This is the 5th of a series of 6 articles about recruitment, retention and culture in long term care. Each of these issues – retention, recruitment, and culture – has a direct bearing on the staffing crisis in the sector. There are no easy fixes, and only careful, disciplined approaches will have long-term, beneficial effects. These articles address leadership and systems, and are based on the best available organizational, behavioral and psychological research.
To address your staffing crisis, contact Stackpole & Associates: istackpole@stackpoleassociates.com or call +1-617-719-9530
Communications problems are often referred to as “culture” in long-term care and healthcare trade publications. Culture, however, is much more than communications. Ignoring the broader scope of culture and its impact on recruitment & retention of frontline workforce is at the root of the staffing crisis in long-term care.
You may agree or disagree, but here are some descriptions and definitions from my decades of experience, as well as the peer reviewed literature.
What is Culture?
“Culture” is the unwritten rules that guide behavior, and in this context, within healthcare and long-term care organizations. The general areas that culture describes and quantifies include: teamwork, communication, satisfaction, professional commitment, general behaviors, and expectations.
At a very practical level, culture is tremendously important and infuses so many other aspects of work, quality, patient experience and staff retention. For example, why is it “okay” for staff in one building to be late for meetings, or to not adhere to dress code, and at another location, these behaviors are never seen? We’ve all seen this, even in chains of nursing homes: at Nursing Home A the staff are timely, adherent and respectful, while at Nursing Home B, the staff are often late, disruptive and challenging. The difference is the cultures. In Nursing Home A, the staff behaviors that are tolerated, even accepted and at Nursing Home B unruly or disruptive behavior wouldn’t be tolerated by the peer staff.
Conflicting Cultures Cannot Cohabit
Forgive the alliteration, but conflicting cultures, whether they are work-related or personal, cannot coexist in the same person or organization.
Among the best practical examples of culture at work in nursing homes is answering call lights. The time lapse between when a call light is turned on and when it’s turned off is quantifiable and most of the time irrefutable. Slow response to call lights is a perennial problem within many healthcare organizations including hospitals and nursing homes.
What is the difference between call lights being answered promptly, within an acceptable timeframe or slowly?
Is it the level staff?
No! It’s the culture.
In our work in long-term care centers around the US and in the UK, frontline staff universally recognize prompt call light response as a critical part of their jobs. When confronted with the irrefutable, quantitative facts about slow call light response, however, there are always two responses:
- Staff externalize specifically (“I was too busy.” “We don’t have enough staff.” “I can’t hear the alarm when I’m in another patient’s room.”)
- Staff acceptance (“Of course, we should get there fast.” “They shouldn’t have to wait.”, “I wouldn’t want my mother wait!”)
What this exercise confronts is an unspoken cultural element (It’s okay to be slow responding to call lights because… fill in the blank).
Accepting slow call light response is in conflict with other, more intimate and personal attitudes. These conflicting cultures cannot cohabit; one or the other will win out. More about this below, when we discuss how to manage culture.
Why Culture Is Important
Culture is important for several reasons, one of which is because culture is positively linked to better outcomes, higher levels of staff retention, better overall clinical quality and higher levels of staff resilience. All of us who have slogged through the pandemic and understand the role of staff burnout can identify with the need for higher levels of staff resilience. Some cultures are better at promulgating and manifesting resilience than others; in today’s employment environment in long-term care, resilience is tremendously important.
In the midst of a staffing crisis, the first step is to stop churn, and to hold onto staff. Certain types of cultures are more effective in nurturing staff loyalty. Staff loyalty has two dimensions:
- Behavioral loyalty is continuing to show up for work and not quitting to take another job.
- Psychological loyalty is measured by willingness to invite others to consider taking a job with their employer, willingness to make concrete recommendations, and active participation in non-mandatory activities.
As previously described, if you want to “test” this aspect of your culture, count how many successful referrals of new employees have come through your employee referral programs. If the answer is known or hardly any, it’s best to start over; you can learn about this here.
Measuring Culture
The nursing culture assessment tool (NCAT) is a standardized instrument that can be used to evaluate healthcare organizations culture in the domains of teamwork, communication, satisfaction, professional commitment, general behaviors, and expectations.
This assessment does require surveying your frontline workforce, but the instrument is in the public domain, and is clear and easy to administer, based on our experience.
Critical Incident technique (CIT) is another methodology for measuring culture which has been applied in healthcare and long-term care environments. The CIT technique is open to more interpretation but can yield excellent insights for management in order to work with staff and effectively move or migrate culture one way or another. The “incidents” might include successful patient outcomes, errors, instances of effective teamwork, breakdowns in communication, patient complaints, or any other time-based event, which significantly impacted resident care or the organization’s work environment overall. For nursing homes and hospitals, Critical Incidents are often the types of events for which management would conduct a quality improvement program, or recovery plan.
Managing Culture
Managing or changing culture in long-term care, in particular, has been challenging. Even before the current staffing crisis, there were many efforts to create or redirect culture. Most of these failed or delivered temporary and / or disappointing results. Part of the difficulty is due to the staggering levels of turnover. No sooner do you manage to have a positive impact among a certain group of frontline workers, and “poof”, 35% – 50% of the workforce are gone. As consultants to the industry since 1993, this has been our frequent experience.
It is a truism that if you can’t measure it, you cannot manage it. Culture isn’t just a fuzzy characteristic. Culture is definable and manageable. The steps for changing culture are:
- Leadership Commitment
- Assessment Survey / Evaluation
- Staff Engagement & Training
- Involve Residents & Families
- Implementation
- Empowerment & Support Frontline Workforce
- Continuous Quality Improvement
- Communication & Transparency
- Celebrating Successes and Milestones
- Sustainability & Transformation
Nothing Great Was Ever Easy
Managing culture is built on measuring culture. To change culture, the steps are clearly laid out and require persistence and determination. The rewards, however, can be great and include significantly lower staff turnover, higher staff loyalty, far better patient outcomes and a host of other benefits. If your organization is ready-made for this level of commitment, we would be delighted to assist you in the journey.
- For a good review, see: Tracey L. Yap, Susan M. Kennerly, Elizabeth P. Flint, Nursing culture assessment tool (NCAT): Empirical validation for use in long-term care, International Journal of Nursing Sciences, Volume 1, Issue 3, 2014, Pages 241-249, ISSN 2352-0132, https://doi.org/10.1016/j.ijnss.2014.08.001.
- J.E. Anderson, A.J. Ross, C. Macrae, S. Wiig, Defining adaptive capacity in healthcare: A new framework for researching resilient performance, Applied Ergonomics, Volume 87, 2020, 103111, ISSN 0003-6870, https://doi.org/10.1016/j.apergo.2020.103111.
- Mallak, L.A., Lyth, D.M., Olson, S.D., Ulshafer, S.M. and Sardone, F.J. (2003), “Diagnosing culture in health‐care organizations using critical incidents”, International Journal of Health Care Quality Assurance, Vol. 16 No. 4, pp. 180-190. https://doi.org/10.1108/09526860310479668
- This quote is generally attributed to Peter Drucker.