Green House Blog

THRIVE: Understanding the Language of Research

The Green House Project has partnered with the Robert Wood Johnson Foundation’s THRIVE (The Research Initiative Valuing Eldercare) collaborative to learn more about the Green House model as well as other models of care. Supported by the Robert Wood Johnson Foundation, the THRIVE team is conducting a series of interrelated research projects that together will comprise the largest research effort undertaken to date in Green House homes. Each quarter, a member of the THRIVE team will contribute a blog post to the Green House Project website.

As the THRIVE research projects head toward completion later this year, our research team has developed plans to share our research findings.  In addition to publishing articles in a special issue of the journal, Health Services Research, we also will share findings through conference and webinar presentations and blog posts.

Because some commonly used research terms may sound like jibberish to non-researchers (after all, who really knows what a p-value is?), we will devote our next few blog posts to explaining a few terms that will help non-researchers better understand the THRIVE articles, presentations, and posts.  We’ll start by reviewing Quantitative and Qualitative research designs.

When people think of research, they’re usually thinking of a Quantitative research design, which essentially measures and compares things.  Quantitative research asks questions like “How many residents in one nursing home have falls compared to residents in another?” or “Does providing one type of care work better than providing a different type of care?”  A quantitative research design allows a researcher to establish “how much”, whether one thing is related to another (such as whether falls are less frequent when certain care is provided), and also – depending on the details of the design – to establish cause and effect.  The data collected are usually in numerical form, and findings are expressed in terms including percents, means, and p-values (to answer the earlier question, a p-value denotes whether or not a number is or isn’t significantly ‘different’ from another…..we’ll come back to this in a future blog post).

Qualitative research designs essentially answer “how” and “why”.  Qualitative research asks questions such as “Why are so many falls occurring?” or “What conditions are necessary for a nursing home to provide a certain type of care?”  A qualitative research design permits a researcher to better understand events and the circumstances under which they occur and vary.  The information gathered in these types of studies are usually textual, and include the researchers notes and observations, as well as in-depth interviews and quotes from people who have knowledge of the event being studied.  This information is analyzed by looking for common themes across all of the information collected and reporting these findings – often contextualized using exemplative quotes.

The THRIVE team is using both quantitative and qualitative methods in their research, which is considered mixed-methods.  This is the best of both worlds, and is allowing us to answer questions such as:

Quantitative:    What was the annual turnover rate for shahbazim over the past two years?
Was this turnover rate statistically different (higher or lower) than that found
among CNAs in other nursing homes?

Qualitative:      What was the role of the Director of Nursing in the Green House homes?
How might variations in this role relate to shahbazim turnover?

Stay tuned for the next THRIVE blog post.  In the meantime, if you have questions about this post, or suggestions for future ones, please let us know.

Questions about THRIVE can be directed to Lauren Cohen (lauren_cohen@unc.edu or 919-843-8874).

Early Research Findings from THRIVE

The Green House Project has partnered with the Robert Wood Johnson Foundation’s THRIVE (The Research Initiative Valuing Eldercare) collaborative to learn more about the Green House model as well as other models of care. Supported by the Robert Wood Johnson Foundation, the THRIVE team is conducting a series of interrelated research projects that together will comprise the largest research effort undertaken to date in Green House homes. Each quarter, a member of the THRIVE team will contribute a blog post to the Green House Project website.

Early findings from the THRIVE research collaborative were published in The February 2014 Gerontologist supplement, Transforming Nursing Home Culture: Evidence for Practice and Policy, a themed issue providing evidence to inform practice and policy related to culture change.  The full articles can be accessed at http://gerontologist.oxfordjournals.org/content/54/Suppl_1.toc and are summarized here.

A paper entitled “A “Recipe” for Culture Change? Findings from the THRIVE Survey of culture change Adopters” provided information from a survey that assessed which components of culture change – and in what combinations – have been adopted by nursing homes.  The survey was completed by 164 nursing homes that had already adopted culture change.  Results showed that adopted components of culture change varied across the type of nursing home model (i.e., small house, household, traditional unit).  As one example, respondents from small houses reported a significantly higher rate of direct care workers preparing meals (79%), but these were some of the least adopted practices for other adopters (22% of households and 13% of traditional units).  Results also showed that some traditional environments have been able to implement certain culture change components without large capital investments.  For instance, respondents reported similar rates of practices related to educational support and quality improvement regardless the nursing home model.  Taken together, these findings suggest that although practices do vary by model, some components of culture change are attainable for homes that have fewer resources to invest in large-scale renovations or reorganization.

A paper entitled “Who are the Innovators? Nursing Homes Implementing Culture Change” focused on the organizational factors associated with culture change implementation.  Using a sophisticated analytic process, information from 16,835 nursing homes was used to determine which resident, facility, and state characteristics related to a nursing home later being identified by experts as having implemented culture change.   These characteristics included being nonprofit, larger in size, and with fewer Medicaid and Medicare residents. Implementers also had better baseline quality with fewer health-related survey deficiencies and greater licensed practical nurse and nurse aide staffing. These findings suggest that nursing homes are in a better position to implement culture change if they start out with more resources and fewer challenges.   In a related article entitled “Culture Change and Nursing Home Quality of Care”, analyses examined how culture change implementation related to later nursing home quality.  This study found that nursing homes identified as culture change adopters later had fewer health-related survey deficiencies, but there was no improvement in the MDS-based metrics of quality.  These finding may suggest that culture change improves nursing home processes of care, and/or that surveyors recognized the homes’ culture change efforts in their ratings.  The lack of impact on MDS outcomes may suggest that either the early focus of such efforts has not been on clinical outcomes, or that because nursing homes adopting culture change already had better outcomes, there was less room for improvement.

Finally, a paper entitled “Developing the Green House Nursing Care Team: Variations on Development and Implementation” explored the roles of the nurse and the Shahbazim in the Green House model, focusing on how variations in the nursing team related to clinical care practices. Data were collected through observations and interviews with nurses, Shahbazim, Guides, and Directors of Nursing, and found that implementation of the nursing role within the Green House model varied both within and across sites.  Four nursing model types were identified: Traditional (nurse manages both care and non-care activities); Parallel (nurse manages care, Shahbaz manage non-care activities); Integrated (nurse and Shahbaz collaboratively manage care and non-care activities); and Visitor (Shahbaz manage care and non-care activities, with input from nurse as requested).  Care processes, Shahbaz skill development, and worker stress varied across each model, and although the Integrated model presents considerable challenges in terms of clarifying boundaries, it seemed to offer the greatest benefits in the areas addressed in this study.  

The THRIVE team will be expanding upon these and other findings in 2014, and will be sharing those with you and others via conference presentations, webinars, blog posts, and more journal articles.  As always, we invite your feedback about the best ways to keep you informed of the latest findings.

Questions about THRIVE can be directed to Lauren Cohen (lauren_cohen@unc.edu or 919-843-8874).