Change Management in Failing Business Management: Nursing Homes in England - Research Proposal Example

Of all the self-fulfilling prophecies in our culture, the assumption that aging means decline and poor health is probably the deadliest. Marilyn Ferguson (1980), The Aquarian Conspiracy Introduction At present, an estimated 20% of the UK population is aged over 60 years. It is predicted that by 2031 this proportion will rise from the current 12 million to 18.6 million people (Kwaw, 1999). Of those who do not have the opportunity to live healthy and rewarding lives it is likely that they will need acute as well as long term care. And as the grey population of Europe steadily increases, it is expected that a larger percentage of older citizens will require the need for care facilities such as nursing homes (Tonks, 1999). It has been reported that one in five men and one in three women reaching the age of 65 years can expect to need the services of 24-hour residential care (Richardson et al., 2003). Nursing homes are established to provide supervised and protective care setting for older persons who are vulnerable to exploitation by others, and or unable to care for themselves due to cognitive dysfunction, mobility issues or physical illness. However, recent research and government commission reports indicate that a number of employees within nursing homes are practicing person-centred care without adequate qualifications or experience, having little understanding of the philosophy of caring for this vulnerable population (Royal Commission on the Funding of Long Term Care, 1999). Further, the image of nursing homes has been discredited by the public associating residential care with that of a "warehouse" or "final way station" given the amassing negative publicity of the management of such facilities. For example, is has been suggested that abuse occurs to a disproportionate level within nursing homes (Richardson et al., 2003). This paper will critically review factors contributing to the apparent mismanagement of nursing homes in the UK to demonstrate the need for undergraduate training in the areas of team-work, quality management and leadership practices. Firstly, recent research into the management practices of nursing homes will be presented. Secondly, issues of quality management, leadership and team-work will be explored. Next, the implications of extending knowledge of these factors on recruitment and retention will be highlighted. Finally, a conclusion shall synthesise the main points of this paper to illustrate the positive benefits of management changes to improve the image and practices of nursing homes, and subsequently the person-centred care of residents and the health and well being of staff. A Review of the Literature Nursing Home Management The current system of nursing home management within the UK is viewed by many elderly, their families and the public in general as unjust, as identified by the Royal Commission set up to investigate perceptions of nursing home care. This perception has been reported in numerous other studies (Heath, 2002). It has been suggested that the current state of affairs has occurred through management trying to improve the cost effectiveness of their facilities by the provision of less care. This situation exists due to the governments decision to privatize long-term care for older people, which ahs occurred on a massive scale. As the government redefined health care of older persons as a social care issue, it was removed from the health service and has been subjected to various means tested charges. The separation of those who were most in need of medical care from those who were in the best position to provide it (i.e., within the National Health System [NHS]) resulted in older people feeling that their trust had been betrayed and feelings of anger and confusion. Studies show that the reshaping of nursing home services can begin immediately with small and systematic changes to administration, wards (i.e., sections of the nursing home) and clinics (Tonks, 1999). As such, wards could have increased access to expertise medical staffs that are better able to meet the needs of residents with multiple issues (e.g., Alzheimers, immobility and lung cancer). The individual staff, be they medical, volunteer or other support personnel, could make a dramatic difference by reflecting on their own prejudices and stereotypes, and taking part in workshops and programs to expand their professional development as human service workers with regard to nursing home care. Further changes are needed though, including management introducing inclusive policies that seek to promote person-centred care by engaging residents in the design and implementation of services (Smith, 1999). As well, it is necessary for management to take on board the findings that medical staffs do not often have aspirations that align with those of residents, and that training needs to be taking place on the job (as well as at the undergraduate level) to return the focus of nursing homes to that of rehabilitation and convalescence. Overall, if the health and social care services of nursing homes could be better matched to the needs and expectations of residents, whilst accounting for their own well being and job expectations, nursing homes would provide better management practices. Factors Influencing Nursing Home Management Recent studies point to a distinct lack of leadership qualities amongst nursing home staff in general, and attribute this to a lack of training in the area (Willging, 2004). Unfortunately, this lack of leadership ability is a waste of resources as nurses, doctors, administration and other support staffs are in key positions to influence nursing home care policies, as well as state and national legislation (Sullivan, 2001). It has also been contended that student human service providers need to be encouraged to develop their leadership and managerial skills as well as their clinical skills (Baker, 2000). For example, a more salient awareness of cost-containment issues could motivate the nursing homes to have set protocols for the bed-care of elderly patients (Antrobus, 1999). Additionally, the use of job re-design amongst the staff could provide nursing homes with a critical evaluation of the sequential tasks of each job a staff member undertakes, and provide solutions for combining tasks to improve resident care (e.g., saying goodnight/see you later to a patient also includes the action of the hands checking the bed-rail is up) (Sullivan, 2001). Quality management is important to nursing home management as it allows for an evaluation of the outcomes of practices. In turn, this style of management provides for a preventative approach to care that identifies potential problems quickly, and facilitates research into viable alternative solutions (Belcher, 2000; Hendel & Steinmann, 2002). As such, the nursing home working environment should be one that facilitates staff to carry out good practice. This requires support from more senior staff to ensure that lower ranking staff have been briefed and assessed on their understanding of tasks and expectations, and have had practical demonstrations of knowledge of known potential problems (Hendel & Steinmann, 2002). However, management that is over-controlling does not contribute to the staff developing self-directed learning and concrete understanding of why it is that protocols are undertaken as they are (Kelly-Hayes, 2003). Efficient and effective person-centred practices with regard to nursing home management will only occur with flexible clinical leadership that recognises and encourages good practice (Capezuti et al., 2002). As such, the practice of nursing home management necessitates scientific and technical knowledge of managerial and clinical practices, but it is also essential that the staff be aware of, and to be motivated to, practice ethical codes of conduct as defined by the ISO9000 (International Organization for Standardization [ISO], 2006), British Medical Association (BMA)(BMA, 1999) and Nursing and Midwifery Council (NMC) (NMC, 2004). Ethical codes of conduct make the staff accountable for their decisions and actions in their delivery of person-centred care. As such, abiding with ethics enables the staff to be guided through value-based judgments (General Medical Council, 2001; Thompson, Melia & Boyd, 2000). Furthermore, these value judgments need to be evaluated in a critical manner in the same way that scientific information is critically analysed. Ethics is a generic word that reflects a set of standards for analyzing and understanding moral life. Hence, ethics requires that the staff of nursing homes to go beyond the individual resident and to apply assumed universal laws (General Medical Council, 2001). A code of conduct is based on four general principles: 1) individual autonomy; 2) beneficence for the person; 3) avoidance of harm to the person (non-maleficence); and 4) justice (BMA, 1999; NMC, 2004). The BMA would encourage the medical staff to draw on past experience that demonstrates their; respect for the residents as individuals, such as having asked for their consent before delivering a procedure; their pattern of maintaining the residents confidentiality in regards to their medical and personal information; and their trustworthiness in their past interactions with the residents. The BMA advice would also encourage the staff to highlight other interactions with the residents that demonstrated their tendency to maintain their professional knowledge and competence at clinical care, as well as circumstances in which they identified and minimised risk for the resident. Ultimately, mistakes occur during the provision of nursing and administrative care to residents. However, the aim of ethical codes of conduct is to guide nursing home staff so as those mistakes are made infrequently (Kelly-Hayes, 2003; Thompson, Melia & Boyd, 2000). Another key feature of nursing home practices is to work within a team environment. The staff may find themselves working in a team environment comprised of other nurses, doctors, volunteers, chaplains, social workers and other health and human service workers (Martin, 2000). Team-work has been a traditional practice that is supported by human service philosophy and is demonstrated in a variety of its practices. It is well recognised within the human service literature of the interdependence of the physical, functional, psychosocial and spiritual dimensions of the workplace account for team member well being, as well as facilitating a multidisciplinary and so comprehensive approach to person-centred care (Cronenwett & Redman, 2003). Collaboration is an important element of team-work. It has been found that medical or administration staff who work alone for a great deal of their time in delivering care and or service are more likely to feel rushed (Baileff & Suite, 2000; Sloan, Prather & Olin, 1996). It appears that team-work is the key to effective and efficient person-centred care, as the team tends to be more structured and organised. When there is a lack of a team-work approach, as appears to be the case in present day UK nursing homes, it is likely that the patient will experience anxiety and distress during future interactions with those staff at the home. Research shows that by sharing the responsibilities of care across staff on duty that the sum of their competencies as a whole team is greater than each as an individual (Sloan et al., 1996). Although for team-work to be enacted and to be effectively productive it is necessary that each member have a common purpose. It is also a requirement that each member is aware of the roles of others as well as themselves. Further, it is critical that staff have the ability to pool their resources (Baileff & Suite, 2000). Overall, it is the workplace dynamics that can provide nursing home staff, and in subsequently the resident, with a sense of care and well being (Crawford & Price, 2003). Implications for Recruitment and Retention One of the identified obstacles to the provision of effective nursing home staff recruitment and retention is that staffs lack the necessary information and training to enable a safe, predictable and positive work experience. Evidently, it is necessary that staffs understand the minimum requirements of ethical expectations and team-orientated focus, likely to influence their levels of motivation to actively engage with residents, on their own perceptions of residents and to place them in a position to challenge negative prejudices and stereotypes. Staff satisfaction is critical to allow the effective and efficient management of nursing home facilities. Job satisfaction has become the work attitude to be investigated by a majority of researchers seeking to establish a relationship between employee attitudes and workplace efficiency (Wright, 2006). Such studies reveal information about the person as an employee, as well as a social entity. "Attitudes," "motives," "values," "perceptions," "personality characteristics," "intelligence," and "performance outcomes," can describe an employee in terms that management can apply to overall business strategies (Kane, 1996). Though we found that wages do influence worker satisfaction, they are not the sole factor that determines whether direct-care workers in aging services facilities can be recruited and retained. This means that a facility that may not have the resources to raise wages can still make strides in staffing, for example, by encouraging all staff to be problem solvers and decision-makers and by ensuring that direct-care staffs are recognized for the important role they play (Edwards, 2003, p. 123). It is suggested that nursing home staff that hold key supervisory positions are critical to change management processes (Edwards, 2003). Those who have strong leaderships skills, are visible to their staff, accessible and directly involved in resident care are able to create a positive team-orientated work environment that motivates other staff to actively engage with residents and co-workers. It is also recommended that staffs are provided with opportunities to be included in decision making and to make suggestions and critiques of the workplace and management, as well as to be provided with adequate management skills, using role-modeling and mentoring to disseminate appropriate information and workplace values. Behavioral management is a psychological approach to understanding and explaining human behavior within the organizational setting, the general theory has been used for performance management. Institutions and corporations have used the theory to define work behaviors that are considered the most effective to get the job done (Coffs, 1997). Behavioral analysis incorporates a set of concepts and methods that can help to establish efficient and harmonious workplace environments. Behavior analysis concepts help us understand how people function within the realities of the world they live in. Drawing also on general systems concepts, behavioural management theory aids in understanding the reasons why an employee takes a course of action that they do, as well as informing management as to how to determine training needs; and how to communicate positive and negative feedback on employee’s performance to ensure retention (Wilson, Lizzio, Whicker, Gallois, & Price, 2003). An organizational study found that use of quality management practices, as defined by the ISO 9000, provided 86% of respondents with improved management, control, and/or organizational planning, which provided staff with a consistent work environment, and encouraged a unique workplace culture of collaboration, inclusiveness and continual improvement (Lloyd, 1992 as cited in Schlickman, 2003). Other benefits which have been cited include; enhanced team-spirit; consistency in work performance; instilled a confidence in the reliability and dependability of co-workers, increased employee satisfaction and decreased perceptions of stress; an d improved employee moral and training programs (Saarelainen, 1997 as cited in Schlickman, 2003). Strategic management, in general, aims to influence the beliefs, values, attitudes and behaviours of management and employees, as well as other stakeholders, in this case residents within nursing homes. Behavioral management emphasizes a psychological approach to understanding and explaining human behavior within the organizational setting, and in recognizing that a clear relationship exists between employee participation, productivity, staff and resident satisfaction (Schlickman, 2003). It is generally accepted that quality management is a critical research area in present day management discourse. The topic has developed into an integral facet of business culture, on par with financial reports. And directly influences process and protocols for recruitment and retention. Focus on individual behaviour is still recognized today by management researchers to be critical in planning management strategies. Behavioral management theory has been modified over time, to incorporate more cognitive and agenetic theories that are inclusive of an individual’s socio and physical environment (Stroh, Northcraft, & Neal, 2001). As such, behavioural management theory provides guidance as to management and employee personal and occupational development, and in the identification of employee and target market expectations and needs, in this case with reference to person-centred planning and cares for the residents of nursing homes. With direct reference to nursing homes, it has been established that a set of criteria should be met by medical personnel in order to be considered suitable for such a facility (Richardson et al., 2003). Specifically, it has been found that the increasing sub-specialisation of medical professionals makes them unable to deliver appropriate services matching the complex and multiple pathologies of many older persons in nursing homes. As such, it is necessary for management to employ medical staffs that have multiple general skills in the areas of health and social cares for the elderly residents. However, this is difficult to enact as studies show that undergraduate medical education is undergoing reforms that are enforcing specific training within the curriculum of geriatric care. Further, post-graduate students appear to be lacking in mandatory assignment to geriatric medicine and social care, meaning that not all doctors, nurses, social workers and other human service providers are capable of managing resident care appropriately. Conclusion In conclusion, it is clear that change management is necessary for nursing home facilities within the UK given the increasingly ageing population and the current negative perception of these institutions. Research recommends management attending to behavioral and cognitive issues of staff training and job satisfaction, by way of focusing on team-orientation, quality management and leadership skills, to improve the recruitment and retention of multi-skilled and competent staff. This present research paper has implications for extending the understanding of undergraduate training requirements, and professional development policies within nursing home workplaces. References Antrobus, S. (1999). 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