Nursing homes that empower their frontline workers to make decisions regarding patient care achieve better performance from certified nurse aides (CNAs), improved resident care, and other positive effects, say the authors of a Commonwealth Fund–supported study.
In one of the few studies to examine the effects of giving long-term care employees decision-making autonomy, researchers found that work teams imbued with such authority improved worker performance and job satisfaction at skilled nursing facilities. "This suggests that those nursing home managers looking to improve resident care should consider implementing empowered work teams," say University of North Texas researchers Dale E. Yeatts, Ph.D., and Cynthia M. Cready, Ph.D., the authors of "Consequences of Empowered CNA Teams in Nursing Home Settings: A Longitudinal Assessment" (The Gerontologist, June 2007).
Teams Empower Workers, Enhance Performance
Empowered work teams that give employees more autonomy to make decisions about their work have had positive effects in other industries, like manufacturing. In the long-term care sector, CNAs have the most direct knowledge about the preferences of nursing home residents and therefore are in the best position to make decisions directly related to day-to-day care. Yeatts and Cready compared two sets of nursing homes—five that had implemented empowered work teams and five that had not. The researchers performed a qualitative analysis that included observations of more than 270 team meetings, as well as a quantitative analysis that drew from base-line and follow-up surveys.
CNA empowerment. The qualitative and quantitative findings suggest that CNA teams boosted feelings of empowerment among the front-line nursing home workers. Workers gained new decision-making responsibilities and were allowed to work on their own, supervised by nurse management. As team meetings allowed CNAs to learn more about their responsibilities and the health conditions of residents, they grew more competent, compared with the control group. The authors noted, however, that CNAs could have been given additional opportunities to make decisions but were impeded by management's perception that it was easier or faster to make decisions without consulting the teams or by nurse management simply forgetting to include the teams in the decision-making process.
CNA performance. The team approach to resident care allowed CNAs to become more aware of residents' health conditions, reducing the possibility that a problem would go unattended for extended periods and increasing the likelihood of proper care. The use of teams also allowed CNAs to get more information on the special needs of residents, opportunities to question poor performance of team members, and more time to clear up misunderstandings.
Empowered work teams may have also had some negative effects on resident care, say the authors, as CNAs were pulled away from providing direct care to attend 30-minute weekly meetings.
CNA job attitudes. The qualitative data supported the proposition that empowered work teams have a positive effect on job attitudes, including satisfaction, commitment, and self-esteem. The researchers observed that the teams allowed individual CNAs to redistribute their work to take on the tasks they most preferred or to serve specific residents.
CNA absenteeism and turnover. Observational data appeared to support the premise that the team approach reduces absenteeism among CNAs, partly because of discussions during team meetings about absenteeism and the problems it produces. The quantitative data found no impact on absenteeism, but did suggest that CNAs were less likely to quit or be fired in the experimental group. Only 37 percent of the CNAs in the experimental group were not working in the same homes after the follow-up survey, compared with 51 percent at the comparison homes. The researchers cautioned, however, that the data are not sufficient to make firm conclusions regarding turnover.
"There is an urgent need to improve the care provided to nursing home residents," the authors say. Empowering direct-care workers can be a key element in improvement efforts that focus on residents' quality of life and satisfaction, as well as their health.
The authors contend, however, that nursing home operators should not implement empowered work teams unless they are willing to provide appropriate organizational and management support. In addition, all nursing home personnel—including administrative and nursing staff—should receive an orientation about the purpose and advantages of empowered work teams. Finally, the authors conclude, "it is important that the CNAs be given the opportunity to work together in a team meeting, to sometimes make mistakes, and to routinely contribute to the management decisions made about their work."
CNA and Nurse Evaluations of Empowered Work Teams
|Statements provided to CNAs and nurses||Disagree or Strongly Disagree (%)||Neutral (%)||Agree or Strongly Agree (%)|
|In team meetings:|
|CNAs learn from each other.||22||20||58|
|CNAs learn what residents like and don't like.||19||22||59|
|My team leader makes all the decisions for my team.||59||28||14|
|CNA team members:|
|provide new ideas that are helpful||11||32||57|
|provide solutions to problems||11||42||47|
|Allowing CNAs to make decisions about their work improves resident care.||5||17||78|
|CNA = certified nurse aide
Source: Adapted from D. E. Yeatts and C. M. Cready, "Consequences of Empowered CNA Teams in Nursing Home Settings: A Longitudinal Assessment," The Gerontologist, June 2007 47(3):323–39.