAP communication, and the impact of this communication on resident care, may reveal resource-saving measures that enhance the quality of care delivery practices in these settings.
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