Long term care and post-acute facility residents are individuals whose personalities and feelings must be considered in an effort to keep them safe and happy.
That is the lesson of culture change, and facilities have embraced it in efforts to ensure quality care and resident satisfaction. Now facilities increasingly have begun to apply this lesson to staff development and motivation with similar results.
Creative efforts to encourage and inspire staff, recognize and nurture potential leaders, and increase job satisfaction and reduce turnover are more widespread than ever. And facility leaders are pleased with the results.

Residents As Educators

Leaders at Kindred Transitional Care and Rehabilitation of Brighton in Colorado discovered that they had the perfect staff trainer living right under their roof. When they discovered that resident Joan was a former nurse, they asked her if she would be willing to speak at new staff orientation programs, and she agreed. Director of Nursing Amy Szczepanski, RN, says, “We thought she would be a great asset to our program because she understands both the nursing and patient perspectives. We hoped that she could help our staff understand the multiple roles and how their words and actions affect residents personally.”
Speaking to new staff, Joan shares the overall experience of being a nurse as well as what it is like to be a resident. “We conduct a survey after the orientation, and participants always say that Joan’s words are touching and moving to them. They say it gives them excellent insight and helps them appreciate what their work means to residents,” says
Jerusha Siegel, facility administrator. Staff have an opportunity to ask questions, and they most commonly ask her what it’s like to make the move from the community to living in a facility.
The opportunity to meet with staff is as rewarding for Joan as it is for them. As Szczepanski says, “It gives her a sense of purpose, something she can feel good about. She’s helping staff and benefiting other residents, and she enjoys that dual role.”
Joan says, “For me, it’s an honor. When I speak to staff, I try to convey to them that this job is never going to be easy, but this is a great place to work.” She adds, “I never stopped being a nurse. The residents are very dear to my heart, and I want to help make sure that every one of them gets the care, support, and compassion they deserve.”

Residents Want Involvement

Since Joan got involved in orientation, other residents have asked to participate, too. Siegel says, “It’s great to integrate residents in determining how orientation will go and what new employees will learn.” The facility actually has taken resident involvement to a new level. Siegel says, “We also have residents who lead various activities.” For example, one resident runs a Christian karaoke event.
“He really loves it, and he is excited and proud to be doing something for his fellow residents. This reminds us that our residents like having independence and a sense of purpose. Having some control over their lives is huge,” says Siegel.
As Joan observes, “People think you come to a nursing home to die. I don’t think that. You come here because you have needs to be filled. People often don’t realize the positive side of nursing homes.”

Personal Connection

Encouraging new hires to get to know residents is a growing trend at today’s long term care and post-acute facilities. For example, at Exempla Colorado Lutheran Home, site orientation includes time for new caregivers to read the care plans for residents they will be working with on a regular basis.
“We give them an hour of private time to review care plans and get to know their residents’ needs, preferences, history, and so on. This gets them thinking about how they will approach the residents, care for them, interact with them, and engage them in activities,” says Christie Wimmer-Christie, RN, MS, Exempla’s staff development coordinator. Later during neighborhood orientation and then regularly as they start their job, they have additional opportunities to review these plans.
Because the plans are written in first person and provide details about each person’s history, communication style, preferred activities, and other information, caregivers can form a real picture of each resident as a person. “The care plans really humanize the residents. People really get wrapped up in the stories.”
Not only does reading the care plans give caregivers information that they can use as icebreakers and conversation starters when they meet residents, they also give staff a head start on their work.
“When they come back from reading the care plans during orientation, we have a debriefing time. Everyone has a chance to talk about something positive they found out or something that may present a caregiving challenge. Even before they start their job, they get started on critical thinking and problem solving,” says Wimmer-Christie. This contributes to the new employees’ job satisfaction and enhances their confidence.
As for the residents, says Wimmer-Christie, “it means the world to them. It makes them feel a little more comfortable with new caregivers.” She adds, “They appreciate that the person has made the effort to get to know them, and this helps them feel a little less apprehensive about change.”

Motivating Through Culture Change

An assessment tool designed to measure and track culture change also can help facilities identify and implement practices that motivate staff and encourage teamwork and job satisfaction. The Artifacts of Culture Change (www.artifactsofculturechange.org/ACCTool/) includes more than 25 items in six domain areas (care practice, environment, family and community, leadership, workplace, and staffing outcomes and occupancy). Some of these items are very specific to staff growth and development.
For example, one item involves including frontline staff in care conferences. “I asked CNAs [certified nurse assistants] how they felt about this, and they blew me away,” says author and educator Carmen Bowman, who also is one of the developers of the Artifacts tool. She says, “They told me that they want to learn more about their residents and see the care conferences as a great way to do this. They know their residents behind closed doors, and they yearned to know people more fully and from the viewpoint of other team members.”
Facility leaders who think that CNAs will balk at taking the time to participate in these conferences will be surprised, says Bowman. “We had talked about doing this at one facility but never formalized it,” she says. “We were having a care conference, and a CNA came rushing in with her lunch. She wanted to give up her lunch hour to attend this conference. It meant that much to her.”
This story didn’t surprise Bowman, who says, “Research has shown that when CNAs attend care conferences, turnover goes down.”
The Artifacts tool includes the concept of “guardian angels,” staff members who are matched with residents to be their special friends.
“Most staff love this idea. One resident was dying in a rural facility, and she ended up passing away in her guardian angel’s arms. Her staff buddy wasn’t on duty at the time, but she wanted to be there for her special friend,” says Bowman. She notes that staff love the opportunity to really impact someone’s life, and being someone’s guardian angel makes them feel more connected and committed.

Dress For Success

One item in the Artifacts tool that some considered somewhat controversial actually may really enhance staff morale, says Bowman. The idea that staff—including caregivers—wear street clothes instead of scrubs or uniforms is designed to encourage a more homelike atmosphere in facilities.
“Some facilities are hesitant to implement this because it would require caregivers—who usually are on a tight budget—to spend more money on clothing,” Bowman says.
Susan Black, administrator at Exempla Lutheran Home, admitted that she “got flack,” mostly from nursing staff, when she raised the idea of doing away with uniforms. “I told them that it’s not about what you’re wearing but what kind of relationship you have with residents.” Indeed, clothing cost was a factor, so Black initiated two ideas to ease the financial burden. First, she implemented the idea over six months so that staff could spread out their expenses for new clothing. She also had staff donate clothes and set up racks where staff could “shop” and pick out clothes for free.
“We still have a dress code, and staff have to dress in a professional manner. They can only wear denim on Fridays. I think they all like it now,” says Black.
Bowman suggests perusing the tool for ideas about ways to motivate and inspire staff.
“The tool is educational, whether you complete it or not. And because these ideas are positive and designed to empower staff and improve the lives of residents, many are easy to implement and quickly embraced by management and staff alike,” she says.
Even in a tight job market, it can be difficult to find the right people to fill challenging leadership positions—especially on short notice.

Prepping Nurse Leaders For Future Opportunities

Kindred Healthcare Senior Vice President of Nursing and Clinical Services Barbara Bayliss and her team tired of scrambling to fill director of nursing services (DNS) positions in geographic areas where job opportunities are abundant and turnover is high. So they adapted an administrator training program for nursing staff to hire and mentor promising nurses to fill DNS positions.
“We seek RNs with some supervisory experience who are interested in investing the time and effort to develop their leadership skills and move up in the organization,” says Bayliss.
The six-month program involved full-time training, involvement on leadership work teams, and professional nurse supervisor-level pay. Participants learn how to recruit and retain staff, work with and educate nursing staff, implement quality improvement initiatives and achieve quality outcomes, and communicate and interact with residents and family members.
On successful completion, they are offered a nurse leadership position at a Kindred facility within a 60-minute commute from the training site. “Participants go through an evaluation process every 60 days and have regular phone conversations with leadership to discuss their progress,” says Bayliss.

Training Pays Off

Last year, Kindred had four nurses complete the program, and three of them were promoted within the organization. “Rather than scrambling to fill leadership positions, we had candidates who were trained nurses who know the organization,” says Bayliss.
The nurse leaders who participated as mentors to the trainees also benefited from the program. “We equipped them with special training on how to be an effective mentor, and they participate with trainees in weekly training activities,” says Bayliss. They used customized training materials that involved eight modules addressing topics such as leadership development, performance improvement, Medicare/Medicaid, medical records and documentation, and clinical systems. The modules help track the program and identify gaps in knowledge and opportunities for learning.
“Mentors feel privileged to be selected. They enjoy assisting another nurse to move forward,” says Bayliss. However, she discovered early on that it is important to clarify that the “new nurse is not there to take the mentor’s job. There had been some early confusion about that, so some were not readily welcoming. Once they understood how the program worked, they appreciated it and were pleased to be involved.”
While the mentoring activities add to the DNS’ already busy schedule, having another nurse around also can be a huge benefit. “The trainee takes on various responsibilities such as handling immunizations or managing a unit. This reduces some of the burden and stress for the DNS,” says Bayliss.
“Sometimes you get a limited amount of applicants for a position, and you have to choose the best of what you get. We realized that if we could develop our own people, we would never have to settle for anything less than the absolute best person for the job,” says Bayliss. “We could be better prepared to fill openings and more proactive in successful hiring.”
It is useful to identify potential leaders from day one. However, this isn’t always easy, and the best leaders may not stand out right away.
As David Farrell, one of the authors of “The Leadership Challenge in Long Term Care,” says, “It’s not always the most talkative or outgoing people who make the best leaders.” Instead, he says, “In nursing homes, people follow the staff who are the nicest, most competent, and have the best attendance records. It’s the ones others go to for guidance and assistance. Sometimes, it’s the most quiet and humble people who are the best leaders.”
Farrell suggests that managers always be cognizant of potential leaders among their staff. “You’re looking for a good mind and a good heart. You’re looking for someone with critical thinking and problem-solving skills. You’re looking for someone who is empathetic and can put themselves in others’ shoes and act accordingly,” he says. Farrell suggests identifying these people through rounding, meetings, and team huddles.
“Watch how they interact with others, how they handle pressures and challenges, how they solve problems, and whether they are willing or eager to take the lead on projects and initiatives,” he says.
When management identifies a potential leader, Farrell suggests having a formal sit-down. “Commend him or her on what you’ve observed and what of their behaviors and actions are especially helpful and positive. Ask them to do more.” He adds, “Give them some additional responsibilities, such as involving them in new staff orientation or presenting inservice programs.”