ORIGINAL ARTICLE

The significance of ‘facilitator as a change agent’ – organisational learning culture in aged care home settings Laurie Grealish, Amanda Henderson, Fritz Quero, Roslyn Phillips and May Surawski

Aims and objectives. To explore the impact of an educational programme focused on social behaviours and relationships on organisational learning culture in the residential aged care context. Background. The number of aged care homes will continue to rise as the frail older elderly live longer, requiring more formal care and support. As with other small- to medium-sized health services, aged care homes are faced with the challenge of continuous development of the workforce and depend upon registered nurses to lead staff development. Design. A mixed-method evaluation research design was used to determine the impact of an educational programme focused on social aspects of learning on organisational learning culture. Methods. One hundred and fifty-nine (pre) and 143 (post) participants from three aged care homes completed the Clinical Learning Organisational Culture survey, and three participant-researcher registered nurse clinical educators provided regular journal entries for review. Results. While each site received the same educational programme over a sixmonth period, the change in organisational learning culture at each site was notably different. Two aged care homes had significant improvements in affiliation, one in accomplishment and one in recognition. The educators’ journals differed in the types of learning observed and interventions undertaken, with Eucalyptus focused on organisational change, Grevillea focused on group (student) change and the Wattle focused on individual or situational change. Conclusion. Clinical educator activities appear to have a significant effect on organisational learning culture, with a focus on the organisational level having the greatest positive effect on learning culture and on individual or situational level having a limited effect. Relevance to clinical practice. Clinical educator facilitation that is focused on organisational rather than individual interests may offer a key to improving organisational learning culture.

What does this paper contribute to the wider global clinical community?

• A sociocultural educational frame-





work provides the scope to offer a staff development programme focused on how to ‘do’ working relationships. Systematic approaches to continuing education, with a focus on social relationships and behaviours, can produce improvements in organisational learning culture. Clinical educator facilitation of work-based learning can have demonstrated effectiveness when targeting organisational rather than individual practices.

Authors: Laurie Grealish, PhD, RN, FCNA, Associate Professor of Subacute and Aged Nursing and Gold Coast University Hospital and Health Services, School of Nursing & Midwifery – Gold Coast, Griffith University, Southport, Qld; Amanda Henderson, RN, RM, PhD, Nursing Director (Education), Queensland Health Research Fellow, Metro South Health, Ipswich Road, Woolloongabba, 4102, Qld, Professor, Griffith Health, Griffith University, Queensland, Australia; Fritz Quero, PGDip in Health Sciences in Leadership and Management, RN, Clinical Educator - Calvary Retirement Community (Canberra 2010–2013), Community Detention Coordinating

RN - IHMS (Sydney 2013–2014), Consultant - AutumnCare (Melbourne 2014-Present); Roslyn Phillips, RN, BN, Clinical Educator, Calvary Retirement Community Canberra, Bruce, ACT; May Surawski, RN, MN, Clinical Facilitator and Tutor, Signadou Campus (Canberra), Australian Catholic University, Watson, ACT, Australia Correspondence: Laurie Grealish, Associate Professor of Subacute and Aged Nursing and Gold Coast University Hospital and Health Services, School of Nursing & Midwifery – Gold Coast, Griffith University, Southport, Qld 4222, Australia. Telephone: +61 7 5635 6277.E-mail: [email protected]

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 961–969, doi: 10.1111/jocn.12656

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Key words: aged care, facilitation, staff development, teamwork Accepted for publication: 8 June 2014

Introduction The number of older people in the developed world continues to rise with implications for health and aged care services (Guzman et al. 2012), with the demand for highquality aged care services expected to accelerate over the next 40 years. The aged care sector is rapidly expanding and as such is challenged to support the burgeoning workforce with meaningful education that improves practice. In some aged care settings, nursing students have been introduced with a benefit to staff learning (Grealish et al. 2010). While the presence of students may benefit staff development, work-based learning strategies designed for staff are emerging in aged care (McCormack & Slater 2006). A sociocultural theory of work-based learning (Billett 2002) provides a framework to expand staff development from training programmes to collective learning through work. Three aged care services in one Australian jurisdiction regularly host nursing and allied health students and agreed to participate in a programme of education focused on social behaviours and relationships. This study aims to investigate the effects of the programme on work-based learning practices and clinical organisational learning culture.

Background As the need for ageing services continues to rise, managers of small and medium aged care services are increasingly challenged to continually develop their services and staff. Health service organisations with a commitment to continuous service improvement are recognised for high-quality services, as well as high levels of staff satisfaction (DeSilets & Pinkerton 2005). Such organisations are often known as learning organisations. Learning organisations are as diverse as the services they offer, but there are some agreed key features (Schaeff & Pilgrim 2006). In particular, learning organisations require an underlying value of trust within the team, where members demonstrate signs of goodwill and collaboration, share in open dialogue about other views, and continuously transform and improve themselves (Schaeff & Pilgrim 2006). The social and cultural aspects of learning are emphasised in a learning organisation. To establish goodwill and collaboration, nursing teams dominated by individuals whose practices are founded upon

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deeply established interpersonal alliances and historical workplace practices must be addressed. The behaviours of these individuals are ‘a deliberate and ongoing array of often subtle and masked behaviours and actions that accumulate over time, experienced as a gradual, cumulative and often hidden and intensively harmful experiences’ (Hutchinson et al. 2006, p. 229) and are often labelled collectively as bullying behaviour. The foundation for developing a learning organisation requires strategies to name and address bullying tactics such as isolating individuals, offering negative criticism, sabotage and invalidation. To share in open dialogue about other views is essential for team approaches to practice. The culture in learning organisations is often premised on team approaches to practice (McCormack et al. 2010, Walker et al. 2011) and requires greater attention to practical knowledge (Olson et al. 2010), including how to ‘do’ relationships. Models of mutual support and learning in the workplace are often associated with learning as a by-product of work processes (Eraut 2007). Individual and collective learning are co-constituted in a dynamic, and sometimes emotional, process (Boreham & Morgan 2004, Simpson & Marshall 2010). To develop a learning organisation, where staff can learn from practice, staff members require social or interpersonal skills, including the skills of providing feedback, seeking clarification and awareness of the emotions associated with learning. Sociocultural learning theory can provide a framework for articulating the value of the social relationships required for teamwork and learning from practice. Ongoing collective transformation of an organisation recognises the workplace as a complex network of social interactions with associated symbols, routines and rituals (Elmer & Kilpatrick 2008). Organisational work teams continually acquire, produce and synthesise knowledge in a longitudinal and iterative process through a range of social interactions (Olson et al. 2010), thereby transforming and improving their practice (Schaeff & Pilgrim 2006). Establishing symbols and rituals to value and reward staff practices that are person-focused is a key element in establishing an organisational learning culture (Schoonbeek & Henderson 2011, Henderson et al. 2013). Facilitation is an important aspect of staff development (Rycroft-Malone et al. 2004), and therefore, in continuously improving the quality of services. Facilitation is also recognised as a key element of work-based learning © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 961–969

Original article

(Williams 2010). The capacity of the facilitator can range from basic provision of practical help and support to the exercise of personal influence to develop and empower individuals and teams (Harvey et al. 2002). In this study, the clinical educator at each aged care home facilitated workbased learning as part of their role. For the purpose of this research study, their individual ability to influence practice is termed ‘agency’. Agency is considered to be a key attribute to facilitate staff development and requires the ability to move from ‘doing for’ others to enabling others (Harvey et al. 2002). While the presence of skilled facilitators can potentially enhance an organisational learning culture, the nature of how facilitators can best effect change is poorly understood (Seers et al. 2012). An investigation into the effects of an education programme focused on social behaviours and relationships on (1) staff learning behaviours and (2) organisational learning culture in aged care homes can provide greater understanding of staff development models for this sector.

Facilitator as a change agent in aged care homes

open to all staff, including ancillary as well as care staff, and achieved high participation rates. The programme was conducted during 2012, in eight two-hour sessions; with three sessions in phase one (April), three in phase two (June) and two in phase three (August). The intensive one-day workshop for three clinical educators was held in August. The purpose of the clinical educator workshop was to provide an opportunity to reflect on leadership and change as part of the educational package. The programme concentrated on the process of building a learning culture in each two-hour session, with staff from across all areas of the organisation engaged in workshop activities, role play and individual/shared reflection to: • Gain acceptance. • Recognise and combat bullying. • Foster learning in practice. • Use reward and recognition. • Build champions (Schoonbeek & Henderson 2011).

Sample selection

Methods A mixed-method evaluation research design was adopted for this study. The study aimed to explore the impact of an educational programme focused on social behaviours and relationships on staff learning behaviours and organisational learning culture in the residential aged care context. The research questions guiding the study were as follows: 1 What is the effect of an educational programme, designed to focus on social behaviours and relationships, on organisational learning culture in an aged care home? 2 What forms of learning activity are generated by the educational programme?

The three aged care homes provided a convenience sample, and each was given pseudonyms: Eucalyptus, Grevillea and Wattle for reporting purposes. The service model for each home is quite different, with two homes (180 and 250 places each) part of two separate larger distributed services and one (140 places) a stand-alone service. The population for the organisational learning culture surveys includes all staff in each of the three aged care homes. The clinical educators in each aged care home were primarily responsible for coordinating and supervising student placements. They made themselves available for this study as participant-researchers.

Data collection methods The intervention Three aged care homes had been working collaboratively to host nursing and allied health students. The managers of these aged care homes reported that while the presence of students had a positive influence on staff learning, they were interested in exploring new ways of promoting learning within their respective organisations. An internationally recognised educational programme to build organisational learning culture (Schoonbeek & Henderson 2011) was adapted to the aged care home setting and implemented in three phases over a six-month period. The aim of the educational programme was to collectively develop shared standards for social behaviours and build relationships that supported learning. An external consultant delivered the programme. The programme was © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 961–969

The data were collected over a six-month period. Surveys were distributed and collected before and after the programme, in April and October. The clinical educator journals were collected second monthly in April, June, August and October. An outline of the data collection in relation to the intervention is provided in Table 1. At two of the aged care homes, the surveys were distributed to all staff by the clinical educators and at one, distributed by the human resource manager. The surveys were collected in a box held in the staff tea room in each facility.

The organisational learning culture surveys Organisational learning culture was measured using the Clinical Organisational Learning Cultures (CLOC) survey

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L. Grealish et al. Table 1 Timing of data collection with intervention T0

April

June August T1

October

Survey of staff at three facilities using Clinical Organisational Learning Cultures (CLOCS) Intervention: Three-day course provided Journal entries from clinical educators collected Intervention: Three-day course provided Journal entries from clinical educators collected Intervention: Two-day course provided Journal entries from clinical educators collected Survey of staff at three facilities using CLOCS Journal entries from clinical educators collected

(Henderson et al. 2010). This survey has been used in a range of settings (Walker et al. 2011, Henderson et al. 2013, in press). The CLOC survey requires the staff member to respond with their level of agreement (five-point Likert scale) to 27 statements. The 27 statements align with the five subscales of organisational learning culture and included some questions on dissatisfaction as follows: • Accomplishment (n = 4). • Affiliation (n = 4). • Recognition (n = 10). • Influence (n = 3). • Dissatisfaction (n = 6). Six of the statements were negatively framed to reduce response bias. Sample size was determined using a power analysis based on calculation of effect size from the intervention using the CLOC survey (Walker et al. 2011). A minimum sample size of 130 responses (40%) from the three aged care homes was required for statistical significance. The CLOC survey data were collated and then analysed using IBM SPSS STATISTICS version 19. Cronbach’s alphas were calculated for each subscale: accomplishment (075), recognition (093), affiliation (083), influence (029) and dissatisfaction (064). All are of an acceptable (06 or higher) or higher standard, with the exception of influence. However, the original authors of the CLOC survey note the construct of influence to be problematic (Henderson et al. 2010). Changes in subscale scores of approximately 05 (e.g. 35–40) have been associated with nurses reporting less gossiping and negative behaviours between staff, and staff adopting a responsive pro-active approach to practice issues (Henderson et al. 2013). An independent-samples t-test was run using each subscale and each question individually, to determine whether there were any significant mean differences from pretest to post-test. In all t-tests run, significance is indicated by a probability value of

The significance of 'facilitator as a change agent'--organisational learning culture in aged care home settings.

To explore the impact of an educational programme focused on social behaviours and relationships on organisational learning culture in the residential...
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