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
3
Philosophy of Care
Financial Constraints
Philosophy of Management
Management Practices
Staffing ratios · Resident Assignment · Callouts· Care Planning· CNAs Working Together·
Coordinating with Other Departments· Hiring·
Training· Promotion· Supervision· Evaluation
and Discipline· Rewards· Retention
Direct Care Workers
4
Residents
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?
5
Variation in Workplace Practices
Across 18 Homes



Not necessarily associated with selfidentification 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
6
Context: Workers and Job Design for ResidentCentered 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

7
(Achieve through environmental changes and
resident schedule flexibility)
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
8
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)
9
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)
10
Organizational Practices associated
with High-commitment HRM (cont’d)






11
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
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


12
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
Is High-Commitment Human
Resources Management Relevant to
Nursing Homes?
13
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!)
14
Our 18 nursing homes vary widely in
organizational practices.

CNA job characteristics

Availability of frontline worker knowledge to
contribute to resident care
15
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
16
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.”
17
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.’”
18
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.’”
19
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
20
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).”
21
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.”
22
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.”
23
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.”
24
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.”
25

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 ?

26
Where we started --
Direct care workers are the
heart and hands of nursing
home care
27
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
28