What staff are saying: a firsthand report; A long-term care scholar visits two facilities and passes along what she heard and saw.

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," p. 61). 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 6 cents-an-hour raise, while new CNAs were starting at 35 cents 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.

My Impressions

My observations reinforced the importance of appropriate leadership as role models, as team and morale builders, and as providers of training and problem solving. The absence of well-planned and-coordinated programming in this new, suburban (near rural), not-for-profit facility creates stress among both residents and staff. To benefit residents, staff, and ownership, the consensus supports stable staffing. This requires peer mentoring, role modeling, support groups, and consideration of the whole person, as he/she fits into the organization/community and shares the same values. Hiring the wrong person creates stress, frustration, and anxiety among existing staff. Good hiring practices precede trust-building. Staff needs monitoring but not micromanaging. Overall, this facility does have dedicated staff. They aren't working short, at least not on the day shift, but staffing could be more stable.

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):

My Visit

A sign identifying a commitment to the values of this facility is posted at the elevator: "Excellence, Integrity, Respect, Innovation, Responsiveness." This 172-bed facility has a special unit, called the Courtyard Club, for 19 of the 44 residents in the Alzheimer's unit. The facility has a New York State Department of Health special projects grant incorporating two social workers to determine if a daily structured program can enhance quality of life for these residents.

My observation begins with an extensive interview with the director of support services, who also functions as director of social services, director of the dementia program, and project manager for the grant. "Long-term care approaches people as body parts," she says. "There are few administrators who address residents' emotional needs. Most are trapped in the medical model. People come to a nursing institution for physical care. Staff members become angry because residents are so dependent on them, but often it is because they make them so." She adds that although all staff members are cross-trained, there is a union, so you often hear staffers saying. "It's not my job." Staff members need to learn residents' "nonverbals," she says--for example, "tugging at clothing is a sign of needing to urinate." Some residents, she notes, revert back to when they were 9 or 10, others to 16 or 17 years of age.

There has been some administrative turnover because of survey deficiencies, but other administrators have been here for 30 years. Sometimes, the support director tells me, there is a power struggle between the DON and the social worker. The social worker is often a "department of one" and is isolated from the team. The facility's Care Plan Team ordinarily has no CNAs, but on this Alzheimer's unit, CNAs are included. However, according to the support director, they don't like to go to the meetings "because they don't have anything to say." She says these CNAs are the most important, the least trained, and do the least organizational decision making of all people on the unit's staff.

This facility has three full-time positions dedicated to staffing alone, with one full-time recruiter, another similar (but open) position, and one nursing person who works solely on maintaining adequate clinical staffing. If you add the cost of training and time, she says, recruitment and retention are comparatively costly.

The unit clerk, a former CNA, says training includes a couple of weeks in a classroom and a couple of weeks on the floor. "Some CNAs are trained in subacute care but then come to this unit and can't deal with Alzheimer's residents. Others just don't show up or might request to move to another floor. Some do 'hours for dollars.' A lot of people who do like the job are not appreciated. There was a great supervisor," she adds, "who would do anything to help. But they let her go on the night shift because she couldn't find aides. Some were sleeping; there are lots of hiding places in the facility. But employees feel they are not appreciated even if they work a double shift. After a year, half the staff is new."

Nurses don't give baths on other floors, but here they're required to do so. "The CNAs appreciate the help from nurses and need a mentor/role model."

There are several comments from CNAs. One says, "It's tough on weekends, because people get accustomed to the Courtyard Club programs, and we don't have them on the weekends. Consistency is important to these residents." Family members get attached to a particular CNA as a caregiver, and they don't like to see change. This CNA, a union steward, said the chief staff complaints are pay and short staffing--but "the biggest gripe is the way management talks to you. The bosses should trade spots for a day, especially when we're short-staffed. Often, when a resident dies, families send a card of appreciation to staff. If family can see the value of staff, why can't the bosses?"

The CNA also says that this "bureaucratic system is not resident-centered. Why call it a 'home' if it's an institution?" An administrator agrees. "For example, a family member says a resident can't use his/her wheelchair. We check it out with occupational therapy. It needs a new part. Maintenance staff require a maintenance request, even if it may only need a screwdriver, and eventually it does get fixed. All are doing their jobs appropriately, but it isn't resident-centered because the resident must wait until the whole bureaucratic process takes place for something that could have been fixed in minutes."

The RN supervisor says, "There's an enormous paper trail in this business. We're still doing both PRI [the Patient Review Instrument required by the state for reimbursement] and Minimum Data Set. We're so overregulated, and the quality-of-life issue is overdone in that respect. Everything can be an infraction or a deficiency.

"Excellence is unachievable with current standards and staffing," he continues. "Surveyors take a textbook approach with regs, but it's not a textbook world. But it is a 'one size fits all' system. We need a new relationship with surveyors. They should leave you alone if you're doing the right thing and have a proven record."

He also notes, "We have better than average staffing on the 3-11 shift, but we can't fill all the slots. Staff have the attitude that they're tired, they're in a rut, it's heavy work, and the next CNA won't last. After general orientation, we put them on the floor, but we don't have base people to train or mentor them. Many staffers don't have family support and can't afford day care at this pay rate. Many have no backup plans--they're struggling as a one- or two-child single parent. We need flexibility to accommodate them: 'Come later if you can't come in [at the designated time]. Come in on Friday instead.' And if the staffer is an otherwise excellent employee who makes a mistake, give a double suspension instead of dismissing him or her."

Before the two grant-supported social workers arrive, TVs, puzzles, games, and newspapers are there for residents, but activities aren't structured. "They don't have massage, art, or music therapies here," a supervisor says, "because residents wouldn't sit still long enough, and some don't like to be touched. Sometimes residents are in the same clothes from Friday to Monday."

A family member who visits once or twice a week says, "You try to choose a nursing home based on reputation and the experiences of others." However, she says she had had a recent problem with the disappearance of a loved one's dental bridge. "The follow-up here is poor. You talk to one person, then another--no one bears responsibility. And there's so much paperwork. They always have to 'write it down.'"

A handful of residents have regular visitors. Resident rooms are personalized with some of their own items. There is bulletin board space outside each room with a descriptive paragraph and photo of the resident. One staff member tells me that this display of the resident's biography was criticized as an invasion of privacy and, as a result, the biographies might have to be removed.

At the end of each shift, CNAs make notes on certain residents--how often the resident toileted, what the resident ate, how much the resident voided, and any crisis-indicating situations, such as bruises.

An administrator offers concluding comments: "With the lack of CNAs and 40% turnover, how can you provide hands-on care? Can you free up nurse managers to do nursing duties, LPN duties, resident helper duties? And, when you have a bad survey, the administrator is fired, when it's the systems that may be screwed up."

My Impressions

My observations reinforce the value of providing smaller units with a less institutional, more family-oriented environment. This environment may never simulate a real home, or even a traditional neighborhood or household with all its freedoms. However, some aspects of the concept of home, with changes in layout, attitudes, culture, and structure, are needed. The unfamiliar can be frightening, so that aspect of institutional living should be minimized. Although certain routines and regimentation are necessary in a large "family" setting to accommodate individual needs, staff should look for opportunities to remove unnecessary restraints on residents' behavior, as well as for opportunities to accommodate reasonable individual preferences within a group living situation. When residents are incapable of stating their preferences, they ask behaviorally, often with unfortunate results.

We should look to successful models in business and industry to reduce the bureaucratic structure that frustrates staff, residents, and families. Current systems are inhibiting flexibility and innovative changes by fostering bureaucracy and massive documentation. Only the facilities with highly innovative and assertive leadership are able to bridge this barrier. By empowering staff to identify opportunities for change after they've been trained for a resident-centered model, a dialogue can begin.

Conclusions

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 on p. 64.

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.

Self-Analysis Tool*

Answers to the following questions should help to determine whether the culture of an organization has the readiness of a winning team and the drivers of success/excellence. Answers should also provide insights about the barriers to quality. Decision makers in long-term care should assign an accurate number (1 = almost always, 2 = usually, 3 = often, 4 = sometimes, 5 = never) to reflect the extent to which they believe they are doing the following:

__________1. Do the members organize themselves in a way that enables them to do their work in the most effective way?

__________2. Do they know what is expected of them?

__________3. Do they care about the results?

__________4. Do they have the skills to accomplish their goals?

__________5. Do group goals have priority over personal goals?

__________6. Do group members trust and support one another?

__________7. Is each member giving his/her personal best effort?

__________8. Are efforts recognized with adequate rewards?

__________9. Are your leaders able to create a shared strategic vision of the organization's purpose?

__________10. Do you hire for attitude and train for skills?

__________11. Are the leaders able to unleash talents and competencies of group members?

__________12. Do you create your own organizational targets apart from system requirements?

__________13. Have you looked for procedures/processes you can do even better?

__________14. Are you committed to hiring the right people?

__________15. Do you replace them quickly when you discover they are not the right people?

__________16. Do you treat family members as you would your best friends?

__________17. Have you defined your own standard of professionalism?

__________18. Have you practiced the art of asking "what if ...?"

__________19. Have you adjusted policies and procedures in the best interest of internal and external publics?

__________20. Do you do what you expect and want others to do?

__________21. Do you find ways to understand other people's jobs?

__________22. Do you make information interesting, meaningful, and relevant to everyone?

__________23. Do you own mistakes, share mistakes, learn from mistakes, and move on?

__________24. Have you aligned systems, policies, and practices with organizational values?

25. Have you examined your spending and your calendar to see if the way you spend your money and your time is consistent with what you value?

__________26. Do you develop a sincere interest in both family members of staff, as well as residents?

__________27. Have you created a committee that protects, promotes, and projects a purposeful culture?

__________28. Do you have celebrations to acknowledge what's important; what you value?

__________29. Do you show your gratitude to the community?

__________30. Do you make serving the community a team-building event for your employees?

__________31. Do you look for creative, unusual ways to tell your story?

__________32. Do you collaborate with others to build spirit, service, and performance?

__________33. Is your technology keeping pace with changes?

__________34. Do you deliver the right information to the right person at the right time in the right format?

__________35. Do your employees come up with clever ideas to outthink and outmaneuver competition?

__________ TOTAL

A score between 120 and 140 indicates a need for significant issues management. A score higher than 140 suggests you may be simply coping in a crisis.

*These questions are adapted from a questionnaire used by Southwest Airlines, which captivated the interest of the business press by "being smart enough to recognize that their most valuable assets are their people and the culture they create" (Tom Peters, 1996). Peters T. In: Freiberg KL, Frieberg JA. Nuts! Southwest Airline's Crazy Recipe for Business and Personal Success. Austin, Tex.: Bard Press, Inc., 1996.

Suggested Reading

Schein E. Organizational Culture and Leadership. San Francisco: Jossey-Bass, 1985.

Schein E. The role of the founder in creating organizational cultures. Organizational Dynamics 1983; 12:13-28.

RELATED ARTICLE: Research Methodology

The research methodology used in this project, based on structured observations, was defined by Edgar H. Schein, professor at MIT Sloan School of Management:

 1. Gain access and note what surprises you.
 2. Observe and check.
 3. Find an insider willing and capable of explaining to you.
 4. Reveal what you find puzzling.
 5. With the insider, try to account for your perceptions.
 6. Form hypotheses.
 7. Check and consolidate.
 8. Seek to the level of assumptions.
 9. Revise earlier findings to suit later ones.
10. Formally report.

BY MARIAN DEUTSCHMAN, PHD

Marian Deutschman, PhD, is a Professor in the Department of Communications at Buffalo State College, Buffalo, New York. For further information, phone [phone]. To comment on this article, please send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].