In today’s fast-paced, economically burdened health care delivery system, long term and post-acute care providers often ask how to do more with less. With funding from a Johnson and Johnson Corporate Foundation block grant, Rutgers researchers and educators initiated the Rutgers Nursing Home Learning Collaborative to test whether nursing homes could use insights from high-performance organizations to strengthen communication and improve staff satisfaction and better meet the needs of their residents.

Learning collaboratives bring together teams from multiple sites to focus on specific quality improvement topics and learn from technical experts and each other. This approach holds promise for many health care settings, including nursing homes.

 

From 2009 to 2011, teams from nine central New Jersey facilities entered the collaborative. Drawing on learning organization principles and basic quality improvement processes, these teams implemented a range of changes.

Effective communication is vital in providing high-quality care that respects and is responsive to the individual needs of residents. Diverse in size, ownership, and structure, the facilities in the collaborative generally performed successfully on surveys and tended to be involved in other quality improvement initiatives. 

However, surveys and interviews with their team members revealed that there isn’t much time in a normal day for managers and staff to exchange ideas, prioritize problems, or think about how to integrate new insights into facility routines.

 

As one director of nursing explained, “Nursing homes are in survival mode.”

 
Over two cycles of the learning collaborative, a total of more than 400 nurses and nurse assistants responded to a one-page work environment survey covering a variety of issues, including supplies and resources; assignments; schedules; safety and health conditions; enforcement of policies; shift-to-shift communication; and relationships with managers, supervisors, and co-workers.

 

The survey also included three open-ended questions that elicited hundreds of comments from nursing staff at each of the facilities. Each facility team used its survey results to identify areas in which its practices could be improved.

On the short-answer questions, nursing staff were most likely to disagree with the following statements: There is good communication between shifts, people on this unit find time to review how the work is going, assignments and schedules are fair, policies are enforced the same for everyone, and managers care about me as a person.

In responding to the open-ended questions, nurse assistants were particularly likely to feel disrespected and unappreciated. Based on survey results and interviews with nursing staff who participated in the learning collaborative, these issues are interrelated.

Given the pace of demands, it is not surprising that staff report that bringing people together to “review how the work is going” is a rare event.

 

Problems with bringing staff together extend to change of shift: Staff may not be able to respond to the current status of the residents they care for if the shift report is abbreviated or if the incoming staff do not have an opportunity to interact with outgoing staff, or if the report is not extended to nurse assistants before they plunge into their work.

Without opportunities to share information and discuss and resolve problems with co-workers, supervisors, and departmental leaders, nursing staff may feel like they have less control over their working conditions and feel less connected to the overall organization.

 

If staff do not understand how decisions are made, they may question the fairness of assignments and schedules and whether policies are fairly enforced.

If managers are not visibly interacting on the floor, staff may not know that their efforts are seen and appreciated.

From therapy and pharmacy communications to broken equipment and incomplete paperwork, participants in the Rutgers collaborative identified scores of problems that are “patched” or worked around as a result of the survey.

 

How can nursing homes move more aggressively to recognize “systems problems” and learn from mistakes? Top leadership and middle managers need to acknowledge that organizational processes and practices are a work in progress that will always need to be refined.

 

Feedback loops and face-to-face opportunities allowing staff to report problems and barriers and engage in problem solving are critical.

 

However, managers must realize that asking line staff to share ideas and report problems may be perceived as involving more effort and risk-taking than muddling through and ignoring the wider systems flaws.

 

Learning organizations require both accountability and psychological safety: Employees are accountable not only for performing their jobs well but for openly questioning ineffective organizational practices, sharing their ideas, acknowledging their mistakes, and taking risks by trying new approaches.

 

For this to happen, they must feel psychologically safe, especially in interacting with their direct supervisor.

One of the most important lessons from the collaborative is that the biggest stressors for nursing home staff are closely related to barriers to providing the best possible care—whether the issue is not having the time, information, or resources needed to meet the needs of the residents or not having a supervisor who will listen to ideas for the best way to organize resident care  tasks. Each project used methods to strengthen the relationships and systems that allow information to flow across shifts, disciplines, and hierarchies.

 

Although the starting point for process improvement was identifying system failures and stressors in each facility’s work environment—all of the projects had implications for improving resident care.

 “Residents can tell when staff do not work well together,” observed one nurse. “Happy staff, happy residents, happy families,” summarized another.

High-performance work practices used by learning organizations come at a cost: actively listening and cultivating honest and supportive relationships with staff at all levels.

 

As one nurse manager said, “If someone has an idea, I will listen. If it won’t work, I’ll say ‘no’—but I’ll also explain the reasons why we can’t follow the suggestion and let my staff know how much I appreciate hearing from them.”

 

This level of engagement among and between direct care staff, supervisors, and managers is exactly what is needed to create communities that are good places to both work and live.