J Nurs Care Qual Vol. 31, No. 3, pp. 282–289 c 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Nursing Assistant Perceptions of Their Role in Quality Improvement Processes in Nursing Homes Heather Davila, MPA; Kathleen Abrahamson, PhD, RN; Christine Mueller, PhD, RN, FAAN; Thomas S. Inui, ScM, MD; Aaron G. Black, MBA, MS, RN; Greg Arling, PhD Nursing assistants provide the majority of direct resident care in nursing homes and are centrally involved in implementing quality improvement (QI), yet little is known about their experiences in QI. Interviews with nursing assistants found that respondents perceive themselves as having a unique and important role in QI. They described key outcomes of QI as positive gains in the daily lives of residents, improved work processes, and increased time between staff and residents. Key words: long-term care, nursing assistants, nursing homes, quality improvement
Author Affiliations: School of Nursing, University of Minnesota, Minneapolis (Ms Davila and Dr Mueller); School of Nursing, Purdue University, West Lafayette, Indiana (Drs Abrahamson and Arling); Indiana School of Medicine, Indianapolis, Indiana (Dr Inui); Regenstrief Institute, Inc., Indianapolis, Indiana (Dr Inui); and Integrated Home Care, St. Paul, Minnesota (Mr Black). This project was supported by grant number R18HS018464 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Heather Davila, MPA, School of Nursing, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455 ([email protected]). Accepted for publication: November 18, 2015 Published ahead of print: January 19, 2016 DOI: 10.1097/NCQ.0000000000000170
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HEN fully authorized, the Quality Assurance and Performance Improvement (QAPI) program, an initiative of the Affordable Care Act, will require nursing homes (NHs) to implement ongoing improvementoriented activities. Although quality improvement (QI) tools and processes are familiar to NHs, the implementation of QI in health and long-term care settings remains a substantial challenge.1,2 Across health and long-term care settings, finding ways to more effectively engage direct care staff members in QI is increasingly viewed as important.3-5 Current initiatives such as NH culture change and efforts to reduce avoidable hospitalizations among NH residents focus on improving communication between nurses and nursing assistants (NAs), as well as meaningfully engaging NAs in the improvement of resident care processes. Similarly, QAPI encourages NHs to involve all members of the organization, including NAs, in improvement-oriented activities.
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Nursing Assistant Perceptions of Their Role in QI Processes Ideally, QI draws on the unique skills and insights of everyone who is involved or impacted by a work process. This is important not only because active engagement in change efforts may increase staff support for change5 but also because staff representing different roles within an organization may hold differing views on work processes, quality of care, and their own ability to influence quality outcomes.5,6 Although conceptualizations of quality may be interrelated across staff roles,7 the views of NAs may differ from the views of other staff. Nursing assistants may perceive themselves as knowing residents better than other staff8 and may be more confident in their ability to positively impact resident quality of life because of their close daily contact and relationship with residents.6 Frontline staff may also be particularly attuned to weaknesses in organizational processes. Research has found, for example, that NAs may assess internal communication and teamwork less favorably than management staff.9 Nursing assistants are on the frontlines of NH care, and modifications in the process, schedule, approach, and documentation of care to improve quality inevitably impact NA work. Although NAs are centrally involved in implementing QI in NHs, little is known about their views toward QI. Better understanding their experiences in QI could create a stronger foundation for engaging NAs in making needed changes in care processes, resident activities, and organizational staff policies. Drawing on the insights of frontline staff also could lead to stronger, more responsive QI programs. As part of a broader study on the impact of implementing QI on the organizational culture of NHs, this study explored the experiences of NAs in NH QI by addressing 3 questions: (1) How do NAs describe their role in QI processes? (2) What factors facilitate and impede NAs’ participation in QI? (3) What do NAs perceive to be key resident and organizational outcomes resulting from QI?
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METHODS Study design As part of a broader mixed-methods evaluation of the Minnesota Nursing Home Performance-Based Incentive Payment Program (PIPP),10 a unique state initiative that provides financial incentives to NHs to implement provider-initiated QI projects, we conducted interviews with 45 NAs from 23 NHs engaged in QI projects that had received support through PIPP. Interviews with NAs were conducted between 2011 and 2012 by 3 investigators. Interviews were done in person, with an average interview time of approximately 20 to 25 minutes. The interviews were semistructured with open-ended responses to probes. Interview questions focused on the respondent’s role in implementing the QI project, facilitators and challenges faced by NAs participating in QI, and perceived successes or positive outcomes resulting from the project. The sampling of NAs took place within a broader series of case studies we conducted as part of the evaluation of PIPP. Thirteen unique QI projects were selected for inclusion in the study by the research team to obtain diverse representation in terms of project focus, implementation strategies, facility size, geographic location, profit/nonprofit status, and whether projects represented single or multifacility initiatives. Of the 13 projects, 5 were implemented within a single facility and 8 involved multiple facilities. Multifacility projects involved those implemented within a single organization (eg, corporation or chain) and collaborative groups of NHs that came together to implement a common QI project. Participating NAs worked in NHs ranging in size from less than 35 to more than 250 beds, with an average size of approximately 100 beds. The majority of NHs were nonprofit organizations, with about half of the NHs located in rural areas of the state. For each of the 13 projects, between 1 and 8 NAs were interviewed (see Supplemental Digital
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Content, Table, available at http://links.lww. com/JNCQ/A241). Although the state issued the request for QI project proposals, it did not specify how facilities would respond or indicate which workers should be given new responsibilities for project implementation. Instead, leadership at the NHs, often working in collaboration with staff, prioritized topics and designed change processes within their facilities. Because PIPPsupported QI projects were developed at the provider level, targeted quality outcomes and implementation strategies varied by project. The selection of NAs for inclusion in the study was accomplished with the assistance of each NH’s QI project manager who, at the investigators’ request, identified NAs who had been involved in the project. In some cases, NAs were selected because they had taken on additional QI project-related responsibilities, such as leading resident group activities or serving as a project aide. In other cases, all NAs within the NH had similar roles in the project, and NAs were selected on the basis of their availability at the time the researchers were conducting interviews. Projects in which NAs participated focused on improvements in areas such as falls, pain, person-centered care practices, resident mood, dementia care, bathing, reducing avoidable hospitalizations, and the use of psychotropic medications. For the majority of sampled projects, expenses related to staffing—such as for staff training or additional staff time to focus on QI project implementation—represented a substantial portion of the project budget. This often meant that an organization had additional staff resources during the incentive period to devote toward implementation of the QI project. Nursing assistants played central roles in implementing each of the sampled QI projects. For example, in a project focused on reducing the use of psychotropic medications, selected NAs engaged residents in individualized activities such as hand massage, games, or oneon-one conversation. In a project focused on improving resident bathing experiences, NAs
coordinated among themselves to cover regular responsibilities while taking turns assisting residents with baths in a “spa-room,” complete with a Jacuzzi-like tub, relaxing music, scented soaps, and heated towels. Analysis The investigators obtained approval from the university’s institutional review board prior to the initiation of data collection. After receiving permission from respondents, interviews were digitally recorded and subsequently transcribed for analysis. Data were analyzed by the same investigators who completed the interviews using a thematic narrative analysis and inductive category development approach. Initially, each investigator read and reflected on the same interview data independently. After creating an initial list of categories corresponding to our primary questions of interest (eg, respondent’s role, challenges, facilitators, and perceived successes), narratives were read and reread until subthemes for each of these categories emerged. Through in-depth discussions, the team established and refined the subthemes (codes) that emerged from the interviews. After developing an initial coding scheme, each investigator recoded portions of text, and the team then discussed findings to maximize intercoder reliability. Throughout the analysis process, the team compared and discussed possible additions or revisions to the codes to reduce discrepancies within the coding scheme. Emergent codes were recorded in a codebook and refined after each batch of coding. Definitions for each code were created to maintain consistent application throughout the analysis. This process, which took place over several months, resulted in multiple subthemes for each broad category of interest. When a respondent’s statement reflected more than 1 theme, individual text fragments were coded into multiple categories. NVivo qualitative data analysis software (QSR International Pty Ltd. Version 10, 2012, Victoria, Australia) was used for managing and analyzing interview data.
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Nursing Assistant Perceptions of Their Role in QI Processes FINDINGS Nursing assistants describe their role in QI as unique and important, particularly because of their close relationships with and knowledge of residents. Teamwork, communication between staff members, and seeing positive results were identified as factors that facilitated NAs’ participation in QI. Communication was also viewed as a challenge, as well as insufficient time to interact with residents. Resistance to change among NAs, particularly at the beginning of a project, was also noted. Positive outcomes were described as improvements in the daily lives of residents and NA relationships with them, improvements in daily work processes and the work environment of NAs, and increased job satisfaction as a result of QI. Role of NAs in QI Nursing assistants played central roles in implementing each of the QI projects. Many respondents noted that successful project implementation depended on them because they work closely with residents and provide the majority of resident care. Several of the QI projects required NAs to watch residents closely to catch subtle changes in their condition, such as signs of pain or confusion. A number of projects focused on reducing avoidable hospitalizations, a current national priority being driven by the Affordable Care Act. A core component of those projects involved NAs reporting changes they observed in residents to licensed nurses so that conditions, such as a resident’s pain or an infection, could be treated early and a hospitalization avoided. Although these processes are considered routine aspects of nursing work, participating organizations often devoted substantial resources to training and retraining staff to achieve desired staff behaviors, such as increased communication between NAs and licensed nurses. As a result of staff training and the changes in work process that resulted, projects that focused on clinical outcomes (such as falls, pain, hospitalizations) seemed to raise the aware-
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ness of the importance of NAs within the organization. Nurses, in particular, reflected that NAs were “more empowered” and “more listened to” as a result of these QI projects. Nursing assistants’ intimate knowledge of and close relationships with residents was often viewed as a necessary aspect of their ability to accomplish QI project and organizational aims. The following comment from an NA articulates this perspective: We’re the eyes and ears because we’re with them on and off throughout the day . . . a lot [has] to do with knowing our resident, knowing when there is any kind of change, being able to figure out if there is some kind of pain, and then just reporting it off to the nurse.
Nursing assistants frequently discussed their role in encouraging residents to participate in QI-related activities they believed would benefit them. As part of a falls reduction project, 1 NA described herself as a “cheerleader” when working with residents on walking. Another NA who was participating in a project focused on improving resident bathing experiences described encouraging a resident who disliked routine showers to try the facility’s new spa-like tub: He was like, I don’t want that shower. I said, we have a very nice tub. How about we go get in there? And he was thrilled . . . then I turned on the bubble jets, and he [said] this is just wonderful.
Facilitators and barriers to NA participation in QI Nursing assistants described teamwork, communication, and seeing positive results as a result of QI efforts as factors that encouraged their involvement in QI. In an initiative focused on reducing the use of psychotropic medications, an NA who had taken on the role of project aide recalls other NAs talking to her about specific residents they thought would benefit from the program. Although fairly uncommon among NAs interviewed, being formally involved in planning and leading QI efforts (eg, by participating in a QI committee) was viewed by NAs as an effective way of increasing staff buy-in. As 1 NA said:
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If we have floor staff, if we have middle management on our teams, on our committees, it really helps with the buy-in because then it’s my project versus it’s what management’s telling me to do.
In projects that required NAs to pay close attention to residents’ patterns and changing conditions, trust and communication (“nurses listening to NAs,” as noted by 1 NA) were critical. An NA who participated in a hospitalization reduction initiative commented: NAs are with them [residents] more than the nurses are, so we can walk in the room in the morning and know something’s going on. The nurse trusts the NA’s evaluation that something didn’t seem right enough to follow-up on it.
Observing positive results, either in data that were shared with NAs or directly in the lives of residents, was often a turning point in staff buying in to the change effort. Being able to identify how QI benefited residents was particularly important for NAs. Interestingly, from the interviews, NAs did not spend a great deal of time talking about challenges associated with QI implementation or their participation in QI efforts. They did, however, discuss communication as a consistent challenge, as well as staff resistance to change, particularly in the initial stages of the project. Although there were exceptions, in the majority of projects, NAs were told about the QI project after the decision to implement the project had already been made and plans were underway. A consistent theme that arose in many of the interviews with NAs was related to the challenge of time. Staff often discussed the difficulty of balancing multiple demands and needing more staff resources to accomplish work responsibilities, including those related to QI. Many NAs expressed the opinion that staff were not given sufficient one-on-one time with residents, and this was a barrier to improving overall care quality. Not only did NAs discuss time with residents as an aspect of their work they highly valued, but they also described the lack of time with them as having a negative impact on residents’ lives. Nursing assistants’ consistent descriptions of wanting
more time to spend with individual residents was a particularly noteworthy theme because it emerged in many interviews, including in organizations that used project funds to support additional staff time. Other NAs expressed concerns about residents feeling lonely or depressed and indicated that the time they were able to spend with residents lessened this pain or burden. As 1 NA stated, time with residents “takes a lot of weight off their [residents’] backs emotionally.” Positive outcomes associated with QI Although NAs, similar to other staff members, talked about project-related achievements in a general sense (eg, a reduction in falls, fewer avoidable hospitalizations, improved quality of care, etc), NAs often focused their descriptions of project success on specific changes they had observed in the daily lives of individual residents, their personal relationships with residents, and their enhanced ability to provide good care. Nursing assistants told vivid and inspirational stories related to outcomes observed as result of QI efforts, such as a story about a resident regaining strength and walking again for the first time after a long period of not walking. Also within the context of QI projects, particularly those who afforded more time between staff and residents, NAs often shared examples that highlighted feeling appreciated or needed by residents and the importance of reciprocal relationships. They also noted the social support NAs provide to residents, as 1 NA commented: . . . depression issues with not even feeling like they’re worth anything and not even wanting to try. Then they have the one person that comes over and over, they start feeling like “I matter.”
Although several NAs discussed the challenge of changing routines when a new initiative was first introduced, they also talked about ways in which their work had improved as a result of QI. Most NAs were overwhelmingly positive about the impact of QI efforts on the organization and themselves individually. Many described increased efficiency within the organization, often because negative and
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Nursing Assistant Perceptions of Their Role in QI Processes ultimately time-consuming events, such as hospitalizations or falls, had been avoided as a result of QI. In several cases, NAs discussed positive changes in the work and living environment that came about because of QI. The implementation of QI typically required increased staff training. Nursing assistants often described appreciating the new knowledge and skills they had gained as a result of the QI projects in which they participated. To NAs, these gains were tied to their perceived ability to provide better care to residents: “For me, it’s an accomplishment. If there’s a resident who needs help . . . we want to make sure that we help them, whatever their needs, we’re always there.” Nursing assistants talked about how QI implementation had created a stronger sense of teamwork, including improved communication between nurses and NAs. Many discussed other benefits they perceived to be a result of the QI projects: having extra time with residents, being able to develop closer relationships with residents as a result of this time, and providing residents with better care. DISCUSSION The aim of this study was to explore the experiences of NAs who had participated in various QI projects initiated by NH providers. Several themes emerged from our interviews with NAs. These included the important contributions of NAs in NH QI: the importance of teamwork, communication, and seeing positive results to NA’s active participation in QI; challenges related to communication and resistance to change; the persistent challenge of time to spend with residents; and positive outcomes such as observable improvements in the daily lives of individual residents, added time with residents, improvements in work processes, and heightened job satisfaction. The findings from this study are consistent with prior research demonstrating that NAs see themselves as knowing residents better than other staff members,8 find meaning in their work largely through time and relationships with residents,11 and value the en-
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hanced ability to provide what they perceive to be good care.12 Our findings, however, are unique in that these themes arose within the context of QI implementation, a contribution to the current literature related to NH QI. Nursing assistants who participated in this study noted receiving more recognition within the organization for their contributions in QI, especially by licensed nurses. They often received additional training or expanded roles, which they valued. Although several NAs described being involved in leading QI efforts, few NAs we interviewed had been meaningfully involved in giving input into project development. Element 2 of the QAPI process, focused on governance and leadership, aims to expand involvement in quality efforts to all members of the organization. Yet, little is known about the most effective strategies for involving NAs in planning and leading QI within NHs. Further research could explore the impact of NAs’ participation in QI leadership, as well as the types of leadership contributions NAs make in QI efforts. Relatedly, although NAs participating in this study described their relationships with and knowledge of residents as beneficial in QI, little is known about the extent to which NAs’ insights about residents, including their needs and preferences, are brought into planning QI priorities within NH organizations. Further research could investigate the most effective ways to use the particular knowledge and insights of frontline workers in QI efforts. Nursing assistants who participated in this study raised challenges that are commonly associated with QI implementation: communication, resistance to change, and time. The value of and preference for more time with individual residents was a striking theme that emerged in our interviews with NAs. The dominance of this theme in the interviews likely reflects one of the primary challenges of direct caregiving work: the need to balance the goals and demands of the organization with the perceived needs of residents.13,14 Relatedly, this finding highlights the tension direct care workers, such as NAs, may experi-
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ence when expected to fulfill caregiving roles normally fulfilled by family members.14 In projects in which increased staff time was a component of the QI initiative, NAs described appreciating the additional time they were able to spend with residents, and they indicated that this time benefitted the quality of residents’ lives. This is consistent with prior research demonstrating that NAs view their personal contact with residents to be a critical component of resident quality of life.6,11 In addition, because prior research has found that NAs may perceive themselves to better able to impact resident quality of life than other staff members,6 finding ways to integrate more individual time between NAs and residents into QI work could increase NA job satisfaction and potentially benefit residents. Demonstrating how specific QI initiatives have the potential to improve residents’ lives could strengthen staff engagement in change efforts. Further research could investigate whether NAs and other direct care staff are more interested in or engaged in certain types of QI projects, for example, initiatives focused on improving resident quality of life or projects that involve increased time between staff and residents. The generalizability of the findings for this study are limited since the NAs who participated in this study were selected by their organizations to be interviewed, often because they had a central role in QI implementation.
The views of the NAs we interviewed, therefore, may not represent the views of NAs in general, even within the NHs in which they work. In addition, because the organizations in which participating NAs worked had received financial support from the state to support the QI project, other NHs may not have the same resources to implement QI. The experiences of NAs who participated in this study suggest that the process of implementing QI itself may improve teamwork and communication, particularly between NAs and licensed nurses. In addition to achieving improvements in targeted outcomes, QI implementation may strengthen the types of organizational norms and behaviors that facilitate ongoing improvement. SUMMARY The findings of this study affirm previous research on what matters to NAs in their work: the time they are able to spend with residents and ability to make a difference in residents’ lives. Nursing home QI efforts could be strengthened by more meaningfully involving NAs in QI. While the QI movement has experienced a mixed history in NH settings, the current policy environment is creating incentives for improving and maintaining a higher quality of care. It may be possible to improve NH quality by better utilizing the unique strengths and insights of NAs in QI efforts.
REFERENCES 1. Sales AE, Bostrom AM, Bucknall T, et al. The use of data for process and quality improvement in long term care and home care: a systematic review of the literature. J Am Med Dir Assoc. 2012;13(2): 103-113. 2. Rantz MJ, Zwygart-Stauffacher M, Flesner M, et al. Challenges of using quality improvement methods in nursing homes that “need improvement.” J Am Med Dir Assoc. 2012;13(8):732-738. 3. Parker LE, Kirchner JE, Bonner LM, et al. Creating a quality-improvement dialogue: utilizing knowledge from frontline staff, managers, and experts to foster
health care quality improvement. Qual Health Res. 2009;19(2):229-242. 4. Singer SJ, Rivard PE, Hayes JE, Shokeen P, Gaba D, Rosen A. Improving patient care through leadership engagement with frontline staff: a Department of Veterans Affairs case study. Jt Comm J Qual Patient Saf. 2013;39(8):349-360. 5. Kirchner JE, Parker LE, Bonner LM, Fickel JJ, Yano EM, Ritchie MJ. Roles of managers, frontline staff and local champions, in implementing quality improvement: stakeholders’ perspectives. J Eval Clin Pract. 2012;18(1):63-69.
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Nursing Assistant Perceptions of Their Role in QI Processes 6. Kane RL, Rockwood T, Hyer K, et al. Nursing home staff’s perceived ability to influence quality of life. J Nurs Care Qual. 2006;21(3):248-255. 7. Chung G. Understanding nursing home worker conceptualizations about good care. Gerontologist. 2013;53(2):246-254. 8. Shadden BB, Debrezzo R, Fort I, Henry J, Gray M. How certified nursing assistants in different LTC facilities frame their work as meaningful. Gerontologist. 2012;52:156. 9. Forbes-Thompson S, Gajewski B, Scott-Cawiezell J, Dunton N. An exploration of nursing home organizational processes. West J Nurs Res. 2006;28(8):935954. 10. Arling G, Cooke V, Lewis T, Perkins A, Grabowski DC, Abrahamson K. Minnesota’s provider-initiated approach yields care quality gains at participating
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nursing homes. Health Aff (Millwood). 2013;32(9): 1631-1638. Bowers BJ, Esmond S, Jacobson N. The relationship between staffing and quality in long-term care facilities: exploring the views of nurse aides. J Nurs Care Qual. 2000;14(4):55-64. Pfefferle SG, Weinberg DB. Certified nurse assistants making meaning of direct care. Qual Health Res. 2008;18(7):952-961. VonDras DD, Flittner D, Malcore SA, Pouliot G. Workplace stress and ethical challenges experienced by nursing staff in a nursing home. Educ Gerontol. 2009;35(4):323-341. Pillemer K, Suitor JJ, Henderson CR, et al. A cooperative communication intervention for nursing home staff and family members of residents. Gerontologist. 2003;43 Spec No. 2(II):96-106.
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Nursing Assistant Perceptions of Their Role in Quality Improvement Processes in Nursing Homes Heather Davila, MPA; Kathleen Abrahamson, PhD, RN; Christine Mueller, PhD, RN, FAAN; Thomas S. Inui, ScM, MD; Aaron G. Black, MBA, MS, RN; Greg Arling, PhD Nursing assistants provide the majority of direct resident care in nursing homes and are centrally involved in implementing quality improvement (QI), yet little is known about their experiences in QI. Interviews with nursing assistants found that respondents perceive themselves as having a unique and important role in QI. They described key outcomes of QI as positive gains in the daily lives of residents, improved work processes, and increased time between staff and residents. Key words: long-term care, nursing assistants, nursing homes, quality improvement
Author Affiliations: School of Nursing, University of Minnesota, Minneapolis (Ms Davila and Dr Mueller); School of Nursing, Purdue University, West Lafayette, Indiana (Drs Abrahamson and Arling); Indiana School of Medicine, Indianapolis, Indiana (Dr Inui); Regenstrief Institute, Inc., Indianapolis, Indiana (Dr Inui); and Integrated Home Care, St. Paul, Minnesota (Mr Black). This project was supported by grant number R18HS018464 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Heather Davila, MPA, School of Nursing, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455 ([email protected]). Accepted for publication: November 18, 2015 Published ahead of print: January 19, 2016 DOI: 10.1097/NCQ.0000000000000170
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HEN fully authorized, the Quality Assurance and Performance Improvement (QAPI) program, an initiative of the Affordable Care Act, will require nursing homes (NHs) to implement ongoing improvementoriented activities. Although quality improvement (QI) tools and processes are familiar to NHs, the implementation of QI in health and long-term care settings remains a substantial challenge.1,2 Across health and long-term care settings, finding ways to more effectively engage direct care staff members in QI is increasingly viewed as important.3-5 Current initiatives such as NH culture change and efforts to reduce avoidable hospitalizations among NH residents focus on improving communication between nurses and nursing assistants (NAs), as well as meaningfully engaging NAs in the improvement of resident care processes. Similarly, QAPI encourages NHs to involve all members of the organization, including NAs, in improvement-oriented activities.
282
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Nursing Assistant Perceptions of Their Role in QI Processes Ideally, QI draws on the unique skills and insights of everyone who is involved or impacted by a work process. This is important not only because active engagement in change efforts may increase staff support for change5 but also because staff representing different roles within an organization may hold differing views on work processes, quality of care, and their own ability to influence quality outcomes.5,6 Although conceptualizations of quality may be interrelated across staff roles,7 the views of NAs may differ from the views of other staff. Nursing assistants may perceive themselves as knowing residents better than other staff8 and may be more confident in their ability to positively impact resident quality of life because of their close daily contact and relationship with residents.6 Frontline staff may also be particularly attuned to weaknesses in organizational processes. Research has found, for example, that NAs may assess internal communication and teamwork less favorably than management staff.9 Nursing assistants are on the frontlines of NH care, and modifications in the process, schedule, approach, and documentation of care to improve quality inevitably impact NA work. Although NAs are centrally involved in implementing QI in NHs, little is known about their views toward QI. Better understanding their experiences in QI could create a stronger foundation for engaging NAs in making needed changes in care processes, resident activities, and organizational staff policies. Drawing on the insights of frontline staff also could lead to stronger, more responsive QI programs. As part of a broader study on the impact of implementing QI on the organizational culture of NHs, this study explored the experiences of NAs in NH QI by addressing 3 questions: (1) How do NAs describe their role in QI processes? (2) What factors facilitate and impede NAs’ participation in QI? (3) What do NAs perceive to be key resident and organizational outcomes resulting from QI?
283
METHODS Study design As part of a broader mixed-methods evaluation of the Minnesota Nursing Home Performance-Based Incentive Payment Program (PIPP),10 a unique state initiative that provides financial incentives to NHs to implement provider-initiated QI projects, we conducted interviews with 45 NAs from 23 NHs engaged in QI projects that had received support through PIPP. Interviews with NAs were conducted between 2011 and 2012 by 3 investigators. Interviews were done in person, with an average interview time of approximately 20 to 25 minutes. The interviews were semistructured with open-ended responses to probes. Interview questions focused on the respondent’s role in implementing the QI project, facilitators and challenges faced by NAs participating in QI, and perceived successes or positive outcomes resulting from the project. The sampling of NAs took place within a broader series of case studies we conducted as part of the evaluation of PIPP. Thirteen unique QI projects were selected for inclusion in the study by the research team to obtain diverse representation in terms of project focus, implementation strategies, facility size, geographic location, profit/nonprofit status, and whether projects represented single or multifacility initiatives. Of the 13 projects, 5 were implemented within a single facility and 8 involved multiple facilities. Multifacility projects involved those implemented within a single organization (eg, corporation or chain) and collaborative groups of NHs that came together to implement a common QI project. Participating NAs worked in NHs ranging in size from less than 35 to more than 250 beds, with an average size of approximately 100 beds. The majority of NHs were nonprofit organizations, with about half of the NHs located in rural areas of the state. For each of the 13 projects, between 1 and 8 NAs were interviewed (see Supplemental Digital
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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Content, Table, available at http://links.lww. com/JNCQ/A241). Although the state issued the request for QI project proposals, it did not specify how facilities would respond or indicate which workers should be given new responsibilities for project implementation. Instead, leadership at the NHs, often working in collaboration with staff, prioritized topics and designed change processes within their facilities. Because PIPPsupported QI projects were developed at the provider level, targeted quality outcomes and implementation strategies varied by project. The selection of NAs for inclusion in the study was accomplished with the assistance of each NH’s QI project manager who, at the investigators’ request, identified NAs who had been involved in the project. In some cases, NAs were selected because they had taken on additional QI project-related responsibilities, such as leading resident group activities or serving as a project aide. In other cases, all NAs within the NH had similar roles in the project, and NAs were selected on the basis of their availability at the time the researchers were conducting interviews. Projects in which NAs participated focused on improvements in areas such as falls, pain, person-centered care practices, resident mood, dementia care, bathing, reducing avoidable hospitalizations, and the use of psychotropic medications. For the majority of sampled projects, expenses related to staffing—such as for staff training or additional staff time to focus on QI project implementation—represented a substantial portion of the project budget. This often meant that an organization had additional staff resources during the incentive period to devote toward implementation of the QI project. Nursing assistants played central roles in implementing each of the sampled QI projects. For example, in a project focused on reducing the use of psychotropic medications, selected NAs engaged residents in individualized activities such as hand massage, games, or oneon-one conversation. In a project focused on improving resident bathing experiences, NAs
coordinated among themselves to cover regular responsibilities while taking turns assisting residents with baths in a “spa-room,” complete with a Jacuzzi-like tub, relaxing music, scented soaps, and heated towels. Analysis The investigators obtained approval from the university’s institutional review board prior to the initiation of data collection. After receiving permission from respondents, interviews were digitally recorded and subsequently transcribed for analysis. Data were analyzed by the same investigators who completed the interviews using a thematic narrative analysis and inductive category development approach. Initially, each investigator read and reflected on the same interview data independently. After creating an initial list of categories corresponding to our primary questions of interest (eg, respondent’s role, challenges, facilitators, and perceived successes), narratives were read and reread until subthemes for each of these categories emerged. Through in-depth discussions, the team established and refined the subthemes (codes) that emerged from the interviews. After developing an initial coding scheme, each investigator recoded portions of text, and the team then discussed findings to maximize intercoder reliability. Throughout the analysis process, the team compared and discussed possible additions or revisions to the codes to reduce discrepancies within the coding scheme. Emergent codes were recorded in a codebook and refined after each batch of coding. Definitions for each code were created to maintain consistent application throughout the analysis. This process, which took place over several months, resulted in multiple subthemes for each broad category of interest. When a respondent’s statement reflected more than 1 theme, individual text fragments were coded into multiple categories. NVivo qualitative data analysis software (QSR International Pty Ltd. Version 10, 2012, Victoria, Australia) was used for managing and analyzing interview data.
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Nursing Assistant Perceptions of Their Role in QI Processes FINDINGS Nursing assistants describe their role in QI as unique and important, particularly because of their close relationships with and knowledge of residents. Teamwork, communication between staff members, and seeing positive results were identified as factors that facilitated NAs’ participation in QI. Communication was also viewed as a challenge, as well as insufficient time to interact with residents. Resistance to change among NAs, particularly at the beginning of a project, was also noted. Positive outcomes were described as improvements in the daily lives of residents and NA relationships with them, improvements in daily work processes and the work environment of NAs, and increased job satisfaction as a result of QI. Role of NAs in QI Nursing assistants played central roles in implementing each of the QI projects. Many respondents noted that successful project implementation depended on them because they work closely with residents and provide the majority of resident care. Several of the QI projects required NAs to watch residents closely to catch subtle changes in their condition, such as signs of pain or confusion. A number of projects focused on reducing avoidable hospitalizations, a current national priority being driven by the Affordable Care Act. A core component of those projects involved NAs reporting changes they observed in residents to licensed nurses so that conditions, such as a resident’s pain or an infection, could be treated early and a hospitalization avoided. Although these processes are considered routine aspects of nursing work, participating organizations often devoted substantial resources to training and retraining staff to achieve desired staff behaviors, such as increased communication between NAs and licensed nurses. As a result of staff training and the changes in work process that resulted, projects that focused on clinical outcomes (such as falls, pain, hospitalizations) seemed to raise the aware-
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ness of the importance of NAs within the organization. Nurses, in particular, reflected that NAs were “more empowered” and “more listened to” as a result of these QI projects. Nursing assistants’ intimate knowledge of and close relationships with residents was often viewed as a necessary aspect of their ability to accomplish QI project and organizational aims. The following comment from an NA articulates this perspective: We’re the eyes and ears because we’re with them on and off throughout the day . . . a lot [has] to do with knowing our resident, knowing when there is any kind of change, being able to figure out if there is some kind of pain, and then just reporting it off to the nurse.
Nursing assistants frequently discussed their role in encouraging residents to participate in QI-related activities they believed would benefit them. As part of a falls reduction project, 1 NA described herself as a “cheerleader” when working with residents on walking. Another NA who was participating in a project focused on improving resident bathing experiences described encouraging a resident who disliked routine showers to try the facility’s new spa-like tub: He was like, I don’t want that shower. I said, we have a very nice tub. How about we go get in there? And he was thrilled . . . then I turned on the bubble jets, and he [said] this is just wonderful.
Facilitators and barriers to NA participation in QI Nursing assistants described teamwork, communication, and seeing positive results as a result of QI efforts as factors that encouraged their involvement in QI. In an initiative focused on reducing the use of psychotropic medications, an NA who had taken on the role of project aide recalls other NAs talking to her about specific residents they thought would benefit from the program. Although fairly uncommon among NAs interviewed, being formally involved in planning and leading QI efforts (eg, by participating in a QI committee) was viewed by NAs as an effective way of increasing staff buy-in. As 1 NA said:
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If we have floor staff, if we have middle management on our teams, on our committees, it really helps with the buy-in because then it’s my project versus it’s what management’s telling me to do.
In projects that required NAs to pay close attention to residents’ patterns and changing conditions, trust and communication (“nurses listening to NAs,” as noted by 1 NA) were critical. An NA who participated in a hospitalization reduction initiative commented: NAs are with them [residents] more than the nurses are, so we can walk in the room in the morning and know something’s going on. The nurse trusts the NA’s evaluation that something didn’t seem right enough to follow-up on it.
Observing positive results, either in data that were shared with NAs or directly in the lives of residents, was often a turning point in staff buying in to the change effort. Being able to identify how QI benefited residents was particularly important for NAs. Interestingly, from the interviews, NAs did not spend a great deal of time talking about challenges associated with QI implementation or their participation in QI efforts. They did, however, discuss communication as a consistent challenge, as well as staff resistance to change, particularly in the initial stages of the project. Although there were exceptions, in the majority of projects, NAs were told about the QI project after the decision to implement the project had already been made and plans were underway. A consistent theme that arose in many of the interviews with NAs was related to the challenge of time. Staff often discussed the difficulty of balancing multiple demands and needing more staff resources to accomplish work responsibilities, including those related to QI. Many NAs expressed the opinion that staff were not given sufficient one-on-one time with residents, and this was a barrier to improving overall care quality. Not only did NAs discuss time with residents as an aspect of their work they highly valued, but they also described the lack of time with them as having a negative impact on residents’ lives. Nursing assistants’ consistent descriptions of wanting
more time to spend with individual residents was a particularly noteworthy theme because it emerged in many interviews, including in organizations that used project funds to support additional staff time. Other NAs expressed concerns about residents feeling lonely or depressed and indicated that the time they were able to spend with residents lessened this pain or burden. As 1 NA stated, time with residents “takes a lot of weight off their [residents’] backs emotionally.” Positive outcomes associated with QI Although NAs, similar to other staff members, talked about project-related achievements in a general sense (eg, a reduction in falls, fewer avoidable hospitalizations, improved quality of care, etc), NAs often focused their descriptions of project success on specific changes they had observed in the daily lives of individual residents, their personal relationships with residents, and their enhanced ability to provide good care. Nursing assistants told vivid and inspirational stories related to outcomes observed as result of QI efforts, such as a story about a resident regaining strength and walking again for the first time after a long period of not walking. Also within the context of QI projects, particularly those who afforded more time between staff and residents, NAs often shared examples that highlighted feeling appreciated or needed by residents and the importance of reciprocal relationships. They also noted the social support NAs provide to residents, as 1 NA commented: . . . depression issues with not even feeling like they’re worth anything and not even wanting to try. Then they have the one person that comes over and over, they start feeling like “I matter.”
Although several NAs discussed the challenge of changing routines when a new initiative was first introduced, they also talked about ways in which their work had improved as a result of QI. Most NAs were overwhelmingly positive about the impact of QI efforts on the organization and themselves individually. Many described increased efficiency within the organization, often because negative and
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Nursing Assistant Perceptions of Their Role in QI Processes ultimately time-consuming events, such as hospitalizations or falls, had been avoided as a result of QI. In several cases, NAs discussed positive changes in the work and living environment that came about because of QI. The implementation of QI typically required increased staff training. Nursing assistants often described appreciating the new knowledge and skills they had gained as a result of the QI projects in which they participated. To NAs, these gains were tied to their perceived ability to provide better care to residents: “For me, it’s an accomplishment. If there’s a resident who needs help . . . we want to make sure that we help them, whatever their needs, we’re always there.” Nursing assistants talked about how QI implementation had created a stronger sense of teamwork, including improved communication between nurses and NAs. Many discussed other benefits they perceived to be a result of the QI projects: having extra time with residents, being able to develop closer relationships with residents as a result of this time, and providing residents with better care. DISCUSSION The aim of this study was to explore the experiences of NAs who had participated in various QI projects initiated by NH providers. Several themes emerged from our interviews with NAs. These included the important contributions of NAs in NH QI: the importance of teamwork, communication, and seeing positive results to NA’s active participation in QI; challenges related to communication and resistance to change; the persistent challenge of time to spend with residents; and positive outcomes such as observable improvements in the daily lives of individual residents, added time with residents, improvements in work processes, and heightened job satisfaction. The findings from this study are consistent with prior research demonstrating that NAs see themselves as knowing residents better than other staff members,8 find meaning in their work largely through time and relationships with residents,11 and value the en-
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hanced ability to provide what they perceive to be good care.12 Our findings, however, are unique in that these themes arose within the context of QI implementation, a contribution to the current literature related to NH QI. Nursing assistants who participated in this study noted receiving more recognition within the organization for their contributions in QI, especially by licensed nurses. They often received additional training or expanded roles, which they valued. Although several NAs described being involved in leading QI efforts, few NAs we interviewed had been meaningfully involved in giving input into project development. Element 2 of the QAPI process, focused on governance and leadership, aims to expand involvement in quality efforts to all members of the organization. Yet, little is known about the most effective strategies for involving NAs in planning and leading QI within NHs. Further research could explore the impact of NAs’ participation in QI leadership, as well as the types of leadership contributions NAs make in QI efforts. Relatedly, although NAs participating in this study described their relationships with and knowledge of residents as beneficial in QI, little is known about the extent to which NAs’ insights about residents, including their needs and preferences, are brought into planning QI priorities within NH organizations. Further research could investigate the most effective ways to use the particular knowledge and insights of frontline workers in QI efforts. Nursing assistants who participated in this study raised challenges that are commonly associated with QI implementation: communication, resistance to change, and time. The value of and preference for more time with individual residents was a striking theme that emerged in our interviews with NAs. The dominance of this theme in the interviews likely reflects one of the primary challenges of direct caregiving work: the need to balance the goals and demands of the organization with the perceived needs of residents.13,14 Relatedly, this finding highlights the tension direct care workers, such as NAs, may experi-
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ence when expected to fulfill caregiving roles normally fulfilled by family members.14 In projects in which increased staff time was a component of the QI initiative, NAs described appreciating the additional time they were able to spend with residents, and they indicated that this time benefitted the quality of residents’ lives. This is consistent with prior research demonstrating that NAs view their personal contact with residents to be a critical component of resident quality of life.6,11 In addition, because prior research has found that NAs may perceive themselves to better able to impact resident quality of life than other staff members,6 finding ways to integrate more individual time between NAs and residents into QI work could increase NA job satisfaction and potentially benefit residents. Demonstrating how specific QI initiatives have the potential to improve residents’ lives could strengthen staff engagement in change efforts. Further research could investigate whether NAs and other direct care staff are more interested in or engaged in certain types of QI projects, for example, initiatives focused on improving resident quality of life or projects that involve increased time between staff and residents. The generalizability of the findings for this study are limited since the NAs who participated in this study were selected by their organizations to be interviewed, often because they had a central role in QI implementation.
The views of the NAs we interviewed, therefore, may not represent the views of NAs in general, even within the NHs in which they work. In addition, because the organizations in which participating NAs worked had received financial support from the state to support the QI project, other NHs may not have the same resources to implement QI. The experiences of NAs who participated in this study suggest that the process of implementing QI itself may improve teamwork and communication, particularly between NAs and licensed nurses. In addition to achieving improvements in targeted outcomes, QI implementation may strengthen the types of organizational norms and behaviors that facilitate ongoing improvement. SUMMARY The findings of this study affirm previous research on what matters to NAs in their work: the time they are able to spend with residents and ability to make a difference in residents’ lives. Nursing home QI efforts could be strengthened by more meaningfully involving NAs in QI. While the QI movement has experienced a mixed history in NH settings, the current policy environment is creating incentives for improving and maintaining a higher quality of care. It may be possible to improve NH quality by better utilizing the unique strengths and insights of NAs in QI efforts.
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