LTCO innovations now seek  to prevent a variety of conditions, including incontinence, pressure ulcers, falls, dehydration, insomnia, dysphagia, abuse of restraints, and elder mistreatment. In Quebec, Canada, as in other industrialized countries (Levenson, 2009), long term care organizations (LTCOs) are encouraged to improve their practices in order to address their residents’ needs more appropriately (Ministère de la santé et des services sociaux [MSSS], 2005). These changes are not only required by governmental policies but also supported by academic disciplines seeking to develop best practices for the multiple health conditions related to old age (Levenson & Morley, 2007). LTCO innovations now seek  to prevent a variety of conditions, including incontinence, pressure ulcers, falls, dehydration, insomnia, dysphagia, abuse of restraints, and elder mistreatment (Etheridge, Tennenbaum, & Couturier, 2008; MSSS, 2002).

Implementation of innovative care practices in LTCOs requires multidisciplinary involvement, and even more importantly, systemic change management approaches (Levenson, & Morley, 2007). Nursing assistants play a key role in LTCOs given their physical proximity to residents. Nursing assistants are generally known as “certified nursing assistants” (or CNAs) in the United States (US), and are referred to as “personal support workers” in many provinces of Canada. In Quebec, as in other Canadian provinces and in the US, nursing assistants working in LTCO are trained to carry out hygiene and daily living assistance interventions (Pennington, Scott, & Magilvy, 2003). Those currently accepted as employees in public LTCOs in Quebec usually have a Diploma of Vocational Studies (DVS) conferred by a professional centre. Nursing assistants typically provide 80% to 90% of all resident care in LTCOs (Bishop, Squillace, Meagher, Anderson, & Wiener, 2009), including feeding, dressing, toileting, and grooming. They average a staffing ratio of 6 to 10 residents per one nursing assistant, depending on the work setting and the severity of the residents’ conditions (Ramarajan, Barsade, & Burack, 2008).

Implementation of innovative care practices in LTCOs requires multidisciplinary involvement, and even more importantly, systemic change management approaches. The goal of our study described below was to identify factors inherent in nursing assistants’ practice in LTCOs that can influence their involvement in change initiatives. We sought to answer the following question: Under what conditions can the team of nursing assistants act on organizational change?

In this article, we will consider the implementation of change in LTCOs and present our study describing both the process by which new nursing assistants are informally integrated into LTCOs in Quebec, Canada, and the process by which informal work strategies are transmitted to these new assistants. Then we will discuss whether teamwork is a ‘deterrent to change’ or a ‘lever for change,’ address issues regarding the collective structure of nursing assistant teams, share a Five-Step Innovation Plan, and propose that organizational change among nursing assistants in a LTCO is best accomplished when the leaders consider the nursing assistants’ strong sense of community to be a change engine rather than a change obstacle.

Implementing Change in Long Term Care Organizations

Implementing change in LTCOs remains a complex task that is often based on intuition and anecdotes and characterized by very uncertain outcomes (Masso & McCarthy, 2009). Although several scholars have undertaken the study of the change process in LTCOs as a whole (Johnson, Ostaszkiewicz, & O’Connel, 2009; Shanley, 2007), it is also important to learn about the peculiarities of specifically managing nursing assistants during these change initiatives. Narine and Persaud (2003) have noted that:

Organizational myths and stories, and core organizational symbols and rituals can be used to manage culture in organizations. Healthcare managers must be aware of the different cultures within their organization and the reactions among these cultural groups to proposed changes. Different cultural groups may require different approaches…. (p. 185).

Implementing change in LTCOs remains a complex task that is often based on intuition and anecdotes and characterized by very uncertain outcomes.  Likewise, Plsek and Kilo (1999) asserted that exploring the rationality of other people’s points of views may help to understand their resistance to change. From this perspective, nursing assistants are not passive individuals forced to adopt innovations, but rather active participants contributing to the creation and development of their practice within the scope of their work teams and the organizational standards and rules imposed by their LTCO (Crozier, & Friedberg, 1980). Work teams refer to groups of nursing assistants working in the same unit or ward, i.e. sharing the same workspace and providing care to the same residents (Tyler, 2010).

In this study, we decided to use the strategic analysis approach, as developed by Crozier and Friedberg (Crozier, & Friedberg, 1980; Friedberg, 1996). The seminal work of Crozier and Friedberg was fundamental in the development of the micro-politics approach to organizational analysis, which has the value of highlighting the nature and effects of the interactions between the actors’ interests and idiosyncrasies and their organization’s structural constraints and opportunities (Haunschild, Nienhueser, & Weiskopf, 2009). The worthwhileness of considering the reciprocal influence between actors or groups of actors and their organizational context in developing change management strategies in healthcare settings has been recognized (Richer, Ritchie, & Marchionni, 2010). The strategic analysis framework explains that collective action is defined not only by the prescribed work, namely post-training ‘good’ practice, but also by the workers’ ability to build innovative practices to meet work requirements. Although Canadian geriatric managers control the entire work process, the aides agree on their daily tasks and the distribution of these tasks. Crozier’s framework makes it possible to define the means of understanding the collective structure of the nursing assistants’ work during the many change endeavours facing LTCOs, as described below in the study findings.

Study Method and Analysis

This section describes the study method and the process of data analysis. It includes a description of the study sample, interview process, and analysis procedure. This qualitative study was conducted in two, non-specialized, long term care wards that were located in two different LTCOs. These two long term care wards were similar in size, and both were situated in a rural environment. In total, 23 interviews were conducted between September and December of 2009 by the first author. This study was approved by both the the Ethics Committee of the Health and Social Services Centre - Institute of Geriatrics of Sherbrooke University and by the research committee of both care centres.

Sample

Table 1 describes the characteristics of the participants, including their gender, age, and years of service. Standard Deviations (SD’s) for age and length of service are provided.

Table 1. Demographic Description of Study Participants

The two long term care wards were selected on the basis of acceptance of the LTCO’s willingness to participate. We met with four head nurses from the two LTCOs that agreed to participate, but only two head nurses voiced willingness to participate. The sample included those nursing assistants who volunteered to participate. To recruit nursing assistants we posted flyers on various billboards of the two LTCOs that detailed the objectives of the study and invited nursing assistants to contact the first author. The head nurses of the participating wards’ encouraged the nursing assistants to volunteer. The nursing assistants who expressed an interest in participating were asked to schedule a time (outside of their working hours) to meet with the interviewer.

A notable feature of this sample is the fact that it was primarily feminine in composition; 20 of the 23 participants were females. This proportion represents Quebec’s general health and social care workforce, of which approximately 80% are women (Grenier, 2008). The fact that most of the study participants were closer to the middle of their career than the beginning (average age: 41; average length of tenure: 12 years) may have had a positive impact on the quality of the data, given that the participants likely had a greater understanding of their work than novice workers. There have been no major structural changes in terms of the role of nursing assistants or the management of LTCOs in Canada since this data was collected near the end of 2009.

Interviews

The interviews were semi-structured and averaged about 70 minutes in length. The first author developed all of the questions. The participants worked the day shift, generally between 6:30 a.m. and 2:30 p.m. Assistants attended to residents’ hygiene, toileting, activity, and mealtime needs. The average resident to nursing-assistant-staff ratio in the wards studied was 6 residents per staff member. Participants were asked to describe organizational issues currently affecting their work, with a focus on the challenges related to the integration of new nursing assistant recruits into the team and on concrete solutions used to address these challenges. Upon receiving the participants’ responses, follow-up questions addressed topics not included in the interview schedule. These questions led to the emergence of organizational level problems and responses previously unknown to the interviewer. The interview schedule was divided into four categories as described in Table 2. Sample questions for each category are included in the table.

Table 2. Examples of Topics and Questions

Analysis

All interviews were fully recorded and transcribed. The content of each transcript was validated by the first author who checked the agreement between the written and audio files. All three authors participated in analyzing data.

A semi-inductive analysis approach was utilized. Data were analyzed using pre-established categories (‘description of work,’ ‘organizational problems stemming from the teamwork,’ ‘temporal problems,’ and ‘integration of new recruits’). However, researchers remained open to any additional categories/themes that might emerge from the interview data.

The nursing assistants’ discourses were categorized according to the structure of the pre-established categories. The discourses did lead to the identification of two new categories that did not fit in any of the above four categories. These new categories included ‘power of teamwork’ and ‘strategies of teamwork.’ Our analysis took into account all six of these categories. This openness to new categories was necessary to capture the true organizational functioning of nursing assistants in these geriatric wards.

The decision to use a semi-structured interview was based on the previous success of the first author in obtaining quality data while conducting another study in a LTCO. Additionally, all three authors discussed the content of the interviews and agreed upon the findings. Both prior experience of interviewing staff members in LTCOs and the group effort to analyze the data enhanced the rigor of the study, as did the appreciable number of participants and the average length of each interview.

Findings

Interview content focused on the nature of the work of nursing assistants and challenges they faced in completing their assigned tasks. Two broad themes emerged from these discussions, namely ‘integrating new recruits into geriatric organizations’ and ‘transmission of informal work strategies to new nursing assistants.’ Each will be described below.

Integrating New Recruits into LTCOs to Manage Heavy Workloads

Most interviewees perceived entering a geriatric organization as a difficult experience. Most interviewees perceived entering a geriatric organization as a difficult experience. All nursing assistants said that the initial training they received did not prepare them to face the daily heavy workload experienced during their integration process. They believed that the work patterns/behaviors they learned during their training did not coincide with the limited time they were given to perform their daily activities. Thus, recruits experienced early on a contradiction between the work patterns/behaviors they learned during their training and the reality of work life within the organization. One nursing assistant explained the gap in this manner:

During our training, we’re told to be careful, to take whatever time we need…that’s why it’s hard when we start working in the organization. When we become nursing assistants and think things over, we think, “It’s impossible; trainers don’t see the reality of things in long term care facilities…” We were told that we had 45 minutes per resident but we actually have no more than 15 minutes.

In short, they saw the gap between the value of care, which takes time, and the value of work efficiency.

The main issue in their criticism of the training they received was that they felt the training was useless with regard to actual field requirements. Given the nursing assistant/residents staffing ratios that are mandated in Quebec’s geriatric organizations, they found the time allotted daily for interaction with residents to be very limited, making it difficult to properly complete assistance tasks in a quality manner. Furthermore,  assistants explained that these ratios only allow for minimal relational (sometimes called interpersonal) work. As one assistant reported:

We’re not enough to provide quality care so we’re asked to take good care of residents; we try to but we’re just not enough. The service we provide, I mean the relational service, is kept to a minimum.

Pressure for productivity affected all nursing assistants, as a nursing assistant who was too slow would interfere with the group’s ability to provide the necessary care.

The data showed that experienced nursing assistants played an essential role in the transmission of productivity requirements to new recruits. Early stages of the recruits’ integration into the ward behaviors were spent on the orientation or training phase. This was a short period of time (two to five days) during which the new recruit worked under the watchful eye of the referent, experienced nursing assistant. A staff member in charge of new recruit activity shared this:

I’m in charge of the orientation of new recruits […]. We look at recruits working; we see how they are when they start; we see what happens. It takes a certain pace, it’s Go! A toileting, go! Another... And we help them to keep the pace because they don’t learn that during their training.

Experienced nursing assistants played a central training role as they helped the new recruit to accept the sustained work pace imposed by the prescribed workload. In Quebec, recruits had multiple experiences during their first work week in order to learn about the LTCO’s many services and the different types of customers. The ward’s heavy workload forced the integration period to be reduced to a minimum, only a few days, and that sometimes without strong leadership. A recruit’s successful inclusion within a team was put to the test during the first hours of work, when the recruits demonstrated that they could keep up the pace prescribed by the team and were judged by the experienced nursing assistant.

Transmission of Informal Work Strategies to Enhance the Work of Nursing Care

Nursing assistants in geriatric organizations collectively share the same organizational constraints/challenges, such as heavy workloads and fast-paced work patterns. This forces them to create very homogenous work groups in which group strategies are quickly shared with new recruits. Some staff members viewed this group homogeneity as having a negative impact on organizational change. Yet we found that this homogeneity had value in that nursing assistants demonstrated collective ingenuity in developing practices to maintain the collectives’ cohesion. Indeed, our findings suggested that in both wards we studied, the nursing assistants’ work team was defined as the true task-control, normative body. Nursing assistants collectively, as a group, worked to find strategies that would enable them to comply with the prescriptions dictated, namely to keep a quick work pace and to respect the assigned workload. Several of their group strategies, including both relational and technical strategies, were characterized by their group ‘collectiveness’ in that they were not transmitted through formal training or by an organizational reference or policy that defined expected practices, but rather transmitted by a group of peers who had learned to compensate for the lack of realistic staffing standards in the matter.

For example, in the case of daily toileting (morning care) nursing assistants were taught by the group to reduce their discussion period with residents. Despite the normative (and abstract) directives to respect residents and attend to their needs, nursing assistants found it was impossible to stop and take a few minutes simply to talk with residents during these periods. A nursing assistant illustrated this point:

Toiletings can’t take more than, oh, I’d say 15 minutes, otherwise we’re late. We lose time. And others tell us, and over time we know it ourselves. So we have to find ways to discuss with residents while washing them, to make up some time any way we can.

It was the informal work group that devised this solution; it was not a solution described in a policy manual.

Other informal work strategies devised by the group would come into play in real-life work situations, for example in managing difficult cases, such as when a resident would refuse to be washed. A nursing assistant reported that in such situations the assistant responsible for the resident’s toileting that day would ask another nursing assistant, known to have a better relationship with this person, to temporarily ‘exchange’ a  resident with the assigned assistant. One participant described this solution below:

On the work plan, we don’t really choose our residents because we want all nursing assistants to care for all residents. That’s alright but sometimes, we don’t have a choice and must ask a specific nursing assistant to care for a specific person because we can’t do anything, he doesn’t want us to clean [him], … he starts screaming and tensing up. It’s easier for someone to ask another person who will know how to calm the person down quickly.

Asking for help from someone who has a good relationship with a reluctant resident was an effective collective strategy. Similarly, knowing how to alleviate a resident’s condition was also an important relational strategy that was transmitted from experienced nursing assistants to recruits.  

Another example given was that during meal times, in order to accelerate the service without being abusive or negligent, nursing assistants might feed two residents simultaneously. One assistant shared the following example:

I tell those who come here for meal times to feed two at a time… I once served three at once. You put two on either side of you and feed them alternately to avoid losing any time.

This would allow the nursing assistant to keep a watchful eye on both residents, while both respecting the residents’ biological rhythms and avoiding any loss of nursing assistant time.

These collective strategies are only a few examples of group-devised strategies used daily by the nursing assistants to address work challenges as they assisted residents to meet their daily needs. Such strategies, created and used by nursing assistants and transmitted from experienced nursing assistants to new recruits, illustrate the incredible resourcefulness of these nursing assistants as they tried to meet their workload requirements. In terms of organizational change terminology, this group is thus both resistant to change and innovative all at once. The group prioritizes to maintain the cohesion of the group so as to meet the actual requirements of the work organization in terms of productivity.

Discussion: Is Teamwork a Deterrent to Change or a Lever for Change?

The change agenda of LTCOs embodies the same paradoxical requirements that characterize the work of nursing assistants, namely, how to simultaneously do more and do it better (Gibson & Barsade, 2003). The ‘quantum-change’ intention (Mintzberg, 1994, p. 200) represented by the resident-centered care movement (White-Chu, Grave, Godfrey, Bonner, & Solane, 2009), as well as the more piecemeal improvement objectives embodied by innovative care programs, such as falls reduction and restraints reduction, make up the innovative agenda of LTCOs. Both aim to transform the work of nursing assistants (Caspar, O’Rourke, & Gutman, 2009). In line with Anderson and colleagues (Anderson et al., 2005; Castle & Anderson, 2011), who demonstrated the importance of studying the practices of caregivers and nursing assistants in LTCOs before attempting to change them to better meet the residents’ needs, this section will discusses ways to take into consideration the value that the nursing assistants whom we studied placed on teamwork in managing change in LTCOs.

The nursing assistants’ teamwork does not have to be seen as an obstacle to change. Rather, it can facilitate change when assistants work together to find ways to incorporate the change in their daily routines. The nursing assistants’ teamwork does not have to be seen as an obstacle to change. Rather, it can facilitate change when assistants work together to find ways to incorporate the change in their daily routines. In contrast, it could become a barrier if a manager attempted to destroy the informal collaboration strategies used by nursing assistants and the assistants reacted by collectively rejecting the change.

Teamwork can offer an efficient change lever if team strategies are incorporated into innovation plans. However, imposing specific innovations on all nursing assistants without considering their collaboration strategies may have the effect of undermining the team’s creative ability to meet requirements of their work in LTCOs, namely to meet the workload while performing acts of relational quality to residents.

It is important to recognize that these group strategies actually creating the ‘true forms of the organization,’ namely the forms required to reach the differing goals at the source of the organization’s purpose. It is recommended that a revision of the work of nursing assistants adapt formal practices to the informal teamwork strategies. Considering informal practices as an ‘organizational resource,’ represented in this case by the nursing assistants’ teamwork, would strengthen the organization’s capacity to resolve tensions within work teams (Friedberg, 1996).

It is important to plan and deploy change management strategies that both recognize the singularities of the numerous individual work groups constituting an organization and also harness these singularities to facilitate implementation of innovations. This approach differs from the mechanistic, Taylorist perspective (Bolton, 2004), which does not consider the human nature of organizational workforces, but rather sees profound and durable relationships between employees as a potential cause of change resistance to be prevented. It contrasts also with Friedberg’s (1996) observation that the informal practices and strategies that bond members of a similar organization or group together must be studied and used to contribute to the development of organizations.

Implications for Practice

Overlooking the potential input of nursing assistants in the development of an innovative care program or else soliciting the input of an individual nursing assistant, rather than that of the ‘team,’ can foster resistance to change.Participative change management interventions favour development of an innovation that is adapted to both formal and informal structures of an organizational group. This eases the inevitably difficult transition from the old to the new state of affairs by drawing upon the potential group members’ thinking about a change. A lack of respect for nursing assistants’ preferences and prerogatives may lead to an attempt to reclaim their share of power over a change process that is pushing a ‘prefabricated innovation’ towards them (Clegg & Walsh, 2004). Overlooking the potential input of nursing assistants in the development of an innovative care program or else soliciting the input of an individual nursing assistant, rather than that of the ‘team,’ can foster resistance to change.

A specific example of an implication stemming from this LTCO investigation might be the implementation of a program to reduce the incontinence of residents. This program, which would include an increased workload related to teaching continence recovery, might result in an unacceptable overload in terms of increased bathroom use and a subsequent need for additional staff help. In response, the change manager might feel a need to personally modify the work plan. However, the nursing assistants could themselves shape their own work plan. Nursing assistants already determine the steps of their specific tasks, such as lifting, cleaning, and repositioning patients, using a sequence of steps that works best for them. Indeed, it has been found that nursing assistants who are personally heavy in terms of their weight wake up patients early in their shift to better control the pace of their day (Aubry & Couturier, 2012). Changing a work plan that currently ‘works’ for the assistants may challenge individual nursing assistants and also change the pace and effectiveness of the collective teamwork. ... facilitating a group effort can enhance the success of an innovation. The group’s subsequent inability to work together might lead to a vicious cycle that makes it unable to sustain group innovation. In contrast, facilitating a group effort can enhance the success of an innovation.

It is important for LTCO managers to take into account the collective dimension of the nursing assistants’ practices, for the sake of greater efficiency and higher quality practices. Figure 1 below outlines five steps for managers to use in their efforts to take into account the structure of the collective teamwork of nursing assistants.

Figure 1. A Five-Step Innovation Plan

The following approaches can be used to implement an innovation using this plan:

1. Identify collective strategies through a specific description of the daily work. This could involve describing, hourly, who works with whom, and how the work plan is distributed among employees.
2. Propose a change model or innovation plan that takes these strategies into account and respects them. For example, when implementing an incontinence reduction program, ask the nursing assistants to establish a toileting schedule based on specific criteria they have chosen. They may choose to begin with the heaviest residents or they may choose to begin with the residents who are the lightest in weight. The important consideration is that they make the choice.
3. Involve the nursing assistants’ work team in the proposed change, allowing the team some freedom as to how to reach the goals set. The nursing assistants must be allowed to rebuild their work plan themselves, team up with the colleagues of their choice, and create a specific link with residents, while respecting the organization’s ultimate goal. However, providing some assistance in developing new collective strategies to meet the new requirements may be appropriate.
4. Identify new collective strategies created by the teamwork, based on the new targets that the nursing assistants must reach.
5. Modify or improve the original implementation plan using a partnership approach.

Study Limitations

The rural settings in which this study was conducted may have influenced the study findings. Indeed, rural LTCOs are more likely to be secluded from other LTCOs than their urban counterparts. Considering that lack of communication and sharing of ideas with other organizations has been documented as being directly correlated to negligence and poor care (Benbow, 2008), the quality norms of the participating organizations may differ from prevailing norms in urban settings. Thus, the results presented in this article may not be applicable to semi-urban or urban settings. Finally, we note that the fact that participation was voluntary may have influenced the nature of the results.

Conclusion

...although fundamental transformation may be required at the systemic level of the long term care sector, change at the working group level should not be mandated in a rigid manner. This article suggests that although fundamental transformation may be required at the systemic level of the long term care sector, change at the working group level should not be mandated in a rigid manner. Expanding the role of nursing assistants appears to be more appropriate than destroying the various structures that jointly hold up their current service network. In LTCOs, the nursing assistants’ strong sense of workgroup community should thus be taken into account and used as a change engine rather than allowing the sense of community to become a change obstacle. We advise individuals who are leading change mandates in LTCOs to approach the core members (workers) of their organization, identify the collectively supported strategies of the workers, and incorporate these collective strategies into the plan for change. Should this change process threaten to lead to a change in collective strategies, the manager can then examine proposed changes and modify the innovation plan in such a way as to meet the plan objectives without changing the collective functioning of the nursing assistant work group.

Authors

Francois Aubry, PhD
E-mail: francois.aubry@irsst.qc.ca

Dr. Aubry received a PhD in gerontology from the University of Sherbrooke, Quebec, Canada, and a PhD in sociology from the University of Franche-Comté, France. Currently, he is Postdoctoral fellow at the Institut de Recherche en Santé et Sécurité du Travail, at Montreal, Quebec, Canada. Dr. Aubry’s scholarship in the field of sociology focuses on the sociology of work and health. He currently is studying the professional practices of nursing assistants in Canadian long term care organizations. His work also focuses on the training of doctors specializing in family medicine.

Francis Etheridge, MA
E-mail: francis.etheridge@usherbrooke.ca

Mr. Etheridge received a MA in gerontology from the University of Sherbrooke, Quebec, Canada. He has developed a specialty in the area of change management issues in Long Term Care Organizations. He is currently completing a PhD at the University of Sherbrooke, focusing on the determinants of the effectiveness of change management in long term care organizations.

Yves Couturier, PhD
E-mail:yves.couturier@usherbrooke.ca

Dr. Couturier received a PhD in applied human sciences from the University of Montréal, Quebec, Canada. He is currently a professor on the faculty of gerontology and social work at the University of Sherbrooke, at Sherbrooke, Quebec, Canada. He has specialized in the study of the professional practices of health professions and in the study of aging. He is responsible for the Canada Research Chair on Integrated Services in Long Term Care Organizations.