Empowerment of nursing home employees could lead to better care for residents, study says

Wednesday, April 4, 2007

Nursing homes in which staff members feel empowered to make management decisions without approval from supervisors and to negotiate over staffing levels, pay and benefits could result in better care for the nursing home residents, according to two separate studies by University of North Texas faculty members.

In a study that will be published in this month's "Journal of Aging and Health," Dr. James Swan, UNT professor of applied gerontology, analyzed the number of reported complaints and the severity of reported violations about quality of resident care at 1,155 nursing homes in California. As defined by the Centers for Medicare and Medicaid Services, the violations caused potential or actual harm to one or more residents, resulting in extreme weight loss, bed sores, falls and other serious problems.

Swan and his co-investigator, Dr. Charlene Harrington of the University of California-San Francisco, compared the data from nursing homes in which staff members had formed unions with nursing homes that did not have unions for staff members.

Unionized nursing homes, Swan said, had an average of three more complaints - made by residents' family members as well as staff members - per 100 beds than the non-unionized facilities. However, the actual number of violations that could endanger residents was lower in unionized facilities.

Swan also divided the nursing facilities by county and determined the percentage of those in a county that were unionized. Counties with large percentages of unionized nursing homes - thus indicating support for unions - had the fewest violations, while the non-union homes in those counties had much higher numbers of violations.

"Family members and workers may complain more in unionized homes, but the presence of a union may cause more complaints to be reported and investigated before they turn into serious violations," Swan said. "Allowing workers to have a voice on the job appears to enhance problem reporting."

While other research has focused on registered nurse unions in hospitals, showing better patient outcomes in the hospitals that had unions, no other study has addressed nursing home employee unions. Swan said the presence of a union could lead to better staffing of nursing facilities, which have a turnover rate of roughly 100 percent during a year for nurse's aides.

"The major benefit of a union is that it fights for better reimbursement," he said. "If workers have more invested in their jobs, they are more likely to be concerned about violations and report them."

Swan said that he and Harrington found, as expected, that facilities located in rural areas, facilities in which the registered nurses worked the most hours per day, and facilities with higher proportions of Medicare and Medicaid residents had more complaints than other facilities. However, contrary to the researchers' hypothesis, larger nursing homes had more complaints than those with fewer residents.

"It may be that larger facilities were more likely to have fewer staff members per resident as well as per bed than smaller facilities, leading to poorer care and lower satisfaction," Swan said.

Swan's and Harrington's finding that giving nursing home employees a voice through unions may improve nursing home quality follows a study on self-managed work teams in nursing homes conducted by Dr. Dale Yeatts, UNT professor of sociology, and Dr. Cynthia Cready, UNT assistant professor of sociology. The study was published in "The Gerontologist."

Yeatts and Cready compared five Dallas-Fort Worth nursing homes in which nurse's aides were organized into work teams - groups of three to 15 employees who are responsible not only for the technical aspects of their jobs, but also for management issues such as determining work schedules - with five homes with no work teams. After 16 months with the work teams, the nurse's aides and nursing staffs reported that the aides' job performances were higher, and the nursing home residents and their family members said that care of the residents had improved.

The researchers noted that work team meetings include reviews of any health problems of residents that were recognized by the nurse's aides, so a problem was less likely to go unattended than if a nurse's aide only reported the problem to his or her supervising registered nurse.

In addition, through work teams, the nurse's aides were better informed about health conditions of residents and their preferences for meals and daily routines, were more willing to learn from each other and assist each other in caring for residents, could identify the most efficient procedures for carrying out tasks, learned which nurse's aide was preferred by each resident so that nurse's aide could be assigned to the resident, and could confront a poorly performing aide.

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