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Developing the Partners for Culture Change: Getting to a New Culture of the Workforce

By Anna Ortigara RN, MS, FAAN

Providers of care throughout the continuum of aging care services are taking a hard look at their culture and how they have designed and delivered services to elders. Elders have clearly told us what they do not want from us. They don’t want to lose control over their lives, or to be discounted and put on the sidelines of real life; nor to be a non-player in their own life, being treated as less than an equal. The very essence of personhood is challenged as elders are expected to be satisfied with these non-adult, dehumanizing roles.

What have elders told us is important to them? Some things that elders have clearly stated is they want to be respected. They want to be in relationships with people they know, like and respect and to feel known, liked and respected in return. Critically important is the right to make decisions and to control their own lives. Elders expect to have opportunities to be meaningfully engaged and be in reciprocal, normal relationships. And to have meaningful, purposeful things to do. Now this may sound a lot like a normal life—what we all pretty much want.

Exactly! So how is an organization supposed to take on the daunting challenge of providing person-centered care, to create a culture of social well-being and to foster and nurture the people in their setting of care?

One first step is for leadership to commit to this vision. Transforming to a person-centered, person-directed care culture is a huge commitment. Elders need to be asked for their input and be involved in the shaping of all culture changes that are undertaken. A culture of choice and self-direction will require redesigning most of the systems of an organization. Consider this vision: creating mealtimes that are flexible, normal and delicious; supporting a staffing model of primary assignments; allowing people to wake up whenever they choose; encouraging staff to engage in self-scheduling and participate in hiring new staff; elders having access to food day and night, and continuing to be an integral member of the community. These are not small changes. And yet they are only the beginning of a transformed culture.

To get to a new culture, organizations need to look at the culture of their workforce. Just as there is an old culture and new culture of the whole organization, there are many “old ways” in how the workforce is seen and valued. In an old workforce culture there was a rigid top down hierarchy. The direct care workers were expected to deliver care to elders but were not empowered to have input into that work. They may have been seen as interchangeable, with pretty much the same talents. Individuality and initiative could even be seen as negative traits.

The role of C.N.A.s
This workforce culture might be most vividly illustrated in the role of C.N.A.s., who, in a relationship-based care culture, are the most important staff members of the care team. Why? Because they should have the strongest relationship with residents. It is often quoted that nursing assistants provide 90 % of the direct care to residents. But beyond the direct care, of all staff, the nursing assistant is most likely to know the resident as a person; their fears and joys and preferences and desires. The C.N.A.s contribute observations and knowledge to the rest of the care team through care plan meetings and by sharing with all the team members each day. So it seems obvious—care settings committed to person-centered care need to empower, develop and involve direct caregivers to successfully meet the expectations of the elders served.

But the reality may be far from the ideal. Nursing assistants often cite being out-of-the-loop in terms of providing information and input into the work they do. In focus groups, nursing assistants talked about how nurses (critical team partners) don’t respect or value their knowledge. Some directs quotes are:

These statements are very powerful!

And nurses have opinions too. They often observe that nursing assistants are not always team players; that they don’t understand the amount of resident documentation the nurse has to do, requiring them to sit behind the desk for long periods of time; feeling like the nursing assistants far outnumber the nurses, and that they consider the care unit as an US (the nurses) versus THEM (the C.N.As) kind of culture.

These feelings have roots in reality, but they are just not useful. How can C.N.A.s, nurses and all team members be in meaningful relationships with residents if they do not value and respect each other?

The key is to start the cultural transformation of the workforce within care settings. There are five elements that shift a care organization the from the old culture of the workforce to a new value-rich, relationship-based culture.

Value of the work
What is the worth that each organization places on the actual work of direct care workers? If the direct care worker provides the overwhelming amount of care for the elder, it would be logical that the work, talents and skills of these individuals be the most highly prized and valued by a provider organization. Nursing assistants consistently report the opposite. They discuss how they are seemingly invisible to the administration and lack relationships with nurses. The establishment of person-centered, respectful relationships with nurses is a powerful first step to valuing the work of each team member.

Input into work processes
People have more invested in their work when they have real input and ownership in the way the work gets done. Edward Deming identified that the person doing a job knows more about the true process of that job than does anyone else. He proposed that it is insane to try to design or improve a work process without the involvement of the people directly involved in that process. It would be crazy to adapt primary C.N.A. assignments without a process design team made up of representative C.N.A.s as well and other departmental staff who interface with a primary staffing model. Including residents!

Recognizing each person’s talents
Each of us comes to this work with unique talents and skills, as well as the heart for committed relationships with elders. And yet organizations have not always seen individual skills and talents as desirable in frontline staff. The notion of empowered, talented nursing assistants can even be threatening for an “old culture” organization. To get to a transformed culture of the workforce it is critical that the talents of each care team member is recognized and encouraged.

Support individual growth
The is a big move towards a new culture. The notion that the success of any organization depends upon the continuing growth and learning of their employees is basic to a person-centered culture of care. This growth may be educational opportunities within and beyond the community. Opportunities for advancement in the form of career paths and career lattices are great, but go beyond just involving individuals in education. Organizations must identify opportunities for staff to be in the roles of teachers and mentors, and encourage them to educate the community and professional groups about the work they do.

Nurturing new staff
The culture of an organization can truly be seen in how it treats new employees. Are they set up for success or failure? Many new staff members recall being thrown into the work with little direction or support. What is expected of them? Who are these residents and what are their needs? Where do I go to lunch and put my purse? Some have called this non-support of staff as the “eating our young” syndrome—the notion that new staff need to sink or swim on their own. To create a care culture that is person-centered, it seems like nurturing our young is a better approach—and an important commitment. Not to mention the incredible cost of recruiting and orienting new staff for organizations.

Creating person-centered care teams
This is where the culture comes together around the elder. We need to be in person-centered relationships with each other to support and model these relationships with elders. So what does this mean? What is the nature of communication between nurses and nursing assistants? Is it respectful and encouraging? Does it value what each person brings to the care team? Once again, it is about relationships.

Cultural transformation is not about creating a new dining program, implementing it and calling it accomplished. It is not a destination, but a journey. Committing to a culture that affirms the personhood of elders is a substantial undertaking. We have no other choice.

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Additional resources

"Creating a High Retention Culture," an essay about creating a positive and productive work environment for long-term care employees (PDF)

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