Current Topics in Care
Acceptability of an e-Learning Program to Help Nursing Assistants Manage Relationship Conflict in Nursing Homes
American Journal of Alzheimer’s Disease & Other Dementias® 2015, Vol. 30(1) 55-60 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1533317514551482 aja.sagepub.com
Elsa Marziali, PhD1, Corey Scott Mackenzie, PhD2, and Illia Tchernikov, MA1
Abstract Background: Management of nursing assistants’ (NAs) emotional stress from relationship conflicts with residents, families, and coworkers is rarely the focus of educational programs. Our objective was to gather feedback from NAs and their nursing supervisors (NSs) about the utility of our e-learning program for managing relationship stress. Methods: A total of 147 NAs and their NSs from 17 long-term care homes viewed the educational modules (DVD slides with voice-over), either individually or in small groups, and provided feedback using conference call focus groups. Results: Qualitative analysis of NA feedback showed that workplace relationship conflict stress was associated with workload and the absence of a forum for discussing relationship conflicts that was not acknowledged by NSs. Conclusion: This accessible e-learning program provides NAs with strategies for managing stressful emotions arising from workplace relationship conflict situations and underscores the importance of supervisory support and team collaboration in coping with emotionally evoked workplace stress. Keywords e-learning, intervention, stress management, long-term care, nursing
Nursing assistants (NAs) provide most of the hands-on direct care to residents living in nursing homes. Daily they interact with residents and provide assistance with activities of daily living. They also frequently interact with families, helping them to cope with the emotional impact of institutionalizing a family member. In addition, they interact with other NAs and their nurse supervisors (NSs) to ensure optimal care of residents. Although most NAs working in nursing homes are trained to provide quality physical care to residents, including the acquisition of skills for communicating with residents diagnosed with dementia, there are few if any training programs that focus on the emotionally stressful components of managing workplace relationship conflicts. Yet, NAs are frequently expected to manage challenging emotional reactions in relationships with residents, with their family members, with coworkers, and with nurse supervisors. In consequence, the physical and mental health of the NAs may suffer, resulting in burnout, an incremental need for sick leave, job dissatisfaction, and attrition.1-3 Under these circumstances, the care of residents can be compromised, often accompanied by escalating concerns and complaints from families and criticism from coworkers and supervisors. Considering the need for supportive programs to prevent negative outcomes for NAs and residents in their care and considering the lack of readily accessible in-service training programs that focus on this important issue, e-learning educational initiatives hold promise for supporting
NAs to advance their knowledge and skills for managing emotionally stressful events that occur in the workplace. In the past decade, study findings show that NA stress experienced in the context of managing workplace relationships with residents, families, coworkers, and supervisors is predictive of quality of resident care, job satisfaction, job performance, and attrition. One study found that NA burnout and job dissatisfaction were related to conflict with family members, often due to differences in care expectations. For example, conflict-related stress increases when NAs feel that, due to large workloads, they do not have enough time to provide optimal care, which includes social stimulation.1 A study of workplace predictors of NA stress showed that experienced stress was more related to work environment psychosocial factors (organizational culture and leadership) rather than patient-related factors such as dementia severity, aggression, and agitation.3 A number of studies have shown that NA intrinsic job factors, such as assuming responsibility, being
1 2
Rotman Research Institute, Baycrest, Toronto, Canada Department of Psychology, University of Manitoba, Winnipeg, Canada
Corresponding Author: Corey Scott Mackenzie, PhD, Department of Psychology, University of Manitoba, 190 Dysart Rd, Winnipeg, Manitoba, Canada R3N 3P2. Email: [email protected]
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
American Journal of Alzheimer’s Disease & Other Dementias® 30(1)
56 self-directive, developing new skills, and obtaining job accomplishment feedback, are associated with job satisfaction and job continuance. For example, Decker and colleagues2 found that NAs’ positive assessment of their supervisors’ behavior was associated with intrinsic job satisfaction. Also, NAs participation in care decisions made in teams reinforces intrinsic satisfaction through mutual respect, recognition of competence, shared responsibility, and open communication with coworkers and supervisors. In a comparative case study, nursing leadership that facilitated open communication and teamwork achieved organizational improvement while nursing leadership that disregarded open communication and teamwork did not.4 Some NA training programs have addressed the challenges faced by NAs in their caring work and have included courses that stress the importance of developing communication and interpersonal skills.5-7 Specifically, NA training programs have focused on enhancing communication with patients in more advanced stages of dementia. However, to our knowledge, none provide a unique focus on NAs’ acknowledgment, understanding, and processing of highly stressful emotions (anger, fear, pain, and hopelessness) evoked in conflict situations with families, coworkers, and supervisors. In summary, we argue that NAs, who are not helped to acknowledge and manage painful/disruptive emotions associated with conflicted interpersonal transactions not only with residents but also with families, coworkers, and supervisors, are at risk of deterioration in their mental and physical health resulting in a decline in optimal caring practices and an increased risk of burnout, sick leave, and attrition. The purpose of this study was to explore NA’s responses to our e-learning in-service program to determine whether we had targeted work issues important for supporting NA’s care practices in long-term care facilities. The e-learning program was based on a training program (Nursing Self-Efficacy Program [NSEP]) developed and evaluated by Mackenzie and Peragine.8 The NSEP was manual guided, and the program was delivered face-to-face in a long-term care facility. Our e-learning program was adapted from NSEP and expanded to include several more components that focus on NAs’ selfcare and on the role of NSs in supporting NA’s care practices.
Methods One hundred and forty-seven NAs and their nursing supervisors (NSs) from 17 nursing homes (half rural and half urban) located across 10 Canadian provinces participated in this study. The aim was to involve approximately 10 NAs and 1 NS from each participating nursing home. A nurse educator functioned as the local institution project coordinator. Local project coordinators received and distributed the project materials (e-learning DVDs, procedural steps for engaging in the e-learning program, and consent forms) to participants. All participants signed consent forms ensuring anonymity of the information that they provided to the researchers. Because we were interested in the potential lasting impact of the program rather than its immediate impact, at approximately
6 weeks following completion of the e-learning program, NAs at each participating institution provided feedback in a group conference call format facilitated by a researcher. The NSs at each institution provided additional feedback in a separate telephone interview with a research assistant. The conference calls and telephone interviews were audio recorded and transcribed for subsequent qualitative analysis. We used qualitative methods9,10 to analyze salient themes from both the NA and NS recorded feedback sessions. We developed codes, recorded initial themes, and carefully documented field notes for identification of salient themes within and across all NA and NS feedback sessions. Two researchers independently engaged in this process using the transcriptions of each feedback session to ensure accuracy and concurrence of extracted themes and dialogue. The aim was to extract consistent feedback themes across all participating NAs and NSs, regardless of their nursing home location. Research assistants who conducted the qualitative analysis were blind to participant identity, nursing home name, and urban versus rural location.
e-Learning Program Unique to our program was its central focus on helping NAs understand and reflect on emotions (both their own and the relationship partner—resident, family member, coworker, and supervisor). In particular, the educational content ‘‘normalized’’ the experiencing of perceived negative emotions (eg, anger, pain, fear, helplessness, and hopelessness). Of importance was acknowledgment of experienced emotions and understanding how they affect management of workplace relationship conflicts. We developed the program within an e-learning framework in which e-learning refers to electronically mediated communication for the purpose of constructing and confirming knowledge.11 To this end, the educational content was presented in Power Point formatted on a DVD with voice-over. Voice-over was used because many NAs working in Canadian long-term care institutions are limited in their ability to read English if it is a second language. The NAs could watch the DVD on a TV with a DVD player or a computer, one module at time (15 minutes), either individually or in small groups; the idea was to facilitate their involvement in the e-learning program by not requiring absence from their service units for any extended period of time. The NA educational content consisted of 5 modules: (1) managing relationship conflicts with residents, (2) managing relationship conflicts with families, (3) managing relationship conflicts with coworkers, (4) NA self-care and management of lifestyle behaviors (diet, exercise, and social networking), and (5) viewing and discussion of animated representations of 3 role play conflict situations between an NA and a resident, an NA and a family member, and an NA and a coworker. The animations were viewed by the NAs in small groups following completion of the first 4 modules. The purpose was to stimulate NAs’ discussion of similar conflict situations in their work environments.
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
Marziali et al
57
At each institution, the participating NAs’ NS was asked to view the NA educational content modules as well as content formatted on a separate DVD that focused on supervisory strategies for supporting NAs’ management of emotional stress associated with working in long-term care environments. The local project coordinator at each participating institution arranged for viewing of DVDs at a time and location that was least disruptive of NA/NS work obligations.
Results Demographics One hundred and forty-seven NAs and their institutional NSs (N ¼ 17) participated. Ninety-two percent of the NAs and all NSs were women. Close to half of the participants had less than 5-year long-term care work experience, with the remainder having over 5 years experience. Almost 90% of the NAs had professional training. Most institutions provided in-service training programs—23% provided 1 training program per year and 67% had more than 1 training opportunity each year. The exact content of the in-service programs varied but by far the most frequently offered were in-service training programs that focused on enhancing communication with patients in more advanced stages of dementia. However, none of the institutions provided in-service programs with a unique focus on NAs’ acknowledgment, understanding, and processing of highly stressful emotions evoked in conflict situations with residents, families, coworkers, and supervisors.
Analysis of Feedback Sessions We summarize key feedback perspectives of NAs and NSs with regard to the content of the e-learning program, the format, and the method of presentation. Most important, however, was whether participants learned anything that was useful for their daily management of workplace emotional stress and its impact on resident care practices.
Nursing Assistant Feedback Themes Most of the NAs found the content of the e-learning program informative, useful, and reassuring as it reflected their actual work challenges with residents, families, and coworkers. The NAs told us that ‘‘it’s informative, very interesting, it makes you think about different aspects about handling clients who are more aggressive’’; ‘‘it was a good refresher to have because it does help you deal with residents’’; ‘‘it’s nice to see that information on self-care is included because it’s something that we don’t necessarily think about over getting irate with people or increasing conflict because we are tired or because we are distracted or because things are going on at home.’’ In terms of novel care strategies, the NAs found identification of specific strategies for managing conflict situations very useful; procedural strategies provided a structure for understanding a conflict situation, reflecting on personal feelings, reflecting on others’ feelings, and determining what action to take.
Similarly, they appreciated suggestions on maintaining a charting system for recording management strategies useful for addressing challenging behaviors with specific residents. Some NAs thought that the information provided was not new and did not always reflect what happens in their actual work situations. For example, they indicated that conflict situations, whether with residents, families, or coworkers, are far more complicated than portrayed in the educational content modules. One NA stated, ‘‘Just taking that learning module you are not going to be prepared. You’re going to think ‘I can do this’ but you are going to get into situations where you are going to be over your head very quickly.’’ Some NAs stated that problem resolution varies and is dependent on the policies and procedures endorsed by the nursing home. For example, some homes required nurse supervisors to manage conflict situation with families, while others expected NAs to manage family issues. Nursing assistants reported the least stress when managing conflict with residents, a moderate amount of stress when responding to family member criticisms of staff, and the most stress when managing coworker conflict situations, including relationships with NSs. Comments with regard to family and coworker conflicts included ‘‘Dealing with family members that are unrealistic in their expectations of their loved ones and our care is an issue’’; ‘‘Sometimes when families come in and ask questions about their loved one we try not to give answers as nursing assistants because it should be directed to the nurse. I think they (families) think that we don’t know the information’’; ‘‘We feel that a lot of our coworkers are not happy. And sometimes I guess some people have brought it up to management and they were told, ‘if you don’t like it leave’’’; ‘‘I think there is so much coworker conflict because we’re so overworked’’; ‘‘It is very common that staff members don’t get along’’; and ‘‘Arguments happen a lot—I do think there’s a lot of miscommunication.’’ Nursing supervisor support for NAs’ management of stress in conflict situations was readily available in many institutions but appeared lacking in others. For example, one NA noted that ‘‘for some reason in this facility there is not much conflict as in other facilities; it’s been engrained that it is teamwork and it seems to work out that way with our relationships.’’ In contrast, an NA from a different institution stated, ‘‘dealing with conflict with other staff hasn’t been dealt with at our institution. It’s just ignored and you’re expected to feel ‘happy go lucky’ until it happens again and nothing gets dealt with.’’ The following comments from NAs at other institutions reflect a similar theme: ‘‘I’m not interested in socializing with people here because they are bullies; the problem is that they have been here so long and the style of management is so poor—so if a staff member hollers at you, that becomes the pattern.’’ ‘‘We have a lot of bullying; staff with more than 20 years experience try to intimidate a junior person to do their work for them.’’ The most prevalent teamwork theme extracted from the NAs’ feedback comments showed differences in how NAs are perceived in the formal caregiver heiarchy. In those institutions with well-functioning teams, NAs viewed their participation in
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
American Journal of Alzheimer’s Disease & Other Dementias® 30(1)
58 determining resident care management positively; open communication and mutual respect among team members are valued, and as a result conflict situations with residents, families, and coworkers are readily resolved. One NA noted that ‘‘we have a lot of say in care planning for patients, that’s good—we do have meetings before each shift and we can make suggestions whenver we want.’’ Another NA told us that ‘‘we have a good group here, a lot of us here have worked together for years, and we can all voice our opinions and not feel pressure from someone else.’’ Other NAs spoke about the importance of leadership: ‘‘In our institution we have very good structure, we have good leadership’’; ‘‘I feel comfortable going up to my supervisor and expressing my concerns.’’ In contrast, in institutions without a team management structure or had poorly functioning teams, NAs experienced more stress and received little support for managing work-related stress as indicated in the following comments: ‘‘We really don’t have much say in what goes on here, usually we’re just told what to do and when to do it’’; ‘‘You’re the lowest man on the totem pole, but yet you’re the frontline worker, you are what makes this facility run’’; ‘‘Our feedback about resident care is generally ignored’’; ‘‘I think we have unit meetings . . . I think they are supposed to be once a month—but most of the time they get cancelled’’; and ‘‘The amount of input you have depends on the nurse—some nurses respect you—and some of them don’t listen to you.’’ Although, institutions were not asked whether interdisicplinary teams were active in monitoring resident care, the analysis of NA and NS feedback showed that not all institutions used a team approach for making care decisions related to residents and their families. Similarly, teams were not viewed as essential for dealing with conflict situations in the workplace whether with residents, families, or coworkers.
Discussion of Animated Educational Content
Nursing Supervisor Feedback Themes
Group Format for Discussion of Animations
In general, the NSs found the NA and NS educational content as not providing anything new about care practices at their respective institutions. Comments included ‘‘there wasn’t anything that I didn’t know before but some of it reaffirmed with me’’; ‘‘I thought the supervisor manager educational content was actually pretty decent.’’ Most did not like the formatting of the DVD Powerpoint slides, nor the voice-over presentation; ‘‘it was a bit slow’’; ‘‘I don’t like having someone read to me’’; ‘‘I think it was too simple.’’ Nursing supervisors’ perceptions of NAs’ role functions in their institutions varied. In contrast to the NAs’ perceptions about not being included in making resident care decisions, most of the NSs believed that they encouraged an environment of open communication; ‘‘Most of the time I think they feel involved in care planning and having input in resident care’’; ‘‘Everybody is free to come up and talk to us; that doesn’t mean that it necessarily is going to happen but they’re all free to make suggestions’’; ‘‘For sure our staff feels involved in care planning.’’ Although we conducted separate analysis of the rural versus urban feedback information provided by the NAs and NSs, we found no differences in the themes extracted from transcripts of the feedback sessions.
The NAs veiwed the animations in small groups and following the viewing of each animation of a conflict situation they discussed its relevance to their care practice situations. The feedback with regard to the group format for sharing reflections on the animated conflict situtations was overall very positive. Some reflected that they rarely had the opportunity to discuss with coworkers their thoughts about care practices. Their feedback comments included ‘‘I really think that the discussion group was beneficial—you learn a lot from discussion’’; ‘‘I found the discussion group more valuable than just watching the video because from there we discussed other scenarios that we’ve been through and we came up with ways to better communicate as a group to deal with those situations’’; ‘‘The group discussion worked out really well. Some people who have failed to bring forward issues even to supervisors seemed more open to bringing it up there because they were part of this critiquing and seeing it in action.’’ ‘‘I prefer watching the animations as a group’’; ‘‘I think something like that is probably better being done in a group because you have a chance to get feedback from everyone and perhaps get a different viewpoint you might not have considered yourself.’’
The NAs’ responses to the animated conflict situations were mixed; some did not like the animated figures and would have preferred actors. Comments included ‘‘The animations were terrible’’; I would have preferred real actors—then you could actually show real life situations.’’ In contrast, other NAs commented as follows: ‘‘I think the animations were the best to see, having seen so many instructional videos that have real people that are lousy actors. Its much easier to follow, there is very little distraction’’; ‘‘I’d rather it be animated—you got your point across this way and we were more focused on what was actually happening in the video.’’ Despite these different viewpoints with regard to the formating of the animations, most of the NAs thought that the relationship conflict situations represented in the animations did reflect what happens in long-term care institutions. Feedback included comments such as ‘‘We like the different scenarios. I thought it was right on. I really think that whoever did this study really must have talked to people who work in this environment’’; ‘‘There are definitely some good ideas that were used in the animations that a lot of people we work with could use.’’ In the feedback provided for each animated scenario (NA and resident, NA and family member, and NA and coworker), the majority of NAs did not find the solutions portrayed as realistic and applicable to their care practices. Their comments included ‘‘The problem was solved too quickly’’; ‘‘The scenarios were appropriate but how to solve the problem wasn’t good’’; ‘‘There is no way that the solutions presented in the animations would ever happen in real life—the scenarios are very pertinent, but the way that the solution was portrayed was not very realistic.’’
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
Marziali et al
59
Discussion Analysis of the participant responses to the e-learning program showed that the content was useful for addressing relationship conflict situations in the workplace. Some specific conflict resolution strategies were identified as especially helpful. While the educational content illustrated in the animations focused on typical relationship conflict issues in the workplace, most NAs did not like the formatting (animations). More successful as a learning experience was the NAs’ participation in group discussions of the animations and how, in their institution, they would handle the conflict issues portrayed in the scenarios. In summary, the NAs reported that higher levels of emotional stress were associated with (1) managing large workloads that prevented spending quality time with residents; (2) managing the stress associated with conflicts in relationships with coworkers and/or supervisors; (3) the lack of structures and processes (eg, staff care teams) for sharing and resolving workplace conflict situation; and (4) challenges communicating effectively with residents’ families. The NAs’ feedback resonated with the findings of previous studies showing that NAs whose work is valued, who are encouraged to share ideas about resident care, and who function in an institutional culture that supports open, mutually respectful communication, experience high job satisfaction and contribute to effective care practices.4 Institutions with healthier institutional cultures have implemented interdisciplinary teams in which NAs play important roles in discussing problems and conflicts in the workplace whether with residents, their families, or among coworkers. For institutions lacking an interdisciplinary team model of communication, its introduction in nursing homes is always challenging. Although studies show the importance of interdisciplinary teams for the provision and maintenance of quality health care to residents in long-term care facilities, in 1 study only 25% of the nursing homes surveyed had teams; yet the majority of nursing home managers reported teamwork as very important to their facilities’ operations.12 Other studies of nursing homes showed that teamwork among direct-care workers was viewed as essential for changing institutional practices; however, teamwork was the least commonly implemented component of cultural change despite the fact that facilities with interdisciplinary teams have consistently reported positive staff attitudes toward coworkers and NA satisfaction with participation in care decisions.13,14 Where teams do exist, their effective functioning varies possibly due to the lack of a culture that promotes open communication and the possible failure in valuing NAs’ contributions to care decisions.15 Clearly, the extent to which health care professionals work well together determines the quality of care provided in nursing homes. Well-functioning staff teams facilitate open communication and positive interaction and are based on mutual respect and valuing of input from all team members. Teams can help resolve interpersonal conflict in the workplace whether between coworkers, residents, and/or their families. Yet most health care professionals do not receive training in
conflict management in the workplace. Nor are they trained to function effectively in interdisciplinary teams. Yet, teams could provide the venue for interdisciplinary management of interpersonal conflict in the workplace resulting in optimal care of nursing home residents. Our e-learning program may provide an opportunity for nursing homes and their staff to learn important conflict management skills and also to build teamwork in the process.
Conclusions Considering the need for educational programs that would help prevent negative outcomes for NAs and their care recipients and considering the lack of such initiatives in general and particularly in remote areas, e-learning programs could provide cost-effective training for NAs who might not otherwise have access to in-service-training opportunities. Targeting knowledge transfer to NAs in a digital, easily accessible format represents the ideal in-service training opportunity; learning modules can be reviewed in sections, at convenient times in terms of work schedule, and require minimal absence from unit of service. Also, an e-learning program can be provided as a ‘‘refresher course’’ at regular intervals, thus reinforcing knowledge gained and its applicability in unique resident care situations. Our results suggest that institutional policies with regard to (1) monitoring staff to resident ratios (workload stress) and (2) establishing management hierarchies that acknowledge NAs as full team care members (coworker/supervisor communication) need to be highlighted. Similarly, NA role functions in relation to residents, their families, and coworkers need to be clear and operable. Following analysis of the project data, we have carefully considered modifications to our e-learning program to enhance its applicability and effectiveness. Based on our results, we revised the NA e-learning program as follows: (1) we withdrew the animations representing interpersonal conflict situations; instead at the end of each content module we inserted relevant brief case studies (resident, families, and coworkers) with instructions to discuss management of similar conflict situations in their institutions and (2) we made significant changes in the NS intervention content with the focus now on the establishment and maintenance of interdisciplinary teams to optimize communication and resolution of conflict situations between NAs and residents, families, and coworkers. Future research is needed to assess whether this revised program is effective in enhancing NAs’ management of stressful conflict situations and in improving care practices. Authors’ Note Long-term care facilities that view our nursing assistant (NA) e-learning program as potentially beneficial to their organizations can order the program from the National Institute for the Care of the Elderly (www.nicenet.ca). This study was supported by the National Institute for the Care of the Elderly (NICE).
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
American Journal of Alzheimer’s Disease & Other Dementias® 30(1)
60 Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The research outlined in this paper was funded by an internal grant from the National Initiative for the Care of the Elderly (NICE).
References 1. Abrahamson K, Suitor J, Pillemer K. Conflict between nursing home staff and resident’s families: does it increase staff burnout? J Aging Health. 2009;29(6):895-912. 2. Decker FH, Harris-Kojetin LD, Bercovitz A. Intrinsic job satisfaction, overall satisfaction, and intention to leave the job among nursing assistants in nursing homes. Gerontologist. 2009;49(5): 596-610. 3. Testad I, Mikkelson A, Ballard C, Aarsland D. Health and wellbeing in care staff and their relations to organizational and psychosocial factors, care staff and resident factors in nursing homes. Int J Geriatr Psychiatry. 2010;25(8):789-797. 4. Vogelsmeier A, Scott-Cawiezell J. Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork. J Nursing Care Quality. 2011; 26(3):236-242. 5. Bryan K, Axelrod L, Maxim J, Bell L, Joedan L. Working with older people with communication difficulties: an evaluation of care worker training. Aging Ment Health. 2002;6(3):248-254.
6. Aylward S, Stolee P, Keat N, Johncox V. Effectiveness of continuing education in long-term care: a literature review. Gerontologist. 2003;43(2):259-271. 7. Bourgeois M, Dijkstra K, Burgio L, Allen RS. Communication skills training for nursing aides of residents with dementia: the impact of measuring performance. Clin Gerontologist. 2004; 27(1/2):119-138. 8. Mackenzie CS, Peragine G. Measuring and enhancing selfefficacy among professional caregivers of individuals with dementia. Am J Alzheimer Dis Other Dement. 2003;18(5): 291-299. 9. Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Thousand Oaks, CA: Sage; 1998. 10. Berg BL. Qualitative Research Methods for the Social Sciences. 7th ed. Boston: Allyn & Bacon; 2008. 11. Garrison RD. E-Learning in the 21st Century: A Framework for Research and Practice. 2nd ed. New York: Taylor & Francis; 2011. 12. Temkin-Greener H, Cai S, Katz P, Zhao H, Mukamel DB. Daily practice teams in nursing homes: evidence from New York State. Gerontologist. 2009;49(1):68-80. 13. Tyler DA, Parker VA. Nursing home culture, teamwork, and culture change. J Res Nurs. 2011;16(1):37-49. 14. Kalisch BJ, Lee H, Rochman M. Nursing staff teamwork and job satisfaction. J Nursing Management. 2010;18(8):938-947. 15. Probst JC, Baek JD, Laditka SB. The impact of workplace environment on job satisfaction among nursing assistants: finding from a national survey. J Am Med Directors Assoc. 2010;11(4): 246-252.
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
Acceptability of an e-Learning Program to Help Nursing Assistants Manage Relationship Conflict in Nursing Homes
American Journal of Alzheimer’s Disease & Other Dementias® 2015, Vol. 30(1) 55-60 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1533317514551482 aja.sagepub.com
Elsa Marziali, PhD1, Corey Scott Mackenzie, PhD2, and Illia Tchernikov, MA1
Abstract Background: Management of nursing assistants’ (NAs) emotional stress from relationship conflicts with residents, families, and coworkers is rarely the focus of educational programs. Our objective was to gather feedback from NAs and their nursing supervisors (NSs) about the utility of our e-learning program for managing relationship stress. Methods: A total of 147 NAs and their NSs from 17 long-term care homes viewed the educational modules (DVD slides with voice-over), either individually or in small groups, and provided feedback using conference call focus groups. Results: Qualitative analysis of NA feedback showed that workplace relationship conflict stress was associated with workload and the absence of a forum for discussing relationship conflicts that was not acknowledged by NSs. Conclusion: This accessible e-learning program provides NAs with strategies for managing stressful emotions arising from workplace relationship conflict situations and underscores the importance of supervisory support and team collaboration in coping with emotionally evoked workplace stress. Keywords e-learning, intervention, stress management, long-term care, nursing
Nursing assistants (NAs) provide most of the hands-on direct care to residents living in nursing homes. Daily they interact with residents and provide assistance with activities of daily living. They also frequently interact with families, helping them to cope with the emotional impact of institutionalizing a family member. In addition, they interact with other NAs and their nurse supervisors (NSs) to ensure optimal care of residents. Although most NAs working in nursing homes are trained to provide quality physical care to residents, including the acquisition of skills for communicating with residents diagnosed with dementia, there are few if any training programs that focus on the emotionally stressful components of managing workplace relationship conflicts. Yet, NAs are frequently expected to manage challenging emotional reactions in relationships with residents, with their family members, with coworkers, and with nurse supervisors. In consequence, the physical and mental health of the NAs may suffer, resulting in burnout, an incremental need for sick leave, job dissatisfaction, and attrition.1-3 Under these circumstances, the care of residents can be compromised, often accompanied by escalating concerns and complaints from families and criticism from coworkers and supervisors. Considering the need for supportive programs to prevent negative outcomes for NAs and residents in their care and considering the lack of readily accessible in-service training programs that focus on this important issue, e-learning educational initiatives hold promise for supporting
NAs to advance their knowledge and skills for managing emotionally stressful events that occur in the workplace. In the past decade, study findings show that NA stress experienced in the context of managing workplace relationships with residents, families, coworkers, and supervisors is predictive of quality of resident care, job satisfaction, job performance, and attrition. One study found that NA burnout and job dissatisfaction were related to conflict with family members, often due to differences in care expectations. For example, conflict-related stress increases when NAs feel that, due to large workloads, they do not have enough time to provide optimal care, which includes social stimulation.1 A study of workplace predictors of NA stress showed that experienced stress was more related to work environment psychosocial factors (organizational culture and leadership) rather than patient-related factors such as dementia severity, aggression, and agitation.3 A number of studies have shown that NA intrinsic job factors, such as assuming responsibility, being
1 2
Rotman Research Institute, Baycrest, Toronto, Canada Department of Psychology, University of Manitoba, Winnipeg, Canada
Corresponding Author: Corey Scott Mackenzie, PhD, Department of Psychology, University of Manitoba, 190 Dysart Rd, Winnipeg, Manitoba, Canada R3N 3P2. Email: [email protected]
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
American Journal of Alzheimer’s Disease & Other Dementias® 30(1)
56 self-directive, developing new skills, and obtaining job accomplishment feedback, are associated with job satisfaction and job continuance. For example, Decker and colleagues2 found that NAs’ positive assessment of their supervisors’ behavior was associated with intrinsic job satisfaction. Also, NAs participation in care decisions made in teams reinforces intrinsic satisfaction through mutual respect, recognition of competence, shared responsibility, and open communication with coworkers and supervisors. In a comparative case study, nursing leadership that facilitated open communication and teamwork achieved organizational improvement while nursing leadership that disregarded open communication and teamwork did not.4 Some NA training programs have addressed the challenges faced by NAs in their caring work and have included courses that stress the importance of developing communication and interpersonal skills.5-7 Specifically, NA training programs have focused on enhancing communication with patients in more advanced stages of dementia. However, to our knowledge, none provide a unique focus on NAs’ acknowledgment, understanding, and processing of highly stressful emotions (anger, fear, pain, and hopelessness) evoked in conflict situations with families, coworkers, and supervisors. In summary, we argue that NAs, who are not helped to acknowledge and manage painful/disruptive emotions associated with conflicted interpersonal transactions not only with residents but also with families, coworkers, and supervisors, are at risk of deterioration in their mental and physical health resulting in a decline in optimal caring practices and an increased risk of burnout, sick leave, and attrition. The purpose of this study was to explore NA’s responses to our e-learning in-service program to determine whether we had targeted work issues important for supporting NA’s care practices in long-term care facilities. The e-learning program was based on a training program (Nursing Self-Efficacy Program [NSEP]) developed and evaluated by Mackenzie and Peragine.8 The NSEP was manual guided, and the program was delivered face-to-face in a long-term care facility. Our e-learning program was adapted from NSEP and expanded to include several more components that focus on NAs’ selfcare and on the role of NSs in supporting NA’s care practices.
Methods One hundred and forty-seven NAs and their nursing supervisors (NSs) from 17 nursing homes (half rural and half urban) located across 10 Canadian provinces participated in this study. The aim was to involve approximately 10 NAs and 1 NS from each participating nursing home. A nurse educator functioned as the local institution project coordinator. Local project coordinators received and distributed the project materials (e-learning DVDs, procedural steps for engaging in the e-learning program, and consent forms) to participants. All participants signed consent forms ensuring anonymity of the information that they provided to the researchers. Because we were interested in the potential lasting impact of the program rather than its immediate impact, at approximately
6 weeks following completion of the e-learning program, NAs at each participating institution provided feedback in a group conference call format facilitated by a researcher. The NSs at each institution provided additional feedback in a separate telephone interview with a research assistant. The conference calls and telephone interviews were audio recorded and transcribed for subsequent qualitative analysis. We used qualitative methods9,10 to analyze salient themes from both the NA and NS recorded feedback sessions. We developed codes, recorded initial themes, and carefully documented field notes for identification of salient themes within and across all NA and NS feedback sessions. Two researchers independently engaged in this process using the transcriptions of each feedback session to ensure accuracy and concurrence of extracted themes and dialogue. The aim was to extract consistent feedback themes across all participating NAs and NSs, regardless of their nursing home location. Research assistants who conducted the qualitative analysis were blind to participant identity, nursing home name, and urban versus rural location.
e-Learning Program Unique to our program was its central focus on helping NAs understand and reflect on emotions (both their own and the relationship partner—resident, family member, coworker, and supervisor). In particular, the educational content ‘‘normalized’’ the experiencing of perceived negative emotions (eg, anger, pain, fear, helplessness, and hopelessness). Of importance was acknowledgment of experienced emotions and understanding how they affect management of workplace relationship conflicts. We developed the program within an e-learning framework in which e-learning refers to electronically mediated communication for the purpose of constructing and confirming knowledge.11 To this end, the educational content was presented in Power Point formatted on a DVD with voice-over. Voice-over was used because many NAs working in Canadian long-term care institutions are limited in their ability to read English if it is a second language. The NAs could watch the DVD on a TV with a DVD player or a computer, one module at time (15 minutes), either individually or in small groups; the idea was to facilitate their involvement in the e-learning program by not requiring absence from their service units for any extended period of time. The NA educational content consisted of 5 modules: (1) managing relationship conflicts with residents, (2) managing relationship conflicts with families, (3) managing relationship conflicts with coworkers, (4) NA self-care and management of lifestyle behaviors (diet, exercise, and social networking), and (5) viewing and discussion of animated representations of 3 role play conflict situations between an NA and a resident, an NA and a family member, and an NA and a coworker. The animations were viewed by the NAs in small groups following completion of the first 4 modules. The purpose was to stimulate NAs’ discussion of similar conflict situations in their work environments.
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
Marziali et al
57
At each institution, the participating NAs’ NS was asked to view the NA educational content modules as well as content formatted on a separate DVD that focused on supervisory strategies for supporting NAs’ management of emotional stress associated with working in long-term care environments. The local project coordinator at each participating institution arranged for viewing of DVDs at a time and location that was least disruptive of NA/NS work obligations.
Results Demographics One hundred and forty-seven NAs and their institutional NSs (N ¼ 17) participated. Ninety-two percent of the NAs and all NSs were women. Close to half of the participants had less than 5-year long-term care work experience, with the remainder having over 5 years experience. Almost 90% of the NAs had professional training. Most institutions provided in-service training programs—23% provided 1 training program per year and 67% had more than 1 training opportunity each year. The exact content of the in-service programs varied but by far the most frequently offered were in-service training programs that focused on enhancing communication with patients in more advanced stages of dementia. However, none of the institutions provided in-service programs with a unique focus on NAs’ acknowledgment, understanding, and processing of highly stressful emotions evoked in conflict situations with residents, families, coworkers, and supervisors.
Analysis of Feedback Sessions We summarize key feedback perspectives of NAs and NSs with regard to the content of the e-learning program, the format, and the method of presentation. Most important, however, was whether participants learned anything that was useful for their daily management of workplace emotional stress and its impact on resident care practices.
Nursing Assistant Feedback Themes Most of the NAs found the content of the e-learning program informative, useful, and reassuring as it reflected their actual work challenges with residents, families, and coworkers. The NAs told us that ‘‘it’s informative, very interesting, it makes you think about different aspects about handling clients who are more aggressive’’; ‘‘it was a good refresher to have because it does help you deal with residents’’; ‘‘it’s nice to see that information on self-care is included because it’s something that we don’t necessarily think about over getting irate with people or increasing conflict because we are tired or because we are distracted or because things are going on at home.’’ In terms of novel care strategies, the NAs found identification of specific strategies for managing conflict situations very useful; procedural strategies provided a structure for understanding a conflict situation, reflecting on personal feelings, reflecting on others’ feelings, and determining what action to take.
Similarly, they appreciated suggestions on maintaining a charting system for recording management strategies useful for addressing challenging behaviors with specific residents. Some NAs thought that the information provided was not new and did not always reflect what happens in their actual work situations. For example, they indicated that conflict situations, whether with residents, families, or coworkers, are far more complicated than portrayed in the educational content modules. One NA stated, ‘‘Just taking that learning module you are not going to be prepared. You’re going to think ‘I can do this’ but you are going to get into situations where you are going to be over your head very quickly.’’ Some NAs stated that problem resolution varies and is dependent on the policies and procedures endorsed by the nursing home. For example, some homes required nurse supervisors to manage conflict situation with families, while others expected NAs to manage family issues. Nursing assistants reported the least stress when managing conflict with residents, a moderate amount of stress when responding to family member criticisms of staff, and the most stress when managing coworker conflict situations, including relationships with NSs. Comments with regard to family and coworker conflicts included ‘‘Dealing with family members that are unrealistic in their expectations of their loved ones and our care is an issue’’; ‘‘Sometimes when families come in and ask questions about their loved one we try not to give answers as nursing assistants because it should be directed to the nurse. I think they (families) think that we don’t know the information’’; ‘‘We feel that a lot of our coworkers are not happy. And sometimes I guess some people have brought it up to management and they were told, ‘if you don’t like it leave’’’; ‘‘I think there is so much coworker conflict because we’re so overworked’’; ‘‘It is very common that staff members don’t get along’’; and ‘‘Arguments happen a lot—I do think there’s a lot of miscommunication.’’ Nursing supervisor support for NAs’ management of stress in conflict situations was readily available in many institutions but appeared lacking in others. For example, one NA noted that ‘‘for some reason in this facility there is not much conflict as in other facilities; it’s been engrained that it is teamwork and it seems to work out that way with our relationships.’’ In contrast, an NA from a different institution stated, ‘‘dealing with conflict with other staff hasn’t been dealt with at our institution. It’s just ignored and you’re expected to feel ‘happy go lucky’ until it happens again and nothing gets dealt with.’’ The following comments from NAs at other institutions reflect a similar theme: ‘‘I’m not interested in socializing with people here because they are bullies; the problem is that they have been here so long and the style of management is so poor—so if a staff member hollers at you, that becomes the pattern.’’ ‘‘We have a lot of bullying; staff with more than 20 years experience try to intimidate a junior person to do their work for them.’’ The most prevalent teamwork theme extracted from the NAs’ feedback comments showed differences in how NAs are perceived in the formal caregiver heiarchy. In those institutions with well-functioning teams, NAs viewed their participation in
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
American Journal of Alzheimer’s Disease & Other Dementias® 30(1)
58 determining resident care management positively; open communication and mutual respect among team members are valued, and as a result conflict situations with residents, families, and coworkers are readily resolved. One NA noted that ‘‘we have a lot of say in care planning for patients, that’s good—we do have meetings before each shift and we can make suggestions whenver we want.’’ Another NA told us that ‘‘we have a good group here, a lot of us here have worked together for years, and we can all voice our opinions and not feel pressure from someone else.’’ Other NAs spoke about the importance of leadership: ‘‘In our institution we have very good structure, we have good leadership’’; ‘‘I feel comfortable going up to my supervisor and expressing my concerns.’’ In contrast, in institutions without a team management structure or had poorly functioning teams, NAs experienced more stress and received little support for managing work-related stress as indicated in the following comments: ‘‘We really don’t have much say in what goes on here, usually we’re just told what to do and when to do it’’; ‘‘You’re the lowest man on the totem pole, but yet you’re the frontline worker, you are what makes this facility run’’; ‘‘Our feedback about resident care is generally ignored’’; ‘‘I think we have unit meetings . . . I think they are supposed to be once a month—but most of the time they get cancelled’’; and ‘‘The amount of input you have depends on the nurse—some nurses respect you—and some of them don’t listen to you.’’ Although, institutions were not asked whether interdisicplinary teams were active in monitoring resident care, the analysis of NA and NS feedback showed that not all institutions used a team approach for making care decisions related to residents and their families. Similarly, teams were not viewed as essential for dealing with conflict situations in the workplace whether with residents, families, or coworkers.
Discussion of Animated Educational Content
Nursing Supervisor Feedback Themes
Group Format for Discussion of Animations
In general, the NSs found the NA and NS educational content as not providing anything new about care practices at their respective institutions. Comments included ‘‘there wasn’t anything that I didn’t know before but some of it reaffirmed with me’’; ‘‘I thought the supervisor manager educational content was actually pretty decent.’’ Most did not like the formatting of the DVD Powerpoint slides, nor the voice-over presentation; ‘‘it was a bit slow’’; ‘‘I don’t like having someone read to me’’; ‘‘I think it was too simple.’’ Nursing supervisors’ perceptions of NAs’ role functions in their institutions varied. In contrast to the NAs’ perceptions about not being included in making resident care decisions, most of the NSs believed that they encouraged an environment of open communication; ‘‘Most of the time I think they feel involved in care planning and having input in resident care’’; ‘‘Everybody is free to come up and talk to us; that doesn’t mean that it necessarily is going to happen but they’re all free to make suggestions’’; ‘‘For sure our staff feels involved in care planning.’’ Although we conducted separate analysis of the rural versus urban feedback information provided by the NAs and NSs, we found no differences in the themes extracted from transcripts of the feedback sessions.
The NAs veiwed the animations in small groups and following the viewing of each animation of a conflict situation they discussed its relevance to their care practice situations. The feedback with regard to the group format for sharing reflections on the animated conflict situtations was overall very positive. Some reflected that they rarely had the opportunity to discuss with coworkers their thoughts about care practices. Their feedback comments included ‘‘I really think that the discussion group was beneficial—you learn a lot from discussion’’; ‘‘I found the discussion group more valuable than just watching the video because from there we discussed other scenarios that we’ve been through and we came up with ways to better communicate as a group to deal with those situations’’; ‘‘The group discussion worked out really well. Some people who have failed to bring forward issues even to supervisors seemed more open to bringing it up there because they were part of this critiquing and seeing it in action.’’ ‘‘I prefer watching the animations as a group’’; ‘‘I think something like that is probably better being done in a group because you have a chance to get feedback from everyone and perhaps get a different viewpoint you might not have considered yourself.’’
The NAs’ responses to the animated conflict situations were mixed; some did not like the animated figures and would have preferred actors. Comments included ‘‘The animations were terrible’’; I would have preferred real actors—then you could actually show real life situations.’’ In contrast, other NAs commented as follows: ‘‘I think the animations were the best to see, having seen so many instructional videos that have real people that are lousy actors. Its much easier to follow, there is very little distraction’’; ‘‘I’d rather it be animated—you got your point across this way and we were more focused on what was actually happening in the video.’’ Despite these different viewpoints with regard to the formating of the animations, most of the NAs thought that the relationship conflict situations represented in the animations did reflect what happens in long-term care institutions. Feedback included comments such as ‘‘We like the different scenarios. I thought it was right on. I really think that whoever did this study really must have talked to people who work in this environment’’; ‘‘There are definitely some good ideas that were used in the animations that a lot of people we work with could use.’’ In the feedback provided for each animated scenario (NA and resident, NA and family member, and NA and coworker), the majority of NAs did not find the solutions portrayed as realistic and applicable to their care practices. Their comments included ‘‘The problem was solved too quickly’’; ‘‘The scenarios were appropriate but how to solve the problem wasn’t good’’; ‘‘There is no way that the solutions presented in the animations would ever happen in real life—the scenarios are very pertinent, but the way that the solution was portrayed was not very realistic.’’
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
Marziali et al
59
Discussion Analysis of the participant responses to the e-learning program showed that the content was useful for addressing relationship conflict situations in the workplace. Some specific conflict resolution strategies were identified as especially helpful. While the educational content illustrated in the animations focused on typical relationship conflict issues in the workplace, most NAs did not like the formatting (animations). More successful as a learning experience was the NAs’ participation in group discussions of the animations and how, in their institution, they would handle the conflict issues portrayed in the scenarios. In summary, the NAs reported that higher levels of emotional stress were associated with (1) managing large workloads that prevented spending quality time with residents; (2) managing the stress associated with conflicts in relationships with coworkers and/or supervisors; (3) the lack of structures and processes (eg, staff care teams) for sharing and resolving workplace conflict situation; and (4) challenges communicating effectively with residents’ families. The NAs’ feedback resonated with the findings of previous studies showing that NAs whose work is valued, who are encouraged to share ideas about resident care, and who function in an institutional culture that supports open, mutually respectful communication, experience high job satisfaction and contribute to effective care practices.4 Institutions with healthier institutional cultures have implemented interdisciplinary teams in which NAs play important roles in discussing problems and conflicts in the workplace whether with residents, their families, or among coworkers. For institutions lacking an interdisciplinary team model of communication, its introduction in nursing homes is always challenging. Although studies show the importance of interdisciplinary teams for the provision and maintenance of quality health care to residents in long-term care facilities, in 1 study only 25% of the nursing homes surveyed had teams; yet the majority of nursing home managers reported teamwork as very important to their facilities’ operations.12 Other studies of nursing homes showed that teamwork among direct-care workers was viewed as essential for changing institutional practices; however, teamwork was the least commonly implemented component of cultural change despite the fact that facilities with interdisciplinary teams have consistently reported positive staff attitudes toward coworkers and NA satisfaction with participation in care decisions.13,14 Where teams do exist, their effective functioning varies possibly due to the lack of a culture that promotes open communication and the possible failure in valuing NAs’ contributions to care decisions.15 Clearly, the extent to which health care professionals work well together determines the quality of care provided in nursing homes. Well-functioning staff teams facilitate open communication and positive interaction and are based on mutual respect and valuing of input from all team members. Teams can help resolve interpersonal conflict in the workplace whether between coworkers, residents, and/or their families. Yet most health care professionals do not receive training in
conflict management in the workplace. Nor are they trained to function effectively in interdisciplinary teams. Yet, teams could provide the venue for interdisciplinary management of interpersonal conflict in the workplace resulting in optimal care of nursing home residents. Our e-learning program may provide an opportunity for nursing homes and their staff to learn important conflict management skills and also to build teamwork in the process.
Conclusions Considering the need for educational programs that would help prevent negative outcomes for NAs and their care recipients and considering the lack of such initiatives in general and particularly in remote areas, e-learning programs could provide cost-effective training for NAs who might not otherwise have access to in-service-training opportunities. Targeting knowledge transfer to NAs in a digital, easily accessible format represents the ideal in-service training opportunity; learning modules can be reviewed in sections, at convenient times in terms of work schedule, and require minimal absence from unit of service. Also, an e-learning program can be provided as a ‘‘refresher course’’ at regular intervals, thus reinforcing knowledge gained and its applicability in unique resident care situations. Our results suggest that institutional policies with regard to (1) monitoring staff to resident ratios (workload stress) and (2) establishing management hierarchies that acknowledge NAs as full team care members (coworker/supervisor communication) need to be highlighted. Similarly, NA role functions in relation to residents, their families, and coworkers need to be clear and operable. Following analysis of the project data, we have carefully considered modifications to our e-learning program to enhance its applicability and effectiveness. Based on our results, we revised the NA e-learning program as follows: (1) we withdrew the animations representing interpersonal conflict situations; instead at the end of each content module we inserted relevant brief case studies (resident, families, and coworkers) with instructions to discuss management of similar conflict situations in their institutions and (2) we made significant changes in the NS intervention content with the focus now on the establishment and maintenance of interdisciplinary teams to optimize communication and resolution of conflict situations between NAs and residents, families, and coworkers. Future research is needed to assess whether this revised program is effective in enhancing NAs’ management of stressful conflict situations and in improving care practices. Authors’ Note Long-term care facilities that view our nursing assistant (NA) e-learning program as potentially beneficial to their organizations can order the program from the National Institute for the Care of the Elderly (www.nicenet.ca). This study was supported by the National Institute for the Care of the Elderly (NICE).
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
American Journal of Alzheimer’s Disease & Other Dementias® 30(1)
60 Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The research outlined in this paper was funded by an internal grant from the National Initiative for the Care of the Elderly (NICE).
References 1. Abrahamson K, Suitor J, Pillemer K. Conflict between nursing home staff and resident’s families: does it increase staff burnout? J Aging Health. 2009;29(6):895-912. 2. Decker FH, Harris-Kojetin LD, Bercovitz A. Intrinsic job satisfaction, overall satisfaction, and intention to leave the job among nursing assistants in nursing homes. Gerontologist. 2009;49(5): 596-610. 3. Testad I, Mikkelson A, Ballard C, Aarsland D. Health and wellbeing in care staff and their relations to organizational and psychosocial factors, care staff and resident factors in nursing homes. Int J Geriatr Psychiatry. 2010;25(8):789-797. 4. Vogelsmeier A, Scott-Cawiezell J. Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork. J Nursing Care Quality. 2011; 26(3):236-242. 5. Bryan K, Axelrod L, Maxim J, Bell L, Joedan L. Working with older people with communication difficulties: an evaluation of care worker training. Aging Ment Health. 2002;6(3):248-254.
6. Aylward S, Stolee P, Keat N, Johncox V. Effectiveness of continuing education in long-term care: a literature review. Gerontologist. 2003;43(2):259-271. 7. Bourgeois M, Dijkstra K, Burgio L, Allen RS. Communication skills training for nursing aides of residents with dementia: the impact of measuring performance. Clin Gerontologist. 2004; 27(1/2):119-138. 8. Mackenzie CS, Peragine G. Measuring and enhancing selfefficacy among professional caregivers of individuals with dementia. Am J Alzheimer Dis Other Dement. 2003;18(5): 291-299. 9. Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Thousand Oaks, CA: Sage; 1998. 10. Berg BL. Qualitative Research Methods for the Social Sciences. 7th ed. Boston: Allyn & Bacon; 2008. 11. Garrison RD. E-Learning in the 21st Century: A Framework for Research and Practice. 2nd ed. New York: Taylor & Francis; 2011. 12. Temkin-Greener H, Cai S, Katz P, Zhao H, Mukamel DB. Daily practice teams in nursing homes: evidence from New York State. Gerontologist. 2009;49(1):68-80. 13. Tyler DA, Parker VA. Nursing home culture, teamwork, and culture change. J Res Nurs. 2011;16(1):37-49. 14. Kalisch BJ, Lee H, Rochman M. Nursing staff teamwork and job satisfaction. J Nursing Management. 2010;18(8):938-947. 15. Probst JC, Baek JD, Laditka SB. The impact of workplace environment on job satisfaction among nursing assistants: finding from a national survey. J Am Med Directors Assoc. 2010;11(4): 246-252.
Downloaded from aja.sagepub.com at UNIV OF PITTSBURGH on November 16, 2015
