In 1991, I began my career as a charge nurse at an amazing SNF in Boston. Full of optimism, energy and passion, I annoyed many people, none more so than the nurse assistants with whom I worked. “Who do you think you are?” Edith demanded, hands on her hips, laser-beam focus on – gulp – me. “You come in here and start changing everything.”
She was right! Well-schooled in primary care nursing models and Change Theory, I quickly realized that, in the nursing home where I was the only nurse on the unit, I needed to adopt those care models for the nurse assistants. Why? Because my ‘eyes and ears’ on the unit spent more time trying to figure out their schedules and the essential nuances of caring for their ever-changing resident assignments than providing quality care and creating meaningful relationships. In addition, the residents spent more time growing anxious over who was going to walk through their door to provide care.
I knew there was no navigating around Edith; she needed to be the solution – the champion of this change. And, we were successful! How, you ask? By making it all about the nurse assistants and the residents and their relationship. The shorthand version is this:
- Nurse assistants identified what attributes of resident care were significant in balancing their workload. Things like:
- ADL dependency
- Behavioral symptoms
- Messy rooms (honest, I never would have come up with that one)
- Challenging families
- Each nurse assistant ranked each resident on these other attributes to create a “total score.” This was useful to make sure there was equity between case load.
- Nurse Assistants then negotiated with each other to create their assignment, again balancing their “total score.”
- Each nurse assistant approached the resident with “I’d like to work with you and be your nurse assistant, is that OK?”
Ruth, one of my beloved residents, confided that she really didn’t want nurse assistant Esther but was willing to try. Esther and Ruth became fast friends. But what about Edith? Six months in when the C-suite visited our unit and I presented this model of care, Edith stood up, again with hands on hips (I admit that I held my breath not knowing what she was about to say). “Well, I thought this idea was awful…but I have to say, I really like it. I have no problems with my residents and they like me. I know what I’m doing and how my day is going to go before I even get here. I am doing a better job and I’m happy.”
Today, consistent assignments for CNAs are discussed and implemented more frequently than the early 90s. For the most part, research studies speak to the positive attributes of this model of care. From improved surveys to reduced staff turnover, it’s hard to ignore the wave of empirical support.
The American Health Care Association identifies this as a strategy for meeting their Quality Initiative goal of staff stability, and it’s no coincidence that it’s also a goal of Advancing Excellence. Here is a great resource: http://www.nhqualitycampaign.org/star_index.aspx?controls=previewgoals.
Please share your own experiences! Do you have a similar “change management” scenario happening in your facility? Post them here (and feel free to put your hand on your hip as you’re typing!). Like with me and Edith, we all learn from each other!
Steven Littlehale is a gerontological clinical nurse specialist, and EVP and chief clinical officer at PointRight Inc.
