Understanding Adaptive Leadership in the Context of Nursing Homes

Abstract

Rapidly growing populations of older adults rely heavily on formal long-term care services such as those provided in nursing homes. Nursing home staff are confronted with complex challenges. We explored how staff (N = 88), particularly care aides, interpreted challenges and responded to them by taking adaptive leadership roles, and engaging in technical and adaptive work in nursing homes. We conducted analysis of the ethnographic case studies. In long-term care settings, staff face complex challenges in improving resident care due to contextual barriers. These include demanding work conditions and inadequate resources. Additionally, top-down communications, despite being well-intentioned, often lead to misinterpretation and a lack of staff motivation. Nonetheless, we found that certain staff managed to overcome these contextual barriers and effectively execute change initiatives by assuming adaptive leadership roles. Formal leaders have a vital role in empowering staff, including care aides, and facilitating their adaptive leadership behaviors.

Keywords

adaptive challenges adaptive work technical work leadership behaviors care aides

What this paper adds

• Insight into Organizational Context: This research provides a deep understanding of how organizational context shapes change initiatives and quality of care in nursing homes. It emphasizes that contextual factors, such as demanding work conditions and limited resources, significantly impact the challenges faced by staff, particularly care aides.

• Challenges in Top-Down Communication: The study highlights the limitations of top-down communication in addressing complex nursing home challenges. It reveals that despite good intentions, top-down approaches often lead to misinterpretation and staff demotivation, emphasizing the need for more effective communication strategies.

• Empowering Frontline Staff: The research underscores the vital role of adaptive leadership taken by diverse staff, including care aides, in overcoming contextual barriers. It demonstrates that empowering frontline staff through open communication, resource provision, and psychological support is essential for driving positive change and enhancing the quality of care for older adults in long-term care settings.

Applications of study findings

• Empowering Frontline Staff: This study demonstrates that frontline nursing home staff, including care aides, possess the capability to exhibit adaptive leadership behaviors. They can effectively address complex challenges through a combination of technical and adaptive work. These findings hold significant implications for nursing homes, as they highlight the untapped potential of frontline staff to lead change efforts.

• Contextual Modification for Improved Leadership: The results offer practical applications for real-life scenarios within nursing homes. They underscore the importance of modifying context factors, such as addressing high-intensity work, alleviating resource scarcity, fostering a more adaptable organizational culture, and revising rigid hierarchical structures. Implementing these modifications can facilitate leadership behaviors at various staff levels and enhance the successful implementation of change initiatives in the care environment.

• Enhancing the ALFCI Framework in Practice: This study enriches our understanding of the Adaptive Leadership Framework for Change Implementation (ALFCI) and its applicability in nursing home settings. By emphasizing the critical influence of context, the study provides valuable insights for real-world application. It underscores the necessity for adaptive leadership to navigate the intricacies of challenges within nursing homes, making the ALFCI framework a practical tool for improving care quality and facilitating positive change in these care settings.

Introduction

The global aging trend poses significant challenges and opportunities for healthcare systems worldwide. By 2050, the number of adults aged 65 and over is expected to reach an unprecedented 1.5 billion globally (Afzal et al., 2018). This demographic shift is not just a global phenomenon; in Canada, for instance, it is projected that by 2036, approximately 25% of the population will be aged 65 or older, with the most rapid increase seen in those aged 85 and above (Ng et al., 2020). Such trends underscore the growing need for robust long-term care services, particularly in nursing homes (NHs), which play a vital role in supporting older adults with age-related diseases and conditions.

In this context, the role of care staff in NHs becomes increasingly pivotal. Care aides, who form the backbone of resident care in these settings, are often subject to high workloads and intense work environments. This is especially true for the predominantly female caregivers from ethnic minority backgrounds, who face the risk of poor job satisfaction and burnout (Bolano et al., 2019; Harvey & Kitson, 2015). To understand and address these challenges, it is crucial to consider the context of their work environment. The Alberta Context Tool (ACT), grounded in the Promoting Action on Research Implementation in Health Services (PARiHS) framework, highlights the importance of this context in influencing change initiatives and staff experiences in NHs. Adaptive changes within this context are essential for mitigating issues like job dissatisfaction and burnout (Berta et al., 2015; Harvey & Kitson, 2015).

One promising approach to fostering positive change in NHs is the application of adaptive leadership. The Adaptive Leadership Framework for Chronic Illness (ALFCI) posits that leadership is not just a role but a dynamic behavior that encourages learning, innovation, and adaptability in complex environments like NHs (Uhl-Bien et al., 2007). This framework emphasizes behaviors that facilitate problem-solving through collaboration, adaptation, and the transformation of values, attitudes, and behaviors. In NH settings, such adaptive leadership can significantly enhance teamwork and decision-making processes, benefitting staff at all levels (Anderson et al., 2015; Helfrich et al., 2010). Our study employs the ALFCI framework to delve into the multifaceted challenges faced by NH staff, particularly focusing on leadership behaviors and their influence within the NH context. We assess this context using the PARiHS framework, operationalized through the ACT (Estabrooks et al., 2009). By applying the ALFCI lens, we aim to dissect the intricate ways staff work and interact within NHs, acknowledging that these challenges are often adaptive in nature, requiring a shift in learning, values, and collaborative efforts (Corazzini & Anderson, 2014; Pype et al., 2018).

While adaptive leadership holds promise for driving change in complex systems, the literature on the relationship between adaptive leadership behaviors and context remains limited. To address this gap, we undertook an exploration, guided by the ALFCI and PARiHS frameworks, to understand the interplay between leadership and context factors and their impact on the successful implementation of quality improvement initiatives in three NHs. In our study we sought to understand how staff, particularly care aides, perceived and reacted to adaptive challenges during change initiatives, involving both technical and adaptive work. Our analysis was driven by the goal to generate new insights into how the organizational context influences change initiatives. We sought to explore the conditions in which adaptive leadership is supported and facilitated, and the conditions that promote adaptive change.

Research Design and Methods

Design

This is a foundational secondary analysis of data that is part of the Influence of Context on Implementation and Improvement (ICII) study, associated with the Translating Research in Elder Care (TREC) program of research (Estabrooks et al., 2009) TREC began in 2007, and focuses on the role of organizational context as a lever for change that endeavors to improve NH resident care and quality of life and care staff quality of work life. In this paper, we report on a secondary descriptive analysis of data from three extensive ethnographic case studies within TREC. Our qualitative data was collected in 2010. The dataset comprises 60 in-depth, in-person interview transcripts, amounting to over 800 pages, and an additional 150 pages of detailed observations recorded in fieldnotes. This rich dataset provides a deep insight into context and its role for staff challenges and responses in NH work and change implementation (Cammer et al., 2014).

Setting

Data were collected from three Canadian NHs, purposively selected from 30 urban NHs in three Western provinces (Alberta, Manitoba, and Saskatchewan). Discussions with health authority decision makers identified the most typical NHs in each province, based on key characteristics such as size and operational model (Table 1) (Rycroft-Malone et al., 2009).

Table 1.

Characteristics of the Three Facilities.

Nursing Homes (NH)	Number of Units	Number of Beds	Availability of Dementia Unit(s)	Location
NH-A	6	228	Yes	Alberta
NH-B	2	69	No	Manitoba
NH-C	2	100	Yes	Saskatchewan

Participants and Data Collection

NH staff of administrators, specialist/allied personnel, directors of care, care managers, registered nurses, licensed practical nurses, and care aides were asked to participate (n = 88; Table 2) in interviews. These in-person interviews were semi-structured and aimed to capture participants’ perspectives on various aspects, including their roles and responsibilities in symptom management, the implementation of change initiatives and care practice innovations, and how key contextual factors would impact their roles during implementation. To ensure relevance, interview guides were customized for each type of participant being interviewed. Additionally, we conducted observations of the daily work pattern in resident care areas and at a variety of meetings, documenting these observations in the researcher’s fieldnotes. Following data collection, both fieldnotes and interviews were transcribed and imported into a qualitative data management/analysis software program (ATLAS. TI version 9.1.2) to facilitate with the analysis process.

Table 2.

Information of Participants (n = 88).

Roles	Facility-A	Facility-B	Facility-C	Total
Care aides	10	10	11	31
Registered nurse (RN)	6	3	3	12
Licensed practical nurse (LPN)	5	4	2	11
Specialist/Allied personnel	11	4	2	17
Care manager	4	3	0	7
Director of care (DOC)	0	1	1	2
Administrator	1	0	2	3
Chaplain	0	1	0	1
Unit manager	0	2	0	2
Program manager	0	1	0	1
Educator	0	1	0	1
Total	37	30	21	88

Data Analysis

We created detailed summaries from each interview and fieldnotes to familiarize ourselves with the qualitative dataset. We used directed content analysis (Hsieh & Shannon, 2005) to create and define codes derived from the ALFCI and ACT (Anderson et al., 2015; Estabrooks et al., 2009). We also used in vivo codes derived directly from the text data, allowing exploratory interpretation of the rich data. We defined a priori codes conceptually (Table 3), guided by the ALFCI (adaptive leadership, adaptive challenges, adaptive work and facilitation, technical work) and elements of the ACT (social capital, informal interactions, formal interactions, and organizational slack in staff, time, and space). These four key ACT concepts were included as context elements affecting staff behaviors during change implementation and care innovations. In the first phase of coding, the coders (J.W. and J.P.) applied the codes to segments of text in the transcripts. Initially, the coders coded the same transcripts and fieldnotes until they reached consensus and consistency in coding. Then the rest of the transcripts were divided between the two coders and the coding team met every week to discuss coding questions and resolve coding disagreements. The coding team kept memos about rationale for coding choices and notes to clarify coding decisions. In the second phase of analysis, guided by senior researchers [R.A. and A.B.] used matrices (Averill, 2002) to visually display data, building a hierarchy of potential themes and subthemes to facilitate within and cross-NH comparison, which also added to the audit trail tracking findings to the original data. Themes were articulated and developed through comparison within and then between facilities. The matrices summarized our interpretive process and a final output of the analysis through the lens of ALFCI and ACT. Throughout this phase, regular team meetings were held every week to discuss questions until a consensus was reached regarding the themes and interpretations. Memos were recorded of thought processes and decisions along the way to document an audit trail to ensure rigor in qualitative research.

Table 3.

Concepts From Adaptive Leadership Framework for Chronic Illness (ALFCI) and Alberta Context Tool (ACT).

Frameworks	Concept	Operational Definition
ALFCI	Adaptive challenges (AC)	Challenges that are difficult to understand require changes in values, beliefs, and approaches to work (Anderson et al., 2015).
	Technical work (TW)	Applying the expertise and technical interventions required to solve the problem, often from a standard procedure or known algorithm, or skill (Anderson et al., 2019).
	Collaborative work (CW)	The process of engaging other staff in developing shared undestanding of the context and a joint plan of action (Anderson et al., 2019).
	Adaptive work and facilitation	Actions taken to learn, change one’s attitudes and behaviors in a manner that addresses an adaptive challenge (Bailey et al., 2012). Facilitation is a type of adaptive work. Facilitation: Addresses adaptive challenges through implementation of change initiatives as adaptive leaders and foster successful implementation in the organizational context (Harvey & Kitson, 2015).
	Adaptive leadership	Behaviors that facilitate the individuals with the adaptive problems to solve them through learning, adapting, collaborating, and changing values, attitudes, and behaviors (Corazzini et al., 2015).
ACT	Social capital	The stock of active connections among people. These connections are of three types: Bonding, bridging, and linking (Estabrooks et al., 2009).
	Informal interactions	Information exchanges that occur among individuals working within an organization (unit) that promotes the transfer of knowledge (Hoben et al., 2020).
	Formal interactions	Formal exchanges through scheduled activities that can promote the transfer of knowledge that occur between individuals working within an organization (unit) (Estabrooks et al., 2009).
	Organizational slack: Staff+ time +space	The cushion of actual or potential resources which allows an organization (unit) to adapt successfully to internal pressures for adjustments or to external pressures for changes (Estabrooks et al., 2009).

Assuring Rigor

Multiple strategies were used to establish qualitative rigor (Fereday & Muir-Cochrane, 2006). To ensure confirmability, we reflected on potential biases that researchers might bring to the analysis. This helped us remain aware of any preconceived notions that could influence our findings. Additionally, we organized meetings with our research team members to review and discuss our analysis procedures. For dependability, we developed a code book to establish consistency across different coders. This provided clear guidelines for categorizing and interpreting the data. To maintain transparency, we also documented memos of our thought processes and decisions throughout the research process, creating an audit trail. Moreover, we employed a consensus-building approach where the refinement of the codes and themes were discussed by the research team, which facilitated joint decision-making the coding schemes and categorization of coded data. This iterative process allowed us to achieve consensus and consistency in coding. To enhance credibility, we employed analysis triangulation by comparing data from interviews with fieldnotes, compared findings with existing literature on the ALFCI and PARiHS frameworks, aligning our results with established knowledge, and engaged other team members so that non-coders could review and challenge our interpretations. For transferability, we provided rich descriptions for potential applicability. See strategies to assure rigor in Table 4.

Table 4.

Data Analysis and Rigor.

Analysis	First phase	Applied a priori codes to segments of text
Analysis	Second phase	Used matrices to visually display data, building a hierarchy of potential themes and subthemes to facilitate within and cross-NH comparison
Rigor	Confirmability	1. Reflect on potential researcher biases 2. Meeting with research team members to review analysis procedures
	Dependability	1. Code book were used to provide for consistency across coders 2. Memos of thought processes and decisions along the way were documented as an audit trail 3. Initially coders coded the same transcripts until everyone reached consensus and consistency in coding. Disagreements were resolved through discussion with team members
	Credibility	1. Analysis triangulation between interview and fieldnote data to strengthen inferences 2. Findings were compared with current ALFCI and PARiHS frameworks literature 3. The matrices helped summarized our interpretive process through the lens of ALFCI and ACT
	Transferability	Rich descriptions in the data to facilitate judgments about potential transferability

Results

For the three NHs, we describe context-sensitive adaptive challenges facing staff, adaptive work undertaken to address these challenges, and technical work that applies expertise and technical interventions to solve the problem (often from a standard procedure, known algorithm, or skill described by staff).

Overview of the Three Facilities

Facility-A consists of three units catering to residents with different conditions, including those with late-stage progressive irreversible dementia, individuals with physical conditions without cognitive impairment, and ambulatory residents with dementia experiencing disruptive behavioral expressions. Staff, especially care aides, consistently identified high work intensity and inadequate staffing as significant contextual barriers, making their work more challenging and complex. Facility-B is a faith-based personal care home focused on creating a home-like environment for residents and staff. Some staff members have been with the facility for over 25 years. Long-tenured staff and a home-like atmosphere pose challenges for introducing new care models, but residents and families appreciate the commitment and familiarity provided by long-tenured care aides. Similar to Facility-A, high work intensity and inadequate staffing contribute to the complexity of challenges. Additionally, language barriers, with English as a second language for over 60% of care aides and some residents, create communication challenges within the facility. Facility-C is a 100-bed facility managed by a volunteer board of directors under the oversight of the health region leadership. The involvement of the volunteer board of directors and the centralized admission process adds to the complexity of challenges faced by the facility. Please refer to Tables 5 and 6 for exemplar quotes and comparisons of strategies used in the three nursing homes.

Table 5.

Exemplar Quotes.

Themes	Subthemes	Exemplar Quotes
Themes	Subthemes	Facility-A	Facility-B	Facility-C
Adaptive challenges and adaptive work	Challenge: Shift from task-oriented to person-centered care	Director of Care (DOC) (A): “Every staff member has a designated role. Therefore, the performance of tasks is dictated by each person’s role and responsibilities within the organization. It is not staff’s [individual] culture [such as] “Asian-ness” that is task-oriented—care aides have specific responsibilities in providing resident care”	Registered nurse: I wondered when residents were being put to bed early, at 6:30 (pm), a time when visitors often came to the NH. I realized this was for convenience of those who went on breaks. It is difficult to move a system, especially when things have been done a particular way for so long	Acting administrator: I wish all residents could have what they wanted when they want it. I’d really like to be able to remove everyone’s thoughts and ideas about routines, but it is very hard making changes
	Adaptive work	Care manager: I make sure care aides do not dehumanize residents by becoming so task-oriented. My biggest job is to get people to value the person who’s in that bed and reprimanding staff who see residents as a task	Care aide: I’m thinking are we not gentle enough now? I don’t know if they realize that with this new program, we have extra duties, but the staffing is the same. Nurse: There was an in-service on gentle care a week ago…doing things in the way that’s convenient for clients and not for us. But it’s very unrealistic. They can talk all they want and it’s a beautiful thought but it’s impossible because you have 4 people putting 50 people to bed and most of them are physically dependent	Registered nurse: [It means] looking at the individual as a whole person rather than just a bed number
	Challenge: Symptom management	A registered nurse stated, “Consultants give you really good ideas, but we have to be able to follow through on them”	A registered nurses also reported challenges relating to management of “so many” residents’ pain and skin care in a high intensity of work context	A registered nurse: “There’s just too many [residents] and I can’t touch base with everyone every day, so I feel inadequate”
	Adaptive work	Care aide: Teamwork is essential in dealing with uncertainty in the dementia unit. …I would let one of the girls know and ask her to tell the nurse, I will stay here with the resident and not let him hurt himself. Registered nurse: We are learning a lot from care aides because they see and talk to residents the most. They often know the best what to do	Care aide: “some people, they have their own things that they like and something that calms them down, like sometimes music will calm a person down, who is just wandering and anxious and hyper all the time, if you find something that they actually like and even though they may have not liked it before. Everything’s kind of new now, sort of, but you just have to find, well what does this person like now. You just gotta go with wherever they’re at”	Care aide: I could go to the (RN) if it was something I didn’t know. I might even ask a co-worker. We’re all really there to work together. Registered nurse: I rely on care aides so much for giving us information. Care aide: You just have to find, what does this [resident] like. If that calms them down…You just gotta go with wherever they’re at
	Challenge: Safety improvement	Recently, a labeled physician order was placed in [the wrong] resident’s chart which caused this resident to take the wrong medication	Care aide: it is challenging finding time to have a person-centered communication with residents and identify potential risks to safety	Care aide: “Probably one thing I notice since I’ve been here that I struggle with is decisions. When decisions have to be made by management, things here just do not happen. Like they take forever. They go from person to this person. Sometimes it just seems like it can go on forever, decisions with anything…”
	Adaptive work	Care manager: “I noticed two different narcotics that appeared to be identical and decided to communicate with pharmacist about how to prevent possible medicine errors this similarity in appearance might cause. We send people to the ‘supportive pathways’ and hopefully they will take some of that knowledge and bring it back”	Care managers played a leadership role by communicating between nurses, care aides and family members to facilitate care provision	Care aide: “I think it’s more communication. I don’t understand all their [nurses] roles. I mean, we know what their roles are. But we don’t always understand what they do. You just want to have a better understanding of how things go up here”
Technical work to adaptive work	Safety improvement	Fieldnotes: There was a flyer posted – Medication safety Alert – with suggestions for night staff to prevent [errors] from happening again and thanking [staff] for keeping residents safe. Care manager: Staff were willing to try one-on-one care for residents with dementia. But ultimately they didn’t like it because working with the same residents with dementia wore on them	Care aide: “You get the work done but you’re doing it as fast as you can because you have to get it done before you go home … that can create a lot of stress and a lot of burden [laughs] because you’re rushing so—and they pay lots of money to stay here. You shouldn’t have to, you know, rush around”	Care aide: There’s nothing you can do but keep your eyes out and watch them and give them the bell. Care aide: “We have the 24 hour report on paper if you want to know. Just kind of take a paper for yourself and take it home with you or something, and just to see each of the residents’ names. I just kind of take that with me wherever I go. Especially [when] you’re jumping around from floor to floor, you just take a report paper from there and from up and down stairs and then you got whose names or whose upstairs and whose downstairs, you know, it’s nice

Table 6.

Strategies/Initiatives Used in the Three Nursing Homes.

Strategy Used	Success	Reasons
NH-A
Emphasis on person-centered care by care managers; reinforcing the value of residents	Partial	Limited by inadequate staffing and resources, but effective in changing staff perspectives
Collaborative teamwork and knowledge sharing among care aides for symptom management	Yes	Improved handling of dementia-related symptoms despite high work intensity
Implementation of safety improvements via staff collaboration and education sessions	Partial	Challenged by high workload but beneficial in enhancing safety awareness
NH-B
Top-down communication for person-centered care model; Gentle relationships program	No	Poor staff understanding and motivation due to exclusion of care aides from planning
Knowledge/information sharing for pain and skin care management	Yes	Effective collaboration between care aides and nurses despite high work intensity
Efforts to transition to person-centered care model	No	Hindered by entrenched staff routines and limited staffing
NH-C
Introduction of “whole person” concept and “relaxed breakfast” for person-centered care	Yes	Successful in changing staff values and beliefs from task-oriented to person-centered
Implementation of consultant recommendations for symptom management	No	Inadequate staffing and time constraints limited practical application
Scheduled weekly meetings and inclusion in resident care conferences	Yes	Improved communication and joint decision-making with care aides
Use of technical interventions (e.g., flyers, hip protectors, and medication printouts)	Partial	Helpful in addressing specific issues but insufficient for broader adaptive challenges

Adaptive Challenges and Adaptive Work

Major adaptive challenges identified in each of NHs A, B, and C included (1) shift from task-oriented to person-centered care, (2) symptom management (dementia-related symptoms, pain, and skin care), and (3) safety improvement (medication safety, fall management, and prevention). We identified two additional challenges in NH-C: gaps between NH practice and health region rules, and communication between management team and staff. Across these NHs, the complexity of challenges was exacerbated by high work intensity, inadequate staffing, limited care capacity, and long-tenure staff entrenched in work routines. Some staff at NHs took leadership roles and used adaptive work to respond to the challenges collaboratively.

Shift from Task-Oriented to Person-Centered Care

In NH-A, participants reported a challenge associated with following guidelines and protocols for person-centered care due to inadequate staffing and limited resources. Despite that, care managers adapted to person-centered care by emphasizing valuing personhood of residents and praising staff to reinforce desired behaviors. Care manager stated, “I make sure care aides do not dehumanize residents by becoming so task-oriented. My biggest job is to get people to value the person who’s in that bed and reprimanding staff who see residents as a task.” A care manager described one care aide reporting on another who she thought was not doing her job, when she was observed “socializing” with her residents and their family. The care manager reported following up at a staff meeting stating that, “Staff members all have different approaches to providing care and that both residents and family members like more people-oriented staff as opposed to task-oriented staff.”

In NH-B, participants reported challenges with changing to a person-centered care model, specifically highlighting difficulties associate with facilitating more flexible schedules for residents.

Registered nurse, “I wondered when residents were being put to bed early, at 6:30 [pm], a time when visitors often came to the NH. I realized this was for convenience of those who went on breaks. It is difficult to move a system, especially when things have been done a particular way for so long.”

However, NH-B did not incorporate adaptive work in their initiatives on person-centered care. The management team initiated top-down communication to implementing the Gentle Relationships program to facilitate holistic and person-centered care change. Brainstorming meetings about implementing the care model excluded care aides, whose work and schedules would be directly affected. The top-down communication and limited resources led to poor staff understanding and low motivation to act during implementation. Comments from a care aide and nurse exemplify the issues:

Care aide: Why is it called gentle care? I’m thinking are we not gentle enough now? I don’t know if they realize that with this new program, let’s say we have extra duties, but the staffing is the same.”

Registered nurse: “Why do they call it gentle caring? There was an in-service on gentle care a week ago…doing things in the way that’s convenient for clients and not for us. But it’s very unrealistic. They can talk all they want and it’s a beautiful thought but it’s impossible because you have 4 people putting 50 people to bed and most of them are physically dependent.”

NH-C needed to change its care culture from task-oriented to person-centered. A registered nurse used a “whole person” concept to guide her in valuing the personhood of each resident and provide person-centered care. Registered nurse: “[It means] looking at the individual as a whole person rather than just a bed number.” One administrator introduced the concept of “relaxed breakfast” to change staff values and beliefs from task-oriented to person-centered. Acting administrator: “I wish all residents could have what they wanted when they want it. I wish I could just wave a magic wand and REMOVE the idea that we have to have a routine around bed-making and bathing.”

Symptom Management

Managing residents’ pain and skin condition is a technical challenge because staff have training and protocols. However, in the context of staff providing care for “so many” residents, it became an adaptive challenge requiring collaboration and innovation. While NH-A relied on in-service education for implementation, care aides often reported insufficient training on dementia-specific care and were challenged when managing dementia-related symptoms in their high-intensity work context. The technical response represented by in-service education, therefore, appeared to be insufficient for this challenge. In response to that, care team members collaborated with knowledge transmission, teamwork, and information sharing to manage uncertainties in dementia care. Care aides exchanged resident information, shared knowledge, and helped each other provide care, particularly in managing dementia-related symptoms.

Care aide: “Teamwork is essential in dealing with uncertainty in the dementia unit. …I would let one of the girls know and ask her to tell the nurse, I will stay here with the resident and not let him hurt himself.”

Care aides also took leadership in observing pain and skin conditions, describing themselves as residents’ first point of contact and “eyes” of nurses through information sharing and teamwork. Some nurses actively learned from care aides’ experience and knowledge. Registered nurse: “We are learning a lot from care aides because they see and talk to residents the most. They often know the best what to do.”

In NH-B, nurses reported challenges in managing pain and skin care for “so many” residents in a high-intensity work context. In response, care aides did adaptive work of knowledge/information sharing with nurses and monitored residents’ conditions. Nurses trusted and relied on information from care aides concerning residents’ pain levels. Furthermore, some care aides tailored pain management strategies for residents’ needs and care situations. Care aide: “I find out from the nurse when they had their meds. [If they] already had their medication, I would distract them from the pain and hopefully by then the pills will have worked.”

NH-C allocated resources, including time and money to implement consultant recommendations aimed at addressing challenges in symptom management. However, the staff faced obstacles in applying these recommendations to their care practices, primarily due to inadequate staffing and time constraints. One registered nurse participant stated, “consultants give you really good ideas, but we have to be able to follow through on them.” Staff who worked across units needed to know about the conditions of more than 100 residents and found it challenging to know all residents well enough to provide high-quality care. A registered nurse stated: “There’s just too many [residents] and I can’t touch base with everyone every day, so I feel inadequate.” NH-C offered only brief orientation for new staff, compounding this adaptive challenge. Care aides and nurses assumed leadership in observing and anticipating residents’ dangerous behaviors to prevent injury. They also facilitated knowledge transmission, teamwork, and effective communication with co-workers. Care aide: “I could go to the [RN] if it was something I didn’t know. I might even ask a co-worker. We’re all really there to work together.”

Even though NH-C could not afford one-on-one care for older residents with dementia-related behaviors, the staff mindset was always “getting prepared,” “don’t take anything personally,” and “be confident.” They adaptively used available resources to address challenges. Staff tried different approaches (trial and error) and actively learned about person-centered strategies. Care aide: “You just have to find, what does this [resident] like. If that calms them down…You just gotta go with wherever they’re at.”

Safety Improvement

An incident related to medication safety occurred at NH-A, prompting a need for improvement. The director of care noted that this, challenge emerged within the context of high-intensity work and inadequate staffing. Additionally, NH-A also aimed to minimize injurious falls. However, given the demanding workload and high number of residents at risk of falling, the challenge became intricate, necessitating adaptive approaches alongside technical work. Responsively, nurses and care aides needed to collaborate when residents fell. Care aides notified nurses, then nurses assessed the resident and guided aides on appropriate care. Other adaptive/collaborative work included prioritizing older residents’ needs in the high-intensity work environment and finding new evidence-based safety strategies. For example, staff reported they gained insights from residents' perspectives. Staff initiated conversations with physicians and pharmacists to explore medication side effects for residents and develop effective strategies collaboratively. Furthermore, during education sessions, care managers encouraged staff at education sessions to discuss with specialists how to prevent and manage resident falls. Care managers also presented articles and facilitated discussion with staff on care, “We discussed an article on …four to 7 minutes to get a resident changed to dressed…one of my care aide (said) ‘this must not be from Canada because I’m sure it takes longer’ and I said well that’s good, that means you’re taking your time.”

The analysis revealed that NH-B faced communication challenges when improving safety, such as time for person-centered communication between staff and residents. Additionally, long-tenure staff also posed challenges for nurses and care managers in driving change, as their entrenched attitudes toward work and years of habitual work routines posed obstacles. NH-B held a care team meeting (director of care, educator, housekeeping, registered nurses, allied specialists) to discuss potential safety improvement plans. These plans were based on survey results from residents and their family. Notably, care aides were excluded. The care team had difficulty accepting the unfavorable results, leading to an atmosphere of tension and skepticism about the survey’s design and the reliability of the findings. Subsequent quality improvement discussions refocused on transitioning from a task-oriented approach to a more person-centered care model, acknowledging the challenges posed by limited staffing and the demanding nature of the work.

Gaps Between NH Practice and Health Region Rules

In NH-C, participants identified a mismatch between health region rules and NH practice. An acting administrator indicated that health region policies are more applicable to acute care settings than to NHs. Gaps between NH practice and health region policies and rules created challenges for NH-C, even rules developed with good intentions. For example, HIPPA rules prohibited posting pictures and names of residents, eliminating a strategy to create a home-like environment. Care manager: “We’re focused on making this their home, but we need to follow rules from the health region even if they don’t always make sense.”

Communication Between Management Team and Staff

Participants reported lack of cohesion and reliance on top-down communication via workplace hierarchy, prolonging management decision-making and reducing communication between care managers and care aides. Care aides wanted more communication with managers for better, more timely understanding of NH-A operations.

Care aide: When decisions have to be made by management, they take forever. They’ll wait till the last minute to tell you if the shift is filled. Especially on some night shifts. They know they need to call us in advance, but don’t.

In NH-B, care managers led communication among nurses, care aides, and family members to facilitate care. Some care managers asked care aides who understood a resident’s primary language to interpret, but short staffing plus language barriers made this difficult at times. Communicating instructions to long-established care aides could also be a challenge.

Registered nurse: It is hard to make some care aides change who have worked here for over 20 years. I asked care aides to make sure that one resident drink enough water because of her urinary tract infection. Care aides replied as “we will try.” I wanted to tell them that they had to do it. But I was very careful about my tone. I said “please, I beg of you….” I would then check if the resident drank enough water, if not, I would ask the care aides as if they were doing me a favor.

In NH-C, care coordinators facilitated scheduled weekly meetings with care aides to discuss problems. NH-C included care aides at resident care conferences, to share information and work as a team on joint decisions.

Technical Work in Response to Adaptive Challenges

NH-A posted flyers at the nurses’ station with suggestions, encouragement, and information. In NH-C, care aides showed residents how to use a bell to call staff. Care aides also kept a walker nearby for residents to grab when needed. One registered nurse put hip protectors on residents at risk of falls. In response to challenges of knowing residents’ conditions well, the pharmacy in NH-C prepared printouts on each resident’s medication. One care aide learned everyone’s name by writing names down on paper and making a note about each. She also read the 24 Hour Report for updates about each person on each floor.

However, technical work alone was not sufficient to address adaptive challenges. NH-A devoted staff to residents with dementia, taking residents for walks, playing music, and constantly talking with them. The strategy was unsustainable, though, creating extra burden for assigned staff. In NH-B, some care aides had to rush to complete their work in a shift, although they were aware that rushing reduced care quality for residents. They rushed as a strategy to meet challenges of high-intensity work and inadequate staff, which increased burden and lowered work satisfaction.

Discussion and Implications

Our study aimed to understand how NH staff interpreted and addressed challenges through technical and adaptive work. Staff consistently reported a high-intensity work context with resource limitations, which compounded the complexity of challenges and hindered their efforts to improve resident care. Despite these contextual barriers, certain staff members in each NH successfully implemented change initiatives, assuming adaptive leadership roles facilitated by co-workers and formal leaders. In contrast, top-down communication during change implementation, while well-intended, resulted in misunderstanding and demotivated staff (Anderson et al., n.d.). In our NH study, we deliberately included input from care staff at all levels, with a specific focus on the perspectives of care aides. Care aides' unique insights, influenced by their direct involvement in resident care, are a strength rather than a bias, as they are often underrepresented in research. Their perspectives offer valuable information about the challenges and opportunities in the nursing home environment.

Contextual Barriers Made Challenges More Complex

All staff, regardless of role, consistently experienced highly demanding, resource-constrained contexts. Indeed, this is recognized as a hallmark of institutional care. Care aides experienced this particularly keenly. Contextual barriers added to complexity of challenges facing staff and impeded their efforts to implement change for enhanced resident care. For example, implementing person-centered care was inherently an adaptive challenge (Anderson et al., 2015) because staff had to drop old patterns and routines and embrace new values and behaviors congruent with the new care model. With inadequate resources, some staff rushed their work as a strategy to complete care tasks. More than half of care aides reported having to rush or miss at least one essential care task per shift in Canadian NHs (Song et al., 2020) This constrained staff ability to deliver person-centered care and led to lower work satisfaction.

Facilitating Adaptive Leadership Behaviors of Frontline Staff

In each NH, some staff overcame these contextual barriers to implement change successfully, with formal leaders facilitating adaptive leadership behaviors. This included care aides taking proactive leadership roles in providing person-centered care, such as sharing information on symptom management, supporting knowledge transfer, addressing medication errors, and collaborating effectively to ensure quality resident care. These behaviors were most effective when fostered by formal leaders in a supportive organizational culture (Corazzini et al., 2015). We observed adaptive challenges in symptom management that required facilitation, such as second-order learning to translate training into action (Tucker, 2004). Second-order learning empowered staff to develop more effective approaches to meet challenges in complex work contexts.

Top-Down Communication

The top-down communication approach in NH-B was meant to facilitate holistic and person-centered care through the implementation of the Gentle Relationship care model. However, it resulted in misunderstanding and a lack of staff motivation during implementation. NH-C also faced issues with top-down implementation, as tensions arose due to discrepancies between health region rules and typical NH practices. Enforcing new models and rules created significant staffing challenges in NH-C and distracted from desired behavior and sound initiatives. Mislabeling initiatives could lead to staff rejection or poor care outcomes despite the initiatives' merits (Mondoux, 2018). Excluding care aides from decision-making missed opportunities for better care planning and was linked to burnout and dissatisfaction among staff (Hoben et al., 2020). This highlights the challenges associated with strong culture, entrenched beliefs, resource scarcity, and rigid hierarchy in top-down communication (Berta et al., 2010).

We emphasize adaptive leadership behaviors, noting that leadership in healthcare often focuses on top managers or administrators (Backman et al., 2017; Castle & Decker, 2011). Complexity leadership literature argues that effective leadership emerges from interactions at all organizational levels, not just from management or authority (Uhl-Bien et al., 2007). Facilitation in the adaptive leadership lens is used to address adaptive challenges by encouraging people to change and supporting them in making changes (Bailey et al., 2012).

Contribution to the Conceptual Frameworks

Our study aligns with the ALFCI framework by showing that NHs can benefit from moving beyond hierarchical, rule-based management strategies. Frontline staff, including care aides, can emerge as adaptive leaders addressing complex challenges through technical and adaptive work. Strong supervisory leadership, support, and trained facilitators are essential to navigate individuals and teams through complex change processes and context challenges. All levels of staff, particularly care aides, need support and empowerment as potential adaptive leaders who can jointly respond to challenges and improve care quality. We explored the barriers that care aides and other frontline staff may encounter when adopting adaptive leadership practices. These barriers include limited access to ongoing professional development, rigid hierarchical structures within nursing home administrations, varied levels of staff empowerment to make decisions, and institutional resistance to change. Furthermore, we examine facilitators that can enable the successful adoption of this framework, such as supportive organizational cultures that encourage innovation supportive management practices that encourage shared decision-making, inclusive policies that recognize and value the input of care aides, and structured training programs focused on leadership and management skills. Second-order learning (Tucker, 2004) is a significant facilitation strategy to help staff translate knowledge into effective actions and address challenges in a complex context. Our findings complement PARiHS (Rycroft-Malone et al., 2013) by offering a more comprehensive understanding of context. Additionally, we delve into the impact of external factors such as changing regulatory requirements and societal attitudes toward elder care and how these can shape the efficacy of adaptive leadership in nursing homes.

We acknowledge the limitation of using data from 2010. However, our findings offer valuable perspectives on facilitating staff’s adaptive leadership in their work and implementing change, which are crucial in the current context where healthcare systems are adapting to the challenges post the pandemic. The pandemic has necessitated unprecedented levels of adaptability and leadership from healthcare workers. The strategies and behaviors observed in our data provide a foundation for developing training and support programs to enhance adaptive leadership skills among nursing home staff. Additionally, our study sheds light on the implementation of changes within nursing homes, an area that has seen significant upheaval during the pandemic. The historical data included instances of nursing homes successfully adopting new technologies and care practices, which is highly relevant today as nursing homes are rapidly adapting to new protocols and technologies. The lessons from our study about change management are invaluable for current nursing homes, offering guidance on how to facilitate smoother adoption of new practices and technologies. Through this repurposing analysis of past experiences, our research provides actionable insights for developing leadership capacities in frontline staff and effectively managing change in nursing homes, both critical aspects in the evolving healthcare landscape post-COVID.

Our secondary qualitative analysis of case study data was limited by lack of data on resident-centered outcomes to compare effectiveness across NHs. Our research does indeed have limitations regarding its transferability to other contexts with significantly different characteristics. These differences can include variations in size, funding models, staffing levels, resident demographics, and cultural context. For instance, the cultural context and regulatory environment can vary widely, influencing the way nursing homes operate and the challenges they face. These variations could impact the direct applicability of our findings in several ways. Specific strategies and solutions identified in our study may not be feasible in nursing homes with different resource allocations or management structures. However, while acknowledging these limitations, it’s important to recognize that qualitative research offers valuable thematic insights that can transcend specific contexts.

Conclusions

Our study was an early analysis to guide further work in the Influence of Context on Implementation and Improvement (ICII) study. We show that frontline NH staff, including care aides, can be adaptive leaders to address complex challenges through technical and adaptive work (including facilitation). Results feed into our ICII project as implications for facilitating leadership behaviors of different levels of staff by taking modifiable context factors into consideration, including high-intensity work, resource scarcity, strong culture, and rigid adherence to hierarchy. Our results enhance understanding of the ALFCI framework by highlighting the critical roles of context in implementing change and the necessity for adaptive leadership in successful change initiatives.

Footnotes

Acknowledgments

Acknowledgement to the nursing homes and staff who participated in the study and shared their experiences with us.

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 study is funded by a grant from the Canadian Institutes of Health Research (#165838) to Carole A. Estabrooks.

Ethical Statement

ORCID iDs

Jing Wang

Ruth Anderson

Janelle Perez

Carole Estabrooks

Whitney Berta

Holly Jordan Lanham

Yinfei Duan

Anna Beeber

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