Nurses as Power Brokers

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					 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
            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
Improving Institutional Long-Term Care for
         Residents and Workers:
The Effect of Leadership, Relationships and
                Work Design

Funded 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)
      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.
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
 Many Paths to Culture Change

For example,
 Eden Alternative

 Wellspring Model for Improving Nursing
  Home Quality
 Action Pact

 Pioneer Network
 Many Paths to Culture Change

Two common themes:
 Empowerment of residents

 Empowerment of front-line staff to meet
  residents’ needs and desires
     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
 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
           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
     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?
        Defining Empowerment

   Control over the work process --
    autonomy
   Control in the workplace – participation in
    decision-making
 Nurses’ Role in Empowering CNAs
Who Champions             Are CNAs
Empowerment?              Empowered?
Neither administrators    No
nor nurses
Administrators only       No

Nurses only               Somewhat (on units, but
                          not within larger NH context)
Both administrators and   Often, but not always
nurses
      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
     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
           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
 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
 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
     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
                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
              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
              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
              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

				
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