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

Dana Beth Weinberg, PhDDana Beth Weinberg, PhDRebekah Zincavage, MARebekah Zincavage, MAAlmas Dossa, MPH, MSAlmas Dossa, MPH, MS

Sue Pfefferle, Ph.D.Sue Pfefferle, Ph.D.

Academy Health Conference 2006Academy Health Conference 2006Seattle, WASeattle, WA

Project TeamProject TeamSenior InvestigatorsSenior Investigators

Christine E. Bishop, Ph.D., BrandeisChristine E. Bishop, Ph.D., BrandeisSusan C. Eaton, Ph.D., Harvard (deceased)Susan C. Eaton, Ph.D., Harvard (deceased)Jody Hoffer Gittell, Ph.D., Brandeis Jody Hoffer Gittell, Ph.D., Brandeis Walter Leutz, Ph.D., BrandeisWalter Leutz, Ph.D., BrandeisDana Beth Weinberg, Ph.D., Queens College Dana Beth Weinberg, Ph.D., Queens College Lisa Dodson, Ph.D., Boston CollegeLisa Dodson, Ph.D., Boston College

Field Staff and Statistical SupportField Staff and Statistical SupportAlmas Dossa, MPH, M.S., Brandeis Almas Dossa, MPH, M.S., Brandeis Susan Pfefferle, M.Ed., Ph.D., Washington Susan Pfefferle, M.Ed., Ph.D., Washington

University University Rebekah Zincavage, M.A, BrandeisRebekah Zincavage, M.A, BrandeisMelissa Morley, Ph.D., BrandeisMelissa Morley, Ph.D., BrandeisJoanne Jannsen, M.S., BrandeisJoanne Jannsen, M.S., Brandeis

Improving Institutional Long-Term Care for Improving Institutional Long-Term Care for Residents and Workers:Residents and Workers:

The Effect of Leadership, Relationships The Effect of Leadership, Relationships and Work Designand Work Design

Funded by Better Jobs Better Care Funded by Better Jobs Better Care ProgramProgram

A collaboration ofA collaboration of

The Robert Wood Johnson FoundationThe Robert Wood Johnson Foundation

andand

Atlantic PhilanthropiesAtlantic Philanthropies

Administered by Administered by The Institute for the Future of Aging The Institute for the Future of Aging Services (IFAS)Services (IFAS)

Traditional Nursing HomesTraditional Nursing Homes

Are organizedAre organized around institutional needs and around institutional needs and standardized practicesstandardized practices

Define qualityDefine quality care as attending to residents’ care as attending to residents’ physical needs, rather than wants and physical needs, rather than wants and desiresdesires

Are medical institutions, following a medical Are medical institutions, following a medical model of care and resemble hospital wards.model of care and resemble hospital wards.

Are typically places that people come to Are typically places that people come to die/or come at the last stage of their life.die/or come at the last stage of their life.

Culture Change Nursing Culture Change Nursing HomesHomes

Customize and individualize care to individual Customize and individualize care to individual residents – person- or resident-centered careresidents – person- or resident-centered care

Focus on finding and creating the essentials Focus on finding and creating the essentials of a “home-like” environment of a “home-like” environment

Central organizing features include the Central organizing features include the dignity, privacy, autonomy of residentsdignity, privacy, autonomy of residents

Respond to residents’ wants as well as needsRespond to residents’ wants as well as needs Are places that people come to live -- Support Are places that people come to live -- Support

life tasks for life stagelife tasks for life stage

Many Paths to Culture Many Paths to Culture ChangeChange

For example, For example, Eden AlternativeEden Alternative Wellspring Model for Improving Wellspring Model for Improving

Nursing Home QualityNursing Home Quality Action PactAction Pact Pioneer NetworkPioneer Network

Many Paths to Culture Many Paths to Culture ChangeChange

Two common themes:Two common themes: Empowerment of residentsEmpowerment of residents Empowerment of front-line staff to Empowerment of front-line staff to

meet residents’ needs and desires meet residents’ needs and desires

Nurses are Pivotal to Culture Nurses are Pivotal to Culture ChangeChange

Nursing homes are nursing institutions. Nursing homes are nursing institutions. Nurses . . . Nurses . . .

Manage unitsManage units Supervise aidesSupervise aides Mediate between aides and upper managementMediate between aides and upper management Develop care plansDevelop care plans Deliver nursing care and medications to Deliver nursing care and medications to

residentsresidents Respond to residents’ needs/requestsRespond to residents’ needs/requests Interact with familiesInteract with families

Do Nurses Resist Culture Do Nurses Resist Culture Change?Change?

Nurses may resist Culture Change if Nurses may resist Culture Change if interventions…interventions…

Threaten quality of careThreaten quality of care Reduce their control over resident Reduce their control over resident

carecare Diminish nurses’ authority over aidesDiminish nurses’ authority over aides

Project DescriptionProject Description

Qualitative data from two different Qualitative data from two different units in 18 high quality nursing units in 18 high quality nursing homes in Massachusetts -- homes in Massachusetts -- administrator interviews, nurse administrator interviews, nurse interviews, CNA focus groupsinterviews, CNA focus groups

6 self-designated as Culture Change 6 self-designated as Culture Change facilitiesfacilities

Research Questions for This Research Questions for This AnalysisAnalysis

What role do nurses play in What role do nurses play in empowering CNAs?empowering CNAs?

Do nurses resist management efforts Do nurses resist management efforts to empower CNAs?to empower CNAs?

Under what conditions do nurses Under what conditions do nurses choose NOT to empower CNAs?choose NOT to empower CNAs?

Defining EmpowermentDefining Empowerment

Control over the work process -- Control over the work process -- autonomyautonomy

Control in the workplace – Control in the workplace – participation in decision-makingparticipation in decision-making

Nurses’ Role in Empowering Nurses’ Role in Empowering CNAsCNAs

Who Champions Who Champions Empowerment?Empowerment?

Are CNAs Are CNAs Empowered?Empowered?

Neither Neither administrators nor administrators nor nursesnurses

NoNo

Administrators onlyAdministrators only NoNo

Nurses onlyNurses only Somewhat Somewhat (on units, (on units, but not within larger NH but not within larger NH context)context)

Both administrators Both administrators and nursesand nurses

Often, but not alwaysOften, but not always

Culture Change ScenariosCulture Change Scenarios

Management wants CNA Management wants CNA empowerment, but nurses do notempowerment, but nurses do not

Nurses want CNA empowerment, but Nurses want CNA empowerment, but management does notmanagement does not

Nurses and management want CNA Nurses and management want CNA empowerment but do not achieve itempowerment but do not achieve it

Nurses and management want CNA Nurses and management want CNA empowerment and achieve itempowerment and achieve it

Do Nurses Resist Empowering Do Nurses Resist Empowering CNAs?CNAs?

Nurses do not always empower CNAs Nurses do not always empower CNAs even when top management even when top management advocates CNA empowermentadvocates CNA empowerment

Nurses may empower CNAs, even Nurses may empower CNAs, even when management does not when management does not advocate itadvocate it

Even when management and nurses Even when management and nurses both want to empower CNAs, CNAs both want to empower CNAs, CNAs may not be empoweredmay not be empowered

Is This Resistance?Is This Resistance?

Does lack of empowerment relate to Does lack of empowerment relate to nurses’ concerns about turf and nurses’ concerns about turf and authority?authority?

Examine similarities between Examine similarities between scenarios in which CNAs are not scenarios in which CNAs are not empoweredempowered

Barriers to CNA Barriers to CNA EmpowermentEmpowerment

CNA IssuesCNA Issues High turnoverHigh turnover High number of calloutsHigh number of callouts High use of agency CNAsHigh use of agency CNAs Quality of CNA labor forceQuality of CNA labor force Understaffing of CNAsUnderstaffing of CNAs Lack of trust in managementLack of trust in management Poor relationships with nursesPoor relationships with nurses Conflict with coworkersConflict with coworkers

Barriers to CNA Barriers to CNA EmpowermentEmpowerment

Nurse IssuesNurse Issues Lack of management skill or experienceLack of management skill or experience OverworkOverwork Do not see management as part of job – Do not see management as part of job –

focus on regulations and nursing carefocus on regulations and nursing care High turnover of nursesHigh turnover of nurses High use of agency nursesHigh use of agency nurses

Top Management IssuesTop Management Issues

Management IssuesManagement Issues High turnoverHigh turnover Constrained resourcesConstrained resources Low exposure to frontline workersLow exposure to frontline workers Changes not meaningful (or have Changes not meaningful (or have

unintended effect)unintended effect) Lack of leadership skill or experienceLack of leadership skill or experience

ConclusionsConclusions

What role do nurses play in What role do nurses play in empowering CNAs?empowering CNAs?

Nurses play the primary role in empowering Nurses play the primary role in empowering CNAs by emphasizing autonomy and CNAs by emphasizing autonomy and participation in decision-makingparticipation in decision-making

Some nurses choose to empower CNAs, Some nurses choose to empower CNAs, even when management does noteven when management does not

Some nurses do not empower CNAs, even Some nurses do not empower CNAs, even when management would like towhen management would like to

ConclusionsConclusions

Do nurses resist empowering CNAs?Do nurses resist empowering CNAs? ““Resistance” in the form of concerns Resistance” in the form of concerns

about turf or authority were not a about turf or authority were not a factor in these 18 casesfactor in these 18 cases

There were other common factors There were other common factors that prevented nurses from that prevented nurses from empowering CNAsempowering CNAs

ConclusionsConclusions

Under what conditions do nurses Under what conditions do nurses choose NOT to empower CNAs?choose NOT to empower CNAs?

Barriers to empowerment occur at Barriers to empowerment occur at multiple levels within an NHmultiple levels within an NH

These relate to staff stability and These relate to staff stability and quality, resources and time, quality, resources and time, leadership and management ability, leadership and management ability, and relationships among workersand relationships among workers

Policy ImplicationsPolicy Implications

Intentions and practice do not always matchIntentions and practice do not always match Viewing nurses as resistant misses key barriers to Viewing nurses as resistant misses key barriers to

Culture Change implementation and may locate Culture Change implementation and may locate problems at the wrong levelproblems at the wrong level

In nursing homes, nurses are middle managers – the In nursing homes, nurses are middle managers – the management part of their job needs to be management part of their job needs to be emphasizedemphasized

Top managers and nurses need training in Top managers and nurses need training in participatory management for Culture Change to be participatory management for Culture Change to be effectiveeffective

HR practices need to promote retention of qualified HR practices need to promote retention of qualified workers for Culture Change to be effectiveworkers for Culture Change to be effective