What Staff Are Saying: A Firsthand Report
|When you ask nursing home staff about their jobs and ideas for improvement, what do you hear? A few years ago I visited several facilities to glean just such information; I used the Schein methodology (see “Research Methodology”). Data were gathered from observation of routine talk and behaviors, as well as in-depth interviews with key personnel serving as informants. The goal was to identify fresh insights and descriptions of each organization, including the attitudinal supports and barriers experienced by its members. What follows are highlights from two such visits.|
|Noteworthy results from four 3-hour observations at Facility X (a suburban not-for-profit dementia unit with 39 residents in eight private rooms, one deluxe, and 16 doubles):|
| My Visit|
The large sign on the wall reads “TODAY IS WEDNESDAY, JULY 19.” Everyone on staff is helping serve food. All residents are wearing very large bibs. Nine staff members, including the unit coordinator, are working in the dining area with 27 residents. Residents who need feeding assistance are in another room. An RN is checking food intake and finds that a lot of food is left uneaten. Residents have breakfast, a snack at 10 a.m., lunch, a 2 p.m. snack, evening dinner, and then another snack. The therapy assistant says, “It’s too much food.” She notices that a resident takes leftover food and scrapes it into a corner of the room. “Maybe she had a cat at one time,” the therapy assistant muses.
Residents here have many visitors. Some residents planted vegetables in a beautiful outdoor garden and one, a former land surveyor, takes responsibility for overseeing the garden. Posted activities begin at 10 a.m. and end at 3:30 p.m., but the weekends don’t offer any activities other than movies. A sing-along and pet therapy are scheduled once a week. A full-time social worker has been on staff for three months. Her role is defined as helping with families’ adjustment, tracking psychotropic drugs, and dealing with depression, among other tasks. However, she did not often participate as a team member during any of my observation periods.
Before a shift ends, CNAs fill out a form reporting on each resident’s toileting, behavioral issues, wandering, and other areas of concern. Items in each category define whether a resident has been verbally aggressive, verbally nonaggressive, physically aggressive, or physically nonaggressive. As the CNAs gather to complete their forms, one says she had been at another facility for 12 to 15 years and was offered a 6ó-an-hour raise, while new CNAs were starting at 35ó an hour higher. “It was an insult! I told them they could keep it.” Another CNA says she loves it here, even though she has to get up at 4 a.m. for a one-hour commute and another facility is only 30 minutes away. One LPN has worked in nursing homes for 17 years, seven of which have been with this organization, and his wife is a CNA at another facility. They have no children, so for him wages is issue number one and health insurance is number two. A new two-person insurance option (in addition to singles or families) that the facility offers gives him a welcome cost reduction.
A consultant pharmacist reviews medications monthly. She says that behavior documentation includes the CNA daily reports mentioned above, as well as reports done by nursing. Unit staff are given special training to respond to residents’ needs appropriately, she says, noting that staff get their positive reinforcement from calm residents and praise from other staff.
There’s a rotating list for staff to float among units. “Generally people don’t like to float,” says one CNA, “and residents don’t like floaters either. It gives you a break, but you don’t like to get out of routine because everything takes longer, and you can be stuck with the worst assignment.” “It’s frustrating,” adds another, “because you can’t find things for the residents. Also, you cooperate differently with different staff.” All five CNAs involved in the conversation nod in agreement. Other comments revealing mixed reactions to staff teams: “Working with the same staff has its downside because a lot of people are not doing their jobs.” “New staff see things that regulars don’t, such as bruises.” “Sometimes staff members are watching talk shows or soaps.” “This job attracts certain kinds of people-uneducated people who use it as a bridge to something else.”
The LPN says he refers some new or prospective staff to Burger King directly because he can tell by their body language that nursing home employment will not work out.
The day shift supervisor keeps information flowing throughout the building. In the staff hierarchy, her position is just below the DON and the assistant DON, and on the same level as the unit coordinator. She deals with staffing issues-if a staff member is not coming in, he or she must call her or the assistant DON at least one hour before work on the day shift and two hours before work on other shifts. The 3-11 shift is the hardest to staff, the supervisor says. One CNA says that particular shift (3-11) “interferes with your whole life, so it’s a greater staffing problem.”
On my third day of observation, the unit coordinator is extremely frustrated by the lack of activity throughout the unit, and with several activity staff members who appear to be highly disorganized. At 11:30, they have not yet started the scheduled 11 a.m. bowling activity. There is little participation by residents, and staff members are recording scores even though residents can’t hear them announced.
“We had mass boredom today,” notes a supervisor. “Four activities people were on the unit, and yet there was boredom. We need short-term activities with one good activity person going from group to group. We need to accommodate residents’ short attention spans. We need a fully integrated team, with each person filling in as needed to creatively solve problems.”
On my final day of observation, the unit is fully staffed with six CNAs, a unit coordinator, an RN, an LPN, and an LPN on orientation. Yesterday a new class of CNAs arrived and there were too many staff members; one was sent home for the day.
Back in the dining room, one female resident says, “When you get older, you try to forget things, don’t you?” She tells her tablemate that the cars have snow on them (it’s August). One woman screams occasionally, while another tells her to “shut up.” One resident is singing a familiar song: “Have you ever loved someone just as much as me? Can’t you see I’m sorry? Life isn’t worth living. Have you ever been lonely?”
One resident continues to get up, setting off her alarm for the fifth time. The unit coordinator asks if anyone has the time to walk her, then finally says she’ll walk her. She is also attempting to persuade a CNA to take the posted activities department job at $8 per hour.
The environment is attractive, with roomy physical space. There are many visitors. The resident assistant has a key role whose importance must be respected, with the position staffed by experienced problem solvers who know their residents and treat them with the dignity and respect they deserve. To deal effectively with ongoing change, upper-level management cannot remain isolated from knowledge of the daily activities on the unit.
|Noteworthy results from four 3-hour observations at Facility Y (urban, not-for-profit dementia unit with 44 residents):|
There is substantial evidence that existing long-term care management systems are not working well. Are Facilities X and Y on the path toward effectively executing their mission? If not, have these organizations adjusted to the current dysfunctional environment so well that change is unlikely? A “Self-Analysis Tool” is provided.
Culture is defined as a set of values, beliefs, norms, and rules that lead people to define themselves as a distinct group with a sense of commonality. Norms and values are learned as part of our cultural conditioning. They shape the way people view the world and the way they interact with one another. Communication is the glue that reinforces the process. To merge the diverse cultures in the long-term care work environment into a high-functioning team is no easy task.
Four principal areas needing improvement can be readily identified:
1. Well-intentioned practitioners are trying to understand the residents’ needs through a process dominated by other agendas.
2. In this adaptation of the acute care model, the recruitment, training, and retention of the CNAs who provide most of the caregiving are weak components.
3. The need for leadership from a role model/mentor is in conflict with an outmoded hierarchical structure. True, as resident demographics changed, caregiving models responded by adding home care, independent living models, and assisted living-but skilled nursing facilities themselves evolved too slowly in struggling to restructure to provide enhanced quality of life. A training/mentoring model must develop, and it must focus on creating teams that will work together and function as role models for facility-wide reinforcement of its values, mission, and vision. Hiring and firing practices should demonstrate commitment to high standards. Job satisfaction should be recognized as key to both senior and junior staff retention.
4. Both internal and external public relations deserve priority attention. Employee relations may be priority number one, because resident satisfaction depends on staff satisfaction. However, relations with community, government, family members, media, and peer organizations must also become high priorities for nursing homes to gain the necessary power to influence change.
| Marian Deutschman, PhD, is a Professor in the Department of Communications at Buffalo State College, Buffalo, New York. For further information, phone (716) 878-4132. To comment on this article, please send e-mail to firstname.lastname@example.org. For reprints in quantities of 100 or more, call (866) 377-6454.|
Topics: Articles , Facility management , Staffing