The Culture Change Way: Empowering direct care workers to improve care

Becka Livesay

NCCNHR, the Pioneer Network, ombudsmen programs, citizen advocacy groups, and others around the country are working to spread culture change principles and practices in our nation’s nursing homes. These principles are aimed at improving quality of life and care for residents by making nursing homes into true homes, not the medical-model institutions they too often are, with inflexible management hierarchies that put residents on the bottom of the pyramid.

To accomplish that goal, we must create a new role for direct care workers, valuing their work and relationships with residents and giving them more autonomy and decision-making power so they can deliver the individualized, “person-centered” care residents want and need. The traditional task-focused, almost assembly-line role assigned to nursing assistants in nursing homes actually gets in the way of delivering good care, forcing workers to do things like wake people up way to early to prepare them for meals or bathe them when they don’t want to be bathed.

Why dis-empowering workers hurts residents
In many traditional nursing homes, direct care workers are underpaid and undervalued. The average wage for direct care workers in hospitals and nursing homes is less than $12 an hour, and many do not get health insurance through their jobs, since they can’t afford the premiums and copays. In general, direct care workers also experience poor working conditions, including a high risk of injury, and many report a lack of respect from their supervisors. All of these things contribute to the profession’s high turnover rate, and high turnover among workers hurts the people who depend on them.

Perhaps even more significant, from the residents’ point of view, is how dis-empowered most nursing assistants are. Nursing homes generally give direct care workers little or no say in deciding how care is delivered. They tend to be overworked, caring for as many as 8, 10, or even more people. And they are often moved around from one shift to the next, which makes it hard to get to know individual residents. No wonder it’s difficult for most direct care workers to tailor care practices to fit the individual needs and preferences of the people they assist.

How worker empowerment looks and feels
Last spring, I got to see how it looks when direct care workers and residents are empowered when I visited the Lebanon Valley Brethren Homes, a long-term care facility in Palmyra, Pennsylvania. Lebanon Valley is a participant in the Green House® project, which implements culture change by creating small communities for residents and staff. The average Green House residence is intended to look and feel like an actual home, housing just six to ten elders.

Upon entering Lebanon Valley, I could immediately sense the difference. Almost everyone was gathered in the bright common room, and the smells of delicious-smelling lunch filled the house. One shahbaz – the term used for direct-care workers in Green Houses – gave a tour of the home. It was warm and welcoming, and each elder had his or her own room and bathroom. In the enclosed backyard, there was a large patio with a raised garden.

The close bond between shahbazim and elders was apparent, too, as was the fact that the role of the shahbazim was valued and honored. Entering the Green House almost felt like intruding on someone’s private home; the space was private and definitely belonged to the elders and the shahbazim.
Each shahbaz worked with the same residents every day, so workers and residents got to know each other well. The shahbaz who conducted our tour in Pennsylvania spoke about the importance of her relationship with the elders in the house, saying she often knows each elder so well that she can quickly detect when something is wrong. Elders and shahbazim also bonded over meals in a combined dining room/kitchen, where they all ate at the same big table in a relaxed, family-style setting.

The shahbazim were responsible for overall management and operation of the household, including meal preparation and light housekeeping as well as caregiving. This integrated model of care helped make the house feel like a home. It also gave the shahbazim the power to change what wasn’t working and adapt to individual residents’ changing schedules or needs. During my visit, a shahbaz shared a story about an elder who couldn’t sleep because she felt as if her room was on fire. Rather than dismiss her concerns as delusional, the shahbaz discussed them with the resident’s family and learned that she had been in a fire as a child. The shahbaz then realized the resident’s room was lit by a red light at night, which might make it look as if it was afire. She replaced the red bulb with a blue one and the problem was solved.

The Green House provides about 120 additional hours of specialized training before shahbazim take on new roles. The curriculum includes culinary training, safe food handling, certification in first aid and CPR, and policies and procedures for the home they are assigned to.  Training also covers communications skills, since the Green House model stresses the importance of clear communication among staff and between staff and residents. To facilitate communication, each house has an open living room, where people tend to gather for informal chats.

What employers can do to improve job conditions and care quality
The following person-directed practices can be adopted by facilities to empower direct care workers and improve job conditions – and, thus, to improve quality of care and quality of life for residents. Furthermore, the majority of the following practices would not cost facilities additional money; in fact, many of these changes might actually save money. For example, allowing staff to manage their own schedules would eliminate the need for a staff scheduler.

1. Empower direct care staff to make decisions in their daily work, focusing on responsibility and accountability and giving them strong support from management.

2. Emphasize the relationship between the resident and direct care worker as central to quality of life for both.

3. Strengthen relationships between hands-on caregivers and residents by using consistent assignment of staff.

4. Hold weekly meetings or regular learning circles with staff, encouraging team building and seeking staff input.

5. Let staff manage their own schedules.

6. Teach and model good communication, especially staff listening skills.

7. Encourage creative ideas from staff, residents, and families.

8. Provide training that includes mentorship and support.

9. Increase direct care workers’ wages to improve staff morale and job satisfaction.