Copyright 1992 by The Gerontological Society of America The Cerontologist Vol. 32, No. 3, 360-366
This study examines the work of the nurse's aide through a combination of participant observation and in-depth interviews with 30 nurse's aides. Data were analyzed using the grounded theory method of constant comparative dimensional analysis. Findings suggest that strategies developed by individual nurse's aides to organize their work are important determinants of both the quality of care and worker turnover. Quality of care may be better explained by Litwak's theory about the difficult juxtaposition between primary and formal groups than by the nurse's aides' lack of knowledge. Key Words: Work strategies, Educational programs, Quality of care
Nurse's Aides in Nursing Homes: The Relationship Between Organization and Quality
The quality of care in long-term care facilities has increasingly come under serious scrutiny by researchers, legislators, and the public. A substantial effort has been focused on discovering the reasons for substandard and impersonal care, while at the same time policies and practices have been implemented to increase the quality of care (OBRA, 1987). Unlike the professional staff who provide most of the direct patient care in acute care settings, the primary caregivers in nursing homes are untrained, "unskilled" nurse's aides (Diamond, 1986; Halbur, 1982; Institute On Medicine [IOM], 1986; KayserJones, 1990; Mohler & Lessard, 1990). It has been estimated that between 80% and 100% of the direct care provided to nursing home residents is provided by nurse's aides (IOM, 1986; Halbur, 1982; Reagan, 1986), and that the average amount of skilled nursing time allocated to each nursing home resident is about 12 minutes per day (IOM, 1986). In recognition of the central role of nurse's aides in nursing home care, attempts to increase the quality of care have often targeted this group of workers. Nurse's aides (NAs) have been described as uncaring and incapable of delivering compassionate or highquality care, or as being defective, unmotivated, or uncommitted to the work they do and the residents they care for (Kayser-Jones, 1990; Mendelson, 1975; National Citizens' Coalition for Nursing Home Reform [NCCNHR], 1985; Wright, 1988). One recently reported study suggested that many NAs are victims
of tragic personal lives who bring their troubles into the workplace, which leaves them with too few personal resources to respond effectively to the residents (Diamond, 1986; Feldman, Sapienza, & Kane, 1990; Tellis-Nayak & Tellis-Nayak, 1989). Kayser-Jones describes residents' perceptions of NAs "in the main [as] rude, neglectful, cold and uncaring, cruel, and sometimes physically and verbally abusive" (1990, p. 169). She identifies infantilization, depersonalization, dehumanization, and victimization as characteristic of interactions between staff and residents in one of the nursing homes she studied. Oliver and Tureman (1988) describe NAs as individuals who are unable to secure any other (better) jobs. Increasing the number and quality of educational programs for NAs is a commonly identified strategy for increasing the quality of care. Recently enacted federal legislation also mandates a certification process for NAs requiring them to complete a standard 80-hour training program followed by the successful completion of a competency exam (OBRA, 1987). This legislation is based on the (untested) assumption that poor care is primarily related to a deficit in the NAs' skill or knowledge and that increasing their knowledge and/or skill will result in a higher quality of care (American Nurses Association [ANA], 1986; Kane, 1989; NCCNHR, 1985; Wright, 1988). A number of studies have examined and documented the impact of organizational, managerial, and professional staffing variables on the quality of care in nursing homes (Halbur, 1982; Holz, 1982; IOM, 1986; Kruzich, 1990; Mullins et al., 1988; Nowlin, 1986; Phillips, 1987; Reagan, 1986; Rublee, 1986; Stryker, 1982). However, because the majority of direct care is provided by the NAs, it can be assumed that the impact of these variables is largely mediated through the NAs. It is therefore necessary
Assistant Professor, University of Wisconsin-Madison, School of Nursing, 600 Highland Avenue, Madison, Wl 53792. 2 PhD Candidate, University of Wisconsin-Madison, School of Social Work.
360
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Birmingham on July 15, 2015
Barbara Bowers, RN, PhD,1 and Marion Becker, RN, MSN2
to look more closely at the NA in order to understand how these variables operate. One explanation for our apparent inability to increase the quality of care provided by nurse's aides can be found in Litwak's (1985) hypothesis that the nursing home is an empirical intersection between primary and formal groups. Litwak suggests that we may have unrealistic expectations about the care that can be provided in nursing homes, that it is impossible to offer individualized, family-like (primary group) care in an institutional (formal group) setting. Studies have indicated, however, that families equate high-quality care with care that is affectively appropriate (Bowers, 1988a; Dobrof & Litwak, 1977; Duncan & Morgan, 1990; Rubin & Shuttlesworth, 1983). What is unique about Litwak's theory is that it acknowledges the centrality of the nurse's aides as care providers, while at the same time placing them within the larger social and organizational context. According to this theory, caregiving that occurs within primary groups relies on affective ties rather than expertise to determine who will perform the work. Generally, a single individual performs many tasks, regardless of expertise, and performs them in the way that the recipient wishes. Also, since primary group members are generally available on a 24-hour basis, and have only one individual to provide care for, the timing and sequencing of care activities is extremely flexible. Under these conditions, unpredictability is not terribly problematic. Formal organizations, on the other hand, must be more concerned with efficiency and economy. In the interest of efficiency, tasks must be carried out in a routine and predictable way. Labor is divided according to skill, often resulting in the breakdown of a single activity into several component parts. Different individuals perform different tasks or different parts of a single task, according to their expertise and the organization of the work. This results in fragmented care provided by several individuals rather than one. Litwak also hypothesized that when caregivers are economically rather than affectively motivated, they will quickly discover ways to make the work more manageable, efficient, and predictable. When the work is also largely invisible, as it is in nursing homes, economically motivated workers will cut as many corners as possible, seriously jeopardizing the quality of care. This theory suggests that it is the juxtaposition of primary groups and formal organizations — and the unrealistic expectation that a formal organization behave as if it were a primary group — that is the source of the problem. The NA may simply be caught in an impossible position. The purpose of this study was to explore the work of NAs from the perspective of the NAs themselves, to gain an understanding of how they organize their work and how they think about their work, including how they conceptualize quality of care. Because so little is known about how NAs work, the study was designed to enhance discovery of the conceptual and organizational dimensions that influenced how NAs understand and carry out their work.
The Sites Data were collected in three nursing homes, all located in an urban, midwestern city with a population of about 200,000. The facilities were similar in many ways. Each of the nursing homes was Medicare/ Medicaid certified. Turnover rates for NAs were between 120% and 145% annually. The size of the facilities ranged from 137 to 166 licensed beds. Two facilities were owned by national for-profit chains, whereas the third was a freestanding, not-for-profit facility owned by a local religious organization. The Sample A total of 30 nurse's aides volunteered to participate in the study. Some signed up at the staff meeting at which the study was described (see below), but the majority of recruits contacted one of the researchers at the worksite or by telephone after the study was already underway. The sample was composed of 30 NAs, most of whom were female (90%), between 19 and 29 years of age (87%), high school graduates (80%), and the sole support of their families (93%). Almost half (40%) of the NAs had worked at their current job 3 months or less, while 47% had at least 1 year of experience. In unsolicited feedback given by nurse supervisors at each site, all of the initial volunteers were described as "good nurse's aides." Several of those who were described by their supervisors as less skilled, less committed, and/or even abusive, volunteered for the study at a later time. Although there was no attempt to discover what criteria were used by supervisors in defining either good or bad nurse's aides, about 60% (18) of the NA volunteers were described as good NAs and 10% (3) were evaluated as "bad" workers, with the remaining 30% (9) being described as "acceptable," "good enough," "not too bad," etc.
Table 1 . Characteristics of Nurse's Aides in Study of the Nature of Their Work (N = 30)
361
Characteristic
n
Age 19-29 30-39 >45
26 (87%) 2 (6.5%) 2 (6.5%)
Gender Male Female
3 (10%) 27 (90%)
Time worked >3 years 1-3 years 3 months-1 year
This study examines the work of the nurse's aide through a combination of participant observation and in-depth interviews with 30 nurse's aides. Data were analyzed using the grounded theory method of constant comparative dimensional analysis. Findings suggest that strategies developed by individual nurse's aides to organize their work are important determinants of both the quality of care and worker turnover. Quality of care may be better explained by Litwak's theory about the difficult juxtaposition between primary and formal groups than by the nurse's aides' lack of knowledge. Key Words: Work strategies, Educational programs, Quality of care
Nurse's Aides in Nursing Homes: The Relationship Between Organization and Quality
The quality of care in long-term care facilities has increasingly come under serious scrutiny by researchers, legislators, and the public. A substantial effort has been focused on discovering the reasons for substandard and impersonal care, while at the same time policies and practices have been implemented to increase the quality of care (OBRA, 1987). Unlike the professional staff who provide most of the direct patient care in acute care settings, the primary caregivers in nursing homes are untrained, "unskilled" nurse's aides (Diamond, 1986; Halbur, 1982; Institute On Medicine [IOM], 1986; KayserJones, 1990; Mohler & Lessard, 1990). It has been estimated that between 80% and 100% of the direct care provided to nursing home residents is provided by nurse's aides (IOM, 1986; Halbur, 1982; Reagan, 1986), and that the average amount of skilled nursing time allocated to each nursing home resident is about 12 minutes per day (IOM, 1986). In recognition of the central role of nurse's aides in nursing home care, attempts to increase the quality of care have often targeted this group of workers. Nurse's aides (NAs) have been described as uncaring and incapable of delivering compassionate or highquality care, or as being defective, unmotivated, or uncommitted to the work they do and the residents they care for (Kayser-Jones, 1990; Mendelson, 1975; National Citizens' Coalition for Nursing Home Reform [NCCNHR], 1985; Wright, 1988). One recently reported study suggested that many NAs are victims
of tragic personal lives who bring their troubles into the workplace, which leaves them with too few personal resources to respond effectively to the residents (Diamond, 1986; Feldman, Sapienza, & Kane, 1990; Tellis-Nayak & Tellis-Nayak, 1989). Kayser-Jones describes residents' perceptions of NAs "in the main [as] rude, neglectful, cold and uncaring, cruel, and sometimes physically and verbally abusive" (1990, p. 169). She identifies infantilization, depersonalization, dehumanization, and victimization as characteristic of interactions between staff and residents in one of the nursing homes she studied. Oliver and Tureman (1988) describe NAs as individuals who are unable to secure any other (better) jobs. Increasing the number and quality of educational programs for NAs is a commonly identified strategy for increasing the quality of care. Recently enacted federal legislation also mandates a certification process for NAs requiring them to complete a standard 80-hour training program followed by the successful completion of a competency exam (OBRA, 1987). This legislation is based on the (untested) assumption that poor care is primarily related to a deficit in the NAs' skill or knowledge and that increasing their knowledge and/or skill will result in a higher quality of care (American Nurses Association [ANA], 1986; Kane, 1989; NCCNHR, 1985; Wright, 1988). A number of studies have examined and documented the impact of organizational, managerial, and professional staffing variables on the quality of care in nursing homes (Halbur, 1982; Holz, 1982; IOM, 1986; Kruzich, 1990; Mullins et al., 1988; Nowlin, 1986; Phillips, 1987; Reagan, 1986; Rublee, 1986; Stryker, 1982). However, because the majority of direct care is provided by the NAs, it can be assumed that the impact of these variables is largely mediated through the NAs. It is therefore necessary
Assistant Professor, University of Wisconsin-Madison, School of Nursing, 600 Highland Avenue, Madison, Wl 53792. 2 PhD Candidate, University of Wisconsin-Madison, School of Social Work.
360
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Birmingham on July 15, 2015
Barbara Bowers, RN, PhD,1 and Marion Becker, RN, MSN2
to look more closely at the NA in order to understand how these variables operate. One explanation for our apparent inability to increase the quality of care provided by nurse's aides can be found in Litwak's (1985) hypothesis that the nursing home is an empirical intersection between primary and formal groups. Litwak suggests that we may have unrealistic expectations about the care that can be provided in nursing homes, that it is impossible to offer individualized, family-like (primary group) care in an institutional (formal group) setting. Studies have indicated, however, that families equate high-quality care with care that is affectively appropriate (Bowers, 1988a; Dobrof & Litwak, 1977; Duncan & Morgan, 1990; Rubin & Shuttlesworth, 1983). What is unique about Litwak's theory is that it acknowledges the centrality of the nurse's aides as care providers, while at the same time placing them within the larger social and organizational context. According to this theory, caregiving that occurs within primary groups relies on affective ties rather than expertise to determine who will perform the work. Generally, a single individual performs many tasks, regardless of expertise, and performs them in the way that the recipient wishes. Also, since primary group members are generally available on a 24-hour basis, and have only one individual to provide care for, the timing and sequencing of care activities is extremely flexible. Under these conditions, unpredictability is not terribly problematic. Formal organizations, on the other hand, must be more concerned with efficiency and economy. In the interest of efficiency, tasks must be carried out in a routine and predictable way. Labor is divided according to skill, often resulting in the breakdown of a single activity into several component parts. Different individuals perform different tasks or different parts of a single task, according to their expertise and the organization of the work. This results in fragmented care provided by several individuals rather than one. Litwak also hypothesized that when caregivers are economically rather than affectively motivated, they will quickly discover ways to make the work more manageable, efficient, and predictable. When the work is also largely invisible, as it is in nursing homes, economically motivated workers will cut as many corners as possible, seriously jeopardizing the quality of care. This theory suggests that it is the juxtaposition of primary groups and formal organizations — and the unrealistic expectation that a formal organization behave as if it were a primary group — that is the source of the problem. The NA may simply be caught in an impossible position. The purpose of this study was to explore the work of NAs from the perspective of the NAs themselves, to gain an understanding of how they organize their work and how they think about their work, including how they conceptualize quality of care. Because so little is known about how NAs work, the study was designed to enhance discovery of the conceptual and organizational dimensions that influenced how NAs understand and carry out their work.
The Sites Data were collected in three nursing homes, all located in an urban, midwestern city with a population of about 200,000. The facilities were similar in many ways. Each of the nursing homes was Medicare/ Medicaid certified. Turnover rates for NAs were between 120% and 145% annually. The size of the facilities ranged from 137 to 166 licensed beds. Two facilities were owned by national for-profit chains, whereas the third was a freestanding, not-for-profit facility owned by a local religious organization. The Sample A total of 30 nurse's aides volunteered to participate in the study. Some signed up at the staff meeting at which the study was described (see below), but the majority of recruits contacted one of the researchers at the worksite or by telephone after the study was already underway. The sample was composed of 30 NAs, most of whom were female (90%), between 19 and 29 years of age (87%), high school graduates (80%), and the sole support of their families (93%). Almost half (40%) of the NAs had worked at their current job 3 months or less, while 47% had at least 1 year of experience. In unsolicited feedback given by nurse supervisors at each site, all of the initial volunteers were described as "good nurse's aides." Several of those who were described by their supervisors as less skilled, less committed, and/or even abusive, volunteered for the study at a later time. Although there was no attempt to discover what criteria were used by supervisors in defining either good or bad nurse's aides, about 60% (18) of the NA volunteers were described as good NAs and 10% (3) were evaluated as "bad" workers, with the remaining 30% (9) being described as "acceptable," "good enough," "not too bad," etc.
Table 1 . Characteristics of Nurse's Aides in Study of the Nature of Their Work (N = 30)
361
Characteristic
n
Age 19-29 30-39 >45
26 (87%) 2 (6.5%) 2 (6.5%)
Gender Male Female
3 (10%) 27 (90%)
Time worked >3 years 1-3 years 3 months-1 year
