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Organizational Research on Nursing Home Human Resource Management: The Frontline Caregiver Christine Bishop, PhD., Speaking for the Project Team


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Title: Organizational Research on Nursing Home Human Resource Management: The Frontline Caregiver Christine Bishop, PhD., Speaking for the Project Team

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

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)

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

Philosophy of Care Financial Constraints Philosoph
y 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
Direct Care Workers
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?

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

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)

Resident-centered Care in a Larger Frame
High-Performance/High-Commitment Human Resources
  • 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
  • Automobiles
  • Steel
  • Banking

High-Commitment Human Resources Management
  • Employees understand and work for goals of
  • 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)

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)

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

Better Jobs Better Care in High Commitment HRM
  • 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)

Is High-Commitment Human Resources Management
Relevant to Nursing Homes?
Hypothesis Resident-centered care adds value
through changing the content of the nursing home
  • 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!)

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

Dimensions of Frontline Jobs CNA Views
  • Very hard physical work
  • Job may be individual vs. helping out vs.
  • 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

For Care to be Customized, CNAs Need Access to
Knowledge about Residents
  • What would you change about your job, besides the
  • 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 its like personal stuff, but were
    the one dealing with them, so we should know
    whats going on with them. So sometimes they do.
    They're supposed to sometimes they do,
    sometimes they dont, so the communication is not
    really there.

CNA Knowledge isnt always Available for Resident
  • Its 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, its like you have to go on
    what they say. You are the CNA. The problem ...
    (inaudible) here, its 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
    dont even pay attention to you, its 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 dont have to tell me what to
    do. I'm the nurse.

CNA Knowledge isnt always Available for Resident
Care (contd)
  • What we are saying is it is not like we have--
    we dont 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 dont 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 dont need to
    tell me nothing.

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

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).

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,
  • The care plans, most of the time, will go
    according to the nurses summary, and the nurses
    summary will take into account the CNA
    assignments. So when Im doing my nurses
    summary, Ill look at the CNAs record, and then
    Ill do my summary from there, and then the unit
    manager will do the care plan from my nurses

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 its determined a change needs to
    be done, then its changed.

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

Several report that CNAs used to attend but no
longer do
  • They dont 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 dont 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.

  • 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 ?

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

What we are thinking now--
  • Direct care workers are the heart and hands AND
    key eyes, ears, and minds for HIGH-VALUE nursing
    home care

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