Transcript Three Measure to Assess Care

THANKS SO MUCH FOR
INVITING ME TO YOUR
CONFERENCE!
Strategies for Empowering
Direct Care Workers and
Improving Job Outcomes
Linda S. Noelker, Ph.D
Senior Vice President
Director, Katz Policy Institute
Benjamin Rose Institute
Presented at the North Carolina Conference on
Aging, September 10, 2007, Winston-Salem, NC.
This research was supported by a grant from the Institute for the Future of Aging Services under the Better
Jobs Better Care initiative funded by the Robert Wood Johnson Foundation and Atlantic Philanthropies
.
Benjamin Rose Institute (BRI)
 Established in 1908
 Endowment (currently 120 million)
 Mission: To advance the health, independence, and
dignity of older adults by raising the standards for
quality of care
 A non-profit agency that includes Home &
Community-based Services(HCBS), Applied Aging
Research, and Public Policy Institutes
What changed at BRI?
 1961: BRI’s first 115-bed nursing home
opened
 1997: BRI’s new 184-bed nursing home
opened
 2006: BRI got out of the nursing home
business
Kethley House @ Benjamin Rose Place
What does it reflect about
Long Term Care?
 Inadequate reimbursement under Medicaid
 Shift to HCBS (“rebalancing”)
 Liability issues (threat to BRI’s endowment)
 Licensed nursing shortage
 Direct care workforce (DCW) issues (e.g.,
increasing health insurance costs, projected
shortages)
Today’s Objectives
 Further understanding of the touch points between
Rosabeth M. Kanter’s theory of worker
empowerment and the stress and social support
model as they affect DCW job satisfaction
 Present findings on factors affecting DCW job
satisfaction with a focus on education and training
 Promote improved DCW training based on their
recommendations
What is empowerment?
A process by which the characteristics of the
organization and the job
create an environment in which the employee
feels in control
and has the power and ability to affect the
achievement of organizational goals (Kanter,
1993)
Key Elements of Empowerment
 Training and education so workers can learn
and grow
 Supportive leadership and work environment
 Information sharing
 Access to needed resources
DCW Training and Education
 Competencies are developed broadly
 Include interpersonal and group process
skills, problem-solving and decision-making
skills, leadership, customer relations skills, and
technical skills
Comments Reflecting a Lack of
Empowerment around Education
“You can’t expect them to learn that.”
“Continuing education is the same old thing
over and over.”
“I can’t leave the unit to attend.”
“They get to go to the Marriott for their
continuing education.”
Empowerment Outcomes
 Higher job satisfaction
 Greater job commitment
 Reduced job-related stress & burnout
 Higher retention
Better Education = Better Jobs
BRI’s Survey of DCWs
 Employed stress & support conceptual model to guide
the research
 Both DCW-level and organization-level analyses
conducted to address issue of nested data
 DCWs from nursing homes, assisted living and home
health agencies included
Study Design and Methods
 Cross-sectional survey; in-person/phone DCW
interviews
 Questionnaires for data on organizational
characteristics and management practices
 Study sites drawn using proportionate random
sampling from all Nursing Homes (NHs), Assisted
Livings (ALs) and Home Health Agencies (HHAs) in
five counties in NE Ohio
 90 sites chosen/49 agreed (41% participation rate)
 27 NHs, 14 ALs, and 8 HHAs
DCW Sample
 Proportionate random sampling of DCWs within
the 49 sites
 Targeted 900, 1058 contacted, 644 participated
(61% participation rate)
 Over time & over budget on sample recruitment
and data collection
 Is is possible to obtain a representative sample of
DCWs?
LTC Stress and Support Model Predicting Direct Care Workers’ Job Satisfaction
A. Background
Characteristics
B. Stressors:
C: Workplace Support:
E: Outcomes:
Direct Care Workers
• Age
• Marital Status
• Race
Direct Care Workers
Personal
• Family & Financial
• Health Changes
Job-Related
• Training
• Pay & Benefits
• Scheduling Changes
• Permanent
Assignment
Direct Care Workers
Positive & Negative
Relationships
• With Residents/Clients
• With Staff
Direct Care Workers
• Job Satisfaction
D. Organizational
Variables:
Characteristics
• Types of LTC Setting
• Profit Status
• % of Minorities Served
• % of Medicaid
Reimbursement
Management Issues
• Turnover of DCWs
• Minimum Pay
Analytic Approach
Multiple Linear Regression Analysis: using
individual-level DCW data to predict job
satisfaction
Hierarchical Linear Modeling: using
organizational-level data to predict average
job satisfaction score in study sites after
controlling for individual-level variables
Perceived Adequacy of Training
 Entry-level
 Job orientation
 Continuing Education
 Recommendations for improvement
Positive and Negative Support
in the Workplace
 Positive interaction with peers and
residents/clients (e.g., feelings of respect,
affection)
 Negative interaction with peers and
residents/clients (e.g., feelings of anger,
frustration)
 Frequency of hearing racist remarks from
residents, families and other staff
Findings: DCW characteristics
 Age (average)
39 years
 Minorities
59%
 Female
95%
 Unmarried
63%
 Work in LTC (average) 8.7 years
Multiple Linear Regression Results
for DCW Job Satisfaction
Adj. R2
.51 (p<.01)
Background characteristics: Non-minority
*Personal Stressors: + Physical health & emotional health
change; lower depression scores
*Job-related Stressors: adequacy of job orientation &
continuing education; fewer scheduling changes; fair
pay & more benefits (health insurance, retirement)
Workplace Support: less negative interaction; fewer racist
remarks
Racist Remarks
Heard make remarks:
To be hurtful:
Clients/Residents
70%
4%
Families
15%
38%
Other staff
21%
65%
Quotes from Workers
 “I want to leave because I cannot take the
racial comments anymore. I am training to go
into medical billing.”
 “There seems to be a ‘white’ standard and a
‘colored’ standard. The white workers are
expected to do more and be more responsible
which makes them feel discriminated against
and angry.”
Results from HLM Analysis of Factors
Affecting DCW Job Satisfaction
Adjusted average DCW job satisfaction scores
were higher for:
 DCWs in Assisted Living and Home Health
Agencies
 Sites reporting less difficulty with DCWs
quitting and being fired
 Sites with a higher rate of starting pay
DCW Reports about Training
NH DCWs
AL DCWs HHA DCWs
Initial training made
me well prepared
55%
59%
71%
49%
47%
63%
74%
77%
79%
53%
51%
70%
Job orientation was
very helpful
Very useful to have
a mentor
Continuing education is
very useful
CEU Topics Most Frequently Covered
 Preventing injuries at work (not as helpful for
NH/ALF DCWs)
 Caring for those with dementia
 Communicating with residents/clients
 Resident/client care skills such as bathing (need more
in ALFs)
 How to deal with difficult coworkers
CEU Topics Needing More Attention
 DCW Teamwork (especially in NHs)
 Organizing tasks so everything gets done (especially
in HHA)
 CPR (especially in NHs)
 Problem solving on the job (especially in ALFs)
 Managing job stress (especially in NHs)
 End-of-life issues/grief (especially in ALFs)
Recommendations for Improving
Entry-Level Training
 Longer/more hours
 More clinical time
 More one-on-one instruction (peer
mentoring)
 Cover teamwork, respect, communication,
dementia care, lifts/transfers, vital signs
Recommendations for Improving
Continuing Education
 More frequent, shorter sessions
 Offer on all shifts/all days of the week
 Interactive training (e.g., role plays)
 Obtain DCW input on content and design
 Ensure coverage to foster attendance
 Cover teamwork, respect, communication, mental
illness, vital signs, and CPR
References
Ejaz, F., Noelker, L.S., Menne, H.L. & Bagaka’s, J. G. (in press)
The impact of stress and support on direct care workers’
job satisfaction, The Gerontologist.
Kanter, R. M. (1993) Men and Women of the Corporation. N.Y.:
Basic Books.
Noelker, L.S., Ejaz, F.K. & Menne, H.L. (in press) Knowledge
as empowerment: Improving nursing assistants’ education
and training, in Empowering Work Teams in Long Term Care:
Why and How to Create Self-directed Teams, Yeatts, D., Noelker,
L.S. & Cready, C.M. (eds.), Health Professions Press.
Today, Tomorrow, Together!
 Working collaboratively to improve the size
and quality of the Direct Care Workforce
 Ensuring quality jobs and quality care for
older and younger disabled citizens