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Local interaction strategies and capacity for better care in nursing homes: a multiple case study

Ruth A Anderson1*, Mark P Toles2, Kirsten Corazzini1, Reuben R McDaniel3 and Cathleen Colón-Emeric45

Author Affiliations

1 Duke University School of Nursing, DUMC 3322, Durham, NC 27710, USA

2 University of North Carolina at Chapel Hill, School of Nursing, 1200 Carrington Hall #7460, Chapel Hill, NC 27599, USA

3 McCombs School of Business, The University of Texas at Austin, Texas, USA

4 Veterans Administration Medical Center, Geriatric Research Education and Clinical Center, Durham, USA

5 Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, USA

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BMC Health Services Research 2014, 14:244  doi:10.1186/1472-6963-14-244

Published: 5 June 2014



To describe relationship patterns and management practices in nursing homes (NHs) that facilitate or pose barriers to better outcomes for residents and staff.


We conducted comparative, multiple-case studies in selected NHs (N = 4). Data were collected over six months from managers and staff (N = 406), using direct observations, interviews, and document reviews. Manifest content analysis was used to identify and explore patterns within and between cases.


Participants described interaction strategies that they explained could either degrade or enhance their capacity to achieve better outcomes for residents; people in all job categories used these ‘local interaction strategies’. We categorized these two sets of local interaction strategies as the ‘common pattern’ and the ‘positive pattern’ and summarize the results in two models of local interaction.


The findings suggest the hypothesis that when staff members in NHs use the set of positive local interaction strategies, they promote inter-connections, information exchange, and diversity of cognitive schema in problem solving that, in turn, create the capacity for delivering better resident care. We propose that these positive local interaction strategies are a critical driver of care quality in NHs. Our hypothesis implies that, while staffing levels and skill mix are important factors for care quality, improvement would be difficult to achieve if staff members are not engaged with each other in these ways.

Nursing homes; Management; Staff interactions; Complexity science; Case study