Empowered Work Teams in Long-Term Care Strategies for Improving Outcomes for Residents and Staff By Dale E. Yeatts, Ph.D., Cynthia M. Cready, Ph.D., and Linda S. Noelker, Ph.D. Foreword by Mary Jane Koren, M.D., M.P.H.

Excerpted from Part I of Empowered Work Teams in Long-Term Care by Dale E. Yeatts, Ph.D., Cynthia M. Cready, Ph.D., and Linda S. Noelker, Ph.D.

Copyright © 2008 by Health Professions Press, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

Empowered work teams (EWTs) are groups of roughly 4 to 10 employees of the same rank or level (e.g., all computer board assemblers or all direct care workers). This is different from interdisciplinary work teams, made up of people with differing job titles and levels (e.g., social worker, nurse, and physician). Those in an EWT are responsible for directing some or most aspects of their work, including planning and scheduling who will do what, ordering supplies as needed, and monitoring the team’s performance. At the same time, the employees are still responsible for performing the technical aspects of their work, whether it is assembling computer boards to be installed in smart bombs or helping residents to the dining hall (Johnson & Johnson, 1994; Wellins, Byham, & Dixon, 1994; Yeatts & Hyten, 1998).

The use of EWTs first occurred in manufacturing settings and has spread widely. Numerous studies have shown that such teams improve an employee’s performance and attitude and reduce turnover and absenteeism. However, the research also indicates that these effects are contingent on successful implementation of the teams. And the research has taken place primarily in manufacturing settings.

More recently, EWTs have been introduced into service and health care settings. Long-term care (LTC) appears to be particularly well suited for EWTs. Traditionally LTC has used a medical model, which is characterized by a rigid hierarchical structure that leaves little room for those providing direct service to contribute to management decisions. It has been suggested that the resulting institutional culture may contribute to poor employee performance, low satisfaction among direct care workers, and exceptionally high turnover, often between 60% and 80% a year, in nursing homes (NHs) (Binstock & Spector, 1997; Cohen- Mansfield, 1997; Halbur, 1986; Packer-Tursman, 1996). Research in the manufacturing industry and some in health care suggests that allowing those who actually do the hands-on work (e.g., direct care workers) to participate in decision making will result in better decisions being made, more satisfied employees, and lower turnover and absenteeism.

Updating management strategies has been recognized for some time as a way to improve resident care. In the 1980s Congress commissioned a study by the Institute of Medicine to determine how best to improve the quality of NH care. This study concluded that the resident care provided was a direct result of how LTC employees are managed (Heiselman & Noelker, 1991; Institute of Medicine, 1986). In the 1990s, Binstock and Spector (1997) conducted an in-depth study funded by the Agency for Health Care Policy and Research to identify the five highest priority areas for research to improve LTC. One of the five areas they identified was management practices. They found that there was a lack of knowledge among NH administrators regarding effective strategies for managing NH staff and that this appeared to be having detrimental effects on the direct care provided to residents (see also Davis, 1991). More recently, the U.S. Centers for Medicare and Medicaid Services have recognized the need to move beyond the medical model for managing LTC facilities. To assist LTC providers, they have set an expectation that quality improvement organizations across the country will help LTC providers transition from a medical model of care to a more person-centered model. The result has been the introduction of a variety of initiatives. For example, the Pioneer Network was organized in the 1990s with the purpose of identifying “deep systematic change” that will allow a “person-centered” focus of care (Fagan, 2003, p. 125). Members of this network include practitioners, researchers, educators, and other professionals who seek to find alternatives to the strictly medical model. In 1992 the Eden Alternative was developed by Thomas and Thomas (Thomas, 1994, 2006) to encourage a more homelike environment in the NH, and a decade later Thomas and his colleagues introduced the promising concept of Green Houses that provide a structural alternative in the form of specially designed houses for older adults (Keane, 2004). In 1994, another approach, the Wellspring Model, was established to encourage NHs to work together to teach line staff best clinical practices and to change the typical NH culture of control (Kehoe & Heesch, 2003; Reinhard & Stone, 2001). In 2001, the Learn, Empower, Achieve, and Produce (LEAP) initiative was under way to change how the NH workforce was viewed and treated by NH management (Hollinger-Smith, 2003; Hollinger-Smith, Ortigara, & Lindeman, 2001). In a more recent development, Grant and Norton (2003) identified various stages that NHs are expected to go through in the process of culture change. Additional recent initiatives include those by Gilster, Accorinti, and Dalessandro (2002, Pillemer, Suitor, and Wethington et al. (2003), Rosen et al. (2005), and Shields (2004).

One characteristic typically found as a component of these and other person-centered initiatives has been the empowering of direct care staff (also called frontline staff). It is reasoned that direct care workers have the most knowledge about residents; they know better than any other employees the likes and dislikes of residents. This might include what they want when they wake up in the morning (e.g., a glass of water or the newspaper), where they prefer to go during the day, and what they want to wear when they go to bed at night. Consequently, the direct care workers are in the best position to make decisions that are directly related to day-to-day resident care (Beck, Ortigara, Mercer, & Shue, 1999).

A second major reason for introducing EWTs into LTC has been offered by Cohen-Mansfield and Noelker (2000, p. 52). They note that “projections indicate there will be a shortage of nursing assistants that will reach crisis proportions in coming years. This will be the direct result of the increasing elderly population, particularly among the oldest-old (those 85 and over) who make the greatest use of nursing home care.” Although the LTC workforce must grow nearly 70% in the first decade of the 21st century, the U.S. labor force is projected to grow at a rate of only 1.2% annually (Cohen-Mansfield, 1997). Unless there is some way of attracting new NH employees, there will not be adequate staff available to provide care. One means of attracting new NH employees is a management strategy that focuses on making the work more attractive, such as by allowing employees to have a voice in management decisions that are related to their work.

While the need for LTC employees is increasing, those who currently work in LTC are quitting at an alarming rate and show high levels of absenteeism (De-Francis, 2002; Eaton, 2000). Turnover rates among NH employees usually range from 40% to 75%, with some reaching 500% (Banaszak-Holl & Hines, 1996; Caudill & Patrick, 1991–1992; Kane, 2001). Such high turnover rates along with high absenteeism negatively affect continuity of care and the establishment of personal relationships between direct care workers and residents. These relationships have been found to be important to high-quality care (Caudill & Patrick, 1991–1992; Waxman, Carner, & Berkenstock, 1984). More specifically, long tenure typically results in the LTC employees becoming more familiar with the residents and their likes and dislikes. This results in higher performance outcomes, particularly when measured in terms of customer (e.g., resident) satisfaction. Similarly, high levels of absenteeism reduce the continuity of care, and as a result residents are served by many different employees, many of whom are unfamiliar with their preferences (Caudill & Patrick, 1991–1992).

Furthermore, turnover has the added problem of cost, because the LTC facility must constantly advertise for new employees and provide orientation training. A study of NH staff turnover by Caudill and Patrick (1991–1992) reveals that NH facilities can pay more than $7,000 per RN replacement and more than $2,000 to replace a certified nurse aide (Cohen-Mansfield, 1997).

One way to retain employees is to make their jobs more desirable (Wiener, 2002). Unfortunately, traditional LTC management strategies do a very poor job of this. Research suggests that appropriately implemented EWTs can make the job of a direct care worker more desirable. Successful implementation entails attention to staff training, team design, and, most importantly, management support.