LEADERSHIP & ORGANIZATION BEHAVIOR FINAL PAPER
The organization I choose to do my project on is Long Term Nursing Care facilities. I believe these facilities strive to give the best care to their residents for the duration of their stay. What concerns me is the staff turnover challenge that I see on a daily basis. I am currently a mobile x-ray technologist and I go into these facilities multiple times a day throughout the greater Charleston area. I have built great relationships with the staff and residents. I notice that the staff keeps changing regularly and I feel this causes a negative atmosphere for these elderly residents who deserve the best care at this stage in their life.
Defining Long Term Care
Long Term Care facilities provide continuous care over a period of at least 90 days for a range of acute and chronic conditions (Barton 2006; Pg. 367). In order to really assess the resident they do a measurement of daily functions. There are two measures used to determine their level of disability. The activities of daily living (ADL) are the most basic self care tasks required for independent functioning (Barton 2006; Pg. 367). The instrumental activities of daily living (IADL) are the skills required to perform social tasks and basic household chores to maintain greater self-sufficiency (Barton 2006; Pg. 367). Analysts believe that the need for Long Term care services is likely to increase for at least the next three decades because: •Aging population- Baby boomers approaching 60.
•Medical advances enable the saving and sustaining of more lives, which may require Long Term Care services. •Medical advances have lengthened the life spans for some congenital and disabling conditions. (Barton 2006; Pg. 369) Even in a nursing home, a site likely to provide the most intensive level of Long Term Care services, the total amount of nursing-care time a patient receives in a 24-hour period is 1.7 hours; 8% with Registered Nurse and 77% with Certified Nurse’s Aide (Barton 2006; Pg. 372).
My thoughts on challenges with staff turnover
I feel that staff turnover poses a challenge for both the nurses and the residents. Obviously nurses are not happy in their career which in turn creates negativity at work. This reflects poorly on their performance and also affects the resident’s happiness. To help compile this paper, I have researched the supply and demand of nurses, found some studies on the social relationships between residents and nurses, and evaluated the wants and needs of nurses to encourage motivation to stay with a company. With the prospective increases in residents that are going to require Long Term Care in the future this has to be changed and improved upon.
My thoughts on building relationships and how this affects quality of care On the other hand, when living in these facilities the resident just wants to build relationships and continue care the best way they can in a positive environment. Nurses and Certified nursing assistants can tend to be very busy during the day and not have time to really get involved with the resident personally. Residents tend to get very lonely and feel neglected. For example: I have been at a facility and had to do x-rays on individuals that are not even cleaned up yet after a night of sleep. Most of these individuals cannot get to the bathroom on their own, so if not cleaned promptly they become smelly and messy. This is not comfortable for them, not to mention embarrassing. This affects their positive atmosphere and quality of care. Stated in the above statistic nursing professionals only spend 1.7 of the 24-hour period with the residents.
Long term nursing care facilities main focus is to create an at home environment for their residents. They are usually coming to this facility to recover from a surgery, no family to take care of them, or simply just to live the independent lifestyle with the care of medical professionals for those added needs you may require on a daily basis at this stage in your life. The challenge that seems to be making this focus hard to achieve is the high staff turnover rates. This creates a constantly changing atmosphere for these residents. I feel that there has to be something causing this to occur. It could be the treatment of nurses from management, the low wages, or lack of incentives to do well. This impacts the quality of care that these patients deserve and the relationships they build. I think that if I can find out what is causing such turnover, then maybe these elderly residents can enjoy their last days being taken care of by someone they have come to know, love, and trust. So in the end the question is, Why do Long Term Care Facilities have such a challenge with maintaining their staff? How can the Quality of Care for these residents improve?
I used a variety of literature for my research on nursing turnover rates and quality of care for residents. I used some national websites which include the National Center for Health Workforce Analyses, Bureau of Health Professions and the US Department of Labor Occupational Outlook Handbook. These resources focused on labor shortage statistics and the definitions and responsibilities of a nursing position. This research helped me focus on what responsibilities and education a nurse can obtain. It also helped me understand the nursing turnover rates and how this affects the quality of care in these facilities. I also used the textbooks Organizational Behavior and Understanding the U.S. Health Service Systems. Organizational Behavior helped me build the concepts that are necessary for the management to implement in these facilities.
I found great management strategies and designs to help maintain these leadership skills. The Health Service Systems textbook explained the logistics of the Long term care facilities. This helped me understand the definitions, main goals, and continuous daily functions these facilities need to continue operating. I used the online library through the college and online search engines for some articles pertaining to staff shortages and quality of care issues. These ranged from research data to relationship experiences between residents and staff. Some of the research gave me insight on mandatory overtime laws, LPN supervisory credentials, stress and burnout statistics and it really brought the leadership and organizational concepts into perspective. The article “Stress in the Health Care Professions” brings up the fact that empowerment shows a strong, negative association with job tension and a strong positive relationship with perceived work effectiveness. This was all very good feedback for my analysis and deemed extremely useful for this paper. The “Care home residents’ experiences of social relationships with staff” was a great find. This article explores two studies that were done to analyze social engagements between older people and staff in care homes. This study was pertinent to my paper because it showed how staff and culture plays an influential part in determining the quality and type of relationship between residents and staff. This was helpful to prove that nursing home staff has to be open, caring and compassionate to really be good at their job.
Challenges with Staff
Registered Nurses treat patients, educate patients and the public about various medical conditions, provide advice and emotional support to the patients’ family member (Occupational Outlook Handbook 2010-11 Edition). Registered Nurses record patients’ medical histories and symptoms, help perform diagnostic tests and analyze results, operate medical machinery, administer treatment and medications, and help with patient follow-up and rehabilitation (OOH 2010-11). Clearly nurses have a wide range of responsibilities and some are more educated than others. They carry a large burden of time management and daily flow so the day runs smoothly. RNs constitute the largest healthcare occupations, with 2.6 million jobs (OOH 2010-11). Research from the National Center for Health Workers Analyses showed in 2004 that the nursing turnover rate in Long Term Nursing homes is anywhere from 45% to 105%. Experts suggest that demographic changes, low-pay, and difficult working conditions are all factors that contribute to this shortage, particularly in paraprofessional occupations such as nursing assistants, home health and home care aides, and personal care attendants (Niesz, Livingston, Arsenault 2002). There are four primary causes of paraprofessional vacancies and high turnover: •Nature of the job
•Lack of respect from management
•Better job alternatives
•Baby Boom Demographics (NCHWA 2004)
The stress and burnout that comes with being a professional in the healthcare field is hard to manage. You have to be strong willed and have a good heart to really treat the patients and residents the way they deserve to be treated. A survey was done with 1,780 RNs; Handwritten comments from 509 of the RNs clarified these ratings by noting the following problems: (a) Inadequate unit leadership and the frequent turnover of nurse managers, (b) Insufficient physical presence of the supervisor on the unit, (c) Failure to address the problems- too much sweeping them aside or not even being aware they exist,
(d) Modest awareness of numerous staffing issues (Jennings Chapter 26) I feel this survey is important because this is true today. Unfortunately, these nurse managers are so occupied doing the paperwork responsibilities they cannot even focus on the fact that some residents are not being attended to or a staff member is not doing their job. Administrative staff and nurse managers are always in meetings on a daily basis, they are discussing the residents, but they are not on the floor assessing the everyday flow of the nursing staff and certified nursing assistants. A South Carolina law directs its Area Health Consortium to include an assessment of recruitment and retention of nurses and nurse’s aides in the state’s nursing homes and hospitals in its mandated statewide needs assessment for all health professionals (Jennings). Another hidden challenge to stress and burning out is the long hours these nurses work. Patients in hospitals and nursing care facilities require 24- hour care; consequently, nurses in these institutions may work nights, weekends, and holidays (OOH 2010-11). Registered Nurses, Licensed Practical Nurses, and Certified Nurses Assistant’s may also be on call, which is the availability to work on short notice. Several states have implemented laws to help maintain or limit the amount of mandatory overtime. Maine in 2001, its legislature passed another law: (1)Prohibiting employers from disciplining nurses for refusing to work more than 12 consecutive hours (they can be disciplined for refusing to work longer hours during an emergency). (2)Requiring employers to give nurses who have worked more than 12 consecutive hours at least 10 consecutive hours off immediately after that (Niesz, Livingston, Arsenault 2002). The quality of care
is failing in these long-term care facilities and upper management has to figure out where the challenge lies. Is it with the nurse managers being too preoccupied with administrative duties and long hours or is the stress of the job too overwhelming and just creating negativity for all nursing personnel forcing them to leave? Some quotes from nurses that left facility:
“I left because they would not revolve my hours with my school schedule.” (Melody)
“Management was just terrible. I had to leave.” (Diane)
Challenges with Residents Relationships with Staff:
In July 2000, CMS reported that understaffing severely affected the quality of care in 54% of the nation’s nursing homes (NCHWA 2004). I believe this goes hand and hand with the relationships these residents build with nurses and certified nursing assistants. Relationships are very important to these residents to create stability, consistency, and trust with the staff. There are two types of social exchange, according to the article “Care home residents’ experiences of social relationships with staff.” The two types are functional and relational. Functional focuses on the task of caregiving. Relational engages in sharing experiences and reciprocity. Importantly, this form of interaction provided opportunities for residents to experience companionships and reciprocity in their lives (Cook, Wilson 2010). Functional interaction is the main type used between residents and staff. This keeps more of a professional relationship. Residents described how continuity of staff had a positive effect on their experience living in the home. “I always say I feel safe with her, Well, if I ask her for something, she does it. Some of them, well, they take ages. She’ll say I’ll go and get somebody and you know that she will come back with somebody very soon, she’s very good” (resident A; Cook, Brown-Wilson 2010) Knowing the staff is very important to the older residents. They were able to identify who they could trust, who would treat them with dignity and would be willing to meet their preferences (Cook, Brown-Wilson 2010). Another resident from this article likes being able to talk with staff and it is very important to her. Her perceptions of the staff being ‘too busy to sit down and chat’ saddened her because she felt that she had few opportunities to interact with them
informally to get to know them. She did feel like she managed to build some relationships: For example ‘When I came back from hospital, matron bought me a tiny little cactus plant. “Welcome” it said on a little card from matron and staff. That was a nice gesture. You see, it is the little things that touch me. It is just the little things that make it so bearable’ (resident A; Cook, Brown-Wilson 2010). On the negative side a resident informed them of the communications of the everyday life: For example ‘One day you have a vest on and the next day you haven’t. I had no vest on today. She was just going to put my blouse on and I said “Oh, I have something on inside my blouse, you can see right through this.” “Oh come on, Mrs, you are not that modest.” She says. I said “It is not being modest. I don’t want to get cold.” So she looked through the drawers’ (resident D; Cook, Brown-Wilson 2010). She was just being careless by not doing what the resident asked in the first place. That is what is creating the negative vibe in these facilities, communication. Some quotes I have personally encountered from residents:
“They just scream up and down the halls at night. They have no respect for us. I can’t wait to get out of here” (Resident A; VA Nursing Home).
“Don’t call them in here to help. They will throw me on the bed” (Resident B; Royal Oaks).
Unfortunately for these certified nursing assistants, the wages are low, appreciation is low from management, requires long hours, and there is no motivation to do good regularly. This all has an effect on staff attitudes. These residents want to know the person who is providing care for them on a regular basis. They want to build trust and feel they are being taken care of. Care staff have little time to sit and talk outside the care routines, it is in these routines that residents take the opportunity to share their stories and initiate social interaction with the staff (Brown- Wilson 2010). So to sum this section up, The Occupational Outlook Handbook states that Nurses should be caring, sympathetic, responsible, and detail oriented. They must be able to direct or supervise others, correctly assess patients’ conditions, and determine when consultation is required. They need emotional stability to cope with human suffering, emergencies, and other stresses (OOH 2010-11)
Leadership Concepts that can help these issues:
There are three concepts that stood out to me in doing my research that may be essential to implement in these facilities. These can help create a better leadership style for the facility and increase quality of care by creating positivity for the staff. The concepts are job satisfaction, positive reinforcement, and motivation. Job satisfaction is a big issue concerning these nursing homes. I think job enrichment has a big effect on job satisfaction. Job enrichment is the practice of enhancing job content by giving workers more responsibility for planning and evaluating duties (Schermerhorn, Hunt, Osborn 2008; Pg. 133). Decreased job satisfaction results in decreased motivation and performance. High job satisfaction increases motivation and performance. This brings to work a positive atmosphere to work together and also causes the staff to become more involved with the day to day work, rather than just coming to work and doing their regular old job every day. I really think this would help bring happiness and fulfillment to the staff which in turn will cause satisfaction. I feel that employers could use the job characteristics model to help figure out how enriched a job is and help influence staff to identify with the core characteristics to fulfill the jobs purpose. The five characteristics are skill variety, task identity, task significance, autonomy, and feedback. I feel that this would help management get a better feel on if a candidate is right for the position or not in the hiring process using this model. Another concept that needs to be utilized is reinforcement strategies. Right now the lack of reinforcement is giving staff low self esteem and no morals for the reason to do well at work. Reinforcement in the administration of a consequence as a result of behavior (Schermerhorn, Hunt, Osborn 2008; Pg. 96). Managing this can change the direction, level, and persistence of an individual’s behavior (Schermerhorn, Hunt, Osborn 2008; Pg. 96). This could really help mold these individuals into the prospective employees necessary to perform these duties in a professional and personal manner. Positive reinforcement is the administration of positive consequences that tend to increase the likelihood of repeating the behavior in similar settings (Schermerhorn, Hunt, Osborn 2008; Pg. 96). I think this helps bring stability to a person’s job from
management. If you keep hearing you are doing a good job, you will strive to do better next time. This is considered continuous reinforcement which administers a reward each time a desired behavior occurs (Schermerhorn, Hung, Osborn 2008; Pg. 97). The third concept I would like to present is Herzberg’s Motivation Hygiene theory. Hygiene factors are sources of job dissatisfaction and they are associated with the job context or work setting (Schermerhorn, Hunt, Osborn 2008; Pg. 115). For example: Paying a low salary makes people dissatisfied, but according to Herzberg, paying them more does not necessarily satisfy them. This is just one example, there is plenty more scenarios to run through. Managers really have to go in depth and figure out what they can do to motivate staff and keep them motivated. Some sources that affect the Hygiene factors are: •Organizational policies.
•Quality of Supervision.
•Base Wage or Salary.
•Relationships with peers.
•Relationships with subordinates
These factors are some of the major concerns these facilities are facing in trying to maintain staff and build professional and personal relationships.
According to the article “Why Nurses Quit”, people will quit jobs solely because they don’t like their direct supervisor- regardless of benefits, job perks, and growth potential offered by the facility (Vaughan 2009). According to this article, nurses need to be offered empowerment, flexible scheduling, mentoring programs, continuing education opportunities, updated technologies, concierge services, and fair compensation. If long-term care facilities can adhere to these measures things can start to change and they will keep their employees for the long term. Some front line managers just don’t have the skills, personality traits, or desire to be an effective leader, and no amount of training or support will change that (Vaughan
2009). Those are the managers who are driving away staff, lowering productivity, and hurting morale (Vaughan 2009). Another thing to consider is maybe Registered Nurses’ are not the only ones who can be supervisors. According to an Iowa Board of Nursing Newsletter, Licensed Practical Nurses (LPN) can supervise in a nursing facility. They must satisfactorily complete the board approved LPN Supervisory Course within six months of employment of the supervisory role. I feel that if LPN’s were considered more for supervisory positions then the Registered Nurse managers and Director Of Nurses could be focused on the meetings and paperwork, while managing the LPN supervisor. This would create less responsibility for the nurse manager to focus on staff challenges or quality of care. The LPN would be responsible for this and bring any issues to the Nurse Manager to review in the frequent meetings. This way they could establish a more fluent management system. Employment in nursing care facilities is expected to grow because of increases in the number of older persons, many of whom require long-term care (OOH 2010-11). Long term care facilities need to make sure they are recruiting the best individuals for the position. Some incentives would be helpful to attract qualified employees and keep them. Sign-on bonuses, family-friendly work schedules, training and continuing education all are great ways to attract valuable employees. For nurse’s aides and other unlicensed direct care workers, states are trying (1) “Wage pass- throughs ” and other ways to increase wages or benefits, (2) Career ladders, (Niesz, Livingston, Arsenault 2002) (3) Work environment improvements,
(4) Incentives for health care employers who offer their staffs additional training, and (5) Recognition programs for people working in those professions A June 2000 Journal of the American Medical Association article predicts that by 2020, 20% of registered nurse positions will be vacant (Niesz, Livingston, Arsenault 2002). Some projected reasons for this are smaller graduating classes, aging workforce, increases in elderly population needing care, and lower nursing salaries. The consequences of leadership not taking responsibility and figuring out solutions to these challenges are decreased quality of care, non-motivated staff, future staff complications, more shortages due to high staff turnover rates, and
Understaffing, turnover rates and relationships are seriously hurting the quality of care in these nursing home facilities. Possible affects are:
•Inadequate, unsafe care which results in inexperienced staff with fewer senior staff available as mentors. •Care without continuity- Constant replacement of staff disrupts the care setting, precludes individualized care, and inhibits the development of strong relationships, which are centrally important to both the client and the caregiver. •Denial of care: Clients are simply turned away or, for those clients who are admitted, underserved. (NCHWA 2004) Change can be unsettling when it is a direct outcome of transient staffing situations (Cook, Brown-Wilson 2010). This had resulted in increased tiredness and irritation throughout the day (Cook, Brown-Wilson 2010). Staff turnover did cause some discomfort for these residents in this study. A quote from the study said “Very upset. You never know who is going to walk through the door when you wake up in the morning and when they bring your breakfast in. you ask their name and you ask that half a dozen times during the day because you have forgotten and the next thing you know they have gone and they don’t even say goodbye- they just disappear” (Resident B, Cook, Brown-Wilson 2010). During this study residents described how continuity of staff had a positive effect on their experience of living in the home. So, how do we help the staff open up, build relationships, and not want to leave just based on commitment to care and quality of care? •Patient care education for staff.
•Make sure to hire individuals who seem to be caring and compassionate as well as hard workers. •Learn to communicate with residents on a more personal level while staying professional. •Continue efforts to maintain staff and motivate them to stay. If Long Term Care facilities utilize the necessary resources, then they could come out of this rut and maintain better employees. According to the Occupational Outlook Handbook the growth rate for nurses in nursing care facilities is 25%. Just by implementing goal setting models and influence staff with positive quality of care these
relationship issues can be addressed and managed.
National Center for Health Workforce Analyses, Bureau of Health Professions (NCHWA, February 2004) -National and Local Workforce Shortages and Associated Data Needs: Chapter 2 Professional Workforce Supply and Demand Retrieved from ftp://ftp.hrsa.gov/bhpr/nationalcenter/RNandHomeAides.pdf Helga Niesz, Principal Analyst; Susan Price-Livingston, Associate Attorney; Kristina Diamond Arsenault, Legislative Fellow (2002). Long-Term Worker Shortage. OLR Research Report: 2002-R-0006 United States Department of Labor Occupational Outlook Handbook (OOH 2010-11). Bureau of Labor Statistics. www.bls.gov Vaughan, Carrie (2009). Why Nurses Quit? Healthleaders. www.healthleadersmedia.com Jennings, Bonnie M. Chapter 26 Work stress and burnout among nurses: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 26retrived from www.ahrq.gov/QUAL/nurseshdbk/docs/JenningsB_WEWCN.pdf February 2010. LPN Supervision in Long Term Care Facilities. Iowa Board of Nursing Newsletter: Page 2
Cook, Glenda & Brown-Wilson, Christine (February 2010). Care home residents’ experiences of social relationships with staff. Nursing Older People: Volume 22, Number 1; Pages 24-29
Barton, Phebe Lindsey (2006). Long Term Care. Understanding the U.S. Health Service Systems 3rd Edition: Chapter 15, Textbook
Schermerhorn, Hunt, Osborn (2008). Organizational Behavior, 10th Edition Textbook