We espouse the notion of teamwork, but do we adequately acknowledge the value of each team member? Needing orthopedic surgery, my priority, of course, was choosing the most skilled surgeon. Lying in my hospital bed after surgery my priorities changed. It was the skills and kindness of the nursing assistant that I valued most. While a resident physician talked to my back, I assume to “keep on schedule,” the aide carefully helped me to the bathroom. While I saw the attending a couple of times during my three-day stay, I saw the aide (and nurse) regularly. During and after my hospital stay the fundamental value of the health care team resonated with me more than ever. This experience and my study of hospice and nursing home care have given me a special appreciation for nursing assistants. Therefore, I was especially interested in the research on palliative nursing assistants by Head and colleagues
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in this month's journal. The good news is that they found palliative nursing assistants (98% employed by hospice programs) were overwhelmingly satisfied with their jobs, not surprising, given the average tenure of respondents was over five years. The not-so-good news is that even from these long-employed nursing assistants there were lots of recommendations for job improvements, and recommendations that extended beyond the need for increased compensation (which most can agree is highly desirable) to include recommendations for better communication and more appreciation, respect, and training. For palliative care teams and managers, these nursing assistant recommendations present an opportunity to revisit the recognition and value accorded nursing assistants—an opportunity to ensure their organizations and systems of care demonstrate that the team is all for one (the patient/family) and one for all (including the nursing assistant). To assist in these examinations, managers may want to study what U.S. nursing homes are doing to change in ways that ensure resident-centered care is provided in more homelike environments where staff are empowered. This effort has become known as “nursing home culture change.” While hospices have been in the forefront when it comes to providing patient/family-centered care, culture change efforts to empower staff may be informative.
A nursing home administrator at an Eden Alternative®
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culture change facility told me about a fellow administrator who voiced skepticism about the uniqueness of his (culture change) facility, since its programs were not all that different from what the colleague's facility offered. The difference, the Eden administrator said, was that at his facility employees choose and help to design the programs offered—they are empowered. In accordance with nursing home culture change, an organization's work is organized to support and empower all staff to respond to residents' needs and desires.
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Also, direct-care workers (and residents) are involved in planning and implementing the changes that empower them.
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Some practices associated with this empowerment include nursing assistants' presence at care conferences and membership on quality improvement committees, their consistent assignment to the same residents, their ability to attend reimbursed outside educational events, their access to career ladders and job development programs, and recognition for their achievement through awards.
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To accomplish staff empowerment, the hierarchy of organizations is flattened and high-quality leadership and management is essential, often requiring formalized training. In fact, research we have conducted suggests that in nursing homes with more successful change efforts, administrators had preexisting leadership and communication skills and management expertise that led to this success. This suggests training for leaders and managers to enhance their skills and expertise is a needed first step for change to occur.
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Such training in palliative care settings may be an important first step in addressing the recommendations for job improvements by palliative nursing assistant team members.
