Academic journal article Generations

Reinventing Management Practices in Long-Term Care: How Cultural Evolution Can Affect Workforce Recruitment and Retention

Academic journal article Generations

Reinventing Management Practices in Long-Term Care: How Cultural Evolution Can Affect Workforce Recruitment and Retention

Article excerpt

Training, team-building, mentoring, and skill development all contribute to positive change.

Nursing assistants, home health aides, and other direct-care workers provide almost all long-term care, and play a central role in the quality of life of those who, due to chronic disease or disability, need help with personal care. Direct-care workers are paid low wages, have limited advancement opportunity, and often lack respect (Stone and Harahan, 2010). The resulting high turnover, inadequate training, and shortages lead to problems accessing services, high costs, and poor quality of care (Institute of Medicine, 2008). Despite their importance, however, recruitment and retention of these directcare workers is a challenge for almost all long-termcare providers (Stone and Wiener, 2001).

It is difficult to recruit direct-care workers because of the emotionally and physically challenging nature of the work, plus there's a lack of training, few chances for advancement, workplace stress and burnout, poor supervision, lack of respect, and chronic understaffing issues. A number of workforce initiatives have sought to improve recruitment and retention (Harris-Kojetin et al., 2004). The initiatives intended to improve staff management are one component of what has become a movement to change the culture in the nursing home sector. The movement promotes structural and, in some cases, regulatory changes to advance resident-centered care, the inclusion of direct-care staff in decision making, and more homelike environments in the care facilities.

Long-Term-Care Management Practices as Cultural Artifacts

Proponents of culture change in nursing facilities identify a number of unproductive practices held over from the medical model of nursing home care (Misiorski, 2003; Koren, 2010). Some artifacts of such cultures are architectural (e.g., hospitallike facilities) or otherwise linked to the physical environment. Others are tied to excessive hierarchy, such as job designs that constrain both clinical skill- and relationshipbuilding by discouraging consistent assignments and teamwork. Changing these practices is at the heart of the culture-change movement.

Edgar Schein, one of the most influential writers on the nature of culture and organizational change, identified three layers of culture: artifacts, values, and assumptions (Schein, 1985). Artifacts are symbols, such as uniforms, or practices managers display or enforce-and can consciously change. Artifacts may be thought of as the tools of culture maintenance and culture change. Examples of management practices that are cultural artifacts include policies affecting which levels of staff have access to what information, or what physical barriers limit residents' independence. When visible changes are made in an organization, they in turn can lead to changes in perceived value among employees. If these altered values persist over time, they become incorporated into the fundamental taken-for-granted assumptions that provide a foundation for changes in attitudes and behaviors.

Changing Management Practices to Change Culture

Some changes in management practices challenge existing organizational values and assumptions. Radical change (such as a corporate takeover) may include destruction of the organization's artifacts, values, and assumptions. In nursing facilities, the Green House® model most clearly represents radical change. There is very little about this model of care that looks or feels like a nursing home. Prior research on this and other deliberative, multifaceted culture-change programs in nursing homes have offered some support for improved outcomes for both residents and providers (Coleman et al., 2002; Stone et al., 2002; Misorski, 2003; Kane et al., 2007; Elliot, 2010).

As evidenced in the recent Commonwealth Fund National Survey of Nursing Homes, however, few nursing facilities are undertaking radical change even with the culturechange movement taking hold (Doty, Koren, and Sturla, 2008). …

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