Despite all the advances in equipment and technology to improve care, leaders should remember that it’s their staff and their relationships that have the greatest influence on organizations’ performance.
Researcher Jody Gittell has documented that high-performing nursing homes have, as their foundation, high-quality working relationships among the staff.
Gittell’s team found that residents’ experiences are powerfully shaped by relationships among staff and that the relationships among the staff who work closest to the residents matter most (see February’s 2013 Management column). The interdependent nature of caregiving work requires what Gittell calls relational coordination.

Positive Chain Of Leadership

Systems that generate a dynamic of staff empowerment and engagement will take hold if leaders follow up with staff on what they share and adjust care and operations to meet needs that staff identify.
The leadership abilities of charge nurses become so much more important because several of these systems support day-to-day decision making among staff closer to the problems and closer to the residents, where nurses set the tone through huddles and ongoing interactions.
The more nurse leaders focus on good working relationships, the better everyone works together.
Some nurses come by these skills naturally, but very few have had formal leadership training. Nurses are better able to step into leadership when directors of nursing (DONs) focus on developing their leadership skills by giving them opportunities to take on new responsibilities and then sharpen the nurses’ skills by providing timely, accurate, problem-solving-oriented feedback in the context of a supportive relationship.
For example, pilot testing implementation of daily shift huddles with the charge nurse most able to succeed, and helping the nurse step into the new role by providing support along the way, builds skills as the leader builds systems.

Stability Starts With Relationships

If a facility is experiencing daily instability, these relational practices may feel out of reach. However, systems to support good working relationships can actually help to stabilize an environment. In an atmosphere of instability, staff have often lost trust in their leaders. In restoring trust, actions speak louder than words. Action is most effective when it is systematic and consistent so that staff can count on it.
The key is to reduce stress. National Research Corp. has consistently found in its My InnerView staff satisfaction surveys that the factors most affecting employees’ decisions to recommend their workplaces to others are that management cares, management listens, and management helps with job stress.
A relational coordination practice to reduce stress is an all-hands-on-deck approach, through which management supports staff at high stress times and staff are able to count both on management’s assistance and their accessibility during those times when they are most needed.

All Hands On Deck A Successful Approach

When Susan Hawver became administrator at Bayberry Commons, the staff had had four administrators and four DONs in five years and had a bunker mentality, believing that they were on their own to address problems.
Bayberry was a special-focus facility, with a one-star rating, a low census, and high rates of pressure ulcers and restraints.
When Hawver began making daily rounds to check in on what people needed and to provide support, staff began to sense that they were not alone.
The turning point came when the management team reviewed results from its family satisfaction survey and noted one bright spot among its dismal ratings: Despite not having staff respond in a timely manner to residents’ needs, families felt that when staff did come, they were kind and caring.
The management team decided to take an all-hands-on-deck approach to meet residents’ needs during the busiest times of the day. Staff identified mealtimes and shift changes for this support. The management team members took assignments to help out and maintained their commitment every day.
They were able to see the inner workings of their staff dynamics, identify simple ways to help work go more smoothly, role-model teamwork, and address staff who needed to step up.
As staffing stabilized, the “all hands” approach allowed them to improve their customer service progressively. They dramatically improved in restraints and pressure ulcers, graduated from the special-focus list, achieved 100 percent census, and won a Silver Quality Award from the American Health Care Association.

Reducing Stress To Improve Results

Bayberry’s experience provided a road map for critical-access nursing homes involved in a four-state Advancing Excellence initiative in which 17 struggling homes stabilized over a one-year period. For many of the nursing homes, utilizing all hands on deck was a turning point.
One DON said that as staff came to trust that they would have management’s help when needed, they became more generous in helping each other. He said it has created a “more nurturing” work environment and reduced conflict among staff. Now he has “more time to think ahead” and implement improvements because he’s not spending time on issues between staff members.

Advancing Excellence Can Help

A Chicago nursing home participating in the Advancing Excellence initiative used huddles to stabilize. Each morning on each unit, nurses, nurse assistants, activities, social services, housekeeping, and management met to discuss what was going on and ensure everyone was working together to provide the necessary care and services the residents needed.
Topics discussed were reported to the rest of the department managers at the morning meeting and addressed immediately. The group huddled again at the end of the shift to check in on whether needs had been addressed. As leaders were able to respond to staff needs, stress eased, staff stabilized, and care improved.

Systems Drive Outcomes

Wherever a nursing home is in its improvement efforts, its systems shape its outcomes. The better staff work with each other, the better they can care for residents.
It sounds so simple, but relational coordination doesn’t happen by itself. It occurs when leaders put the systems in place to generate “timely, accurate, problem-solving” communication; help staff to develop the skills needed to make the most of these systems; and create an environment that supports staff to talk issues through and problem-solve together.
Whether struggling to improve from a one-star rating, focused on reducing antipsychotics or decreasing rehospitalization rates, or working on culture change, nursing homes succeed when using systems that support and foster relational coordination among the staff and with leadership who follow through and support what their staff need and have to offer.
David Farrell, Barbara Frank, and Cathie Brady are co-authors of “Meeting the Leadership Challenge in Long-Term Care: What You Do Matters.”