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contingency theory, nursing facilities, nurse aides, work structure



  1. Zinn, Jacqueline S.
  2. Brannon, Diane
  3. Mor, Vincent
  4. Barry, Theresa


The purpose of this paper is to describe how the work associated with psychosocial and physical caregiving is structured within nursing facilities. Arguing from a contingency perspective, our central hypothesis is that because the technology underlying physical care is less variable and more interpretable and the process-outcome relationships underlying care processes are better understood than for psychosocial care, work in the physical care domain will be comparatively more mechanistically structured even though work in both domains is performed by the same paraprofessional nurse aide staff. Data for this analysis derive from a survey of unit charge nurses (n = 739) in 308 nursing homes in eight states undertaken as part of a large NIA-funded study of the relationship between nursing home organization and resident outcomes. With the exception of centralization, contingency theory correctly predicts how the work associated with physical and psychosocial care is differentiated.


The paucity of professional staff with specialized expertise to care for a resident population representing a wide range of clinical and functional conditions is an ongoing source of public concern with the quality of nursing home care. While nursing home care is not acute, it is complex in that residents tend to have multiple conditions and functional limitations. For long-term residents, the facility and its staff are particularly challenged to provide both health care and serve as home/social support substitute in an institutional setting.1 The intent of the Nursing Home Reform Act (OBRA 1987) provisions for preadmission screening and periodic assessment was to reduce variability in resident outcomes and encourage more informed and presumably better differentiated care for residents. Prompting this legislation was widespread concern that nursing facilities provided generic custodial care that was not reflective of individual needs. While clinical outcomes are now assessed and reported in all facilities, research that documents structure-process-outcomes patterns in nursing facilities homes are exceedingly rare, and this setting continues to be "[horizontal ellipsis] the black hole of the health services system."2 This paper reports findings that begin to address, in the post-OBRA 1987 environment, the question of whether and how care processes are differentiated in nursing homes.


We compare physical and psychosocial domains of nursing facility care because prior research in hospitals provides evidence that good psychosocial care would be structured differently than would good physical care.3-5 While ultimately it is important to document the extent to which care can be and is individualized at the resident level, this paper has a more fundamental objective. Using the tenets of contingency theory, we aim simply to describe whether and how the work associated with psychosocial and physical caregiving is differentiated within nursing units.


Several physiological conditions experienced by residents of nursing facilities are viewed as intolerable (e.g. unrelieved pain, pressure ulcers, contractures, etc.). As such, the prevalence or incidence rates of these conditions are used by regulatory bodies as indicators of adverse quality. Their cause and prevention are the object of considerable study and accepted standard protocols for preventing, identifying, and treating these problems have been widely disseminated.6-11 However, the same unambiguous determination is not present for a broad array of psychosocial dimensions of quality of life in nursing facilities. Both the measurement of psychological health and interventions in the behavioral health arena are less well developed than those related to the physical care provided in nursing homes.12,13 Thus, in contrast to the well-known physical care protocols referenced above, consensus on the process-outcome knowledge base for identifying and treating depression and mood disorders and for reducing the rate of cognitive decline in the institutional setting has not been established to a degree that would justify widespread dissemination.14 In the absence of clearly specified evidenced-based procedures for nonprofessional staff, it may be that the best "care" to counteract mental health problems exacerbated by the institutional setting is that which evolves from the natural process of human interaction between caregiving staff and residents.15,16


From a managerial perspective, training and supervision of direct care staff, the allocation of caregiving work across staff and the evaluation of the quality of care could all potentially benefit from improved differentiation of the nature of caregiving work in nursing facilities. For example, in their recent evaluation of the Wellspring Model for improving nursing home care, Stone et al.17 note their inability to conceptually link observed clinical improvements to specific structures surrounding care processes. It is not clear, then, that a given staff empowerment strategy (e.g. advanced training or involvement in care planning for nurse aides), that seems to help reduces falls will be beneficial in some other clinical care domain. In the case of the nursing facility industry, the field of practice is innovating by trial and error in the absence of sound hypotheses about what should work.


In this paper, we apply the tenets of contingency theory to determine whether nursing facilities differentiate work structure in the provision of representative examples of psychosocial and physical care. Our objective is to determine if work is structured in nursing homes in ways that achieve an appropriate fit with the technologies underlying psychosocial and physical care.