Nurses as Power Brokers: Changing Roles and Culture Change in Nursing Homes

1. Nurses as Power Brokers: Changing Roles and Culture Change in Nursing Homes Dana Beth Weinberg, PhD Rebekah Zincavage, MA Almas Dossa, MPH, MS Sue Pfefferle, Ph.D. Academy Health Conference 2006 Seattle, WA

2. Project Team Senior Investigators Christine E. Bishop, Ph.D., Brandeis Susan C. Eaton, Ph.D., Harvard (deceased) Jody Hoffer Gittell, Ph.D., Brandeis Walter Leutz, Ph.D., Brandeis Dana Beth Weinberg, Ph.D., Queens College Lisa Dodson, Ph.D., Boston College Field Staff and Statistical Support Almas Dossa, MPH, M.S., Brandeis Susan Pfefferle, M.Ed., Ph.D., Washington University Rebekah Zincavage, M.A, Brandeis Melissa Morley, Ph.D., Brandeis Joanne Jannsen, M.S., Brandeis

3. Improving Institutional Long-Term Care for Residents and Workers:The Effect of Leadership, Relationships and Work DesignFunded by Better Jobs Better Care Program A collaboration of The Robert Wood Johnson Foundation and Atlantic Philanthropies Administered by The Institute for the Future of Aging Services (IFAS)

4. Traditional Nursing Homes • Are organized around institutional needs and standardized practices • Define quality care as attending to residents’ physical needs, rather than wants and desires • Are medical institutions, following a medical model of care and resemble hospital wards. • Are typically places that people come to die/or come at the last stage of their life.

5. Culture Change Nursing Homes • Customize and individualize care to individual residents – person- or resident-centered care • Focus on finding and creating the essentials of a “home-like” environment • Central organizing features include the dignity, privacy, autonomy of residents • Respond to residents’ wants as well as needs • Are places that people come to live -- Support life tasks for life stage

6. Many Paths to Culture Change For example, • Eden Alternative • Wellspring Model for Improving Nursing Home Quality • Action Pact • Pioneer Network

7. Many Paths to Culture Change Two common themes: • Empowerment of residents • Empowerment of front-line staff to meet residents’ needs and desires

8. Nurses are Pivotal to Culture Change Nursing homes are nursing institutions. Nurses . . . • Manage units • Supervise aides • Mediate between aides and upper management • Develop care plans • Deliver nursing care and medications to residents • Respond to residents’ needs/requests • Interact with families

9. Do Nurses Resist Culture Change? Nurses may resist Culture Change if interventions… • Threaten quality of care • Reduce their control over resident care • Diminish nurses’ authority over aides

10. Project Description • Qualitative data from two different units in 18 high quality nursing homes in Massachusetts -- administrator interviews, nurse interviews, CNA focus groups • 6 self-designated as Culture Change facilities

11. Research Questions for This Analysis • What role do nurses play in empowering CNAs? • Do nurses resist management efforts to empower CNAs? • Under what conditions do nurses choose NOT to empower CNAs?

12. Defining Empowerment • Control over the work process -- autonomy • Control in the workplace – participation in decision-making

13. Nurses’ Role in Empowering CNAs

14. Culture Change Scenarios • Management wants CNA empowerment, but nurses do not • Nurses want CNA empowerment, but management does not • Nurses and management want CNA empowerment but do not achieve it • Nurses and management want CNA empowerment and achieve it

15. Do Nurses Resist Empowering CNAs? • Nurses do not always empower CNAs even when top management advocates CNA empowerment • Nurses may empower CNAs, even when management does not advocate it • Even when management and nurses both want to empower CNAs, CNAs may not be empowered

16. Is This Resistance? • Does lack of empowerment relate to nurses’ concerns about turf and authority? • Examine similarities between scenarios in which CNAs are not empowered

17. Barriers to CNA Empowerment CNA Issues • High turnover • High number of callouts • High use of agency CNAs • Quality of CNA labor force • Understaffing of CNAs • Lack of trust in management • Poor relationships with nurses • Conflict with coworkers

18. Barriers to CNA Empowerment Nurse Issues • Lack of management skill or experience • Overwork • Do not see management as part of job – focus on regulations and nursing care • High turnover of nurses • High use of agency nurses

19. Top Management Issues Management Issues • High turnover • Constrained resources • Low exposure to frontline workers • Changes not meaningful (or have unintended effect) • Lack of leadership skill or experience

20. Conclusions What role do nurses play in empowering CNAs? • Nurses play the primary role in empowering CNAs by emphasizing autonomy and participation in decision-making • Some nurses choose to empower CNAs, even when management does not • Some nurses do not empower CNAs, even when management would like to

21. Conclusions Do nurses resist empowering CNAs? • “Resistance” in the form of concerns about turf or authority were not a factor in these 18 cases • There were other common factors that prevented nurses from empowering CNAs

22. Conclusions Under what conditions do nurses choose NOT to empower CNAs? • Barriers to empowerment occur at multiple levels within an NH • These relate to staff stability and quality, resources and time, leadership and management ability, and relationships among workers

23. Policy Implications • Intentions and practice do not always match • Viewing nurses as resistant misses key barriers to Culture Change implementation and may locate problems at the wrong level • In nursing homes, nurses are middle managers – the management part of their job needs to be emphasized • Top managers and nurses need training in participatory management for Culture Change to be effective • HR practices need to promote retention of qualified workers for Culture Change to be effective