Schneider Institute for Health Policy Heller School for Social Policy and Management

1. Organizational Research on Nursing Home Human Resource Management: The Frontline Caregiver Christine Bishop, PhD., Speaking for the Project Team Schneider Institute for Health Policy Heller School for Social Policy and Management Brandeis University AcademyHealth Annual Research Meeting Boston June 26, 2005

2. Improving Institutional Long-Term Care for Residents and Workers:The Effect of Leadership, Relationships and Work DesignFunded byBetter 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)

3. 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 Elizabeth Dodson, Ph.D., Boston College Student Research Assistants: Almas Dossa, MPH, M.S., Brandeis Susan Pfefferle, M.Ed., Brandeis Rebekah Zincavage, M.A, Brandeis Consultants: Barbara Whalen, M.P.A., Harvard Frank Porell, Ph.D., U Mass Boston  Administrative Assistant: Joanne Jannsen, Brandeis

4. Philosophy of Care Financial Constraints Philosophy of Management Management Practices Staffing ratios · Resident Assignment · Call-outs· Care Planning· CNAs Working Together· Coordinating with Other Departments· Hiring· Training· Promotion· Supervision· Evaluation and Discipline· Rewards· Retention Direct Care Workers Residents

5. Research Questions • How do organizational factors (human resources practices, staffing and scheduling patterns, participation in decision-making) and leadership shape care practices, teamwork and workplace relationships in nursing homes? • How do these factors and mechanisms ultimately shape outcomes for workers, facilities and residents in nursing homes?

6. Variation in Workplace Practices Across 18 Homes • Not necessarily associated with self-identification as engaged in culture change • Strategies to produce high-value, customized service • Parallels to human resources approaches in other industries -- contrast • Hierarchical command-and-control organization • “High commitment” human resources management

7. Context: Workers and Job Design for Resident-Centered Care (“Culture Change”) • Focus on finding the essentials of “home” in an institutional environment • Customize care to individual residents • Achieve through empowering frontline caregivers to give more to resident care • Recognize frontline workers as “heart and hands” • Better Jobs for Better Care (hypothesis) • Project hypothesis: many ways to reach this goal • (Achieve through environmental changes and resident schedule flexibility)

8. Resident-centered Care in a Larger Frame: High-Performance/High-Commitment Human Resources Management • Evolving in American management • Labor is not just a cost but ADDS VALUE • Bundles of personnel practices that improve the bottom line • In manufacturing industries • In service industries • Win – Win: Better jobs for greater business success • Automobiles • Steel • Banking

9. High-Commitment Human Resources Management • Employees understand and work for goals of organization • Employees are flexible, willing to take on expanded jobs as needed • Employees exercise judgment and contribute ideas for improvement of work process (Source: Baron & Kreps 1999 p. 189)

10. Organizational Practices associated with High-Commitment HRM • Extensive screening of prospective employees, emphasizing cultural fit • Extensive socialization and training of employees, including cross-training • Job enlargement (the job includes more tasks than is typical) and enrichment (the variety and challenge of tasks is larger than usual) • Self-managing teams and team production • Extensive job rotation (Source: Baron & Kreps 1999 p. 190)

11. Organizational Practices associated with High-commitment HRM (cont’d) • Premium compensation: “productivity” wages, superior benefits • Employment security, job with a future • Open information about all aspects of the enterprise • Open channels of communication: Employees at all levels allowed /expected to contribute ideas • Worker autonomy, less hierarchical management structure • Fairness

12. Better Jobs Better Care in High Commitment HRM Context • Research in industry shows certain bundles of human resources practices DO add value in some situations –e.g. customized, high-value products and services • Lower turnover; retention of the best workers • Quality circles, TQM: engaging front line in quality improvements and cost reduction improves the bottom line • Self-managing teams enable better use of management resources • To hire, train, and retain workers ready to do expanded jobs: need premium wages, benefits, jobs with a future • Unions: resist job flexibility, job expansion –or partner to support industry (and thus worker) success

13. Is High-Commitment Human Resources Management Relevant to Nursing Homes?

14. Hypothesis: Resident-centered care adds value through changing the content of the nursing home service • Not just a day of “maintenance” • Improved clinical quality (“zero defects”) • Improved quality of life • Valued by residents  value for nursing home (?) • Win – Win – Win ??? • Residents • Frontline workers • Nursing homes (IF willingness to pay for value!)

15. Our 18 nursing homes vary widely in organizational practices. • CNA job characteristics • Availability of frontline worker knowledge to contribute to resident care

16. Dimensions of Frontline Jobs:CNA Views • Very hard physical work • Job may be individual vs. helping out vs. teamwork • Care work: attachment, willing to go beyond defined tasks • CNAs hold knowledge about residents • But this is seldom explicitly called on • Assignment to a stable group of residents facilitates CNA knowledge • CNAs often do not feel respected and valued for what they contribute Source: BJBC group interviews with CNAs in 18 Massachusetts nursing homes

17. For Care to be Customized, CNAs Need Access to Knowledge about Residents What would you change about your job, besides the pay? “ The communication between the nurses and the CNAs. Sometimes they're supposed to at least let us know about new people, when they come in, instead of us coming in and figuring out on our own. I know it’s like personal stuff, but we’re the one dealing with them, so we should know what’s going on with them. So sometimes they do. They're supposed to; sometimes they do, sometimes they don’t, so the communication is not really there.”

18. CNA Knowledge isn’t always Available for Resident Care “It’s like a kind of attitude problem, too. Like some of the nurses, they think because -- it doesn't happen to me -- because they are nurses and you are a CNA, it’s like you have to go on what they say. You are the CNA. The problem ... (inaudible) here, it’s like when you go to the nurse and tell the nurse about the patient, you know you are dealing with them, we are the ones who see everything on the patient, but when you go tell them that the patient needs this, the patient needs that, the patient does this, they don’t even pay attention to you, it’s like you have to go so many times before they do something about it.   “And I heard one CNA said when they go to report something to the nurses about the patient, they're like ‘You don’t have to tell me what to do. I'm the nurse.’”

19. CNA Knowledge isn’t always Available for Resident Care (cont’d) “What we are saying is it is not like we have-- we don’t have any problem with anybody, but there are some things,because sometimes if you are the nurse, and I am a CNA, there are some things I cannot tell you because you don’t think I'm telling you the right thing, because maybe you have another experience of how you handle things, but maybe if we sit down and you listen to it, you're going to see what I'm telling you is better than what you know. And sometimes people see you when you are a CNA, they say, ‘No, I went to school for this and this, you don’t need to tell me nothing.’”

20. Organizational Practice Variation: Care Planning Involvement • Minimal input • Input through charting • Input through verbal report • Input through attending care plan meetings Reports of unit charge nurses

21. Minimal CNA input Do CNAs have input into the care plans? “In a way they do, because we are reflecting on their work ... (inaudible) or whatever they do for the patient. ... (inaudible) so that patient is more tired, we need to ... (inaudible) timely basis so they ... (inaudible).”

22. CNA input through charting “They chart, and we [nurses] look at the charts. They have the kind of diet they're on, their transfer, whether or not they have a restraint, positioning, hygiene, like whether or not they're independent, or any special skin care, limitations.” “…The care plans, most of the time, will go according to the nurse’s summary, and the nurse’s summary will take into account the CNA assignments. So when I’m doing my nurse’s summary, I’ll look at the CNA’s record, and then I’ll do my summary from there, and then the unit manager will do the care plan from my nurse’s summary.”

23. CNA input through verbal report “They're the ones directly giving the care, so if they notice a change, they go to the charge nurse and they give their recommendation and their reasoning. If it’s determined a change needs to be done, then it’s changed.”

24. CNA input through attending care plan meetings “Sometimes CNAs will come to the meetings, yes. They try to get them involved, because I think they’re really the front line people. They see [the residents]. They know them better than we do. So yes, they’re encouraged to go. They’ll get the primary aides whenever they’re doing that particular resident, they’ll bring them in. …Besides mine, their input is really important. Because ... anything they will see for the patient, they will be the first. If it’s not any open area like on their face or something that anyone can see, because they’re always changing the patient or doing things, they will tell us what’s going on, if we didn’t see it, like at first.”

25. Several report that CNAs used to attend but no longer do “They don’t have an aide go anymore. We used to have aides go to the care plan meetings, which was good. Now, I would say today I went to my very first one in probably seven years and there was just the MDS, MMQ, social worker, myself and the family, and the patient...But we don’t have an aide, which I think might be a better part of that team. Because some of the aides know far more about people than I do.”

26. Including CNAs in care planning may increase • accuracy of care plan • CNAs’ knowledge of other disciplines, other aspects of resident care • resident quality of care • resident quality of life • But CNA must feel her voice will be heard • Many CNAs feel committed to their residents • What do CNAs believe the nursing home is committed to ?

27. Where we started -- Direct care workers are the heart and hands of nursing home care

28. What we are thinking now-- Direct care workers are the heart and handsAND key eyes, ears, and mindsfor HIGH-VALUE nursing home care