Consistent assignment study shows need for careful culture change implementation, Eden Alternative leader says

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Consistently assigning nursing home aides to particular residents could cause the aides to feel isolated and overburdened, suggests a study forthcoming in the Western Journal of Nursing Research. However, a prominent voice in the nursing home culture change movement says the study simply shows that providers must adhere to best practices to see the benefits of consistent assignment.

Investigators at the University of British Columbia and the University of Alberta interviewed 22 care aides from five Canadian nursing homes. All the facilities had adopted models of care associated with the Eden Alternative®. The Eden Alternative® is a not-for-profit organization advocating for culture change in long-term care, which involves moving away from institutional models toward more person-centered approaches, including consistent assignment.

The aides who were interviewed generally said they were excited to move to consistent assignment, and they all said that they developed close relationships with their assigned residents, according to the researchers.

However, the aides' initial excitement over consistent assignment soured, the researchers found. Isolation was one issue the aides described, as they began to feel cut off from other caregivers and residents. Aides sometimes balked at providing care for residents outside their assigned charges, meaning some residents went unattended even though someone was available, the interviewees said. New equipment diminished the need for teamwork in tasks such as lifting, adding to feelings that they were expected to be self-sufficient in caring for their assigned residents.

“Care aides described feeling not only that they were expected to manage alone, but discouraged from seeking assistance,” the researchers wrote.

Consistent assignment also could create heavy emotional burdens, as residents' family members came to see aides as accountable for all aspects of care, the investigators reported. And aides said they were not successful in petitioning management to grant them temporary relief from their consistent assignments.

Chris Perna, chief executive officer of the Eden Alternative®, disagreed with the study.

“What the researchers can conclude is that the organizations involved did not do a very good job implementing these changes,” Perna told McKnight's.

While the Eden Alternative® provides guidance and resources for organizations implementing culture change, it does not dictate how a facility should implement the Eden philosophy, Perna emphasized. The nursing homes in the study did not exemplify the principles of consistent assignment that Eden advocates, which Perna said would involve creating “cross-functional teams, bringing people together from different departments.”

These teams would be self-directed but work collaboratively, he said. The model does not call for staff to “fly alone” or “be all things to all people.”

Previous research has linked consistent assignment to increased satisfaction for staff and residents, Perna noted. He argued that the small size of the study is problematic for drawing conclusions about consistent assignment generally.

The testimony from these aides underscores that simply implementing consistent assignment is not guaranteed to improve outcomes or staff satisfaction — it must be done properly, Perna said.

“Talk to other organizations that have done it, get some consulting support if you don't feel equipped to do it on your own, and go slowly,” he advised. “It's a major shift.”