What you hear when you listen to staff.

Some of the people who work here belong on the assembly line." This was an observation from one of the elderly residents in a focus group at a large nursing home in western New York. Residents were discussing obstacles to quality of life. "We are the assembly line," another resident added. "They do the same things for us day after day."

The more humanistic model of nursing home care that has emerged in the last decade is "adding life to years rather than years to life." The medical model, never a good fit for nursing homes, is finally shifting to a more social model of caring. As quality of life is emphasized more and residents' dependence increases, the environment of care becomes more uncertain; tasks are more individualized, and the need for communication and collaboration among staff members is more critical.

We all know that simply calling a group of caregivers a team doesn't make them effective communicators and collaborators. They must be trained to raise and clarify communication issues, and to choose communication alternatives that support commitment, integrity, respect, accountability and other values that are cherished by the organization.

In the recent GAO report of nursing home abuses in California, certified nursing assistants were found to frequently document care that was never provided. High patient-to-staff ratios were blamed, but that might not be the full explanation. Further scrutiny might reveal how such behaviors are modeled and shaped in many facilities through listening and observation.

Listening takes place when meaning is attached to what is heard. [1] Members of an organization need to look at the messages they're sending, especially to new employees, because this sets up patterns of repeated behavior.

Newcomers learn appropriate (and sometimes inappropriate) behaviors by listening to stories and anecdotes, hearing about rituals and observing the nonverbal behaviors of their peers and supervisors. The experience of one typical aide might illustrate this point:

Following training and orientation, she worked the late shift and was eager to do all that was expected of her. After a few days, she began noticing that her peers were taking coffee breaks, while she couldn't seem to find the time to complete all her tasks. They weren't working as diligently as she was, but they were being paid at least as much, or more. If she continued to work this hard, she thought she should be earning more, but that seemed unlikely. She could leave (and many do), or she could start to reduce her effort in order to reduce the inequity she was feeling.

Deciding on the last option, she began to search for what she could overlook. One possibility was the 45-degree ROM in the resident care plan. She said she could pretend that she forgot what that meant. After all, the resident found these ROM exercises painful, and nobody was monitoring the completion of this task, anyway. Thus, the chain of events began, leading to a gradual loss of commitment, honesty and integrity.

Four years ago, in an attempt to identify the internal organizational issues that stand in the way of quality and excellence and receive some ideas on what to do about these, eight nursing homes in Western New York participated in a series of 14 different focus groups. Separate focus groups took place: first, with administrators, then with directors of nursing (DONs), followed by certified nursing assistants (CNAs), social workers, family members and, finally, with residents in each of the eight facilities. Although all staff positions are critical to achieving a high-quality nursing home, employees in these positions were chosen because they can have significant influence on the issue of quality and excellence. All of the sessions were audiotaped.

At the beginning of each session, before any discussion took place, an open-ended survey form was distributed asking each participant to identify as many barriers to quality as space and time permitted. The most frequently mentioned obstacles to quality were:

1. Inconsistent staffing and shortages

2. Need for individualized care

3. Cooperation, attitude problems/prejudgment of residents by staff

Responses among participants varied. "Inconsistent staffing and shortages" was a barrier acknowledged by participants in all groups. However, "need for individualized care" was never mentioned by an administrator, while state surveyors (who also conducted their own focus discussions) clearly established this as a high priority. "Staff cooperation, attitude problems and prejudgment of residents by staff' was a much greater concern for CNAs than for all other participants.

At the end of each session, after two hours of discussion, another survey was distributed asking each participant in each focus group to list opportunities for change to improve quality. Those most frequently mentioned opportunities were:

1. Training/orientation/education

2. Improve communication among staff

3. More personal care and choices/understanding individual needs of residents

4. Quality staff

5. Interdisciplinary team 

6. Improve communication with family

Improved communication predominates as a need but, again, the distribution of responses is significant. "Training/orientation/education" and "quality staff" were relatively high priorities for all, while "improve communication among staff" was more important for the CNA. The "interdisciplinary team" was never mentioned by an administrator, but the CNAs frequently identified this as extremely important. The surveyors repeatedly mentioned more personal care and choices--understanding individual needs of residents," making this their highest priority for change, yet no administrator or DON listed anything in this category as an opportunity for change.

It is not surprising that family members see "improve communication with family" as a high priority, but it is not as clear why administrators and DONs would not mention this at all. The conclusion might be that we don't see things as they are, we see them as we are.

It is important to see things as they are. Peter Drucker, one of our leading thinkers on management practices, states that an organization must be single-minded, with a crystal-clear mission and vision, or its members will become confused; without a focused and common mission, members will define "results" in terms of their own specialty and impose that specialty's values on the organization. [2]

Moreover, the population of workers in long-term care is growing more diverse, as is the population of residents. Diversity is expected to characterize our work force in this new millennium with even more differences in communication styles and values. Already there are gaps in age, gender, income, education, culture and ethnicity wide enough to cause communication problems. Given this diversity, how can the organization foster shared organizational values and inculcate them in its members?

Every expert states that organizational change always requires commitment from those at the top. Managing change requires vision, skills, incentives, resources and an action plan. Without vision, confusion is the likely result. Without appropriate skills, expect anxiety. Without incentives, anticipate resistance, and without resources, look for frustration. In the absence of an action plan, an endless repetition of the same mistakes can be the consequence. Leaders have to make relationships work, and communication is the glue that holds this together.

Leaders need to open channels for others to talk, listen, contribute and reflect. They need to listen to feedback about how others in the organization perceive the same situation. [3] Leaders need to give up some control and refrain from taking credit for the good work of others. Systems thinking should be reflected in leaders using the pronoun our with greater frequency than "my."

The DONs in their focus group clearly did not trust aides, sometimes discussing them as parents discuss irresponsible children (see DON Focus Group Highlights, at right). Yet, empowering aides can yield valuable insights on ways to achieve higher levels of efficiency, quality and collaboration (see CNA Focus Group Highlights, p. 42). A new worker with a new perspective could be a major resource for fresh ideas and innovation.

Unfortunately, a newcomer soon learns that the regulatory process motivates nursing home providers to meet standards of care in paper documentation. Clearly, problems in long-term care facilities are many, even in those that are deficiency-free, with staffturn-over rates well over 50%, absenteeism, call-ins, thefts and the filing of false worker's compensation claims, as well as problems of low morale and low job satisfaction.

It won't take long for a newcomer to discover that many aides have personal problems with dysfunctional families, children, drinking and drugs; they often lack transportation and other resources. Turnover among aides can also be explained partially by the wages. In 1995, a study found the average annual salary for a nursing home aide was under $10,000, the average hourly wage was $5.60, and 28.5% of these aides had no health insurance. [4] Increases since have not been substantial. More money is not the miracle answer, however; other studies have shown that aide turnover can be significantly reduced by involving them in interdisciplinary care plan meetings. [5] It is worth noting that this same study found that none of the following factors were significantly related to aide turnover: involving aides in assessments; aide training; workload; case-mix severity; payer source mix; or facility size.

Personal characteristics and attitudes are good predictors of turnover. [6] Are the values of this applicant compatible with those of the organization? How will that person fit as a team member? Aides in the focus groups said they would rather work "short" than have to put up with a new employee who has little commitment and a poor work ethic (see CNA Focus Group Highlights). Experienced aides know within a relatively short time whether the new employee has the appropriate combination of qualities to work "with" residents rather than "to" and "for" residents.

The organization's values must be supported by policies and actions that make them real. Mentors can highlight what loyalty and commitment do for those who give them--for example, learning how to be loyal, trusting and committed to the organization can be a source of personal growth for the individual.

Drucker suggests that an organization is always in competition for its most essential resource: qualified, knowledgeable people. The discussion at the focus groups clearly demonstrated that nursing home employees are eager to learn where autonomy, trust and respect are valued, and they are anxious to seek employment there (see CNA Focus Group Highlights).

According to a recent study, annual turnover among nursing home administrators might be 40% or higher. [7] Administrator turnover can be especially damaging to staff morale and to achievement of the organization's vision and mission. That is why it is worth remembering that the real difference between success and failure in any business can be traced to how well the organization binds people to a common cause, despite their rivalries and differences. Rather than finger pointing, excusing, blaming and ducking, core values need to guide behaviors. Leaders need to be straight-talking advocates for the organization, asking irreverent questions, giving positive strokes, admitting mistakes and learning from them (see Administrator Focus Group Highlights, at right). [8]

Registered nurses often provide the primary professional authority and leadership in nursing homes. Studies have found that, although they raise issues, RNs often lack the decision-making skills to "choose the alternative." They need better training on how to present persuasive arguments, using research findings and tangible data when appropriate.

Listening must be a high priority if the untapped resource of employee communication is to reduce costs, increase revenue and enhance customer satisfaction. Staff members don't all have to work the same way, but they do need to work together and listen to each other. With both formal and informal listening, and a balanced relationship of trust, it's surprising how many issues can be raised, clarified and resolved.

Focus groups can provide insights into behavior and attitudes to bridge those communication gaps and the differences in interpretation. Individuals are more willing to talk about a subject in the security of a group. Collaboration in a safe environment, occasionally with other facilities, can encourage reflection on problems and opportunities, and provide a wealth of useful information.

To illustrate, we offer excerpts from the focus groups we conducted.

Marian Deutschman, PhD, is an associate professor of communications at Buffalo State College, Buffalo, NY.

References

(1.) Shockley-Zalabak P. Fundamentals of Organizational Communication. White Plains, NY: Longman Publishers, 1995.

(2.) Drucker PF. Peter Drucker on the Profession of Management. Boston, MA: Harvard Business School Publishing, 1998.

(3.) Kanter RM. Rosabeth Moss Kanter on the Frontiers of Management. Boston, MA: Harvard Business School Publishing, 1997.

(4.) Crown WH, Ahlburg DA, MacAdam M. The demographic and employment characteristics of home care aides, hospital aides, and other workers. The Gerontologist 1995;35:162-70.

(5.) Banaszak-Holl J, Hines MA. Factors associated with nursing home staff turnover. The Gerontologist 1996;36(4):512-15.

(6.) Kiyak HA, Namazi KH, Kahana EF. Job commitment and turnover among women working in facilities serving older persons. Research on Aging 1997;19(2):223-46.

(7.) Singh DA, Schwab RC. Retention of administrators in nursing homes: What can management do? The Gerontologist 1998;38(3):362-9.

(8.) Matejka K, Dunsing R. A Manager's Guide to the Millennium. NY:AMACOM, 1993.

(9.) Anderson RA, McDaniel RR. Intensity of registered nurse participation in nursing home decision making. The Gerontologist 1998;38(1):90-100.

DON Focus Group Highlights 7 Directors of Nursing from 7 Different Facilities

Definition of quality:

Ideal facility sets standards higher than health department, with input from all staff. Quality is a philosophy, an administrative attitude. Minimum can be acceptable, but the organization gets farther and farther behind. Often can't do much more than minimum. Reimbursement pays for minimum standards; No difference in quality between for-profit and not-for-profit; it depends on ownership. Same problems regardless of size. Quality is personalized care, doing better than basic. Camaraderie in the organization is important.

Recommendations/opportunities for change:

Make long-term, care facilities centers for research, education and training. Long-term care needs respect and recognition; perceptions need changing, even among professionals.

Hospitals are not expert in long-term care; CNAs do better job of maintaining clean, fed and dry residents than RN in hospital. Need to get CNAs involved, listen to them, involve them, get their buy-in. Have CNAs prepare one in-service per year, alone or in groups of two; on subjects such as lifting, transferring. Enhance their well-being and education.

Training and practice:

Unions can be a barrier, especially every three years when contract is renegotiated. Staff becomes adversarial, undoing relationship building. Some won't do one more thing outside job description.

Primary, permanent assignments are great, except for burnout. Support, education, training and counseling prevent burnout. Turnover is the second most important barrier to quality (after money). Most CNAs reflect society as it is now. Twenty-year-olds don't take pride in their work; attendance is not important to them; they don't have a work ethic; can't spell, write or read. Nobody resigns--just no-show. Lack of responsibility, accountability. Some facilities require call only to DON if calling about absence. Pitiful salary, little education, single parents, tons of problems, different culture, different way of life, survival, with thousands of excuses.

Need to have reputation in community as "that's the place I'd like to work." Frequent changes in director of nursing and administrator make team building difficult-staff senses insecurity and fear of firing. Middle managers are not given attention.

Nobody wants to be in a nursing home because they're institutions, not homes: live with strangers; don't want to be bathed by someone; lose dignity, choices, privacy; forced to eat and sleep at certain time. Residents are sicker now at admission. People with no personality or low competence are good for case mix but make others uncomfortable by screaming, drooling, spitting, jabbering, swearing, wandering, frightening others. To compensate, encourage personalized care; decrease institutional structure; have residents exercise rights. Involve alert residents in off-unit activities.

CNA Focus Group Highlights 15 CNAs from 8 Different Facilities

Definition of quality:

Meeting resident needs-socially, physically and mentally. Total dedication of each department working together; good communication among nursing staff, social work and administration. Quality is the little extra things you do: spruce the residents up, spend time with them, notice problems, listen to them, touch them, let them know they matter.

Recommendations/opportunities for change:

Involve resident and family in care planning. CNAs should attend resident care plan meetings because they know the resident better than anyone else. Don't tell CNAs how important they are when you hire them and then forget to give them recognition or respect. Listen to them. When a doctor comes to the CNA, the CNA is told to say, "You have to speak to the nurse." The nurse, who may be new, is often too busy with paperwork and "pushing pills" to know the resident well. Most people don't take the CNA seriously. Many nurses will say, "I'm busy right now, tell me later."

Training and practice:

Training should include familiarizing CNAs with all departments. Have them meet in small groups to improve knowledge, awareness, performance. More hands-on training--watching is better than reading a book. Need occasional role reversal-others should be an aide for a day. An LPN feels it's an insult to do the aide job. Many nurses and LPNs don't like "stepping down" to do an aide's job. They say, "I didn't go to school to do patient care." They become good at giving orders. Nurses who do help are sometimes told, "You're being too nice to aides; that's not what you were hired for." Need more work sharing. There is a lack of empathy. "Many don't have the foggiest idea what we do." They issue unreasonable, ludicrous orders and make promises to residents and families that can't be kept. This causes chaos. "And God forbid if you question the head nurse."

"I was so pumped up when I was hired. It was totally different when I got on the floor. I love what I do but I get so discouraged." "If you can't get respect, go for the money." "A bunch of us will go talk to administration. They say they'll look into it--and that's the last you hear about your issue."

"We're working short 80% of the time. Need better screening and selection of aides. Test to be certified is a disgrace. My ten-year-old daughter could pass it. It's really discouraging to work with some of these people who only do it for the paycheck."

"Biggest problem is the combative resident who responds to no one. Explosive resident results in turnover."

Aides prefer special wing for residents with Alzheimer's and related dementias, but it can be "shell-shock" at first for some who work there. Good to rotate assignments within floor but not between floors. Rotation preference depends on type of residents-need break from some.

Strengths of the job:

Appreciation from residents and family. Hearing family tell you "you're the only good thing this woman has." This is a short list of joys but it "doesn't get much better."

Administrator Focus Group Highlights 8 Administrators from 8 Different Facilities

Definition of quality:

"Whatever Janet says it is!" ("Janet" was the director of long-term care for the state health department at the time.) Three key words: look, smell and listen. Look at residents' appearance, smell the facility and listen to staff interaction. Quality is motivated employees.

Barriers to quality:

Unmotivated employees, inconsistent staff and staffing. Definite difference in attitudes, and personal issues that accompany attitudes in suburban, rural and urban locations.

Can't depend on steady cash flow. Moved from committed, caring profession to big business. Keeping facilities updated takes huge amounts of money. Inconsistent policies of state health department.

Private-pay dropping each year. People are taught how to shelter investments. Indigent of the past now have family, and are now educated, demanding residents. "Smarter people making us smarter" but "quality care is tied to financial support--no way around it." Negative public perception. Uneducated reporters, in search of scandal, lack objectivity.

Recommendations/opportunities for change:

Need education on definition of quality and people's expectations. It's an ongoing philosophy that can't be done with in-services. Some facilities have developed Quality Care Councils on how to do things better with involvement of nursing assistants. Others have developed Customer Service Programs.

Nursing assistants are savvy; most are willing to change, while others aren't. Takes 3 to 5 years to get buy-in and understanding of major philosophical change. Important to have staff read, see and remember the change.

Supervisors are often the barrier to change. Old paradigms are a problem. Nurses are apprehensive, not doing job of motivating--need reassurance they won't lose job. Team leaders need management training--can't automatically become supervisors. They need to redefine their roles. "Aides need to have input into care plan, need to know ADLS inside and out." Permanent, primary care assignment results in increased attendance, "their" resident, and residents love it.