Advancing Nursing Leadership in Long-Term Care
Nurses working in the long-term care (LTC) sector face unique workplace stresses, demands and circumstances. Designing approaches to leadership training and other supportive human-resource strategies that reflect the demands of the LTC setting fosters a positive work life for nurses by providing them with the skills and knowledge necessary to lead the care team and to address resident and family issues.
Through the St. Joseph's Health Centre Guelph demonstration site project, funded by the Nursing Secretariat of Ontario's Ministry of Health and Long-Term Care, the Excelling as a Nurse Leader in Long Term Care training program and the Mentor Team program were developed to address these needs.
Evaluation results show that not only have individual nurses benefitted from taking part in these programs, but also that the positive effects were felt in other parts of the LTC home (as reported by Directors of Care). By creating a generally healthier work environment, it is anticipated that these programs will also have a positive effect on recruitment and retention.
In the autumn of 2007, a coalition of eight not-for-profit long-term care (LTC) homes in Ontario received funding to develop programs and tools that would address barriers to recruitment and retention of registered nurses (RNs) and registered practical nurses (RPNs) in the LTC sector. The coalition was led by St. Joseph's Health Centre Guelph, along with the LTC homes' provincial association, the Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS). HealthForceOntario funded the project.
The partner homes represented a broad cross-section of facilities. Four were urban and four were rural. They ranged in size from 78 beds to 241 and included both municipal and charitable organizations. Geographically, they stretched from Kingston in the east to St. Thomas in the west and south to the Niagara Peninsula. (See Acknowledgements below for the list of partner homes.)
OANHSS represents not-for-profit providers of long-term care, community services and housing for seniors operated by municipalities, charities and not-for-profit corporations. Member organizations operate over 27,000 long-term care beds and over 5,000 seniors housing units across the province.
OANHSS had been hearing from its members for some time about the difficulty of recruiting and retaining nursing staff, resulting in problems in maintaining full staff complements. Chronically working short has obvious implications for quality of care; the implications of staff turnover for quality of care are less obvious.
Continuity of nursing staff has been identified as a central factor in LTC resident satisfaction and the quality of care they perceive (Sharkey 2008). Relationships between staff and residents can last much longer in LTC than in other areas of healthcare – sometimes decades, rather than days or weeks – and these extended relationships form an important part of residents' quality of life and quality of care. Residents like their routines and gain comfort and peace of mind from having people around them who know their routines.
But a number of realities in LTC nursing make the ideals of maintaining a full staff complement and of providing continuity of nursing staff difficult to achieve. Here are a few of them:
- Nursing training at colleges and universities provides nurses with excellent clinical and leadership skills. However, the specific leadership skills LTC nurses need (such as how to work effectively with families and with cognitively impaired individuals, geriatric care, time management and conflict management) are difficult to incorporate into generic leadership programs for nurses. When nurses (and others) do not have these personal leadership skills, tensions can escalate and create an emotionally unhealthy work environment.
- Nurse leaders are working with staff for whose results they are responsible, but over whom they have no disciplinary authority, a situation that is further complicated by often being members of different unions. Knowing how to get co-operation without direct authority depends on having high-level interpersonal skills that nurses may never have been taught.
- Nurses need to interact effectively with residents (the majority of whom have some degree of cognitive impairment) and their families. It is fair to say that the quality of life of residents depends just as much on how well nurses perform their non-clinical leadership roles as it does on how well they employ their clinical skills.
- Outside of normal business hours (that is, nearly three-quarters of the time in the 24/7 world of long-term care), the person in charge of an LTC home is an RN – and may be the only RN in the home on a shift. Although a senior manager is always on call, that RN is responsible for everything from organizing the emergency transfer of a resident to an acute care hospital, to co-ordinating the institutional response to a fire alarm, to dealing with an overflowing toilet. These additional responsibilities only add to the stress of an already high-pressure job.
- When nurses, especially new graduates, join the staff of an LTC home, they naturally have many questions about all aspects of the facility, from their own jobs to the functioning of other departments in relation to their jobs. To help new staff find their feet, LTC homes have orientation programs, and many have a "buddy" system as well. But when that orientation and buddy period ends, the new nurse may feel responsible for knowing "everything" and be reluctant to ask more questions. Long-term staff may also have questions about, for example, procedures in other departments, but not be sure whom to ask. These sorts of situations can impair everything from interpersonal staff relations to resident care and are certainly detrimental to a person's comfort in her or his job.
- There are more nurses seeking full-time positions in LTC homes than there are full-time positions available. On the other hand, the homes have part-time positions going begging. So nurses who need full-time work cobble together a full-time income by taking two (or more) part-time jobs at two (or more) homes. But when they have a chance at a full-time job elsewhere, they are gone – and the homes where they were working are faced yet again with part-time vacancies.
These factors are among the barriers to recruitment and retention of nurses in LTC because they contribute to burnout, stress leaves and high turnover. They also result, at times, in nurses leaving the profession altogether. Accordingly, these particular barriers were chosen as the focus of this project. The project was divided into the following phases: research, design, delivery, implementation, evaluation, modification and dissemination.
In order to determine whether their experiences and anecdotal evidence were borne out by academic research, the steering committee (comprising a representative from each of the nine partners) directed that a literature review be undertaken. This review also pointed in the direction of strategies, programs and tools that would assist in addressing the identified barriers to recruitment and retention. The resulting report on the research and literature review (Gilmer and English 2008) confirmed that the academic research does indeed support the anecdotal evidence.
While this was being done, the project consultants held two sets of focus groups with nurses and their managers from the partners' homes and from a few non-partner homes. The first set was designed to determine what nurses and managers felt the issues were regarding recruitment and retention of nurses in LTC. On these occasions, nurses and managers met separately. For the second set, held six weeks later, nurses and managers were brought together to discuss possible solutions to the issues they had previously identified. Once these two steps were complete, a Researchers' Symposium1 was held, at which nine academic researchers in the field of nursing shared the results of their work with the consultants. It was gratifying that the academics once again corroborated the day-to-day experience of LTC nurses and their managers in all areas.
Based on this combination of research and experience, the steering committee chose the following three initiatives for development and testing:
1. Leadership training
The Excelling as a Nurse Leader in Long Term Care program provides nurses with experiential training in the leadership knowledge and skills they need to be nurse leaders specifically in long-term care settings.
2. Mentor Team
A permanent, facility-wide team of trained mentors is available to answer questions about their departments from all staff, both new and longer-term. Once the program is up and running, the team becomes self-directed.
3. Two Jobs in One
A management–union agreement melds two part-time nursing positions at two homes into one full-time position (with guaranteed hours and benefits).
The rest of this article will deal in depth with only the first two of these programs, as the third does not address nursing leadership directly. (Free resource guides that describe each of the three programs in detail are available on the OANHSS website: www.oanhss.org. Click on Education & Resources, then on OANHSS Publications/Resources, then on Free Resources.)
B. Leadership Training
The overall objective of the Excelling as a Nurse Leader in Long Term Care training program is to enhance and develop nurses' leadership skills in verbal communication, human relations, abstraction, reflection, question-framing and time management. Thus the program helps them develop the insights and skills that enable them to maximize their "use of self" in their encounters with their colleagues. The learning objectives include:
- Understanding how the LTC homes' mission, vision and values guide the role of a nurse leader
- Recognizing the need to respond to different situations with different leadership approaches
- Understanding and demonstrating when and how to use different leadership approaches
- Empowering others by encouraging them to self-discover core issues through effective probing skills
- Using professional and procedural knowledge to guide ethical decision-making
- Enhancing staff relationships through collaborative problem-solving
- Developing effective and assertive interpersonal skills
- Learning how to confront and manage interpersonal conflicts
Methodology and Content
The program has been designed expressly to address the day-to-day challenges LTC nurses face and to reflect the uniqueness of the long-term care setting, which is home for the residents and in which families and others of importance to the residents play an integral role. In addition, nurses in this setting work primarily with unregulated caregivers who make up over 80% of the staff providing direct resident care.
The program provides participants with a supportive environment in which to build on their existing strengths, to experiment with different leadership styles, and to acquire and practise new skills. The principles of adult learning are incorporated into the teaching strategies and approaches. They include presentation of material by the instructors, small-group and large-group discussions and exercises, spontaneous large-group discussions, and practicums to be undertaken by participants between sessions as well as post-program.
The test was conducted in the autumn of 2008. Eighty nurses from 20 homes – 37 RNs (including one Assistant Director of Care and one unit manager) and 43 RPNs – attended three full days of training. Training days were held three weeks apart to give participants time to practise and integrate the material and to complete the practicums assigned at the end of each day. The first two practicums were to be submitted at the subsequent class; the third was to be worked on for two months post-course and reviewed with the nurse's manager. Submission of all three practicums to the instructors was required for the participant to receive a certificate of completion.
Before the course, both participants and their managers completed an online assessment to provide baseline data about the nurses' leadership skills and styles. After the course, participants and managers completed the same assessments again so that change as a result of the course could be measured. (The striking results are presented in Figure 1.) The course was also preceded by a Managers' Education Day so that those to whom the nurses reported would have an understanding of what their staff were being taught and what changes in leadership style were being sought. Managers were also advised on how to support their nurses in using their new skills and how to provide assistance with their practicum work. The overarching themes of team-building, time management and conflict resolution were woven throughout the curriculum, which focused on the following leadership skills: human relations, communication, perception, effective questioning, reflection and abstraction. The program was structured to achieve the learning objectives (Table 1).
|Table 1. Learning objectives of the Excelling as a Nurse Leader in Long Term Care' training program|
Evaluation consisted of four steps and involved both participants and their managers. At the end of each training day, each participant completed an evaluation form that included rankings of the instructors' abilities and of the accomplishment of the learning objectives; the form also offered the opportunity for personal comments. This evaluation was anonymous; however, participants were offered the option of signing the form and indicating which LTC home they worked for. Written surveys of practicums were completed by both participants and managers; there were different questions for each of these two groups.
At the conclusion of the program, day-long focus groups were held. These were attended by 71% of participating nurses and 85% of managers. The two groups met both separately and together to provide their opinions on what they liked about the program, what they would modify and whether the program addressed the issues identified in the research-phase focus groups. Pre-program and post-program online assessments by both participants and managers were designed to measure change in knowledge and skills as a result of the course. While the assessments posed different questions for each of these two groups, each group was asked the same set of questions both pre-program and post-program.
Key Evaluation Findings
Managers' assessments of behavioural changes among participants clearly indicated that real changes in the nurses' leadership skills were evident. While 46.6% of the participants had low scores before the program, only 14.8% had low scores afterwards. Similarly, while only 20.3% of the participants had high scores before the program, 57.4% had high scores afterwards. The average participant score was 62.98% pre-program; this increased to 75.37% post-program.
These results are elaborated in the Figure 1 charts, which show the specific areas in which managers reported that they saw behavioural changes in their staff.
The first pair of charts shows the dramatic drop in the percentage of participants who were scored as "poor" or "fair" before taking the course versus afterwards. The second pair shows the equally dramatic rise in those who were scored as "good" or "excellent." It is significant that these were not self-assessments, but were done by participants' managers.
While the RN group scored better than the RPN group on a question-by-question and overall-assessment basis, the variance in averages and the overall participant success in correct responses suggest that the program was effective in serving the training needs of both groups. Only one of the five RPN low-average scores was more than 8.3% lower than the RN group. Similarly, the RPN group average for the overall correct responses was 72.75%, while the RN group scored 79.99%. In addition, there were no discernable differences in knowledge improvement or implementation success between participants from urban and rural settings.
Participants reported clear outcome benefits – for example, using the skills learned and knowledge acquired, and engaging in self-reflection both during and after various kinds of interactions. They found the new knowledge and skills very appropriate and relevant to their work.
It was clear that managers' understanding of the program and their ongoing support of participants during the program and afterwards were crucial to fostering change in the participants' behaviour and practices at work. It was also evident that the more participants who attended per home, the more positive the response was among participants and the more positive their interactions at work were with their colleagues who did not attend. Overall, participants emerged from the program with a renewed sense of commitment to their changing role as nurse leaders in long-term care.
Feedback from Directors of Care
One of the clearest indications that this program makes a significant difference on the floor is the change that Directors of Care (DOCs) see in both their staff and their own workload. The assistant DOC at a 140-bed home in downtown Toronto said,
Half a dozen of our nurses took the program. I can see that they have more confidence now in working issues through. They're using their new skills, especially the four leadership styles, and so they're meeting each colleague's needs in a way that's appropriate for that person. There's greater peace on the floor because the nurses are able to solve problems as they arise, rather than putting off finding a solution, which only allows things to fester. Now they're thinking things through for themselves on the spot. As a result, I'm not getting as many calls for minor things as I used to, which makes my own job less stressful. So from my perspective, this program is well worth the time and the cost, which are both minimal – especially compared to the benefits.
The newly appointed DOC at a 96-bed facility in a rural community in southern Ontario reported,
We were fortunate to be able to send three RNs and six RPNs to the program. At the time, I was MDS-RAI coordinator here and was one of the RNs who attended. I've only been DOC here for a few months, but even before being promoted to this position, I was able to be more assertive and more effective in communicating. So what I learned in the course has helped me in my new position. I'm also seeing that what our nursing staff are doing now, in terms of communication, is more effective than what they were doing before. There's more credence being given now to what they're saying. The RNs and RPNs are more listened to and respected. As a result, the Personal Support Workers (PSWs) are following directions better because the message, which hasn't changed, is being given more effectively.
These outstanding results, and the enthusiasm of participants and managers alike for the Excelling as a Nurse Leader in Long Term Care program, encouraged OANHSS to enter into a contract with Silver Meridian (the Ontario company that had designed and delivered the training during the test) to deliver the program. During the autumn of 2009, it was presented at three sites in southern Ontario: Cambridge, Kingston and Toronto. In the spring of 2010, it is being presented at four sites: Cornwall, Ottawa, Sarnia (Petrolia) and London (Dutton). It is anticipated that the program will continue to be offered twice a year (spring and autumn) in three or four centres each time.
In addition, the project received supplementary funding for the development of a distance-learning version of the program. This online course became available through Silver Meridian in October 2009.
C. Mentor Team
The Mentor Team program is based on a concept developed and implemented at Gilmore Lodge, a Regional Municipality of Niagara LTC home in Fort Erie, Ontario, with the involvement of regional staff. It offers unique features that extend its reach far beyond that of the usual orientation and short-term buddy programs to encompass the whole facility. Like many orientation-and-buddy programs, each new employee is paired with a trusted, knowledgeable co-worker who has been specially trained for the task. In addition, however, the Mentor Team offers all staff ongoing informal access to a well-informed group of colleagues. Thus information flows better within the organization, the work environment becomes more collegial and the commitment of all employees to the organization is strengthened.
In this model, the Mentor Team is facility-wide, interdepartmental, multidisciplinary and permanent. Members volunteer their participation because they are committed to promoting a positive and healthy work environment. Team membership per department is in proportion to the size of each department. Thus larger cohorts, such as nursing and personal support workers (PSWs) are likely to have more representatives on the Mentor Team, whereas smaller departments may have only one or two representatives. Staff selected for the team are trained to provide help to anyone in the facility who comes to them with a question. Once the program is up and running, the mentors evolve into a self-directed team working with the guidance of management.
The uniqueness of the Mentor Team program was recognized at Health Innovations Expo, part of the OHA's HealthAchieve Conference in November 2009. One of the teams created through the test of the Mentor Team program in the fall of 2008 won the People's Choice Award, which included a substantial cash prize. Unlike the other Health Care 2009 Innovation Awards, which were chosen from within each category, the People's Choice Award is selected by conference attendees from all finalists in all categories.
Implementing the Mentor Team Program
The project consultants provided managers with a checklist (based on the Gilmore Lodge experience) to use in introducing the program. It included developing a communications plan, determining the criteria for and process of selecting mentors, educating supporting managers, connecting the program to staff orientation, selecting the mentors, providing mentor training, setting up regular team meetings and ensuring official recognition of mentors' contributions.
Once the mentors were selected, an external trainer provided them with half a day of training, which incorporated the principles of adult learning described above. Content included the goals, objectives and underlying assumptions of the program, the criteria for selecting mentors (both prescriptive and descriptive) and the role of mentors, staff and managers in the context of the program. Following these discussions, mentors practised role-playing as mentors and staff members in order to give them a taste of the mentor experience. Following a discussion of conflict resolution in a mentor–staff situation, participants undertook additional role-plays to give them practice in potentially difficult situations. The methods for evaluating the program were then described. The training concluded with a discussion of future plans for the team, including regular meetings and quarterly training related to being an effective mentor.
During the test, written surveys were completed by mentors and staff, with different questions for each group. After the test, written surveys were completed by mentors, staff and supporting managers (again, with different questions for each group). After reviewing the surveys, the consultants met with each Mentor Team and subsequently interviewed the supporting managers.
Key Evaluation Findings
Both mentors and staff rated the Mentor Team program as "excellent" or "good." Both groups felt that the impact it had made on their job satisfaction and their ability to cope with work was "very positive" or "somewhat positive." The training was very well received. However, over half of the mentors felt that they needed more training in dealing with "challenging" situations, that is, communication and conflict. (This aspect of the training has since been strengthened.) It was noted that it is important to have one person responsible for spearheading the organization of the program and that each home must modify the design and implementation of the program to suit its own culture and circumstances. All three LTC homes at which the Mentor Team program was tested chose to continue the program and build on the foundation laid during the test.
When people join a new organization, they come with a positive and committed attitude. Their experiences in the first three to six months of employment are crucial. If these experiences are generally positive, they will demonstrate superior performance in their jobs and develop a long-term commitment to the facility. On the other hand, if an employer does no more than introduce new employees to their co-workers and provide them with a short orientation period, the risk is high that the employee will feel unsupported, lost and anxious. These are all conditions that lead to loss of commitment and eventually to attrition. On the other side of the coin, people who have been with an organization for a few years – or, indeed, many years – can get used to relying on informal communication channels that may not always have the most up-to-date or reliable information. Because of shift work, some staff may go for long periods without being at work at the same time as managers, who are most often the ones designated to respond to staff inquiries. Thus, simple questions can fester, leading to frustration and misinformation. All staff benefit from having a trusted, trained team of colleagues to turn to when they have questions.
The Mentor Team ensures that new employees learn how the particular LTC home functions according to its policies and procedures, as well as the highest intentions of its mission, vision and values. It enables new employees to feel at home and develop good relationships in their new jobs and work environment more quickly. (For example, all members of the Mentor Team know who the newest employees are and can introduce them to others.) As a result, the stress of starting a new job is reduced and everyone's comfort level is enhanced. In addition, a well-informed and well-trained Mentor Team provides a valuable, reliable resource for all staff members, regardless of their length of service. Thus, through its interdisciplinary, interprofessional nature and structure, the Mentor Team helps to knit all the departments of the home into a cohesive whole.
Connection to Leadership
In long-term care, nurses make up the second-largest cohort in the home; their numbers are exceeded only by PSWs. The Mentor Team program develops leadership among the nurses by providing those who are showing leadership informally with a more formal, recognized opportunity to do so. As the administrator of a 241-bed home in a medium-sized city noted, "Inviting certain staff members to join the Mentor Team gave us a way to foster the leadership skills that we were already seeing in these individuals." In addition, the leadership abilities of all mentors are encouraged and strengthened as the team becomes more self-directed and undertakes more training.
The Mentor Team program is available to anyone with access to the Internet (via the OANHSS website, as noted above). The free resource guide is designed to provide managers of LTC homes and other healthcare facilities with all the information and tools they need to create an effective, enthusiastic Mentor Team. Consultants are also available to assist with the process, for those who so wish.
The impacts of both the Excelling as a Nurse Leader in Long Term Care training program and the Mentor Team program on the recruitment and retention of nurses at participating LTC homes are not yet known. It takes time for any new program to have a measurable impact on the degree to which a particular work environment is a healthy one that encourages current staff to stay and new staff to join. As with any organization, turnover in LTC homes depends on a broad range of factors, many of them related either to individual circumstances or to fluctuations in capacity within the job market. Therefore it will be another year or two before the participating LTC homes can review the relevant statistics and evaluate what impact these two programs have had on their success in recruitment and retention.
That said, these two programs, as developed and refined through this project, have already been shown to be effective – over the short term, at least – in improving the work environment of nurses at the participating homes. While further evaluation is necessary to determine their long-range effectiveness, it is anticipated that the improvements already noted will lead to increased commitment on the part of staff, resulting in measurable improvements in recruitment and retention.
About the Author
Jennifer O'Brien, Vice President, Human Resources and Support Services, St. Joseph's Health Centre Guelph
Margaret Ringland, Director of Member Relations and Professional Services, Ontario Association of Non-Profit Homes and Services for Seniors
Susan Wilson, Principal, Starmaker Project Management Group
Correspondence may be directed to: Jennifer O'Brien, E-mail: firstname.lastname@example.org, Tel: 519-824-6000 x. 4389, Fax: 519-763-0264.
Project Partners/Steering Committee Members
Glencia Brookes-Dos Santos, Director of Nursing, Maple Health Centre, York Region
John Buma, CEO, Albright Manor, Beamsville
Maria Elias, CEO Belmont House, Toronto
Shelagh Nowlan, Administrator, Providence Manor, Kingston
Jennifer O'Brien, Vice President, Human Resources and Support Services, St. Joseph's Health Centre, Guelph
Susan Rae, Administrator, Knollcrest Lodge, Milverton
Margaret Ringland, Director, Member Relations and Professional Services, OANHSS
Rhonda Roberts, Director of Senior Services, Terrace Lodge, Aylmer
Victoria Stewart, Director of Resident Care, Nithview Home, New Hamburg
Susan Q. Wilson, Starmaker Project Management Group
Angelo Pesce, Principal Consultant, Pesce & Associates
Darlene Legree, Trainer, Consultant and Co-owner, Silver Meridian
Ron Martyn, Trainer, Consultant and Co-owner, Silver Meridian
Milton Orris, Principal Consultant, Orris Consultants
Additional Homes Participating in Leadership Training
Bobier Villa, Dutton
Deer Park Villa, Grimsby
Elgin Manor, St. Thomas
Gilmore Lodge, Fort Erie
Greenwood Court, Stratford
Heidehof, St. Catharines
Linhaven, St. Catharines
Meadows of Dorchester, Niagara Falls
Newmarket Health Centre, York Region
St. Joseph's Villa, Dundas
Spruce Lodge, Stratford
Upper Canada Lodge, Niagara-on-the-Lake
Woodlands of Sunset, Welland
Initial Development of Mentor Team Program
Bev Goodman, Administrator, Gilmore Lodge, Fort Erie
Jane Beamer, Resource Coordinator, Niagara Region
Gilmer, C., and K. English. 2008. Research and Literature Review to Support the St. Joseph's Health Centre Nursing HHR Demonstration Site Project. Woodbridge, ON: Ontario Association of Non-profit Homes and Services for Seniors.
Sharkey, S. 2008. People Caring For People. Impacting the Quality of Life and Care of Residents of Long-Term Care Homes. A Report of the Independent Review of Staffing and Care Standards for Long-Term Care Homes in Ontario. Toronto, ON: Ministry of Health and Long-Term Care.
1 The researchers who attended the Researchers' Symposium in May 2008 were:
Jennifer Blythe, Nursing Research, McMaster (and U of T)
Catherine Brookman, Ontario Community Support Assn.
Raisa Deber, Co-Director, CRNCC (U of T)
Kim English, Trent/Fleming School of Nursing
Cyndi Gilmer, Trent/Fleming School of Nursing
Mabel Hunsberger, Nursing Research, McMaster (and U of T)
Nadine Janes, West Park
Linda O'Brien-Pallas, Canadian Health Services Research Foundation
Karen Ray, Researcher, Saint Elizabeth Health Care.
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