Facilitating Staff Adoption of New Policies and Procedures in Aged Care Through Training for Readiness for Change

Abstract

This study examined whether training staff in preparation for organizational changes, such as the implementation of new practices, can increase levels of change readiness in residential aged care. Four aspects of organizational readiness were compared across time and between training and control conditions. Participants (n = 129) were employed in eight residential aged care facilities in Australia. Survey data were collected at four time-points: preintervention and three postintervention time-points. The two conditions (training and control) differed significantly from one another on the subscales of appropriateness, personal valence, and efficacy postintervention but not at preintervention. The finding of support diminishing at 6 month and 12 months following the intervention for the training group was unexpected. The findings suggest that within aged care facilities, training in change processes may enhance an organization’s readiness for change, and booster training may be needed to help to sustain all aspects of change readiness over time.

Keywords

health services policy training

Organizational change such as adoption of new workplace processes often requires collective and coordinated behavior change by many organizational members to achieve desired outcomes. Similar to health and community sectors worldwide, the need for system and policy changes in aged care in Australia has been identified by Government reviews (Australian Institute of Health and Welfare, 2007; Department of Health, 2016). These reviews have highlighted the importance of better training for staff in aged care facilities in the management of depression and dementia and informed a move toward an increasingly person- and consumer-centered approach to caring for residents. In Australia, the changes have now been embedded in legislation thereby ensuring sector-wide reform (Martins & Isouard, 2019).

However, achieving quality improvements and therefore change in the aged care sector is highly challenging. Although changes needed in aged care practices have been identified, the facilities in which change is most-needed may be ill-prepared to manage the requisite changes. Both researchers and health care practitioners have demonstrated that organizational readiness for change is an important antecedent to successful implementation of changes to workplace practices (Holt et al., 2007; Weiner et al., 2008). Evidence to further support this claim can be derived from a systematic review examining the effectiveness of communication training in dementia care, mostly conducted in nursing homes (Eggenberger et al., 2013). Eggenberger and colleagues concluded that without addressing organizational factors, obstacles, and influences as part of training, the implementation of staff programs is insufficient in bringing about change. Furthermore, the authors also suggested booster training as a mechanism to sustain change implementation after training. Drawing on past research and the challenges faced by aged care facilities in successfully implementing new policies and staff care routines, the purpose of this project is to investigate whether a targeted training program, with a focus on addressing organizational factors, can increase the readiness for change among staff in adopting new practices in the management of resident depression and dementia.

Readiness for change has been defined as the “beliefs, attitudes, and intentions regarding the extent to which changes are needed and the organization’s capacity to successfully undertake those changes” (Armenakis et al., 1993, p. 3). Successful implementation of change relies on the ability of individuals to adopt and adapt to change. A necessary precondition for successful adoption of policy and procedural change is alignment of employee beliefs, thoughts, and feelings with those of the change leaders, thereby creating a state of change readiness (Armenakis et al., 1993; Ford & Foster-Fisherman, 2012; Holt et al., 2007). Therefore, leaders have an important role to play in setting the work environment “tone” for change for employees. In addition to individual-level change, change also needs to occur at a team-based or organizational level. One predictor of successful organizational change is the level of support employees perceive the organization has for change (Oreg et al., 2011).

Holt et al. (2007) found that readiness for change was a multidimensional construct encompassing four dimensions: (a) appropriateness (i.e., whether staff members considered the change appropriate for the organization and were of the view that there was a valid need for change), (b) change efficacy (i.e., whether staff members had confidence in their abilities to change), (c) management support (i.e., whether the leaders in the organization were actually committed to the change), and (d) personal valence (i.e., whether the change was believed to be personally beneficial). At a practical level, predictors of readiness for change are becoming of interest to intervention researchers (Al-Hussami et al., 2017; Kelly et al., 2018) as these factors can be modified (e.g., through training) to assist the successful implementation of organizational change.

Whether a training program designed to increase sustainable readiness for change in aged care can bring about change is unknown. Staff perceptions of the appropriateness for change could be increased through training where the reasoning for introducing the new procedures is explained. Change efficacy can also be enhanced by increasing staff competencies and knowledge about the new practices. The inclusion of leadership training in such programs can also enhance the understanding of managers in leading quality-improvement initiatives, which may increase levels of manager support. Perceptions of personal valence related to the change could also be optimized through highlighting the staff benefits of the new procedures during the training.

Sustaining the implementation of readiness to change and subsequent staff adoption of the new procedures is a potential challenge (Miller et al., 2010; Ray, 2016; Yous et al., 2020). In a qualitative study by Yous et al. (2020), a training program that focused on teaching assessment and management of the physical, intellectual, emotional health, and capabilities of individuals with dementia identified that despite positive program benefits, staff reported that new practices attenuated at approximately 1-year after training. The authors concluded that educational reinforcements and sustainability strategies for dementia care programs in acute care settings were needed to sustain practices. Therefore, providing training in understanding and improving workplace environmental factors and leadership may be integral to the sustained success of the implementation of training designed to bring about change in the practices of aged care staff.

Aspects of the work culture and employee support within the organization, are likely to play important roles in the successful implementation of the required changes (Miller et al., 2010). Therefore, to achieve the full implementation of desired changes, such as uptake of new policies and or procedures, interventions (i.e., staff training) would need to also target both the individual (employee) and the work environment. A meta-analytic study conducted by Blume et al. (2010), revealed that supportive workplace relations were a key factor in the transfer of learning into practice. Consequently, workplace environment issues need to be addressed to reduce barriers (to change and to achieve optimal results from training; Bennett et al., 1999; Cohen-Mansfield et al., 1997; Koys & DeCotiis, 1991; Schulte & Vainio, 2009). Evidence of levels of workplace support (Casper et al., 2018; Chiaburu et al., 2010; Karantzas et al., 2012), trust (Kirkman et al., 2006) and cohesion (Montes et al., 2005; Reagans & McEvily, 2003) are examples of workplace environmental factors that have been associated with workplace change. Moreover, the organizational factors of workplace support, trust, and cohesion, are likely to be especially important to target in enhancing change readiness. These three organizational factors reflect related constructs that speak to the confidence and reliance of a staff member on their fellow employees and workplaces to follow through with proposed actions, and to engage in practices that consistently attend to the needs and challenges of all staff (e.g., Karantzas et al., 2012).

Nevertheless, the ability for staff and organizations to enact change requires that leaders within the organization engage in behaviors that promote a positive culture for change readiness (Bass & Riggio, 2006). Indeed, the link between leadership and quality performance has been well established (Anderson et al., 2003; Casper et al., 2018; Wong & Cummings, 2007). Castle et al. (2018) analyzed Quality Award Recipients in U.S. nursing facilities and found that leadership has been linked to enhanced quality performance. In particular, transformational leadership promotes a vision of what the change may look like and can play an important role in supporting employees’ sense of readiness for change (Bass & Riggio, 2006; Hawkins, 2009). In turn, transformational leaders ensure that people are inspired to change and aid in developing levels of trust. Leaders need to attend to, and acknowledge, staff needs through a period of change, and this relies on the leader’s communication. Clear, considerate, and direct communication is central to change (Horner & Boldy, 2006; McCabe et al., 2009), insofar as staff understanding what is expected of them in implementing change and providing feedback through times of change. Optimizing these leadership, communication, and work environment factors should lead to an increased readiness for change over time. Findings from a more recent study (von Treuer et al., 2017) revealed that the organizational climate variables of work pressure, innovation, and transformational leadership were predictive of employee perceptions of organizational readiness for change. However, whether training focused on these organizational factors can enhance an organization’s readiness for change is yet to be shown.

While there is a body of emerging research on readiness for change in health care, no such study has been conducted in the aged care sector. This study was conducted to address that deficiency, and in preparation for the changes required in aged care in Australia such as the introduction of procedures for implementing Consumer Directed Care and in identifying and managing depression and dementia. Specifically, this study sought to implement a novel program designed to prepare staff for organization changes in policies and practices to better support aged care residents. The factors of readiness for change point to areas of leverage (whether people or systems) that can facilitate successful change programs. In addition, we were interested to know whether any increase in the readiness for change, as a result of the training, could be sustained over a 12-month period.

The training was designed to help staff prepare for change. Specifically, the training had two foci: (a) to assist staff to identify and manage resident’s depression and dementia and (b) to enhance workplace relations and climate by focusing on organizational variables (Supplement 1). These two aspects of the training were necessary to help foster the capacity of staff to develop new procedures in how they managed resident depression and dementia and an understanding for how new procedures were important to embed into practice, thereby enhancing staff understanding of the appropriateness of the change and their personal valence. The training components on transformational leadership (including management support) and aspects of the work environment including trust, cohesion, and communication were designed to enhance staff’s change efficacy through providing skills to empower staff to understand and manage change.

Aims and Hypotheses

This study investigated whether training in change processes (focusing on transformational leadership and work environment) can increase levels of readiness for change in residential aged care, and whether the increased levels of change readiness can be sustained up to 6 and 12 months after training. It was hypothesized that compared to a waitlist-control group, an intervention group that underwent training that targeted organizational trust, cohesion, communication, and transformational leadership—alongside skills-based training in identifying and managing residents with depression and dementia—would demonstrate increases across all four domains of organizational change (appropriateness, change efficacy, management support, and personal valence) immediately post-training as well as at 6 and 12 months after training.

Methods

Participants

Participants were 129 staff (M = 43.76 years; SD = 12.11 years; 110 women and 19 men) employed across 16 residential aged care facilities in Australia. The facilities were randomly allocated to either the training (n = 8, staff n = 73) or waitlist-control condition (n = 8, staff n = 56). All participating staff within a given facility were assigned to the same condition. Staff included managers, registered nursing staff, education managers, direct carers, a diversional therapist, and a cleaner. Table 1 provides a breakdown of the number of staff (including their role) that participated in the study across each facility assigned to the training and waitlist-control conditions. Across both conditions, approximately 36% of staff were of a managerial level within their respective facility. On average, staff had worked in the aged care sector for 10.20 years, with experience ranging from 1 to 38 years. All aged care facilities provided a level of care to residents that ranged from low (i.e., assisted-living level) through to high (i.e., nursing-home level). The recruitment of aged care facilities that provided low- and high-level care was to strengthen the generalization of research findings to facilities that encompass diverse aged care services.

Table 1.

Facility and Staff Characteristics by Condition.

Facility/staff characteristics	Intervention condition
Facility/staff characteristics	Facility 1	Facility 2	Facility 3	Facility 4	Facility 5	Facility 6	Facility 7	Facility 8
Bed size	60	91	90	73	76	69	75	92
General staff in RCT	3	7	5	11	6	6	4	5
Role	PCA/DC: 2 Lifestyle: 1	PCA/DC: 5 Lifestyle: 2	PCA/DC: 4 Lifestyle: 1	PCA/DC: 10 Lifestyle: 1	PCA/DC: 6	PCA/DC: 5 Lifestyle: 1	PCA/DC: 3 Lifestyle: 1	PCA/DC: 5
Years in aged care	2.00 (.84)	10.18 (5.76)	14.75 (8.10)	8.14 (6.35)	5.33 (4.07)	4.08 (3.68)	2.38 (3.09)	6.05 (6.86)
Senior staff in RCT	2	2	2	3	5	5	3	4
Role	Team leader: 2	Manager: 1 Team leader: 1	Manager: 2	Manager: 2 Team leader: 1	Manager: 1 Team leader: 4	Manager: 2 Team leader: 3	Manager: 1 Team leader: 2	Manager: 1 Team leader: 3
Years in aged care	22.00 (9.90)	14.42 (11.12)	13.50 (12.02)	11.75 (3.18)	10.41 (4.04)	8.17 (2.12)	8.00 (7.11)	13.74 (9.87)
	Control condition
	Facility 1	Facility 2	Facility 3	Facility 4	Facility 5	Facility 6	Facility 7	Facility 8
Bed size	60	113	109	64	75	60	72	125
General staff in RCT	4	2	2	8	5	4	6	5
Role	PCA/DC: 4	PCA/DC: 2	PCA/DC: 2	PCA/DC: 6 Lifestyle: 2	PCA/DC: 4 Lifestyle: 1	PCA/DC: 4	PCA/DC: 6	PCA/DC: 4 Lifestyle: 1
Years in aged care	4.00 (.60)	10.00 (3.23)	10.50 (6.36)	7.38 (5.20)	8.22 (6.56)	10.75 (4.72)	14.50 (8.36)	3.57 (3.16)
Senior staff in RCT	2	2	2	2	3	3	2	4
Role	Team leader: 2	Team leader: 2	Team leader: 2	Management: 1 Team leader: 1	Management: 1 Team leader: 2	Team leader: 3	Team leader: 2	Manager: 2 Team leader: 2
Years in aged care	12.50 (10.61)	15.83 (2.36)	14.46 (7.397)	11.71 (3.11)	12.13 (5.58)	13.67 (4.73)	26.50 (9.19)	7.00 (2.12)

Note. PCA/DC = Personal Care Assistant/Direct Carer; RCT = Randomised Control Trial.

Measures

The 25-item Readiness for Organizational Change scale (Holt et al., 2007) was used to assess the readiness of individual employees for organizational change. The scale dimensions included staff perceptions of (a) appropriateness (of the change, or whether there was a valid need for change), (b) change efficacy (whether staff had confidence in their own abilities to change), (c) management support (whether organizational leaders were actually committed to the change), and (d) personal valence (does the change benefit staff personally?). These four dimensions were found to account for approximately 63% of the variance in organizational readiness (Holt et al.). Participants recorded their level of agreement with each item using a 5-point Likert-type scale ranging from one (strongly disagree) to five (strongly agree). All dimensions had very good internal consistency in this sample: (a) appropriateness (α values ≥.89), (b) change efficacy (α values ≥.86), (c) management support (α values ≥.87), (d) personal valence (α values ≥.91), and (e) overall (α values ≥.89). Consistent with the findings of Holt et al. (2007), the four dimensions were moderately correlated with associations varying between r = .33 to .52 (across all time-points).

Procedure

Approval to conduct the study was granted by the University Human Research Ethics Committee. Recruitment of aged care facilities involved contacting the research, training, or education managers of 26 residential aged care providers located in metropolitan or rural areas of Australia, via email. The email outlined the aims of the study and invited the facility to participate in the study. Sixteen aged care facilities agreed to participate in the study. All participants were informed of the research and signed a consent form to participate. Surveys were distributed prior to the intervention, following the intervention, and at 6 and 12 months postintervention.

The training intervention called Staff as Change Agents—Enhancing and Sustaining Mental Health in Aged Care consisted of a four-session training program for aged care staff. The development of the training intervention was drawn from evidence from established mental health training programs for aged care settings (Davison et al., 2013). Staff were provided with lecture-based psychoeducation each week with respect to both mental health care and the organization factor (e.g., trust, cohesion, communication, support, and transformational leadership) of focus for that given module. (For details regarding the specific focus and content covered in each session, refer to Supplement 1). As part of each module, staff also engaged in interactive learning activities to help embed the knowledge disseminated by way of lecture material. These activities involved, reflective exercises, group discussions, roleplays, case studies, as well as collaborative activities in which staff were to develop an implementation plan for how to embed revised practices and procedures for dealing with dementia and depression with their facility. These activities also provided staff with formative assessment regarding their understanding of the material. Between 4 and 14 staff attended each of the four sessions at each facility.

A Cluster Randomized Controlled Trial Design was utilized. A mixed-design multivariate analysis of variance (MANOVA) was conducted in which the four subscales of organizational readiness (appropriateness, personal valence, support, and efficacy) were compared across time and between training and control conditions. Polynomial contrasts were performed to test for linear and nonlinear patterns in the data across time for the two groups.

Results

Analyses revealed a significant condition × time × organizational readiness interaction (Pillai’s Trace = .164, F(9,119) = 2.59, p < .01, power = .93). As illustrated in Figure 1, the trends over time for both the training and control groups were best represented by a cubic pattern F(1, 127) = 4.465, p < .05 (panels A to D).

Figure 1.

Non-linear patterns over time for organizational readiness subscales (A) Appropriateness of the change, (B) Personal valence, (C) Management support and (D) Change efficacy, as a function of condition.

The two conditions demonstrated inverse cubic patterns for appropriateness and personal valence and similar cubic patterns for support and personal valence. The training group demonstrated an increase across all four subscales of organizational readiness from pretraining to posttraining, followed by slight nonlinear fluctuations in levels of organizational readiness at 6- and 12-month follow-up. The control group demonstrated a decrease across the organizational readiness subscales of appropriateness and personal valence from pretraining to posttraining. This was followed by nonlinear fluctuations at 6- and 12-month follow-up (Figure 1, panels A and B). For the support and efficacy subscales, the control condition demonstrated the same pattern as the intervention group; however, the pattern was significantly attenuated compared with the intervention group (Figure 1, panels C and D).

With the exception of the preintervention assessment (T1), the two conditions differed significantly from one another on the majority of subscales across subsequent time-points. The training condition demonstrated higher scores on the organizational readiness subscales of appropriateness, personal valence, and efficacy over time (T2–T4) than the control condition (Table 2). In relation to the support subscale, the two conditions differed significantly in mean levels at T2 only.

Table 2.

Means and SDs for Organizational Readiness Over Time by Condition.

Organizational readiness	Training M (SD)n = 73
Organizational readiness	T1	T2	T3	T4
Appropriateness	3.71 (.57)	4.01 (.57)	3.84 (.56)	3.80 (.59)
Personal valence	3.98 (.76)	4.46 (.64)	4.19 (.65)	4.15 (.79)
Support	3.55 (.61)	3.88 (.67)	3.48 (.73)	3.56 (.67)
Efficacy	3.78 (.56)	4.12 (.50)	3.89 (.46)	3.97 (.52)
	Control M (SD)n = 56
Appropriateness	3.65 (.62)	3.56 (.56)	3.48 (.47)	3.57 (.60)
Personal valence	3.90 (.77)	3.46 (.94)	3.62 (.71)	3.54 (.93)
Support	3.36 (.64)	3.41 (.51)	3.30 (.56)	3.35 (.57)
Efficacy	3.66 (.53)	3.71 (.48)	3.50 (.50)	3.66 (.58)

Note. T1 = preintervention; T2 = postintervention; T3 = 6-month follow-up; T4 = 12-month follow-up.

Discussion

Aged care facilities are increasingly required to adapt to changing regulations and procedures as part of the ever-evolving emphasis of governments on enhancing the quality of care provided to residents in aged care and increasing the level of choice and decision making of consumers. More than ever, aged care facilities need to adapt and to be ready to change their governance and procedures for the care of residents. It has become increasingly apparent that for aged care providers to successfully implement change, they need to have strong leadership and an organizational climate that fosters collaborative and cohesive workplace relations. Despite this, aged care facilities often do not have the resources or training in how to foster workplace environments that can effectively prepare them to embrace changes in their workplace practices. As a way of addressing these challenges, we aimed to develop a program that trained staff in how to foster effective organizational leadership and a positive workplace environment within aged care facilities that would enhance readiness to adapt to changes in the ways in which they managed residents with depression and dementia. Evaluation of our cluster randomized controlled trial demonstrated that our intervention (compared with a waitlist-control group) demonstrated sustained increases in all four aspects of readiness for organizational change up to 12 months posttraining.

We hypothesized that compared with the waitlist control, the intervention group would demonstrate increases in levels of the four subscales of the Readiness for Organizational Change scale (appropriateness, change efficacy, management support, and personal valence) immediately posttraining, at 6 months posttraining and at 12 months posttraining. Of the four subscales, three (appropriateness, change efficacy, and personal valence) demonstrated statistically significant and improved change not only immediately posttraining but maintained improvement over 6- and 12-months postintervention. The maintenance of staff readiness for change following a relatively brief training program indicates that this approach offers potential for sustained improvements in staff practices over the extended period of time that is often required to introduce and embed major changes. These findings largely deviated from those of Yous et al. (2020) who reported the effects of training tapering off a year after training. The addition of addressing organizational factors may have resulted in the training effects being sustained.

However, in contrast, management support demonstrated significant change immediately after training, but this factor dropped back to pretraining levels at 6- and 12-month follow up. Given, we addressed the organizational challenges as part of our training, reported to be a barrier to sustained effects from training (Eggenberger et al., 2013), we expected all measures to increase following training. While there was an early perceived increase in management support following the training, it was not maintained. The decrease in perception of management support at 6- and 12-month postintervention was unexpected. This is of concern because the level of management support is required to maintain staff vision of the change, over time. This result may have been accounted for by managers who showed their support by introducing the training program but did not then demonstrate commitment to the changes advocated in the program. Alternatively, the managers may have moved to other positions or other facilities, aligned with previous reports of a high turnover in aged care workers (Karantzas et al., 2012). This suggests that a booster training session, also a strategy suggested by Eggenberger et al. (2013) at 6 months postintervention, focused on managerial support may be required. The leadership support training would then be either reinforced with previous attendees or be introduced to new leaders within the facility.

Strengths and Limitations

A mixed methodological approach may have been useful in this study as open-ended, exploratory questions may have assisted in understanding why unexpected findings occurred. Further details about the participants, such as whether the facility leaders were over-represented the staff attrition across time may have helped explain our unexpected findings (i.e., reduction in perception of management support).

In general, to mitigate potential methodological issues, this study included multiple aged care facilities and staff working at different levels to address the potential for single-source bias. Furthermore, a longitudinal design that included several facilities was utilized to demonstrate causation and allow generalizability of findings. Thus, this design offered the best opportunity to understand and capture the effect of the training on creating a workplace environment ready for change in aged care organizations. Replication would be a useful next step to validate findings.

Conclusion

Implementation of change initiatives is a complex due to involving many interrelated factors that are often required for successful change. Unless staff from residential aged care have a readiness for change, the implementation of planned changes in policy and processes is unlikely to be successful. The findings of this study suggest that readiness for change in the aged care sector can be enhanced using interventions (i.e., training) focused on enhancing leadership and the work environment prior to implementation of change. This finding is significant because it indicates that staff training that fosters effective organizational leadership and a positive workplace environment can enhance staff readiness to adopt organizational change. Given the scope of change that is expected across the aged care sector both now and into the future, the findings suggest that the effective implementation of such change can be achieved within aged care facilities if staff are trained in how to engage in leadership that supports change as well as skills in developing and maintaining positive workplace relations. Hence, training in these organizational factors may facilitate the effective implementation of sector-wide policies. Determining how changes in the readiness for change among staff in aged care is aligned to the adoption of new policies and procedures is a critical next step.

Supplemental Material

Org_Readiness_Supplementary_file – Supplemental material for Facilitating Staff Adoption of New Policies and Procedures in Aged Care Through Training for Readiness for Change

Supplemental material, Org_Readiness_Supplementary_file for Facilitating Staff Adoption of New Policies and Procedures in Aged Care Through Training for Readiness for Change by Kathryn M. von Treuer, Marita P. McCabe, Gery Karantzas, David Mellor, Anastasia Konis and Tanya E. Davison in Journal of Applied Gerontology

Footnotes

Ethics Approval and Consent to Participate

Ethics approval was gained from the Australian Catholic University, Human Ethics Committee (201500024T) and all participants signed a consent form prior to participating in the research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work has been supported by the National Health and Medical Research Council as the funding source for this project (grant no. 1042156).

ORCID iDs

Kathryn M. von Treuer

David Mellor

Supplemental Material

Supplemental material for this article is available online.

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