FRONTLINE CAREGIVERS: DOES CONSISTENT ASSIGNMENT MAKE A
DIFFERENCE IN NURSING HOME RESIDENT CARE?
Mary Margaret Chappell
B.S., California State University, Fresno, 1995
THESIS
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SCIENCE
in
SPECIAL MAJOR
(Administration and Management for Older Adults)
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
FALL
2010
FRONTLINE CAREGIVERS: DOES CONSISTENT ASSIGNMENT MAKE A
DIFFERENCE IN NURSING HOME RESIDENT CARE?
A Thesis
by
Mary Margaret Chappell
Approved by:
__________________________________, Sponsor
Cheryl Osborne, Ed.D.
__________________________________, Committee Member
Jennifer Piatt, Ph.D.
__________________________________, Committee Member
Katherine Pinch, Ph.D.
____________________________
Date
ii
Student: Mary Margaret Chappell
I certify that this student has met the requirements for format contained in the University
format manual, and that this thesis is suitable for shelving in the Library and
credit is to be awarded for the thesis.
______________________________________________
Chevelle Newsome, Ph.D.,
Office of Graduate Studies
iii
___________
Date
Abstract
of
FRONTLINE CAREGIVERS: DOES CONSISTENT ASSIGNMENT MAKE A
DIFFERENCE IN NURSING HOME RESIDENT CARE?
by
Mary Margaret Chappell
By the year 2030, America may have over one million centenarians. The issue of
delivering quality nursing home care to the elderly population is becoming critical and
greatly dependent on the frontline nursing staff. Since 1997, there has been a national
“culture change” movement that has identified consistent assignment as a cornerstone
practice of its advocacy. The review of the literature examines staff assignment and its
correlation for improving quality indicators in nursing home care. Regulatory bodies
require nursing homes to report certain objectively measurable data to aid rating the
quality of care. The purpose of this study is to examine a nursing home that uses
consistent assignment compared with a rotating assignment nursing home and its effect
on staff turnover, resident restraint use and frequency of pressure ulcers. Data obtained
from the Medicare and OSHPD websites were used for examining the two nursing homes
selected. The data presented lower percentages overall for the nursing home using
consistent assignment protocols, which can translate into improved Medicare quality
rating. This study, due to the small sample size and with the absence of raw data could
not draw any statistical correlation between consistent assignment and improved nursing
home care among the three quality indicators examined.
, Sponsor
Cheryl Osborne Ed.D.
iv
DEDICATION
I would like to dedicate this thesis to my children, Hannah and Ben who sacrificed more
than they realized.
v
ACKNOWLEDGMENTS
Some say it takes a village to raise a child I say it takes a village to write a thesis.
Many friends and family have supported me through this process, which at times felt like
an insurmountable task. I want to first thank my parents who gave me the love of
learning and taught me that I can do anything I set my mind to. I am grateful for Bernie,
who gave me my first job working in a nursing home; little did I know my amazing
journey would begin there. I thank my, elder mentors, Jeanada and Joy who provided
words of encouragement when I needed them most. I am indebted to my family, Brett,
Hannah and Ben who were patient with me during this process. This thesis presented its
challenges and without Lori and Sandy this paper would have been very different. I
thank Bonnie, for her mentorship she has made available her support in a number of
ways.
I give my gratitude to my special masters committee, Dr. Osborne, Dr. Paitt and
Dr. Pinch who not only guided me through this paper but also taught me how to set my
expectations high and exceeded my goals. I thank my reviewers, Stacey, Brigitte, and
Dr. Osborne for your objective advice. I send my appreciation to one of my dearest
friends Stacey and her husband Andy for providing me with food and shelter when I
needed to get away to focus on my writing. Last but not least, I give my love and
appreciation to my cousin Elisa. We shared laughter and delirium during late night
editing sessions. Without her support and guidance, writing this thesis would not have
been as enjoyable.
vi
TABLE OF CONTENTS
Page
Dedication ..................................................................................................................... v
Acknowledgments....................................................................................................... vi
List of Tables ............................................................................................................... ix
List of Figures ............................................................................................................... x
Chapter
1. INTRODUCTION .................................................................................................. 1
Need for the Study ............................................................................................ 5
Purpose Statement ..............................................................................................8
Research Questions ........................................................................................... 9
Definition of Key Terms ................................................................................... 9
Limitations and Delimitations......................................................................... 12
2. LITERATURE REVIEW ..................................................................................... 13
History of Aging and Nursing Homes in America ......................................... 14
Organizational Culture in Long-Term Care .................................................... 25
Theory and Culture Change ............................................................................ 28
Culture Change Models in Long-Term Care .................................................. 30
Consistent Assignment, Culture Change and the Frontline Caregiver ........... 36
Quality Indicators: Staff Turnover, Physical Restraints and Pressure Ulcers 41
Quality Indicator: Staff Turnover ....................................................... 42
Quality Indicator: Physical Restraints ................................................ 44
Quality Indicator: Prevalence of Pressure Ulcers ............................... 48
Conclusion ...................................................................................................... 50
3. METHODOLOGY ............................................................................................... 52
Research Design.............................................................................................. 53
Purpose Statement ........................................................................................... 54
vii
Research Questions ......................................................................................... 54
Setting and Participants................................................................................... 54
Data Collection Procedures............................................................................. 55
4. RESULTS ............................................................................................................. 56
Staff Turnover Data and Summary ................................................................. 57
Physical Restraint Data and Summary ............................................................ 62
Pressure Ulcer Data and Summary ................................................................. 64
5. DISCUSSION AND IMPLICATIONS ................................................................ 71
Recommendation ............................................................................................ 76
Closing Statement ........................................................................................... 77
References ................................................................................................................... 78
viii
LIST OF TABLES
Page
1. Table 4.1 Nursing Home Comparison of CNA Turnover Rates ........................... 59
2. Table 4.2 Long-Stay Residents who were Physically Restrained......................... 63
3. Table 4.3 High-Risk Long-Stay Residents who Have Pressure Ulcers ................ 66
4. Table 4.4 Low-Risk Long-Stay Residents who Have Pressure Ulcers ................. 66
ix
LIST OF FIGURES
Page
1. Figure 4.1 CNA Turnover: A National and State Comparison ............................. 60
2. Figure 4.2 Physical Restraint Use: A National and State Comparison ................. 63
3. Figure 4.4 Low-Risk Long-Stay Residents who Have Pressure Ulcers:
A National and State Comparison......................................................................... 69
4. Figure 4.4 Low-Risk Long-Stay Residents who Have Pressure Ulcers:
A National and State Comparison......................................................................... 69
x
1
Chapter 1
INTRODUCTION
Current estimates indicate that men and women 85 and older, the oldest among
us, are the fastest growing part of the elderly population in the United States. By the year
2030, America may have over one million centenarians (Dychtwald, 1999). Although we
are living longer and healthier lives, nursing homes will still be the last residence for
many Americans (Shields & Norton, 2006). The issue of delivering quality nursing care
to our elderly population is becoming more and more critical. Maintaining a high level of
quality care in a nursing home is greatly dependent on the nursing staff (Burgio, Fisher,
Fairchild, Scilley, & Hardin, 2004). Certified Nursing Assistants (CNAs) are the directcare employees that work most intimately with residents in America’s nursing homes and
are responsible for 90 percent of hands-on activities of daily living care (Eaton, 2005).
There are 15,691 nursing homes in the United States (American Health Care
Association website, 2010). In fact, nursing homes are one of the most regulated
industries, second only to nuclear power. Yet, with all of this regulation, negative
conditions continue to exist within the industry (Eaton, 2005). Appropriate and effective
regulations are important because a vulnerable population resides within nursing homes:
frail older adults who are unable to care for or advocate for themselves (Teal, 2002).
The vast majority of nursing homes operate through a hierarchical system which
does not place value where it belongs most, the resident and the direct care worker
2
(Shields & Norton, 2006). This type of managerial structure lowers the likelihood that
resident needs are being effectively met. Many industry leaders agree that the
organizational structure of nursing home operations needs improvement in quality,
specifically in the area of the role of direct care workers. Frontline workers are not
empowered in the traditional culture of nursing homes. Despite their critical role in
nursing care delivery, direct care employees are among the lowest paid staff with little or
no benefits. This lack of outward professional and financial value in frontline staff has
led to the highest staff turnover rate in the industry. National data supports that staff
turnover for CNAs ranks the highest, totaling 74.5 percent per year (Donoghue, 2010).
Staff turnover in nursing homes negatively affects the quality of care by placing a
financial and organizational strain on a nursing home. Further, this high turnover rate
negatively affects quality and continuity of care and can often be personally disturbing
for residents (Bowers, Esmond, & Jacobson, 2003).
In order to address these financial strains on care delivery, many nursing homes
have begun to change their organizational structures to place more value and ownership
of care with the CNAs. Many nursing homes are beginning to adopt practices that allow
direct care workers to establish ongoing relationships with residents through the practice
of “consistent assignment” (Koren, 2010). This practice assigns caregivers the same
resident on a day-to-day basis, which helps foster meaningful relationships between the
direct caregiver and the nursing home resident. These consistent relationships are used to
improve the quality of nursing home culture and more directly address the needs of
3
residents (Burgio et al., 2004; Rahman, Straker, & Manning, 2009). Researchers also
support this practice through King’s theory, which places value on the direct relationship
between the nurse and resident through a concept described as “mutuality” (Secrest,
Iorio, & Martz, 2005).
King’s theory of goal attainment can be visualized as a transaction process which
operates around a triad of systems in which nurses are expected to interact with. Social,
interpersonal and personal systems all influence the nurse-resident transaction which
occurs when goals and means to achieve those goals are agreed upon (King, 1999;
Whelton, 1999). Although the theory represents a series of separate transactions that
occur over time the human being, nurse and resident, is the core of the system and
according to King the theory communicates “dynamic wholeness” (King, 1999, p. 159).
The systems process of King’s theory is relevant to modern nursing home organizational
culture combined with the holistic nature of the nurse-resident relationship discussed in
the theory makes this theory relevant for this thesis. King’s theory is discussed further in
chapter two aligning with consistent assignment and the frontline caregiver.
Consistent assignment differs dramatically from the traditional approach, where
the nursing home hierarchy “rotates” the caregiver to different residents on a scheduled
basis. The original intent behind this rotating assignment practice was that caregivers
would not get burned out, overworked, or bored (Burgio et al., 2004). However, the
value of developing ongoing relationships with consistent assignment has the potential to
dramatically alter the way care is delivered to residents and improve the overall quality of
4
nursing home culture (Farrell, Frank, Brady, McLaughlin, & Gray, 2006; Shields &
Norton, 2006).
Consistent assignment emerged as an outgrowth of the culture change movement
in the nursing home industry. The heart of culture change is the creation of meaningful
relationships between staff and nursing home residents to create a feeling of family. The
movement asserts that an effective way to build these familial-type relationships is to
consistently assign staff to the same residents on a daily basis (Koren, 2010). Frontline
caregivers become empowered when they have the opportunity to care for the same
residents every time they are on shift. Staff who are rotated on a scheduled basis do not
have the same opportunity to “get to know” each resident. Rotating staff can negatively
impact both the CNA and the resident because there tends to be a learning curve for care
with each scheduled rotation. In a scheduled rotation structure, once a CNA begins to
establish a rapport with the resident, they are assigned to a different rotation with
different residents. This traditional practice of rotating staff has been found to be
disruptive to both the resident and the CNA (Bowers et al., 2003). Substituting consistent
assignment for scheduled rotation is believed to reduce the high staff turnover rate that
has existed in long term care. Less staff turnover with more valued CNAs has been seen
to produce an increase in quality of care, improve resident satisfaction and decrease
overall costs (Donoghue, 2010; Donoghue & Castle, 2009).
In addition to staff turnover, use of restraints and frequency of pressure ulcers are
critical quality-of-care indicators. These quality measures were chosen for this study
because they are objective clinical indicators reported to government agencies by which
5
the nursing homes are rated. The purpose of this study is to examine a nursing home that
has adopted consistent assignment practices compared with one that practices rotating
assignments and its effect on CNA turnover, resident restraint use and frequency of
pressure ulcers. The frequency of both restraint use and pressure ulcers correlates with
resident satisfaction and the quality of care provided in nursing homes (Degenholtz,
Rosen, Castle, Mittal, & Liu, 2008).
This study is designed to discuss how staff assignment can translate into improved
quality care in nursing home research. Many scholars have studied consistent assignment
and why it is thought to positively influence a variety of nursing home quality care
indicators such as staff turnover, pressure ulcers and physical restraints. The Centers for
Medicare and Medicaid (CMS) publish these quality care indicators for public viewing
via the World Wide Web. Each nursing home reports specific quality indicator data to
CMS each month. The Minimum Data Set (MDS) is an instrument used in all nursing
homes to assess residents, guide improvement, report on quality, and act as a data source
for systems payment (Rahman & Applebaum, 2009). This published data often helps
consumers while choosing a nursing home because it allows them to compare the quality
of each nursing home.
Need for the Study
America’s population is aging. Over the past 10 years, government and state
agencies have been reviewing the importance of America’s direct care work force. This
is in order to proactively recruit and retain workers in anticipation of the potential
shortfall in the workforce that may exist with current trends in retention and entry into the
6
field. These trends have the potential to negatively affect the industry’s ability to provide
the necessary workforce to meet the needs of our aging population (Department of Health
and Human Services, Office of the Assistant Secretary for Planning and Evaluation,
Centers for Medicare and Medicaid Services, Health Resource and Services
Administration, Department of Labor’s Office of the Assistant Secretary for Policy,
Bureau of Labor Statistics & Employment and Training Administration [HHS], 2003).
Both the anticipated need in future staffing of nursing homes and the high
turnover rate of existing staff present a difficult problem which has been studied by
researchers in the profession. The expected need for growth for the long-term care work
force is two percent per year, totaling an additional four million new jobs by 2050
(Lehning & Austin, 2010). Harris-Kojetin, Lipson, Fielding, Kiefer & Stone (2004)
research synthesis for the U.S. Department of Health and Human Services (HHS) began
to explore why state agencies and long-term care providers were reporting turnover rates
between 45 percent to over 100 percent among direct care employees.
Societal dynamics and population trends will also significantly increase the need
for more direct care workers. The HHS report (2003) suggests that an increase in the
elderly population, coupled with fewer adult children to provide needed care for their
elders, creates a direct care worker deficit and has the potential to add to the long-term
care workforce crisis (Harris-Kojetin, Lipson, Fielding, Kiefer, & Stone, 2004). This is
supported by population trend data. Beginning in the year 2030 the baby boom
generation will begin to turn 85. The increase in this aging population will likely
increase long-term care workforce demands on its own. However, it was speculated, in a
7
2003 report to Congress, which focused on the long-term care need of the baby boomer
generation, that many elderly baby boomers are more likely to be childless or have fewer
children to provide care than prior generations (HHS, 2003). This projection reveals that
there will potentially be fewer informal caregivers available to an increasing elderly
population. This, in turn, will increase the need for more formal long-term care labor
force providing direct care to America’s future elders.
Traditionally, the field of skilled nursing records a high staff turnover percentage.
Low wages, lack of benefits, undervaluing, and heavy workloads contribute to the
instability of the direct-care workforce in nursing homes (Lehning & Austin, 2010). It is
important to find reasonable proactive solutions to retain and recruit America’s direct
care workforce before it fails to meet the needs of our most vulnerable elderly population.
Turnover for direct care workers or CNAs is most likely to occur during the first three
months of employment, which is costly to the facility due to training and replacement
costs (Barry, Kemper, & Brannon, 2008). Current literature has demonstrated that the
quality of nursing home resident care is related to CNA turnover (Barry et al., 2008;
Bishop et al., 2008; Donoghue, 2010). Some significant change is needed to stop this
trend.
This high turnover in the direct care workforce is becoming a catalyst of many
state and federal workforce initiatives to address this growing problem (Barry et al.,
2008; Bryant & Stone, 2008). Although the federal government sets nursing home
quality standards, it is up to individual states to shape policy and monitor and implement
regulations through an annual survey process (Kane, 2008).
8
Many states have set up task forces and studies to help develop the direct care
workforce (Bryant & Stone, 2008). States such as Oregon and Kansas are forming
collaborative relationships between state surveyors and direct care providers in order to
implement workforce initiatives (Bryant & Stone, 2008). In 2002, the State of Kansas’
Department on Aging adopted the PEAK project, which is a recognition and education
program that promotes culture change in long-term care, a major of component of which
includes the use of consistent assignment protocols. The PEAK project recognizes
nursing homes for excellence with new, more inclusive indicators of performance with a
primary focus on resident control and staff empowerment. The first nursing home to
receive the PEAK award, Windsor Place, measured their progress closely. This PEAK
awarded home in Kansas has reduced staff turnover each year it has implemented
changes. In 2003 Windsor Place, reported a 29 percent turnover rate. From 1995 to
2003, turnover decreased dramatically by 68 percentage points from its initial turnover
measurement in 1995 at 97 percent (Doll, 2004). As illustrated by Doll (2004), culture
change initiatives when successfully implemented, decreased staff turnover dramatically
and proved less disruptive to their residents.
Purpose Statement
The purpose of this study is to examine nursing homes that practice consistent
assignment compared with rotating assignment nursing homes and its effect on certified
nursing assistant (CNA) turnover, resident restraint use and frequency of pressure ulcers.
9
Research Questions
1. How does consistent assignment versus rotating assignment affect turnover of
certified nursing assistants?
2.
How does consistent assignment when compared with rotating assignment in nursing
homes affect the use of resident restraints?
3. How does consistent assignment versus rotating assignment affect nursing home
residents’ frequency of pressure ulcers?
Definition of Key Terms
The following terms introduce the reader to the concepts and will be explored in
greater depth in the literature review and discussion of this thesis. Many of these terms
are commonly cited through gerontological research and used within scope of nursing
homes.
Nursing Home – also known as skilled nursing facility or convalescent hospitals is a
health care facility that provides medical care to residents. Residents are often frail and
elderly and require skilled care.
Certified Nursing Assistant (CNA) – A CNA is the primary caregiver for nursing home
residents and provide 90 percent of direct patient care (Bowers et al., 2003). Duties
include assisting with activities of daily living (ADLs) including but not limited to
bathing, feeding, dressing, toileting, and ambulating (Merck and Company Inc., 2006).
Consistent Assignment – According to the Quality Partners of Rhode Island (2007)
consistent assignment is where the nursing home nursing staff is permanently assigned to
10
the same resident 80 percent or more of the time while on shift. The nursing homes that
implement this staffing practice never rotate assignments.
Rotating Assignment – The opposite of consistent assignment which includes rotating
nursing staff among nursing home residents on a scheduled basis (quarterly, monthly, or
weekly). A common reason for the rotation staff is to help with short staffing as well as
lightening the burden of hard to care for residents (Quality Partners of Rhode Island,
2007).
Nursing Home Resident – A person with skilled medical needs who resides in a nursing
home. Residents can be classified into short stay or long stay residents. Short stay
residents return to independent or assisted living whereas long stay residents live
permanently in the nursing home. Long stay residents are usually frail and need
assistance with ADLs.
Activities of Daily Living (ADL) – Residents who need assistance with ADLs often are
frail and require skilled care to carry out basic self-care needs. Ambulating, transferring,
bathing, dressing, eating and toileting are needs classified under activities of daily living
(Merck and Company Inc., 2006). ADLs are provided by CNAs employed in nursing
homes.
Staff Turnover – The percentage of nursing home employees that terminate employment
either voluntarily or involuntarily over the course of a year (Donoghue & Castle, 2006).
The equation to measure turnover is terminations in a year divided by the total number of
staff members (Donoghue, 2010).
11
Pressure Ulcers (PrUs) - Also known as bedsores. These areas of localized damaged
skin or underlying tissue, usually occur over a bony prominence, because of pressure
moisture or friction. Pressure ulcers are common for those limited to a wheelchair or bed
for prolonged periods, due to immobility. Pressure ulcers are clinically staged I, II, III, or
IV, mild to severe respectively (Long, 2007; Merck and Company Inc., 2006).
Physical Restraints - A physical restraint includes technical devices that restrict a
resident’s movement, inhibits freedom and or prevents access to his or her body.
Restraints can not be easily removed (Engberg, Castle, & McCaffrey, 2008; Pellfolk,
Gustafson, Bucht, & Karlsson, 2010). Belts, wrist restraints, chairs with tables are
common restraints cited in nursing home literature (Engberg et al., 2008).
Culture Change – Represents a fundamental shift in nursing home organizational
culture. Quality of life and dignity are equally important to quality of care. Honoring
individual rights of the resident and valuing all employees equally support the culture
change philosophy. Moving from hierarchical decision making process to the employees
who work closest to the resident is critical for culture change transformation (Doty,
Koren, & Sturla, 2008). Creating a home like atmosphere for staff and residents is
important when changing the nursing homes environmental culture (Koren, 2010).
Minimum Data Set (MDS) – A collection instrument used in nursing homes to assess
residents. This software is published by the Centers for Medicare and Medicaid Services
(CMS), a government regulatory agency. MDS is intended to guide improvement for
nursing homes through tracking quality indicators, identifying resident populations, and
serving as a data source for payment systems (Rahman & Applebaum, 2009).
12
Limitations and Delimitations
California is currently home to 1250 nursing facilities (Office of Statewide
Planning and Development website, 2010). Two California nursing homes are examined
in this study and located in different counties therefore, social and economical
demographics may vary. Both nursing homes are for-profit enterprises, owned by
different corporations but similar in resident capacity. The nursing homes were selected
based on personal knowledge by the author and interviews were conducted with each
administrator to determine if the nursing home would be appropriate for use in the study.
This thesis uses secondary data that is publicly available through the Medicare website.
Each home is required to submit data in the same manner to the State and Federal
Government through the MDS system. This government-collected data is available to the
public via the Medicare website. Both nursing homes do practice some culture change
and participate in the California Culture Change Coalition’s Regional Collaborative
training (S. Haskins, personal communication, April, 2010; L. Cooper, personal
communication, March, 2010). The nursing home that does not consistently assign staff,
is currently striving for improved quality through the adoption of other culture change
practices. The influence of these culture change practices are not isolated and can
potentially sway the results of the research questions posed for the study.
13
Chapter 2
LITERATURE REVIEW
Over the past 11 years, advocacy groups have prioritized changing the way
nursing homes deliver care. Groups such as Pioneer Network, Wellspring Institute, and
Eden Alternative have been innovators toward resident-centered care (Rahman &
Schnelle, 2008). Since 1997, the strength and support for the implementation of the
culture change movement in nursing home care has grown. This groundswell of support
for culture change has promoted the beginnings of implementation of ideals in the
nursing home industry. However, some experts in the field believe that full
implementation, industry-wide, is pre-mature without further study. Rahman and
Schnelle (2008) examined a need for a more empirical study to validate what the culture
change advocacy groups are postulating about the correlation between implementation of
their ideals and improvement in the quality of care.
Consistent assignment is a core principal of culture change and has been credited
with leading to improved resident satisfaction and employee job performance (Farrell et
al., 2006; Patchner & Patchner, 1993; Rahman et al., 2009). Certified Nursing Assistants
(CNAs) are the frontline caregivers employed by nursing homes and provide 80 to 90
percent of direct care to residents (Burgio et al., 2004; Riggs & Rantz, 2001). The
performance of CNAs is most critical for efficient care delivery and the quality of care
delivered in nursing homes (Patchner & Patchner, 1993; Tellis-Nayak, 2007). Consistent
assignment is one essential way that nursing homes can improve their delivery of care to
residents, retain the jobs of its direct care workers and improve job performance. A study
14
by Burgio and colleagues (2004) notes that CNAs report that consistent assignment
enables them to deliver higher quality care to their residents and provides increased job
satisfaction, compared to the CNAs that worked in a nursing home with rotating
assignment. In a field that traditionally has high worker turnover (Bowers et al., 2003;
Donoghue, 2010; Donoghue & Castle, 2009) combined with the future demand on the
LTC workforce, it is important to find reasonable proactive solutions to retain and recruit
LTC workforce before it is too late (Harris-Kojetin et al., 2004).
To set the framework for this thesis the literature review examines several aspects
of nursing home culture. The history of aging, nursing homes and culture change in
America provides the groundwork and progresses into the research of appropriate theory
and models related to the frontline caregiver and consistent assignment. Staff turnover,
physical restraint use and prevalence of pressure ulcers are the quality indicators selected
for this thesis and will be discussed in detail toward the end of the review of literature.
History of Aging and Nursing Homes in America
Americans are aging and living longer and healthier. One in five Americans will
be over the age of 65 by the year 2020 (Fleming, Evans, & Chutka, 2003). To understand
the future of aging and long-term care, one must include the history of our American
view of elders.
In the past, American elderly populations were small in numbers with a lower life
expectancy. New social and religious ideals about lifespan and its elder population
developed throughout American history and culture. An example of this ideal was the
book Pilgrims Progress. This popular literature written by John Bunyan reflected the
15
Puritans’ journey of aging as a path to God. Bunyan’s work marked the beginning of
segregating the spiritual growth of his characters over time from physical aging (Cole,
1992). During the same time, the latter half of the 17th century, American societies held
the elderly in high regard. However while a positive cultural ideal may have generally
existed in this early American culture, in practice it was not universally applied to the
elder population as a whole. Many societal practices did not reflect equality among
elders because American attitudes about race, wealth, and status wove into the social
milieu and affected how certain subsets of elders were treated (Cole, 1992).
During Colonial times, the government levied local “poor” taxes to provide poor
elders with food and lodging. However, at the same time, poor elders were still expected
to work as long as they were physically capable (Kaffenberger, 2000; Ogden & Adams,
2008). As the population grew and larger cities began to emerge, public institutions
known as almshouses or poor farms were established to serve the needy including the
elderly (Kaffenberger, 2000). Although some politicians during early American history
recognized a link between poverty and age, the notion of a national pension plan for the
elderly was never adopted and responsibilities were assumed by individual states. Poor
conditions and abuse at public almshouses continued with minimal oversight by state
agencies (Ogden & Adams, 2008).
The Victorian era placed a greater importance on health ideals and brought health
reform to the forefront with parallel reforms in the same era for the elderly. Victorian
reforms brought hygiene practices into the education system along with other health
related initiatives such as physical education and preventative medicine to younger
16
populations. These and other advancements in medical practices resulted in decreased
childhood mortality, shifting the importance of the link between death and old age
(Fischer, 1977). This shift in cultural emphasis on well-being was a catalyst for changing
popular ideas about illness and death. The cultural meanings of this transformation
translated the way society understood aging and old age. The Victorian health reform
movement perpetuated the notion that declining with age into death was considered
undisciplined (Cole, 1992). This paradigm shift about becoming old is thought to mark
the beginning of negative generational perceptions toward the aged. During this time,
widely published self-help manuals reflected this negative sentiment about aging. At the
same time, a declining sense of obligation from the younger generation to the older
generation further lowered the cultural status of the elderly (Cole, 1992).
Until the mid-1800s, almshouses continued to be the only form of elder care.
However, almshouses continued to be wrought with terrible conditions. As a reaction to
these poor conditions for the elderly, the mid-1800s brought about the beginnings of our
modern “nursing home care structure” (Ogden & Adams, 2008). During this era,
charitable organizations affiliated with various religions and immigrant populations
started housing their elderly members and providing health services to meet their needs.
These services planted the seeds of what would become our modern nursing home care
(Ogden & Adams, 2008). These charitable and religious based care homes provided a
better quality of care for the limited number of residents who were able to benefit from
their care. However, by the turn of the 20th century, poorhouses controlled by county
17
government agencies, were still housing about 37 percent of the poor elderly (Fleming et
al., 2003).
At the turn of the 20th century, “old-age” began to be viewed as a social problem
worthy of society-wide solutions prompting cultural, political and academic action. This
society-wide shift in ideology started to change the way we cared for our elders; from this
the new science of Geriatrics emerged (Cole, 1992; Fischer, 1977). Also, at this time,
some politicians and government officials began to see the need for old age support. For
example, Massachusetts formed one of the first public commissions on aging in 1909.
Between 1903 and 1929 Massachusetts also introduced 114 pension bills before the
legislature to address these issues. Unfortunately, despite continued effort, not one
proposal passed (Fischer, 1977). Despite similar legislative efforts throughout the
country, the basic structure of care delivery for the elderly remained unchanged.
By the 1920’s, a skeleton regulatory structure began to emerge for the facilities
caring for the aging. What began as poorhouses caring for the elderly in the 1800s and
progressed into an increasing number of charitable homes finally began to transform into
nursing facilities with minimal state licensing requirements in the 1920’s. Although
more structured care was being delivered to poor older-adults during this time, the
majority of the elderly still received sub-par care because they were housed outside these
licensed structures on “poor farms.” These “poor farms” were continually cited as
providing inhumane and institutionalized conditions for the elders in their care (Fleming
et al., 2003).
18
By 1933, a majority of the states provided some type of old age support, but the
monetary support varied widely between the states. Further, the emerging state support
system proved difficult for elders and caregivers to navigate and receive necessary
support (Ogden & Adams, 2008). The Social Security Act of 1935 changed this
landscape by providing significant grant funding to states for housing the elderly (Social
Security Act of 1935). Using Social Security grant money, “rest homes” were
established throughout the country. The increasing establishment of rest homes
eventually filtered “poor farms” out of the elder care system (Cole, 1992).
The funding mechanism of the Social Security of Act of 1935 was not without its
stumbling blocks in creating uniform care among all states. Title I of the Social Security
Act federally matched state funding and added to systems that many states already had in
place. The Social Security Act failed to establish a minimum level of spending for each
state, along with fair eligibility requirement for grants, which allowed many state
governments to spend modestly. This Title I spending funneled larger and larger
amounts of money into the nursing home system for the states that chose to participate in
the program fully, creating a larger chasm between states creating nursing care facilities
and those who did not improve their system with federal grant money (Ogden & Adams,
2008).
In addition to federal grant money to states, the Social Security Act of 1935
provided funding to the elderly to obtain their choice of care through a variety of
facilities including private board and care homes or non-profit homes (Social Security
Act of 1935). This consumer based empowerment of the elderly or their beneficiaries to
19
select the care that fit them best would soon be taken away by amendments to Social
Security Act in 1950. These 1950’s amendments represented a major policy shift which
would forever shape the nursing home industry. Among others, 1950’s Social Security
Act amendments shifted payment for elder care services directly to vendors where
“beneficiaries were essentially removed as purchasers, and the locus of negotiation over
payment rates (and regulation) shifted to facility owners and states” (Ogden & Adams,
2008, p. 147). This resulted in leaving the elderly consumer with little or no power
through the process that gave rise to a new sector of lobbyists within the nursing home
industry (Ogden & Adams, 2008).
The next significant change in the elder care industry occurred in 1946 with
Congress’ passage of the Hill-Burton Act (Hill-Burton Act of 1946). The Hill-Burton
Act provided grant funding for the construction of hospitals, nursing homes, and
rehabilitation facilities. The condition for this major construction public funding required
newly constructed hospitals to provide free or reduced-charged medical services to those
facing difficulty in paying (Mantone, 2005). Lawmakers thought that the passing of such
public monies would improve overall quality and supply care to a rapidly growing elderly
population (Ogden & Adams, 2008). This large scale construction of hospitals and
medical rehabilitation facilities for the elderly through the Hill-Burton Act caused a
cataclysmic shift in nursing home care from a residential care model to a medical care
based paradigm, as part of the national health system. The economic ramifications of this
shift were significant to elder care. Caring for the aged went from “being a social good to
a consumable good, like other health care” (Ogden & Adams, p. 146).
20
In 1965, Congress amended the Social Security Act to create the Medicare system
which provided guaranteed health insurance for the elderly and disabled (Medicare Act of
1965). The Medicare repayment structures created by these amendments paid hospitals
and rehabilitation facilities for caring for the elderly covered by Medicare. This
prompted the rapid growth of the elder care industry to take advantage of these
guaranteed Medicare payments. More nursing home facilities were constructed to house
more residents who qualified for these reimbursements. Currently, there are 15,691
modern day nursing homes which can largely be credited to the economic sustainability
created by the Medicare Act (Fleming et al., 2003; Medicare Act of 1965).
Despite the over two hundred year journey of maturation of nursing homes in this
country, it was not until 1987 that the Federal Government enacted comprehensive
regulations to oversee the industry. In 1987, Congress enacted the “Nursing Home
Reform Act” (NHRA) as a part of the Omnibus Budget Reconciliation Act (OBRA) of
1987 (Omnibus Budget Reconciliation Act of 1987 [OBRA ‘87]). This benchmark
legislation established the complex regulatory structure upon which the last 20 years of
nursing home care have been guided, including certification for Medicare for both
facilities and the nursing staff and enforcement and compliance protocols across the
industry (OBRA ’87).
The NHRA also “made nursing homes the only sector of the entire health care
industry to have an explicit statutory requirement for providing what is now called
‘person-centered care’” (Koren, 2010, p. 2). The law required that each nursing home
resident “be provided with services sufficient to attain and maintain his or her highest
21
practicable physical mental and psychosocial well-being” (Koren, 2010, p. 2). These
person-centered portions of OBRA stemmed from studies like the one published in 1985,
called “A Consumer Perspective on Quality Care: The Resident’s Point of View” (Koren,
2010) in which surveyed residents of elder care facilities define quality of care and
quality of life in their nursing homes. This survey spells out that from a resident’s
perspective the quality of care is equally important to quality of life considerations.
Koren (2010) discovered the following:
Residents told federal officials that “quality of care” (which encompasses such considerations as the
medical treatments a resident receives, and physical care routines including assistance with bathing, using
the toilet, and eating) and “quality of life” (how one is treated-for instance, having one’s privacy respected
by others’ knocking before entering a bathroom, or having one’s dignity maintained by not being wheeled
down a hallway scantily covered en route to the shower) are inseparably linked and, from the resident’s
perspective equally important. This principle figured prominently in subsequent legislation and regulations.
( p. 1)
In order to achieve these objectives and others to improve the services provided to
the elderly, OBRA also called for increased education and training for front-line
caregivers and legislated the use of ombudsman, social and physician services in care
facilities (Fleming et al., 2003). In spite of this well-meaning federal legislation,
implementation was slow or ineffective. Despite the focus in OBRA to make facilities
more “homelike” to improve the quality of service, many facilities continued to create
environments that were more “institutional” than “homelike” (Koren, 2010, p. 2).
Striking the right balance between providing appropriate and effective medical care to
residents and delivering a high “quality of life” in nursing homes is still a struggle in
present day facilities. Advocates and professionals continue to characterize long-term
care practices as “assembly line models” and agree that the continued institutionalized
22
delivery of care does not service America’s elders or staff appropriately (Ragsdale &
McDougall, Jr., 2008; White, Newton-Curtis, & Lyons, 2008).
Over the past decade, there has been a slow growing movement to change the
culture of long-term care. The culture change movement grew in part out of the desire to
implement the “person centered care” and quality of life /quality of care nexus outlined in
the NHRA (Koren, 2010). This culture change movement encompassing a whole host of
changes in the delivery of service in nursing homes has gained momentum to promote
resident-centered and individualized care to those who live and work in nursing homes
(Ragsdale & McDougall, Jr., 2008).
The culture change movement has a fascinating albeit brief history in the elder
care industry. The founders of the modern day culture change movement were
innovators who began their careers during the 1970’s in a few isolated nursing homes
across the nation. In 1997, industry innovators and advocates across the nation convened
to network and discover the possibilities for the future of long term care (Fagan, 2003).
This first meeting included approximately 30 invited participants that represented all
stakeholders affiliated with the nursing home industry including regulators, nurses, and
administrators. This group initially centered around commonly held values embraced by
the four innovative nursing homes instead of focusing their efforts on attempting to
change specific regulations or policies (Baker, 2007). The forefront of the movement
really arose from the shared values of the attendees at that first conference. Focus on
certain principles provided the fundamental “community model” structure for the
inception of the culture change movement: building relationships, providing choice to
23
residents, quality of life, understanding and valuing elders for what they offer a
residential community and staff empowerment (Baker, 2007; Fagan, 2003).
At the time of its founding, these core values were not common in nursing home
culture. Finding a vehicle to implement these core values into a practical advocacy
movement for the nursing care industry led to the development of the Pioneer Network
(Baker, 2007; Fagan, 2003).
Consistently assigning staff is one of many “culture change” practices that
nursing homes are using to improve resident quality of life. The Pioneer Network is one
organization at the forefront of the culture change movement helping nursing homes to
adopt consistent assignment practices as well as other policies to improve residential life.
The Pioneer Network held their first summit in 1997, this marked the beginning of a new
era in advocacy to fundamentally change the nursing home culture (Rahman & Schnelle,
2008). The Pioneer Network is a national grass roots culture change organization that
seeks to change the way society views aging and deliver quality of life to elders living in
nursing homes (Fagan, 2003). The Pioneer Network promotes “a culture of aging that is
life-affirming, satisfying, humane and meaningful in whatever setting that takes place –
home, assisted living or nursing home” (Pioneer Network, 2004).
Since its inception, the Pioneer Network has grown to become the definitive
national coalition for the advocacy and implementation of culture change practices in
nursing homes to improve the quality of care. The Pioneer Network provides networking
opportunities, education, and resources for providers across the country. In addition to
providing national support resources, they have become a catalyst for the development of
24
state coalitions working toward the same goals. California is one of the most recent
states to form a coalition. The California Culture Change Coalition’s Executive Director,
Bonnie Darwin explains that the coalition began with an action plan by three industry
employees at the Pioneer Network’s national conference. Today, there are coalitions in
more than 30 states. These non-profit organizations spread the shared values of the
culture change movement and the mechanics of how to practically implement those
values in nursing home care (B. J. Darwin, personal communication, January 2010).
California leaders and volunteers quickly put the plan into action. In a few short years,
California’s coalition is among the few state coalitions that pay an executive director to
fulfill their mission of providing educational programming to nursing homes throughout
the state (B. J. Darwin, personal communication, January 2010).
Over the past decade, it has been a challenge for professionals to change the longstanding culture of nursing homes. Developing community and building relationships are
cornerstone principals of changing the nursing home culture. The essence of culture
change embraces a positive resident-staff relationship and challenges nursing homes to
move beyond superficial changes to promote caring communities in which residents and
employees can experience enhanced quality of care (Rahman & Schnelle, 2008).
“Culture Change means transformation of the facility’s fundamental values” (Moles,
2006, p. 20). This involves moving away from a hierarchical model, to a person-centered
focus, where the resident has the power of choice. Although the frontline caregiver
engages in the relationship with the resident, support from all levels of administration are
necessary to sustain a true culture change facility (Ragsdale & McDougall, Jr., 2008).
25
Although the goal of culture change policies is to improve the quality of resident care, it
has been shown to produce other ancillary benefits for nursing homes. Many studies
have shown that the development of culture change improves the work environment and
staff retention (Bowers et al., 2003; Donoghue, 2010; Lehning & Austin, 2010; Stearns &
D’Arcy, 2008; Tellis-Nayak, 2007). Culture change encourages respect, teamwork, and
communication between the direct care worker and administration (Anderson, Corazzini,
& McDaniel, 2004; Ragsdale & McDougall, Jr., 2008; Tellis-Nayak, 2007). In order for
providers to pursue changing the long-term care industry one must have a general
understanding of organizational culture.
Organizational Culture in Long-Term Care
Despite its venerable objectives to improve the lives and care for nursing home
residents, transforming nursing home culture has proven to be difficult due to deeply held
beliefs from the staff and management within the organizational hierarchy. According to
Gibson and Barsade (2003), the informal organizational structure of any business is
considered its organizational culture. Organizational culture is comprised of three layers
(Gibson & Barsade, 2003). The first layer of organizational culture is the element within
the culture that you can see (Gibson & Barsade, 2003). Some examples of what one may
notice when stepping into a nursing home are the type of dress employees and residents
don or the décor of the interior. This first layer is important to acknowledge because it is
reflective of the non-visible layers below (Gibson & Barsade, 2003). The second layer of
organizational culture structure is what evolves into “normal” behavior. This behavior is
generally guided by the boundaries set by people within the organization and what they
26
consider appropriate for themselves. Normal behavior is not dictated by formal policies
or control systems. People often conform to what is expected, “normal” behavior and
“unwritten” guidelines set by their peers on what is acceptable behavior when the
motivation is intrinsic (Gibson & Barsade, 2003). The third and final layer of
organizational culture provides the very foundation upon which the other two layers sit
and poses the most difficult challenges for change. This foundational layer is where the
most deeply held values and beliefs of an organization are rooted. Visions of how an
organization “should be” are also deeply held within the third layer (Gibson & Barsade,
2003). The history of long-term care, as described earlier in the chapter, has anchored
modern day institutional values and is a reason for the slow progression toward positive
change. Most culture change leaders recognize that the key to guiding change involves
fostering an understanding of these three layers as outlined by Gibson & Barsade (2003).
Training leaders within nursing homes to work with the individual culture of the
home will help foster sustainable change (Shields & Norton, 2006). Then, in turn, getting
those leaders to use that intimate knowledge of the culture to change the values of
employees who work most closely with the resident is the lynchpin of success. Without
changing the values of executives, management, and those employees closest to the
resident, changing the organizational culture can be near impossible (Shields & Norton,
2006).
Certified Nursing Assistants (CNAs) provide the majority of direct care to the
residents in nursing homes. This thesis reflects the importance of the CNA in long-term
care settings and staff training is one way to move toward changing organizational
27
culture within nursing homes. An article by Kemper and colleagues (2008) summarizes
needs of direct care workers across long-term care settings. Kemper’s review of this
long-term care workforce study summarizes the top three needs of CNAs. In order of
importance, the participants in this study cite the top three identified needs as follows;
increased staffing, ability to form relationships with the residents and fellow workers, and
increased pay and benefits (Kemper et al., 2008). One fundamental way to form
meaningful relationships between caregiver and resident is through the practice of
consistent assignment (Patchner & Patchner, 1993; Rahman et al., 2009; White et al.,
2008).
Creating new cultural norms within nursing homes has been a slow progression.
Consistent assignment can become a significant tool for changing the organizational
culture for both staff and residents of nursing homes (Rahman et al., 2009). This practice
has become more common in the nursing home industry over the last decade with
positive results (B. J. Darwin, personal communication, January, 2010). Consistent
assignment is a staffing practice that permanently assigns the caregiver, certified nursing
assistant (CNA) to the same residents the majority of the time (Burgio et al., 2004;
Quality Partners of Rhode Island, 2007; Rahman et al., 2009). Nursing homes employ
CNAs to provide the full spectrum of service required by residents including routine
physical care, such as bathing, grooming, dressing, eating, as well as the equally critical
aspects of psychological and emotional support demanded by residents (Kemper et al.,
2008; Lehning & Austin, 2010; Patchner & Patchner, 1993). To further culture change in
the literature it is important to examine a theory that connects the organizational structure
28
to the personal nature of the CNA’s role within the long-term care environment (Rahman
& Schnelle, 2008).
Theory and Culture Change
The elderly population is growing (Dychtwald, 1999) and the industry predicts a
nursing shortage (HHS, 2003; Hollinger-Smith & Ortigara, 2004) one would expect that
nursing home scholars and professionals continue to explore culture change practices to
address anticipated shortcomings. One way scholars can validate culture change within
the long-term care industry is through theory development (Rahman & Schnelle, 2008).
King’s Theory of Goal Attainment, summarized in chapter one, has been applied in
pediatric and acute care settings (Messmer, 2006) and may be useful to the long-term
care sector. This theory examines the importance of the nurse-resident relationship and
may be useful when implementing culture change practices, such as consistent
assignment that is explored in this thesis.
Consistent assignment provides a platform to test King’s theory in a nursing home
setting. Care planning and goal setting is a daily part of resident care in nursing homes
and aligns with the theoretical concept. Although the theory title sounds didactic, the
framework is dynamic, concerned with relationships and the value of every staff member
and resident. The essence of this nursing theory is about the nurse-patient relationship
and therefore it would be prudent to explore it in a nursing home setting specifically the
CNA and resident relationship (King, 1999; Messmer, 2006; Whelton, 1999).
According to the literature, King’s nursing theory involves working with three
systems, social, interpersonal and personal (King, 1999, 2007; Messmer, 2006). Nursing
29
homes are complex organizations, and the nature of nursing home daily life involves
interaction within the three systems. For example, working as a CNA involves
interaction with the larger nursing home community, (the social) which includes other
departments such as administration, housekeeping, or activities. In addition to the
broader spectrum the CNA must work with the clinical team (the interpersonal) which
includes licensed nurses, dietary, and therapy personnel. The third and closest system the
CNA must interact with is the resident, representing the personal system that King’s
theory refers to (King, 1999, 2007; Whelton, 1999). Ultimately this theory assumes,
through a transaction process, which includes, setting and attaining goals in the course of
mutuality, that the whole individual has the power of experience to make a choice to
reach a mutual goal set with information gathered between the larger system interactions
as well as exchanges between nurse and resident at the interpersonal level (King, 1999,
2007; Whelton, 1999). The philosophical core of King’s Theory explains the human
being, nurse and patient, has equal worth implying respect and value when a transaction
process occurs and goals are met (King, 1999, 2007; Messmer, 2006; Whelton, 1999).
Since much of the criticism about culture change is the lack of empirical study,
linking culture change in long-term care to a theory that is deeply rooted within the
nursing profession is important for further exploration (Rahman & Schnelle, 2008).
Personal growth and development is a key part of King’s theory and parallels culture
change philosophy. As a whole, King’s theory symbolizes the essence of the culture
change movement; similar to the culture change journey, it serves as a feedback loop, to
always set goals to do better for residents and staff. Additionally, the theory relates to the
30
individual resident by engaging in mutual goal setting through meaningful interactions
with the nursing team (King, 1999, 2007; Messmer, 2006; Whelton, 1999). The nursepatient relationship engages in a series of events described as a transaction process. This
process occurs at the social, interpersonal and personal level where each individual
engages in growth development through perception, judgment, and action which leads to
a reaction, interaction, and transaction (King, 1999, 2007; Whelton, 1999). According to
King’s theory, a transaction occurs between the nurse and patient when the goal is agreed
upon along with the means to achieve that goal (King, 1999, 2007; Messmer, 2006).
As culture change models begin to be connected with a theoretical framework it
would be logical that increased empirical research will follow and validate what
advocates and practitioners already know and experience on a daily basis. The theory, as
discussed, may sound impersonal describing relationships as transactions it is paramount
for those putting theory into action that the system model communicates dynamic
wholeness (Whelton, 1999). The theory suggests; for the action to be proper it must
include knowledge and choice (King, 1999, 2007). Culture change models are similar to
King’s theoretical concept related to honoring resident choice and encouraging positive
relationships between the resident and caregiver. Establishing this foundation, through
theory or culture change models, is thought to contribute to positive outcomes in resident
and nursing care (King, 1999, 2007; Messmer, 2006; Shields & Norton, 2006).
Culture Change Models in Long-Term Care
Many culture change models are currently available and may provide a good
environment for scholars to test King’s Theory of Goal Attainment in nursing homes.
31
Two models that use consistent assignment as a key component are The Eden Alternative
and Household models (Bruck, 1997; Shields & Norton, 2006). While all culture change
models are rooted in the founding principle of building relationships between staff and
residents, various models have been explored in nursing home literature since the
formation of the Pioneer Network (Baker, 2007). However, the implementation of
culture change values in the elder care industry across the nation cannot be characterized
as monolithic. Implementation is in fact often unique to the needs of the staff and the
facility. However, examination of two popular models will help illuminate how the
movement and its goals have progressed.
Two of the more common culture change models are The Eden Alternative and
Household models and discussed below to help illustrate the progress and promise of the
movement to improve the quality of care to residents. These models provide a
framework that can transform a nursing home within the current physical structure. In
order to encourage change, it is important to give providers a model where success is
possible while working with the physical structure of nursing homes. Nursing homes
were built as “mini hospitals” and project an institutional atmosphere (B. J. Darwin,
personal communication, January, 2010). Many administrators do not believe
meaningful cultural change can be achieved without physically rebuilding the structures
of nursing homes with the goals of change laid out as part of the construction process
from the ground up. While optimistic in theory, the task of rebuilding the over 1200
California nursing homes is not feasible. As a result, adopting a successful model like
the Household concept or the Eden Alternative can transform the institution while
32
working with the existing physical structure of the home (B. J. Darwin, personal
communication, 2010).
The Eden Alternative began in the early 1990’s by Dr. William Thomas and
involves creating a human habitat inside the nursing home where residents thrive and
grow rather than decline and die (Bruck, 1997). Dr. Thomas was the physician for a top
quality “deficiency free” nursing home in up-state New York. One day, during an
examination, the resident complained of loneliness. With no drug to prescribe for what
was really ailing her, he began to view the nursing home through a new lens (Thomas,
2006). Dr. Thomas went on to discover residents were suffering from three plagues:
loneliness, helplessness and boredom (Bruck, 1997; Rosher & Robinson, 2005). He
began to transform the institutional structure of his nursing home, searching for antidotes
to the three plagues. He started by injecting small changes into the environment such as
giving each resident the responsibility of caring for a house plant. The Eden Alternative
emerged from this innocuous idea (Bruck, 1997). In the present-day Eden model, the
core still relies on creating a human habitat which empowers the staff and provides
solutions to the three problems of loneliness, boredom and helplessness.
To address loneliness, the residential care community needs to provide
companionship. There are a few key ways to encourage the Eden model companionship:
allowing staff to engage in meaningful relationships with residents, providing easy access
to animal companions and inviting children into the community. To combat helplessness,
Dr. Thomas discovered that elders need to be able to give care as well as receive care. In
the Eden model, nursing home staff foster opportunities for residents to give care in many
33
simple and achievable ways. As listed above, adding plants to a resident’s room
encourages them to care for something else and is easily and cheaply implemented.
Encouraging an activity as simple as folding laundry also combats helplessness
effectively. Finally, asking residents for advice and input about their surroundings is also
a simple way to get residents to care. A daily life filled with spontaneity and an
unexpected interaction is the antidote for the third and final plague: boredom.
Unscheduled spontaneous activities are one way to keep residents from boredom.
Although these simple techniques can bring a nursing home closer to achieving its culture
change goals, it is merely one tenant of community transformation. The Eden Alternative
also encourages system-wide transformation and staff empowerment as critical
components in sustaining the ideal “human habitat” that Dr. Thomas envisions for all
elders.
Not only does the Eden Alternative have the potential to provide a positive
environment for residents and staff, a study by Rosher and Robinson (2005) examined the
wider implications the Eden alternative could have on nursing students’ attitudes toward
aging. Educators view students’ experience with actual nursing homes a valuable
resource for clinical practice and education of nursing students. However, actual homes
are not always utilized in the education process because educators fear the reality might
create negative attitudes toward aging (Rosher & Robinson, 2005). The study concluded
that students receive clinical education at an Eden Home have an increase in enjoyment
of field of geriatric care and considered extending their career into geriatric nursing
(Rosher & Robinson, 2005). This study is promising given the predicted shortage of
34
long-term care workers because clinical education can be used to attract more nurses to
the field earlier with training in newer models of care.
It is estimated that implementation of culture change models like Eden may aid
with a new generation of elder health care providers. A 2003 report to Congress about
the future of America’s long-term care work force estimated that by 2025, the year baby
boomers begin to reach the age of 80, nursing homes will need 1.84 million direct care
workers to care for American elders (HHS, 2003). Any effort to increase the long-term
care workforce is valuable.
As with all culture change models, the Eden Alternative is a journey of finding
the right balance between meeting the clinical demands of the residents while becoming
an elder-centered community that nurtures the spirit. Nursing homes are forever
entrenched in a system of rules and regulations, which makes change of any kind difficult
to navigate. Dr. Thomas states “the failure belongs to the system, not the people who
struggle to make that system work” (Thomas, p. 216). The Eden Alternative, created by
Dr. Thomas, is one way to create systemic nursing home transformation while valuing
both the residents and staff.
The next culture change model that has promoted a positive systems change
within nursing home industry is the Household model. This model, like Eden, seeks to
transform the institutional system that exists in the majority of nursing homes. The
Household model core principle attacks the decision-making hierarchy of nursing homes.
This model provides a new foundation for long-term care by placing value on shared
decision making and reordering the priorities of that decision making (Baker, 2007;
35
Shields & Norton, 2006). The Household model values decision making that advances
the good of resident over the good of the system and focuses on fostering a “home” for
residential care versus an “institution.” This foundation of values provides staff the
ability to change the way they relate to residents and co-workers (Shields & Norton,
2006). Unlike Eden, the Household model also has a formalized physical component to
achieve its cultural objectives. The ultimate goal of the physical component of the
Household model is that the structural elements of the nursing home environment reflect
a home. Each nursing home building complex can have multiple households with
microenvironments (Baker, 2007; Shields & Norton, 2006). These homes within the
nursing care facility contain the same important symbols of what we as society
commonly understand as a being part of a traditional home; such as having a front door
with a door bell, a common living room, a kitchen and personalized bedrooms. Each
household is designed to hold approximately 20 residents and appropriately ratioed, selfled staff of nurses, housekeepers, and caregivers. Household staff also empowers the
resident to contribute to their environment. A true household model has a front door for
every self-contained home within the larger confines of the building (Shields & Norton,
2006). However, modified versions of the household model are also in use. A common
modification of the Household model in California is the neighborhood approach. In the
neighborhood approach, each designated “wing” becomes a household in the
organizational structure. To successfully implement any model, decentralization of the
system is paramount. The household way to dismantle the old system is through the
formation of self-led teams that are consistently assigned to each neighborhood and
36
empowering the team (including elders) to design the structure of daily life in the
neighborhood (Shields & Norton, 2006). The concepts of the household systems’
transformation are possible to attain in any nursing home, regardless of physical
structure, improved relationships between staff and residents are also sustainable. The
neighborhood approach may not complete the major physical structural remodel for each
household to have their own door, kitchen, and living areas.
The culture change movement, no matter the model, seeks to empower the
frontline staff and residents. To truly embrace culture change as described earlier in this
chapter, staff should be permanently assigned to residents as part of a consistent
assignment protocol and every effort should be made to reduce turnover in the hopes of
providing American elders the best care possible. Culture change models are not a
panacea. They have challenges, and the prime directive of any nursing care facility is to
deliver responsible care (Moles, 2006).
Consistent Assignment, Culture Change and the Frontline Caregiver
Consistent assignment represents a fundamental change to the long-standing and
most prevalent norm of assigning frontline workers to residents on a rotating basis. A
nursing home that rotates staff assigns different residents to the CNA and nursing staff on
a quarterly, monthly, or weekly basis (Quality Partners of Rhode Island, 2007; Patchner
& Patchner, 1993). Consistent assignment facilitates the development of long-term
relationships with the resident; the rotating assignment model shifts care workers too
often, away from the same residents, eliminating any possibility of a continuous
relationship. Nursing homes that use consistent assignment never rotate staff (Quality
37
Partners of Rhode Island, 2007). As a result, implementing this culture change practice
to the norms of the nursing care industry has been met with considerable resistance
despite its ample benefits (Burgio et al., 2004; Farrell et al., 2006).
Despite the effective and standard use of the consistent assignment model in
hospitals over 70 years ago, the present day battle to make consistent assignment
commonplace has faced significant opposition. The consistent assignment model was a
standard hospital practice prior to World War II. In this pre-World War II paradigm of
care, nurses were the primary caregiver for patients from admission to discharge.
Further, the organizational structure of the hospital supported the direct care worker, the
nurse, by creating clinical teams for each patient in order to improve efficiency and
accommodate the large number of patients nurses served (Patchner & Patchner, 1993).
The pre-World War II health care industry thought that each person’s job should be
routine and specialized. Present day culture change which advocates consistent
assignment practice, returns to this pre-war model of personalized service through the
direct care worker. Consistent assignment enables a CNA to care for the resident
holistically and personalize service for each resident (Quality Partners of Rhode Island,
2007; Koren, 2010)
Numerous studies have demonstrated that consistent assignment provides benefits
to the residents, the nursing aids, and the nursing home (Bowers et al., 2003; Burgio et
al., 2004; Rahman & Schnelle, 2008; Tellis-Nayak, 2007). One such benefit is fostering
relationships between the CNAs and their residents to give and receive better care. When
a longer term and more trusting relationship has been formed through continued service
38
residents feel more secure with their care (Patchner & Patchner, 1993). In addition to
residents feeling better about the care they are receiving, CNAs report they perceive an
ability to provide better care to residents. Improvements in quality of care is not just
anecdotal but measurable. Studies report two key indicators of the quality of care
reported to the regulatory authorities: the prevalence of pressure ulcers (Farrell et al.,
2006; Lynn et al., 2007) and the degree of resident restraint use have both decreased
under consistent assignment (Farrell et al., 2006; Rahman et al., 2009). This increased
ability to satisfy their residents’ needs under a consistent assignment staffing pattern has
also lead to higher job satisfaction for CNAs (Burgio et al., 2004).
Recently national and state quality improvement organizations (QIOs)
recommend that nursing homes adopt the practice of consistent assignment. In 2002,
Centers for Medicare and Medicaid (CMS) began administering and contracting with
QIOs to address quality issues in long-term care facilities. Nursing home cooperation
with QIOs and their recommendations to address the nursing home quality control is still
voluntary. However, lower performing homes are usually targeted to participate and
strongly encouraged to work within the QIO recommendations. There are 53 QIO
organizations serving in all 50 states (Advancing Excellence in America’s Nursing
Homes, n.d.). Working with a QIO has been credited with helping nursing homes
improve quality of care. In a press release, the American Health Quality Association
announced that nursing homes that worked with their QIO successfully reduced stage III
and IV pressure ulcers by 69 percent over the course of a year. The findings were a result
of a study by Lynn and colleagues (2007). Nationally, the QIO support structure is also
39
in place. The Advancing Excellence campaign is currently serving as a national QIO
with eight goals for nursing homes to choose from (Advancing Excellence in America’s
Nursing Homes website, n.d.).
It is important to take a systematic approach when attempting a fundamental
organizational change to a current practice such as consistent assignment. The state QIO
organizations provide free implementation guidelines to providers so they can achieve
success (Advancing Excellence in America’s Nursing Homes website, n.d.). Guidelines
suggest that administrators and managers include staff, start small, and test the practice
on one floor or wing to begin. To make a commitment to consistent assignment,
managers should assemble the team to address and answer all concerns the staff may
have about the proposed change (Advancing Excellence, 2009; Farrell et al., 2006;
Quality Partners of Rhode Island, 2007).
When making a staff assignment changes it is important that the management
does not use a hierarchical approach. For example, when selecting residents to their shift
assignment it is critical for CNAs to be included as part of the decision making process
(Advancing Excellence, 2009). One way to involve the direct care worker is to allow
them to balance the caseload of “easy” and “hard” residents in the consistent assignment
model and not simply assign a basic nurse to resident ratio, regardless of the degree of
difficulty. The CNAs collaborate and rank each resident on a scale from one to five,
easiest to most difficult respectively (Farrell et al., 2006; Quality Partners of Rhode
Island, 2007). Once they are ranked, the nurse aid should be allowed to select their own
residents. This process empowers staff and fosters the acceptance of the workload and
40
the perception that the caseload is fair. Once the program is in place, it is critical to
continue communication with the staff and re-evaluate the caseload (Advancing
Excellence, 2009; Farrell et al., 2006).
In 2007 The Commonwealth Fund sponsored a national nursing home survey to
measure the extent which culture change principals are being adopted (Doty et al., 2008).
A final sample size of 1435 nursing homes completed surveys and based on their answers
were placed into three categories; culture change adopters, culture change strivers, and
traditional nursing homes. The largest group represented in the survey was the traditional
nursing home at 43 percent of those surveyed (Doty et al. 2008). Although it appears
traditional nursing homes continue to dominate the profession, this national survey
reported that 74 percent of the 1435 participating nursing homes used a consistent
assignment model with their CNA staff (Doty et al., 2008). This appears to be a step in
the right direction toward improving resident-centered care and moving more homes
toward the “culture change adopter” end of the spectrum.
Adopting a consistent assignment program is a good first step to changing nursing
home culture. However, tracking key quality indicators is a simple way for
administrators to quantify their progress. The three quality indicators selected for this
thesis; staff turnover, use of physical restraints, and prevalence of pressure ulcers were
examined because of the connection to quality of care for the resident. One can imagine
that being tied down, enduring pain associated with pressure sores, and having to get to
know staff with great frequency can be distressing for anyone and influence their quality
of life.
41
Quality Indicators: Staff Turnover, Physical Restraints and Pressure Ulcers
Quality control measures are typically conditions that are prevalent, relevant, and
have a process of specific care (Coleman, Martau, Lin, & Kramer, 2002). Scholars are
constantly searching for better answers to improve nursing homes and the care delivered
to one of society’s most vulnerable populations. Staff turnover, use of physical restraints
and presence of pressure ulcers (PrUs) are quality indicators that can influence the
home’s quality rating and be disruptive to the nursing home resident and staff (Baker,
2007; Bergstrom et al., 2008; Degenholtz et al., 2008; Hantikainen & Käppeli, 2000;
Sirin, Castle, & Smyer, 2002). Donoghue & Castle (2009) note that nursing home quality
has improved in the past 20 years, but 20 percent of the nations nursing homes are still
considered “poor quality” by regulatory authorities. This significant percentage of poor
performing homes still leaves room for improvement and motivation to adopt
fundamental changes like those that seek to transform the frontline staff and most directly
influence the quality of care delivered to elders.
CNA turnover has been linked to lack of emotional and financial support, from
the leadership within the long-term care industry (Donoghue & Castle, 2009). This lack
of support can contribute to increased costs to the nursing home including; recruitment,
training, increased workload for remaining CNAs and decreased employee and resident
satisfaction (Hollinger-Smith & Ortigara, 2004; Stearns & D’Arcy, 2008).
Use of physical restraints and the prevalence PrUs for nursing home residents
grab the most public attention as outward emotional symbols of good and bad care. The
frequency of nursing home use of physical restraints on residents and the occurrence rate
42
of pressure ulcers are a part of mandated reporting requirements to governing regulatory
agencies. Regulatory bodies use the Minimum Data Set (MDS) statistics to help
objectively rate the quality of care in each reporting facility (Rahman & Applebaum,
2009).
Quality indicator: staff turnover. Because nursing homes are complex
organizations, studies also show that improving staff retention improves quality of care
for the residents (Castle & Engberg, 2006). Staff turnover and retention have been
widely studied for decades across a variety of healthcare settings and are linked to
adverse effects such as high cost and lower quality of care (Bowers et al., 2003;
Donoghue, 2010; Donoghue & Castle, 2006; Riggs & Rantz, 2001). Many scholars
consider reduced staff turnover rates a key indicator for higher quality nursing homes
(Bryant & Stone, 2008; Donoghue & Castle, 2006; Lehning & Austin, 2010; Patchner &
Patchner, 1993).
By 2012, it is expected that the demand for CNAs will increase by 24 percent
within long-term care (Kemper et al., 2008). This anticipated increased staffing demand
for the industry is a result of our aging population and their predicted future medical
needs (Dychtwald, 1999). There are direct and indirect replacement costs that make it
very difficult to replace CNAs. Direct costs account for about 20 percent and include
increased management time hiring and training new employees (Hollinger-Smith &
Ortigara, 2004; Stearns & D’Arcy, 2008). Indirect costs can account for up to 80 percent
of total cost and infiltrate into many levels of the nursing home. Indirect costs cited in
the literature are employee inefficiency, burden to others covering the shift, (Stearns &
43
D’Arcy, 2008), a decrease in resident quality care, reduced employee and resident
satisfaction, and increased overtime and agency costs (Hollinger-Smith & Ortigara,
2004). Addressing the financial issues related to continual replacement of CNAs will not
only make nursing homes more solvent but could free up resources that could be directed
to implement cultural changes like the structural construction changes proposed by the
Household model. For purposes of this thesis, it is important to note that turnover rates
are high for the frontline worker, and that staying the tide of turnover in nursing home
facilities has been proven to improve care to its residents (Anderson et al., 2004;
Donoghue & Castle, 2006; Donoghue, 2010).
Retaining nursing home frontline staff is a benefit to the organization’s bottom
line. The cost to a nursing home to replace a CNA ranges between $2,500 and $3,500 per
CNA (Bishop et al., 2008; Castle & Engberg, 2006; Hollinger-Smith & Ortigara, 2004).
There are many factors that contribute to CNA turnover in nursing homes; several studies
cite expense, burdening existing staff, and decreased quality of care (Barry et al., 2008;
Bowers et al., 2003; Castle & Engberg, 2006). Many have attributed staff turnover as
one indicator of nursing home quality. Culture Change leaders believe that consistent
assignment, the foundation of many resident-centered organizations, can lead to
decreased turnover and can promote relationship centered care within an organization
(Farrell et al., 2006; Kemper et al., 2008; Koren, 2010). Being empowered to increase
engaging relationships with residents has been shown as a major contributor to increased
CNA job satisfaction (Bowers et al., 2003; Kemper et al., 2008; Ragsdale & McDougall,
Jr., 2008).
44
Donoghue’s (2010) national turnover and retention study estimates CNA turnover
nationally at 74.5 percent. Donoghue also concludes that CNAs continue to rank higher
rates of turnover than other segments of the nursing profession (Donoghue, 2010).
Annually, CNA turnover rates remain high (Donoghue, 2010; Donoghue & Castle, 2006,
2009; Kemper et al., 2008). This consistent turnover data out of scholarly research
reinforces the need to focus on efforts which both reduce turnover and simultaneously
improve the quality of care for residents. Consistent assignment, the extensively
discussed lynchpin of the culture change movement, achieves these dual objectives of
improving care to residents and raising the job satisfaction of the care providers.
Additionally, the implementation of culture change protocols like Eden and Household
models can increase the job satisfaction of all employees in the nursing home, not just the
direct care workers. Happier workers at all levels are less likely to leave their jobs
(Donoghue & Castle, 2009; Kemper et al., 2008).
Quality indicator: physical restraints. Nursing home scholars have extensively
studied the use of restraints and their effects on resident wellbeing. A physical restraint is
defined as a device that restricts resident’s movement and /or prevents access to his or her
body and cannot be easily removed (Advancing Excellence in America’s Nursing Homes,
n.d.; Engberg et al., 2008). Patient safety remains the primary reason clinical staff in
nursing homes defend using restraints. It is thought that restraints are necessary to
prevent injuries and falls (Engberg et al., 2008; Hantikainen & Käppeli, 2000; Pellfolk et
al., 2010). Although nursing home staff justifies restraint use, in the name of patient
safety, many studies have shown that restraining a resident can actually increase fall risk
45
and can cause emotional distress, immobility, and social isolation (Engberg et al.;
Hantikainen & Käppeli; Pellfolk et al.). Although physical restraints are still prescribed
by physicians, many professionals and advocacy groups believe it is not good practice to
physically restrain residents and are advocating for restraint free homes (Engberg et al.
2008; Goldman, 2008).
Advancing Excellence’s national campaign to improve quality in nursing homes
has established eight goals for improvement, and among them are the reduction of PrUs
and restraint use (Advancing Excellence in America’s Nursing Homes, website n.d.).
The need for a national campaign in 2010 focusing on PrUs and restraint use serves as a
reminder that some nursing homes continue to perpetuate old practices that have already
been proven to lower the standard of care and to institutionalize the elderly. For
example, physical restraints are often used too frequently on patients that are perceived to
be difficult in the traditional, institutional structure (Engberg et al., 2008). Having the
same staff work with the most difficult or strenuous residents on a daily basis through
consistent assignment improves the relationship between the resident and the care
worker, often refocusing the CNA’s first line response to residents and providing
alternatives that do not include physical restraint. On the resident side, restraint use has
been associated with decline in physical health including increase in pressure ulcers,
decrease in ADLs, and lower cognitive status (Engberg et al., 2008).
Since the enactment of the Nursing Home Reform Act of 1987, which imposed
increased restrictions on the use of restraints, the national restraint use average has
significantly dropped from 41 percent in 1990 to approximately 20 percent by 1994 (Sirin
46
et al., 2002). The American Health Care Association Reimbursement and Research
Department’s quality measure report (2010) claims physical restraint use in nursing
homes averages 3.3 percent nationally. This data is based on collected MDS data. The
same report estimates California nursing home residents being restrained at an average of
6.6 percent (American Health Care Association Reimbursement and Research
Department [AHCA], 2010). At a glance, California is double the national average;
however in an interview with a nursing home administrator, it was discussed that
California identifies and measures restraints very carefully. A restraint is defined as
anything that the resident cannot undo or free themselves from on a consistent basis.
Some residents may be secured with a restraint belt, but if they can free themselves
consistently it is not considered a restraint (S. Haskins, personal communication, April,
2010). Although there are strict guidelines for reporting, the potential subjective nature
of measuring restraints can influence the nationally reported data.
A qualitative study by Hantikainen and Käppeli (2000) explored “nursing staff
members’ perceptions of restraint and how these perceptions govern decision-making on
the use of restraint” (Hantikainen & Käppeli, 2000, p. 1197). Safety for the resident and
reducing liability were popular reasons for using restraints. Many of the nursing
decisions appeared to be based on routines and emotions rather than facts (Hantikainen &
Käppeli, 2000). The ability for nursing homes to educate and “change” the nursing staff
perception can be an effective way to enhance the nursing home culture and reduce the
use of physical restraints (Engberg et al., 2008; Hantikainen & Käppeli, 2000).
47
Within the modern nursing home culture, there are many barriers to achieving a
care delivery system without the use of physical restraints. There are already many
programs available to aid with restraint reduction. However, many nursing homes lack
the leadership and policies to effectively take advantage of such programs (Engberg et
al., 2008; Sirin et al., 2002). Nursing home leadership includes administrative personnel
and nursing supervisors. Unfortunately, the leadership of nursing homes often lacks the
resources and skill sets to effectively manage any kind of change including the
fundamental changes proposed by the culture change movement and the limitation of
physical restraints (Goldman, 2008). Another barrier cited in nursing home literature to
providing restraint free nursing home environments is the high turnover rates and short
staffing. Consistency in staffing also helps manage programs such as restraint reduction
more effectively from introduction to execution and maintenance. Finally, Goldman’s
(2008) discussion on rotating assignment demonstrates that scheduled rotation serves as a
barrier to restraint reduction. Rotating staff do not readily identify care needs for the
resident, and rotation often delays or prevents staff from understanding the particular
needs of a resident. When this happens, restraints are more often used as a default rather
than catering to specifically identified needs.
The literature also reveals another potential misconception about the use of
physical restraints, that it costs less to simply “restrain” residents. When physical
restraint reduction and elimination programs were first suggested, the argument against
them was that it would likely increase the cost and resources used (Goldman, 2008). In
fact, Engberg and colleagues (2008) revealed it is often more expensive to restrain a
48
resident because increased staff is necessary to supervise and monitor a restrained
resident. Additionally, a resident who is consistently restrained can decline in several
key indicators such as walking dependence, resident ADL performance, and cognitive
function (Engberg et al., 2008). This decline can cost the facility more over time to care
for the resident. Despite national campaigns and increased restrictions for use, physical
restraints are still present in nursing homes across the country.
Quality Indicator: Prevalence of Pressure Ulcers
Pressure ulcer (PrU) prevalence is another quality indicator that nursing homes
report to government agencies and is publicly available to the consumer. A pressure
ulcer is defined as a “localized injury to the skin and /or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in combination with shear and/or
friction” (NPUAP, 2007 p. 344). Degenholtz (2008) examined the association between
health status and quality of life in nursing homes and found that when residents with
stage II PrU or higher were interviewed there was a significant negative impact on their
answers in the study’s quality of life interview. Residents with serious PrUs also risk
pain, slower recovery, decreased quality of life, immobility, and infection (Bergstrom et
al., 2008; Capon, Pavoni, Mastromattei, & Di Lallo, 2007; Kwong, Pang, Aboo, & Law,
2009). Although research has enabled clinicians to understand and treat PrUs with
success, they still remain a significant problem for both nursing home providers and
residents (Black et al., 2007).
Skin care, nutrition, mechanical loading, support surfaces, and education are five
important risk factors associated with developing pressure ulcers (National Pressure
49
Ulcer Advisory Panel [NPUAP], 2007). Comprehensive educational PrU programs that
are organized and supported by all team members are important to a quality nursing home
care. The team should be educated on risk factors, assessments, nutrition,
documentation, and necessary support surfaces in order to succeed. Evaluating
programming and monitoring preventative measures are important to sustain success and
accountability (NPUAP, 2007).
It is necessary to individualize the care plan to prevent ulcer development and aid
healing (NPUAP, 2007). To prevent tissue breakdown, a daily skin assessment, in
conjunction with individualizing bathing, incontinence considerations such as products
used, and immediate cleansing are important ways the clinical team can aid with
appropriate skin care (NPUAP, 2007). Further preventative measures include support
surfaces the resident uses and resident loading on bony areas, which disrupts blood flow
to the tissue (Merck and Company Inc., 2006). A resident’s ADL status is also important
to consider when individualizing care. A study by Bergstrom and colleagues (2008)
concluded that stage II PrUs healed more slowly when residents needed extensive ADL
assistance. The lower the activity levels of the resident the slower the healing process
(Bergstrom et al., 2008; Kwong et al., 2009) and the greater the risk to develop a PrU
(Kwong et al., 2009). Understanding residents’ ADL ability is important for reducing
skin breakdown. It is recommended by NPUAP that chair-bound residents be
repositioned each hour and bed-ridden residents be repositioned every two hours.
Individual care plans should have the appropriate positioning schedule, equipment
50
necessary, and activity status to aid the CNA (National Pressure Ulcer Advisory Panel
[NPUAP], 2009).
Studies have been conducted examining different staffing protocols and their
effect on skin integrity to improve quality of care. The more direct care hours that
nursing teams provide residents, the lower the incidence of pressure ulcers developed
within the nursing home (Kwong et al., 2009). Other staffing characteristics important to
improving quality of care in nursing homes by lowering the risk of PrUs include
turnover, staffing guidelines, staffing levels, and staffing patterns (Hickey et al., 2005)
such as consistent assignment.
Conclusion
This literature review detailed many aspects of the long-term care profession.
The history of aging and health care for our elderly population established how the
profession became entrenched in regulations and institutional processes. The research
reviewed detailed what today’s advocates are doing to find reasonable and practical
solutions for change. Culture change, including adopting innovative models, is begging
to form a sea change within the profession and places the resident and CNA as the most
important yet undervalued part of the solution.
Modeled after hospitals, long-term care is a heavily regulated industry as a result
of a history of neglect and abuse. Nursing homes are beginning to establish residentcentered practices and individualized care through the adoption of legislation and reform
policies. Research postulates that with the support of national and statewide advocacy
groups, culture change principals parallel with what legislators and regulators are
51
attempting to enforce; honoring resident choice and development of individualized care.
It is important for the profession to continue to find models and publicize success through
the mainstream media, and scholarly research.
Building relationships is the heart of all culture change models and many studies
have shown that consistently assigning staff to the same residents daily is the cornerstone
for relationships to develop (Baker, 2007; Farrell et al., 2006; Rahman et al., 2009).
Caregiving for our elders is one of the most difficult but important jobs in America and it
is the responsibility of regulators to work with providers to strive for creating a better
environment for nursing home staff and residents.
52
Chapter 3
METHODOLOGY
The regulatory bodies governing the nursing home industry require nursing homes
to report certain objectively measurable data to aid them in rating the quality of care
provided by each facility (Castle, 2000; Rahman & Applebaum, 2009). Much of this
aggregate data, as well as the final rating of the nursing home, is publicly available on the
internet through the Medicare website (Medicare website, n.d.). This available data is
initially reported by the nursing home to CMS through the Minimum Data Set (MDS)
reporting process. This thesis is examining two quality indicators that are reported
through the MDS system; physical restraint use and the presence and severity of pressure
ulcers (PrUs). Staff turnover is not a quality indicator currently tracked by CMS;
however, public data for staff turnover is collected and examined in California through
the Office of Statewide Health Planning and Development (OSHPD) website. The
importance of staff turnover, PrUs, and physical restraint use to the subjective quality of
care has also been widely studied by all types of groups involved with the nursing home
profession including academicians, advocacy groups, and government bodies (Barry et
al., 2008; Bergstrom et al., 2008; Bowers et al., 2003; Castle & Engberg, 2006; Bishop et
al., 2008; Engberg et al., 2008). The culture change movement in the nursing home
industry has also turned to these three factors as measurable indicators of the success of
their programmatic changes to the nursing home culture. Specifically, any examination
of the culture change advocacy of consistent staff assignment practice should include
these three factors, which have proved insightful to the industry on both an objective and
53
subjective basis (Baker, 2007; Fagan, 2003; Patchner & Patchner, 1993; Rahman &
Schnelle, 2008; Shields & Norton, 2006).
For the purpose of this thesis, 2010 public data was used from two California forprofit nursing homes. The data was used to analyze three nursing home quality
indicators: physical restraint use, prevalence of pressure ulcers and CNA turnover. This
paper uses a convenient sample where two nursing home administrators were asked the
nature of their CNA staffing assignments and willingness to participate in the study (S.
Haskins, personal communication, April 2010; L. Cooper, personal communication,
March 2010). Data collected through the MDS process is analyzed by Government
agencies and made available to the public in the form of percentages; however, the
administrators of the nursing homes selected were interviewed to obtain insight into their
current staff assignment practices. Two nursing homes resulted in the final sample size:
one nursing home using rotating assignment and one nursing home using consistent
assignment.
Research Design
A between-groups comparison design is used to examine differences between
CNAs staffing patterns and quality indicators between the two nursing homes; one
nursing home self-identified as using rotating assignment and one self-identified as using
consistent assignment when caring for the nursing home residents. Although the nursing
home administrators self-identified their staffing patterns, the parameters were defined
through a telephone interview, based on the current nursing home literature. For the
nursing home to be considered as utilizing a consistent assignment staffing pattern, the
54
CNAs had to be consistently assigned to residents a minimum of 80 percent of their time
at work. The definition of key terms in chapter one describes appropriate consistent
assignment criteria.
Purpose Statement
The purpose of this study is to examine nursing homes that have begun to adopt
culture change principles with a focus on nursing homes that practice consistent
assignment compared with rotating assignment nursing homes and its effect on staff
turnover, resident restraint use, and frequency of pressure ulcers.
Research Questions
1. How does consistent assignment versus rotating assignment affect turnover of
nursing home staff?
2. How does consistent assignment versus rotating assignment in nursing homes
affect the use of resident restraints?
3. How does consistent assignment versus rotating assignment affect nursing home
residents’ frequency of pressure ulcers?
Setting and Participants
The nursing homes selected were both for-profit facilities that accept Medicare
and Medicaid as payment methods in addition to private pay. Nursing homes that accept
payment from a governmental source report MDS data monthly (Rahman & Applebaum,
2009). All data reported by the nursing home is available via the internet through the
official Medicare website. Staffing patterns of the nursing home were acquired through a
personal interview with each nursing home administrator.
55
Data Collection Procedures
Research and data collection were accomplished through the use of a computer.
Websites accessed for data collection included www.medicare.gov and
www.oshpd.ca.gov.
Two California nursing homes were used for the study - one nursing home with
consistent assignment and one nursing home with rotating assignment. The data for
pressure ulcers and restraint use were collected on the official Medicare website. As
discovered during the literature review, many studies use public data to compare nursing
home quality indicators; this appears to be a consistently accepted practice in journals
within the gerontology field (Bellows & Halpin, 2008; Degenholtz et al., 2008;
Donoghue, 2010; Rahman & Applebaum, 2009). Staff turnover was collected through
the Office of Statewide Health Planning and Development (OSHPD) website. The
reported data for all quality indicators examined is based on available data and is reported
in the aggregate in the form of percentages for all three of the quality measures examined
comparing the two participating nursing homes.
56
Chapter 4
RESULTS
The primary goal of this thesis is to study the effects of adopting consistent staff
assignment through the examination of three objectively-measured industry-wide quality
of care indicators: pressure ulcers, physical restraint use and staff turnover (specifically
CNAs). Due to the nature of the culture change movement and the slow or partial
adoption of its practices in California nursing homes, it is difficult at this early stage to
statistically attribute improvement to the adoption of consistent assignment or other
culture change practices on a comprehensive basis. Even nursing homes that identify
themselves as utilizing consistent assignment practices are possibly not in compliance
with the standards set in the culture change arena. For example, nursing home staff,
especially CNAs, need to be permanently assigned to residents a minimum of 80 percent
of the time to qualify as utilizing consistent assignment (Advancing Excellence, 2009;
Donoghue & Castle, 2006; Farrell et al., 2006). Some homes may not be assigning staff
up to 80 percent of the time. At this time, this study sample size is too small to draw
definitive conclusions about industry wide practices based on this data subset alone.
However, this two-home comparison, coupled with examination of similar practices in
the literature review does suggest trends and provides a comprehensive basis to adopt
consistent assignment to improve quality of care in nursing homes.
Publicly available data reported to CMS for recording of physical restraints,
prevalence of pressure ulcers were used as the primary data source for comparison. This
secondary data source was used to examine the influence of consistent assignment. The
57
data represented on the Medicare (CMS) website represents an accumulation of the three
previous reported quarters by the nursing home through the MDS collection process as
described in chapter three. Data for this thesis comparison was collected in April 2010.
As a result, the data is summarized from the three prior quarters dating backward from
April 2010. Since staff turnover data is not posted on the Medicare website, data were
obtained through Office of Statewide Health Planning Department (OHSPD) website
(2010). OSHPD is a California government agency responsible for tracking financial and
safety data for a variety of state health facilities, skilled nursing among them. The staff
turnover data from OSHPD is representative of the 2009 fiscal year, therefore the reader
must keep the timeline differences in mind when comparing the CMS Medicare data and
the OSHPD data. Although staff turnover is not collected by Medicare as an objective
measure of the quality of care delivered in nursing homes, the literature review
demonstrates that staff turnover rates are considered a key indicator for quality. For
consistency of analysis for all three quality of care indicators discussed in this chapter,
national and state averages have been placed side by side with the percentages for the
rotating and consistent assignment nursing homes represented by figures throughout this
chapter.
Staff Turnover Data and Summary
As described in the literature review staff turnover is an important indicator in
nursing home quality. Continually having to hire and retrain staff can be costly as well as
disruptive to the resident (Bishop et al., 2008; Hollinger-Smith & Ortigara, 2004; Kemper
et al., 2008). Culture change groups advocate for adopting consistent assignment staffing
58
and postulate that this practice enables CNAs to develop meaningful relationships with
their assigned residents to reduce turnover and improve overall quality of care delivered.
Research Question #1: How does consistent assignment versus rotating assignment affect
turnover of nursing home CNA staff?
Staff turnover is tracked via the Office of State Wide Health Planning and
Development (OSHPD) and publicly reported on their website (Office of Statewide
Planning and Development website, 2010). The data set reviewed for this study reflected
the 2009 staff turnover numbers submitted to OSHPD by administrators of the specific
nursing home. Staff turnover, as discussed extensively in the review of literature, is an
important and measurable indicator of quality care. Staff turnover data track the rate in
which employees leave their place of employment for various reasons, including
voluntary and involuntary termination. As previously discussed in chapter two, high
rates of staff turnover have proven disruptive to residents within a nursing home and
profession wide workforce retention alike. Culture change and nursing home workforce
advocates focus on reducing staff turnover, especially for the direct care worker or CNA
for a variety of reasons. Nursing home work force trends suggest that future long-term
care will experience a major work force shortage among the resident’s primary caregivers
(HHS, 2003). Culture change advocates have targeted workforce retention for two
significant reasons. First, the core culture change principle of consistent assignment is
implemented most effectively when staff remain in their jobs for longer periods of time at
individual homes not just when their shifts are assigned consistently at those homes. The
more developed the relationship is between resident and staff, the better the life for the
59
resident and the higher the quality of demonstrable care, as discussed above (Barry et al.,
2008; Castle & Engberg, 2006; Tellis-Nayak, 2007).
As seen in table 4.1 the two home comparison shows that the consistent
assignment nursing home has a lower staff turnover rate than the rotating assignment
home. As described in the literature review a lower staff turnover rate aids in
establishing relationships between staff and residents.
Table 4.1
Nursing Home Comparison of CNA Turnover Rates
Quality Indicator
Nursing Assistant Turnover
Nursing Home Staff Assignment
Rotating Assignment
Consistent Assignment
Nursing Home
Nursing Home
40% *
34.78%
* Staff turnover for rotating assignment nursing home was not submitted to OSHPD.
Personal communication with the nursing home administrator calculated that their CNA
turnover for 2009 was 40 percent.
While the focus of this comparison is the implementation of consistent versus
rotating staffing pattern, culture change is a national movement which involves a myriad
of programmatic changes both large and small which are often difficult to quantify and
draw a straight line from change to consequence. As discussed above, both nursing
homes in this comparison have adopted some form of culture change to improve the
quality of life for residents and staff. For this factor, the more relevant statistical
comparison is not between staff turnover rates at the two interviewed homes, which have
60
both implemented some form of culture change policies, but between the state and
nationwide staff turnover averages as illustrated in Figure 4.1.
Figure 4.1. CNA Turnover: A National and State Comparison
80%
70%
60%
National Average 74%
50%
State Average 70%
40%
30%
Rotating Assingment Nursing
Home 40%
20%
Consistent Assignment Nursing
Home 35%
10%
0%
CNA Staff Turnover
As seen in Table 4.1, the consistent assignment nursing home produced a 34.78
percent turnover rate and 40 percent turnover rate at the rotating assignment facility
which has implemented other culture change policies. Both the rotating assignment and
consistent assignment nursing home used for this comparison had less than half the staff
turnover rate at 40 percent and 35 percent respectively compared with the 70 percent
average turnover at both the state and national level. A 35 and 40 percentage point
difference, is not statistically significant due to the limitations of this study, however it
appears to be a large enough gap for other researchers to explore further. These numbers
are the most persuasive objective argument for the implementation of culture change
policies and bode well for the future of this workforce. Whether these staff turnover rate
61
reductions hold up under larger study, the current system is not sustainable at average
turnover rates of 70 percent.
Culture change advocates understandably and aggressively focus on policies that
concurrently improve workforce retention and humanize resident care. When culture
change policies can potentially cut staff turnover rates in half as seen above and
anecdotally have been shown to improve worker outlook and retention as discussed in
chapter two, current efforts to implement culture change practices such as consistent
assignment hopefully derail the predicted shortage of direct care workers for our aging
population that many government agencies forecast (Bishop et al., 2008; Burgio et al.,
2004; HHS, 2003). Ultimately, the fiscal uncertainty that flows from an unstable
workforce may force the change that the profession has been slow to adopt thus far.
Moreover, reducing turnover serves not only the present workforce concerns but
future challenges. The more satisfied the present day workers are in their jobs, the more
likely they will be to continue their employment and more importantly, remain working
in the industry as a whole (Anderson et al., 2004; Barry et al., 2008). Positive workforce
sentiment of present day direct care workers also helps produce a future workforce, as
potential direct care workers often visit or serve as trainees while deciding whether to
enter the field. Current workers will encourage new workers (Bowers et al., 2003;
Donoghue, 2010). Whether this compounding factor addresses workforce shortfalls in
the future, it will be impossible to cement good practice without a basis to empirically
study culture change implementation and result. What is absent from the staff turnover
62
statistics in Figure 4.1 is a clear designation of how many nursing homes statewide and
nationwide are currently implementing culture change or resident centered care practices.
Physical Restraint Data and Summary
A physical restraint is defined as a device that restricts resident’s movement and
or prevents access to his or her body and cannot be easily removed (Advancing
Excellence in America’s Nursing Homes website, n.d.). Resident safety is commonly
cited in nursing home literature as a reason to justify the use of restraints (Engberg et al.,
2008; Hantikainen & Käppeli, 2000; Sirin et al., 2002). Homes that use a consistent
assignment model are more likely to identify residents needs than default to restraining
difficult residents (Goldman, 2008).
Research question #2: How does consistent assignment versus rotating assignment in
nursing homes affect the use of resident physical restraints?
The physical restraint data collected from the Medicare website is summarized in
the following table. The reported data are listed in the same format as the source (in the
form of percentages) because the raw measurements of residents and staff were not
available or feasible for this study.
As seen in Table 4.2, no long-stay residents were physically restrained in the
consistent assignment nursing home in this study. In contrast, nursing home staff
physically restrained four percent of long stay residents in the rotating assignment
nursing home. Since raw figures of physically restrained residents were not available, it
is difficult to determine if the four-percentage point difference would correlate with any
significance. However, even without raw data on the number of affected residents, the
63
difference is not without importance. This comparison of a culture change standard of
consistent assignment yielded no use of physical restraints which is noteworthy in any
context.
Table 4.2
Long-Stay Residents who were Physically Restrained
Quality Indicator
Nursing Home Staff Assignment
Rotating Assignment
Consistent Assignment
Nursing Home
Nursing Home
Long-Stay Residents who
were Physically Restrained
4%
0%
Given there are only two homes in this comparison study, it is important to place
physical restraint use in context and analyze how these two homes compare with the
national and statewide averages for physical restraint use.
Figure 4.2. Physical Restraint Use: A National and State Comparison
7%
6%
National Average 3%
5%
State Average 6%
4%
3%
Rotating Assingment
Nursing Home 4%
2%
Consistent Assignment
Nursing Home 0%
1%
0%
Physical Restraint Use
As illustrated by Figure 4.2, the use of consistent assignment practice produced a
reduction in physical restraint use on residents against both state and national averages.
64
With the use of no restraints in the consistent assignment home seen in Table 4.2, the
state average of six percent shows a 600 percent increase in restraint use statewide and an
average of three percent nationwide shows a 300 percent increase nationwide. While the
culture change movement believes consistent assignment is a cornerstone practice
necessary to facilitate resident centered care, it is not the only important programmatic
change. Many nursing homes, like the rotating assignment facility examined for this
study, have adopted other resident-centered practices that are advocated by the culture
change movement (S. Haskins, personal communication, April, 2010). While the rotating
assignment community is one percent above the national average of three percent, when
compared with the average for all California nursing homes, this home outperforms the
rest at four percent compared with six percent statewide.
Pressure Ulcer Data and Summary
Many factors can contribute to the development of PrUs. Skin care, nutrition,
level of assistance needed, and support surfaces all need to be managed appropriately to
reduce prevalence of pressure ulcers (NPUAP, 2007). Residents with serious PrUs risk
pain, slower recovery, infection, immobility and decrease in quality of life (Bergstrom et
al., 2008; Capon et al., 2007). Assigning the CNA to the same resident every time they
are on shift is important for the prevention of PrUs and improved quality of life for the
resident.
Research question #3: How does consistent assignment versus rotating assignment affect
nursing home residents’ frequency of pressure ulcers?
65
Pressure ulcer data is collected and reported through nursing home MDS system
as described in chapter three. Because of the nature of this quality of care indicator, only
data for long-stay residents was examined. Due to the risk factors to patient health and
mortality involved with the prevalence of pressure ulcers on nursing home residents,
nursing homes are required to report that data in two categories. One subset of data is
collected for prevalence of pressure ulcers in high-risk residents. Another subset of data
is collected and reported for low-risk residents. Low-risk and high-risk residents are
categorized based on the standards set by the government and codified for guidance in the
National Nursing Home Quality Measures Users Manual v 1.2. For a resident to qualify
as high risk, the resident must have impaired bed mobility, be comatose and /or suffer
malnutrition (Abt Associates Inc., 2004). Low risk residents are considered as all those
who do not qualify as high risk. According to the National Nursing Home Quality
Measures Users Manual v 1.2, pressure ulcer occurrence rates for both low and high-risk
long-stay residents are reported together and are significant for both populations as a
quality of care indicator (Abt Associates Inc., 2004). As a practical matter, it is not
prudent for nursing homes to report one without the other, therefore this study mirrors
this data approach for both populations of long-stay residents.
Table 4.3
High-Risk Long-Stay Residents who Have Pressure Ulcers.
66
Quality Indicator
High-Risk Long-Stay Residents
who have Pressure Ulcers
Nursing Home Staff Assignment
Rotating Assignment
Consistent Assignment
Nursing Home
Nursing Home
29%
21%
Table 4.4
Low-Risk Long-Stay Residents who Have Pressure Ulcers
Quality Indicator
Low-Risk Long-Stay Residents
who have Pressure Sores
Nursing Home Staff Assignment
Rotating Assignment
Consistent Assignment
Nursing Home
Nursing Home
6%
5%
As seen in Table 4.3, 29 percent of high-risk long-stay residents were reported to
have pressure ulcers. In contrast, the consistent assignment nursing home only had 21
percent of high-risk residents with pressure ulcers. Once again, the consistent assignment
nursing home data showed better delivery of care for residents on a key quality indicator
measured by CMS. An eight percent improvement suggests that the consistent
assignment practice may help reduce the development of pressure ulcers and therefore
contributes to improving the quality of care. It is important to note that often residents
have pressures ulcers upon admission to a nursing home which could skew the data
collection for this quality of care factor and in turn the relevance of that data to that
nursing home. Upon admission, the presence of a pressure ulcer on a new resident could
be inappropriately attributed to the new home’s level of care and type of care practice
instead of the previous living and care situation. CMS accounts for this by not requiring
nursing homes to report pressure ulcers on the MDS report for the first three months after
67
admission (D. Trisel, personal communication, May 2010). By eliminating this
ambiguity, the data reporting the development of a pressure ulcer becomes more
reflective of the quality of care provided to the patient by the particular facility. For
purposes of this study, the elimination of this ambiguity also allows a more accurate
assessment of the presence or absence of the pressure ulcers as a reflection of the
successful use of the consistent assignment practice versus the rotating assignment to
improve the quality of care.
As seen in Table 4.3 and Table 4.4, as a baseline, nursing homes report
significantly less occurrences of pressure ulcers in low-risk residents, with a high of six
percent occurrence, versus high-risk residents at a high of 29 percent occurrences. For
low-risk residents, Table 4.3 shows that the consistent assignment nursing home has a
five percent prevalence rate of pressure ulcers. At the rotating assignment home, the data
show a slight increase of pressure ulcers occurrence at six percent for low-risk residents.
It is difficult to determine if this small percentage difference has any notable significance
given, once again the lack of access to raw data on the Medicare nursing home compare
website reports (Medicare website, n.d.). However, in some respects, even a one percent
improvement in the quality of care for this lower risk resident population is important for
the population that is being helped.
At the heart of culture change policies like consistent assignment, small changes
can make large differences in individual patient quality of life and in staff satisfaction and
retention. If that one percent of residents are more satisfied with their care, perhaps the
staff serving them will be more satisfied and in turn the nursing home with the consistent
68
assignment practice will seek to adopt more fully additional resident-centered policies.
This ripple effect cannot be easily measured. The one percent difference could
hypothetically have a greater significance in the near and short term for the current and
future resident and nursing home. What is presently measurable is that in both
populations of high-risk and low-risk residents, consistent assignment produced less
pressure ulcers.
According to government standards for rating nursing homes, when the MDS
nursing home data shows lower pressure ulcer percentages, then those facilities are rated
higher by governing agencies in care delivery (Medicare website, n.d.). When the
pressure ulcer percentages are taken at face value, consistent assignment appears to have
a positive correlation. As seen in Figure 4.3, the two studied homes performed
considerably worse than the national and state average for the occurrence of pressure
ulcers. A large number of demographic factors could account for this discrepancy given
the variety of homes that exist statewide, including the large number of residents served.
If the statewide percentage could be publicly parsed with a standardized designation for
facilities using consistent assignment or other core culture change principles, then the
averages could be more clearly attributed to the suggested practices’ success or failure.
For this study, two homes with similar characteristics such as populations, size,
designated as for-profit Medicare-certified and that filled a specific definition of
consistent assignment and rotating assignment were selected. If all nursing homes were
required to provide staff assignment practices to government data collection services, be
it 80 percent, 60 percent rotation standard, then the averages could be more illustrative.
69
Figure 4.3. High-Risk Long-Stay Residents with Pressure Ulcers: A National and State
Comparison
35%
National Average 11%
30%
25%
State Average 12%
20%
Rotating Assingment Nursing
Home 29%
15%
10%
Consistent Assignment
Nursing Home 21%
5%
0%
High-Risk Long-Stay Residents with Pressure
Ulcers
Figure 4.4. Low-Risk Long-Stay Residents with Pressure Ulcers: A National and State
Comparison
6%
National Average 2%
5%
4%
State Average 2%
3%
Rotating Assingment
Nursing Home 3%
2%
1%
Consistent Assignment
Nursing Home 5%
0%
Low-Risk Long-Stay Residents with Pressure Ulcers
The future adoption of resident centered practices may depend on culture change
advocates focusing on ways to accurately measure success. This study has demonstrated
70
a need for long-term care agencies and professionals to require designation and reporting
of staff assignment that have repeatedly been defined in nursing home literature. There
may be other fundamental culture change practices additional to consistent assignment
that the movement and profession may wish to propose which will aid in further objective
study and research. A permanent assignment designation seems to be an important start.
In the two home comparison, interview and background questions established the
qualifications for each nursing home’s staff assignment. When standards for designating
a nursing home as a consistent assignment facility become standardized and codified,
then a large data set can be examined along with these three quality of care criteria to
analyze aggregate outcomes.
71
Chapter 5
DISCUSSION AND IMPLICATIONS
As a society, creating humane habitats where elders can grow old and thrive is
an ideal most can agree upon. Since the inception of modern day long-term care
facilities, experts and advocates have disagreed on how to achieve that laudable goal. An
examination of the tortured and haphazard development of long-term care in this country
(Cole, 1992; Fischer, 1977) reveals that the growing elderly population and the need to
care for them in long term care settings has not been sufficiently or swiftly met with
adequate solutions to meet both the basic human needs of food, clothing, shelter and aid
and the loftier ideal of creating sanctuaries for the elderly to be honored, respected and
valued until the end of life (Baker, 2007; Shields & Norton, 2006; Thomas, 2006). If
current trends hold for population growth, longevity, worker retention and recruitment,
the current system of care will not be sufficient to serve the ever-growing elderly
population even on the most basic level (HHS, 2003).
History has demonstrated that the long-term care industry was not born out of a
systematic architecture built with precision. Instead, it is and has always been a living
case study born out of a patchwork of ever changing laws, funding, needs and experience
(Cole, 1992; Shields & Norton, 2006). As such, any proposed changes, including those
advocated by the culture change movement, will probably take hold in the same way
because individual institutions adopt small changes that work and then build into larger
system-wide transformations; over time, these small changes of today can become
consistent and widely-adopted practices. Certainly, this common sense adoption process
72
is already working to some degree, but it does not appear to be working fast enough to
meet growing needs. Although tougher to obtain buy-in upfront, systematic and planned
change should be undertaken industry-wide at the same time to meet this growing gap. It
is unclear whether our society can continue to allow such an important segment of its
economy and population to develop without a clear plan for sustainability. A 70 percent
workforce turnover rate will never breed enough stability (Donoghue, 2010), especially
in long-term care.
Industry standards of long-term care still disproportionately emphasize the
meeting of “basic” needs in their administrative and fiscal decision making to the
exclusion of higher order needs like being respected or creating “homes” in the true sense
of the word. The culture change movement has demonstrated extensively through the
literature that creating a humane environment where both staff and residents are respected
and validated in big and small ways can improve delivery of basic care services and
ultimately help sustain a continuously dwindling workforce (Baker, 2007; Shields &
Norton, 2006).
This research study has sought to highlight the programmatic goals of the culture
change movement to make organized change with a focus on what the movement asserts
is the industry’s most valued, untapped resource - the resident and staff relationship. A
cornerstone principle of nurturing this relationship is the utilization of consistent
assignment staffing (Bruck, 1997; Castle & Engberg, 2006; Shields & Norton, 2006).
Over decades of service in long-term care in this country, this relationship serves as a
73
living and breathing case study from which industry wide policy can be informed and
meaningful, planned change can be implemented.
This thesis has advocated the need for systemic and well thought out
improvement that truly transforms nursing home culture from the bottom of the nursing
home “food chain” by empowering the direct care worker and the resident. Consistent
assignment is a foundation principle of culture change which helps foster this
relationship. The upside to these empowerment objectives to the bottom line, to
improving the quality of care, to workforce retention, to achieving that admirable societal
goal of providing humane sanctuaries for our elderly have not yet been adequately
measured. This paper demonstrates the need to standardize and measure residentcentered approaches.
The call for this standardization of information may be a “chicken and egg”
problem. Industry standardization of data collection for culture change nursing homes or
consistent assignment practice may not occur until it is so widespread that facilities
cannot help but collect the information in a uniform way for their own wellbeing and
profession as a whole. However, systems transformation may not be adopted until
empirical evidence convinces budget planners and administrators to adopt them (Rahman
& Schnelle, 2008). Perhaps the continued groundswell of subjective experiences seen in
this thesis will motivate the long-term care profession to more widely adopt culture
change practices. And in turn, with the more widespread adoption of resident-centered
practices, the standardization of culture change designations will become essential to
rating nursing homes, just as MDS data collection regarding pressure ulcers and restraint
74
use has grown out of the storied history of long term care in this country. However it
comes about, the need for empirical support seems to be growing in importance. CMS
will begin to evaluate resident centered data beginning in October 2010 with the launch
of MDS 3.0. This collection of resident preferences takes into consideration many
culture change ideals (Nolta, 2010).
While the MDS data collection process of pressure ulcer and physical restraint use
is uniform and accurate, and the OSHPD collection of staff turnover rates is helpful in
assessing overall quality of care, neither statewide system is a clean fit for a data
collection ripe for analyzing the value of nursing homes’ implementation of culture
change practices. It will always be difficult to identify a culture change home because
the changes incorporated in the movement are amorphous and range vastly. A nursing
home which has implemented a small change, such as providing every resident a plant to
care for, can make a big difference in resident and staff satisfaction and can ultimately be
reflected in the use of restraints and pressure ulcers. However, even with, for example, a
one-thousand facility data set, it would be difficult to classify a nursing home that
implemented only that and absolutely nothing else as a culture change facility or to draw
a clear statistical connection between the implementation of plants and reduction of
pressure ulcers. Objectively, many culture change policies may never be measurable.
However, the culture change movement, within itself, has identified consistent
assignment as a cornerstone practice of its advocacy. Unlike other changes, it can be
numerically defined. This research has found strong evidence to support this proposition
and the need for standardized classifications to permit further study of culture change
75
efficacy based on this core principle. An 80 percent assignment of staff was used as the
benchmark for this thesis. Many professionals in the field have advocated for this level
of assignment (Advancing Excellence, 2009; Farrell et al., 2006; Quality Partners of
Rhode Island, 2007). Right now, even nursing homes that self-identify as consistent
assignment do so at different levels of assignment with levels at or below 80 percent (B.
J. Darwin, personal communication 2010). This two home comparison of a rotating
assignment versus consistent assignment is not statistically significant in the aggregate
but the results are congruent with the vast anecdotal evidence of the value of consistent
assignment in improving the quality of care. When coupled with the extensive anecdotal
evidence, the two-home comparison provides the groundwork for the importance of an
industry wide study of consistent assignment and the development of profession wide
standards.
The need for empirical support for culture change objectives seems no more
important than convincing industry budget planners. Perhaps widespread adoption of
resident-centered practices will come by first targeting the budget planning process in this
billion-dollar industry, which requires concrete numbers to function and forecast. From
an administrative standpoint, a happy workforce is usually a more productive workforce.
If some larger conglomerates of nursing facilities would begin to adopt culture change
policies and keep internal statistics perhaps those statistics and success or failure rates
could bolster an industry wide call to implement successful practices. The next big
change will likely result from a combination of common sense practice becoming policy
and fiscal necessity motivating change. Ultimately, the lifeblood of the long-term care
76
profession is its workforce. If larger nursing home chains can effectively budget its
staffing needs while implementing consistent assignment, turnover can be reduced by up
to 40 percent as seen in figure 4.1, then the business side of the industry can be motivated
to adopt resident-centered practices that are fiscally advantageous to the home and their
boards or corporate offices. While intended or not by the fiscal administrators in this
business who may choose to adopt a financially sound policy to secure its future
workforce, adoption of these culture change policies will simultaneously benefit the less
quantifiable aspects of making the lives of residents and staff better.
Recommendation
The nursing home profession is a large industry with many stakeholders including
government agencies that monitor nursing home performance. This thesis examined how
staff assignment affected staff turnover, resident restraint use and prevalence of pressure
ulcers in a two home comparison. The top recommendation out of this research is to
have government agencies include staff assignment as part of their MDS data collection
process. As of October 1, 2010 CMS launched MDS 3.0 which include interviewing for
and implementing resident preferences. Under the current nursing home payment
structure, assessing and honoring resident preferences, such as bathing time or activities,
is not tied to monetary reimbursement like clinical practices are. Understandably, it may
be hard to reimburse nursing homes for honoring a resident’s dining preferences but staff
assignment is measurable and can potentially be tied to the payment process. If nursing
homes can get reimbursed for using consistent assignment practices they would be forced
to transition away from a traditional institutional model.
77
Closing Statement
This thesis has raised important questions on the long-term policy and economic
considerations of an aging population. Empirical studies are likely needed to motivate
the industry to make the suggested programmatic changes of the culture change
movement. Fundamentally, the way to revolutionize long-term care is to simply make
the decision today to change and re-focus to the basic human interaction between a
resident and their caregiver. With approximately 1.4 million elders residing in skilled
nursing facilities nationwide and about 102,000 residents in California alone (American
Health Care Association website, 2010), we as society can no longer ignore the urgency
of the task. With more and more people living out their final days in nursing homes, it
should be axiomatic that we are treated with loving respect and dignity until the end.
Motivating entrenched organizations to make a fundamental change is very difficult even
when that fundamental shift is a simply a philosophical one: value the elderly and
validate their care workers and their relationship. With a goal as simple and important as
valuing our elders, the time is now.
78
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