High-performing and low-performing nursing homes: a view from complexity science

Health Care Manage Rev. 2007 Oct-Dec;32(4):341-51. doi: 10.1097/01.HMR.0000296789.39128.f6.


Background: There continues to be concern for the quality of care and quality of life for nursing home residents. Some scientists have turned their attention to viewing nursing homes as complex adaptive systems to inform our understanding of organizational performance.

Purpose: The purpose of this study was to describe the working conditions in four nursing homes-two high performing and two low performing-through the lens of complexity science theory.

Methods: A qualitative case study approach was used to examine four nursing homes. Extreme case examples-high- and low-performing nursing homes-were purposefully selected. More than 100 hr of observation, 70 formal interviews, numerous informal interviews, and document review were the primary data collection methods.

Findings: Using select complexity science principles added richness to the analysis, highlighting the stark contrast between the high- and low-performing nursing homes. Leaders in the high-performing homes behaved congruently with the nursing home's stated and lived mission by fostering connectivity among staff, ample information flow, and the use of cognitive diversity. In contrast, leadership in low-performing homes behaved disharmoniously with the stated mission, which confused and eroded trust and relationships among staff members, contributed to poor communication, and fostered role isolation and discontinuity in resident care.

Practice implications: The study offers insights into the importance of mission- and values-based leadership behaviors, suggesting that an overuse of mechanistic, linear command-and-control approaches to improving care, such as punitive measures to insist on regulatory compliance, will do little to ultimately improve care. Rather, relationship-centered leadership that embraces co-management and mutual shaping of resident care complements doing the right thing for residents from a values-based shared experience. Examples of practice implications include developing a strong, coherent organizational mission; having fewer, more flexible rules to foster creativity; and allowing lateral decision making.

MeSH terms

  • Allied Health Personnel / psychology*
  • Communication
  • Decision Making, Organizational
  • Humans
  • Interprofessional Relations
  • Leadership*
  • Nursing Assistants / psychology*
  • Nursing Homes / organization & administration*
  • Nursing Homes / standards
  • Operations Research*
  • Organizational Case Studies
  • Organizational Culture
  • Organizational Objectives
  • Professional-Patient Relations
  • Qualitative Research
  • Quality of Health Care / organization & administration*
  • Quality of Life*
  • Trust
  • United States
  • Workplace / psychology*