Nurses as Power Brokers:
Changing Roles and Culture
Change in Nursing Homes
Dana Beth Weinberg, PhD
Rebekah Zincavage, MA
Almas Dossa, MPH, MS
Sue Pfefferle, Ph.D.
Academy Health Conference 2006
Seattle, WA
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
Lisa Dodson, Ph.D., Boston College
Field Staff and Statistical Support
Almas Dossa, MPH, M.S., Brandeis
Susan Pfefferle, M.Ed., Ph.D., Washington University
Rebekah Zincavage, M.A, Brandeis
Melissa Morley, Ph.D., Brandeis
Joanne Jannsen, M.S., Brandeis
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)
Traditional Nursing Homes




Are organized around institutional needs and
standardized practices
Define quality care as attending to residents’
physical needs, rather than wants and desires
Are medical institutions, following a medical
model of care and resemble hospital wards.
Are typically places that people come to die/or
come at the last stage of their life.
Culture Change Nursing Homes





Customize and individualize care to individual
residents – person- or resident-centered care
Focus on finding and creating the essentials of a
“home-like” environment
Central organizing features include the dignity,
privacy, autonomy of residents
Respond to residents’ wants as well as needs
Are places that people come to live -- Support
life tasks for life stage
Many Paths to Culture Change
For example,
 Eden Alternative
 Wellspring Model for Improving Nursing
Home Quality
 Action Pact
 Pioneer Network
Many Paths to Culture Change
Two common themes:
 Empowerment of residents
 Empowerment of front-line staff to meet
residents’ needs and desires
Nurses are Pivotal to Culture
Change
Nursing homes are nursing institutions. Nurses . . .
 Manage units
 Supervise aides
 Mediate between aides and upper management
 Develop care plans
 Deliver nursing care and medications to
residents
 Respond to residents’ needs/requests
 Interact with families
Do Nurses Resist Culture Change?
Nurses may resist Culture Change if
interventions…
 Threaten quality of care
 Reduce their control over resident care
 Diminish nurses’ authority over aides
Project Description


Qualitative data from two different units in
18 high quality nursing homes in
Massachusetts -- administrator interviews,
nurse interviews, CNA focus groups
6 self-designated as Culture Change
facilities
Research Questions for This
Analysis



What role do nurses play in empowering
CNAs?
Do nurses resist management efforts to
empower CNAs?
Under what conditions do nurses choose
NOT to empower CNAs?
Defining Empowerment


Control over the work process -autonomy
Control in the workplace – participation in
decision-making
Nurses’ Role in Empowering CNAs
Who Champions
Empowerment?
Neither administrators
nor nurses
Administrators only
Are CNAs
Empowered?
No
Nurses only
Somewhat (on units, but
Both administrators and
nurses
Often, but not always
No
not within larger NH context)
Culture Change Scenarios




Management wants CNA empowerment,
but nurses do not
Nurses want CNA empowerment, but
management does not
Nurses and management want CNA
empowerment but do not achieve it
Nurses and management want CNA
empowerment and achieve it
Do Nurses Resist Empowering
CNAs?



Nurses do not always empower CNAs even
when top management advocates CNA
empowerment
Nurses may empower CNAs, even when
management does not advocate it
Even when management and nurses both
want to empower CNAs, CNAs may not be
empowered
Is This Resistance?


Does lack of empowerment relate to
nurses’ concerns about turf and authority?
Examine similarities between scenarios in
which CNAs are not empowered
Barriers to CNA Empowerment
CNA Issues
 High turnover
 High number of callouts
 High use of agency CNAs
 Quality of CNA labor force
 Understaffing of CNAs
 Lack of trust in management
 Poor relationships with nurses
 Conflict with coworkers
Barriers to CNA Empowerment
Nurse Issues
 Lack of management skill or experience
 Overwork
 Do not see management as part of job –
focus on regulations and nursing care
 High turnover of nurses
 High use of agency nurses
Top Management Issues
Management Issues
 High turnover
 Constrained resources
 Low exposure to frontline workers
 Changes not meaningful (or have
unintended effect)
 Lack of leadership skill or experience
Conclusions
What role do nurses play in empowering
CNAs?



Nurses play the primary role in empowering
CNAs by emphasizing autonomy and
participation in decision-making
Some nurses choose to empower CNAs, even
when management does not
Some nurses do not empower CNAs, even when
management would like to
Conclusions
Do nurses resist empowering CNAs?
 “Resistance” in the form of concerns about
turf or authority were not a factor in these
18 cases
 There were other common factors that
prevented nurses from empowering CNAs
Conclusions
Under what conditions do nurses choose
NOT to empower CNAs?
 Barriers to empowerment occur at multiple
levels within an NH
 These relate to staff stability and quality,
resources and time, leadership and
management ability, and relationships
among workers
Policy Implications





Intentions and practice do not always match
Viewing nurses as resistant misses key barriers to
Culture Change implementation and may locate
problems at the wrong level
In nursing homes, nurses are middle managers – the
management part of their job needs to be emphasized
Top managers and nurses need training in participatory
management for Culture Change to be effective
HR practices need to promote retention of qualified
workers for Culture Change to be effective