Geriatric Nursing 35 (2014) 132e136
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Empowering certified nurse’s aides to improve quality of work life through a team communication program Erin E. Howe, DNP, RN, ANP-BC University of Rochester, School of Nursing, 255 Crittenden Boulevard, Rochester, NY 14627, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 June 2013 Received in revised form 1 November 2013 Accepted 10 November 2013 Available online 5 December 2013
The purpose of this pilot study was to explore the impact of a certified nurse’s aide (CNA)-led interdisciplinary teamwork and communication intervention on perceived quality of work environment and six-month job intentions. CNAs are frequently excluded from team communication and decision-making, which often leads to job dissatisfaction with high levels of staff turnover. Using a mixed quantitative and qualitative approach with pre- post-program design, the intervention utilized the strategy of debriefing from the national patient safety initiative, TeamSTEPPS. Inherent in the program design, entitled Long Term Care (LTC) Team Talk, was the involvement of the CNAs in the development of the intervention as an empowering process on two wings of a transitional care unit in a long-term care facility in upstate NY. CNAs’ perceptions of work environment quality were measured using a Quality of Work Life (QWL) instrument. Additionally, job turnover intent within six months was assessed. Results indicated improved scores on nearly all QWL subscales anticipated to be impacted, and enhanced perceived empowerment of the CNAs on each wing albeit through somewhat different experiential processes. The program is highly portable and can potentially be implemented in a variety of long-term care settings. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: CNA empowerment TeamSTEPPS Staff turnover
Introduction In this country, older adults are the fastest growing segment of the population with an anticipated census of 19 million people aged 85 or older by the year 2050 and nursing home costs expected to skyrocket to 540 billion dollars by 2040.1 The supply of CNAs available to provide quality care for our aging elders has become an increasingly urgent issue over the last two decades. Given the crisis of CNA turnover in long term care settings, identifying reasons for staff dissatisfaction and finding ways to improve retention should be a priority for health care administrators and nurse leaders. Staff turnover and job satisfaction are strongly tied to management support, job opportunities, workload, coworker relationships, communication, teamwork, and salary/benefits.2e5 Interventions identified to improve the complex construct of CNA job satisfaction involve a combination of extrinsic financial rewards, career opportunities and advancement, organizational culture, individual/ family factors and economic forces.2 The multitude of combinations incorporating these variables makes a challenging case for determining the most effective strategy for impacting global CNA job satisfaction. Yet a number of investigators have examined strategies designed to enhance work-place empowerment as a means to
E-mail address: [email protected]. 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.11.004
improve staff satisfaction and influence job retention.6e9 Few studies have explored the influence of empowerment on the CNA role, specifically. It is generally believed, however, that a combination of competence, autonomy and job meaningfulness contribute to feeling empowered in the workplace, which has been shown to enhance job satisfaction and retention of CNAs.10e12 The role of the certified nurse’s aide (CNA) as a primary provider of care in many health care settings is well established. This unlicensed position is critical in the nursing home environment, where CNAs are utilized to provide the majority of “hands-on” care.13 CNAs in nursing homes leave their positions at alarmingly high rates with turnover ranging from 70 to 100% annually. The cost to replace a single CNA is estimated to be greater than $4000.2 In addition to the financial costs, high rates of CNA turnover jeopardize quality of care. Health outcomes such as challenging resident behaviors, pressure ulcers, falls, and infection increase when CNA continuity of care to individual residents is interrupted.3 Failure of managers to recognize the impact of the CNA role on patient care and to institute measures to support, educate, and motivate their employees can lead to feelings of job dissatisfaction and ultimately a loss of quality caregivers.4 Approximately one year prior to development of this pilot study, CNAs in a long-term care facility in upstate New York were surveyed using a tool designed to assess psychological empowerment within the work environment.14 The results of that survey (N ¼ 12)
E.E. Howe / Geriatric Nursing 35 (2014) 132e136
revealed that the CNAs generally felt competent to do their work and found meaning in their jobs but they experienced little autonomy in their daily functioning, perceived having minimal impact on team decisions, and felt communication amongst team members to be poor. All of these factors were sources of disempowerment and job dissatisfaction. Based upon the literature regarding CNA job satisfaction and low perceived empowerment along with the communication issues identified by CNAs in the facility, a program entitled Long Term Care (LTC) Team Talk was developed that aimed to boost the CNAs’ sense of autonomy and empowerment, with the goal of potentially alleviating job dissatisfaction and turnover through a team communication approach. This pilot program, LTC Team Talk, was comprised of a communication and teamwork intervention led by the CNAs. The intervention consisted of a debriefing strategy, which is a simple mechanism that involves an informal and brief yet routine gathering of the team to discuss an experienced event. This method is an abbreviated version of what has been utilized in the successful national patient safety initiative, TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety as a way to improve the teamwork and communication of tiered groups of disciplines functioning in settings such as the operating or emergency room.15 This debriefing strategy is typically incorporated into a surgical setting, for example, as one of a number of peri-operative procedures designed to enhance patient safety and staff communication. Such fast-paced, acute environments often have a rigid hierarchy of authority and power, creating a vertical channel of downward communication. This type of structure often precludes a sense of egalitarianism and can hinder open communication to the detriment of teamwork and patient safety.16,17 Though this curriculum has not been studied in long-term care, nursing homes share the multidisciplinary and hierarchical nature of more acute care settings, which makes the TeamSTEPPS strategies, as used in the LTC Team Talk program, effective in this environment. Another key feature of the LTC Team Talk program involved the CNAs’ tailoring of the debriefing to meet their particular needs in the context of their respective units. The experiential process of the CNAs developing and then implementing this team communication program including making revisions to the process was assessed through post-program focus groups and interviews with the staff. The impact of the intervention on the CNAs’ perceived empowerment and quality of work life also was assessed. Methods Setting LTC Team Talk was implemented on a 68-bed sub-acute transitional care unit within a 362-bed, not for profit, long-term care facility in upstate New York. The unit was comprised of two separate wings (Northeast, NE and Southwest, SW) that constituted one entire floor with a similar population of rehabilitating elders. The program was approved by the University of Rochester’s Institutional Review Board and senior nursing home administrators prior to implementation. Other than to provide initial administrative approval, facility managers were not involved in the project so to protect the privacy and rights of the participants. Study design The study was a single group mixed quantitative and qualitative study with a pre-post-program design. The group was composed of staff on two separate wings within one transitional care unit that functioned independently of one another. Due to the distinctly separate geographical nature of the two wings, the intervention
133
was administered in two phases, first on the NE wing and then replicated on the SW wing. Pre and post-program surveys were obtained on both wings at the beginning and conclusion of the initiative on each side respectively. A second post-program survey utilizing a sub-sample of the group was administered eight weeks post-intervention to assess for preliminary indications of longerterm impact. Participants This pilot study utilized a nonrandomized convenience sample of CNAs and nurses on the two wings of the sub-acute rehabilitation unit. Inclusion criteria involved being a day shift CNA or nurse working more than 24 h/week on the rehabilitation unit. Exclusion criteria involved working primarily evening or night shifts, working less than 24 h/week, primarily working shifts on other units versus the rehabilitation unit, or not being employed as a CNA or nurse. Fifteen staff members were approached to voluntarily participate in the program and the study but were informed they could join LTC Team Talk but opt out of the study. All fifteen were eligible and agreed to participate in both LTC Team Talk and consented to the study. The participants were comprised of 8 CNAs and 7 nurses on the combined wings of this one unit. The four nurses and four CNAs on the NE wing and the three nurses and four CNAs on the SW wing were approached for participation during each wing’s routine monthly staff meeting. Informed consent forms were subsequently obtained by the organization’s nurse educator prior to administration of the pre-program Quality of Work Life (QWL) survey. Intervention The LTC Team Talk program involved regularly scheduled 5-minute debriefing sessions at the end of the day shift led by a rotating schedule of CNAs. The CNAs posed three questions to the staff during these sessions: 1) What went well today? 2) What can we improve upon? 3) What do we need in order to improve? Participants included CNAs, floor nurses and other interdisciplinary team members as invited by the CNAs. Each phase of the LTC Team Talk program last four weeks during which time the project director observed the debriefings and completed an activity audit form that documented attendance, question responses by staff, themes, notable staff interactions, and challenges encountered. Quantitative measures The QWL survey was administered pre and post-program as a validated 45-item Likert scale questionnaire modified from its original 65-item format that has been used previously to measure quality of work life for employees in health care organizations.18 The tool is composed of ten subscales, five of which were expected to be impacted in a positive direction by the intervention because they involved the key components of empowerment (competence, meaning, impact, and autonomy). These subscales included: co-worker and supervisor support, teamwork and communication, job demands and decision authority, characteristics of the unit and intent to leave/transfer units. The Cronbach alphas for these scale items were 0.91, 0.83, 0.58, 0.84, and 0.93 respectively. The remaining subscales were not expected to change with the intervention and included characteristics of the organization, staff
134
E.E. Howe / Geriatric Nursing 35 (2014) 132e136
training and development, patient/resident care, compensation and benefits, and overall impressions of the organization. The Cronbach alphas for these subscales were 0.84, 0.94, 0.93, 0.84, and 0.65 respectively.
Table 1 Summary of CNA age and employment in facility by wing.
SW NE
Years old
Years employed
30 46
2.8 14.3
Qualitative measures Activity audits were developed specifically for the debriefing sessions. Each audit included attendance, length of session, CNA leading the session and CNA timekeeper, a grid to record CNA and nurse responses to each of the three repeated questions (what went well today, what can we improve on, what do we need to improve) and a section for session themes. Focus groups were used at the conclusion of the program to evaluate the experience of the program and assess for feelings of empowerment. Two to three CNAs and nurses, in separate groups, were gathered to engage in the focus groups on the respective units. This arrangement was selected due to the scheduling challenge of convening a large group meeting during the day shift. The focus group was the CNAs’ requested method of evaluation as they expressed a preferred comfort level in speaking in small groups/pairs (as opposed to individually or in a larger group) and it was easier for them to simultaneously leave the floor in smaller numbers. These focus groups occurred based on staff availability during the day. The interview guide used during the focus groups consisted of ten open-ended questions pertaining to the staff’s feelings of empowerment. The questions were intended to address their sense of impact on the team, degree of job autonomy, experience of teamwork and communication on the wing both before and after the program, their perception of the debriefing sessions, how their day to day interactions with the team were similar and different and their description of their quality of work life. Quantitative data analysis Quantitative data was collected from participants via pencil and paper and included the demographic data of age, job title, and number of years employed in the current facility and the QWL survey. Data analysis involved the use of a paired t-test to compare the mean CNA scores pre and posttest on the following QWL subscales: Coworker and supervisor support, teamwork and communication, job demands and decision authority, characteristics of the wing, and intent to leave/transfer units. Qualitative data analysis Qualitative data was collected by capturing the themes discussed during the program and post-study focus groups. The study coordinator analyzed the data by first re-writing the activity audits as a transcript after each debriefing session. Staff expressions of recurrent issues were then labeled by category with the frequency of key words recorded. This content was then coded into themes. The data collected from the debriefing sessions via the activity audits were documented in table by role (CNA vs. nurse) and wing (NE vs. SW). The focus group responses were similarly transcribed immediately afterward by the study coordinator with key words noted and creation of codes by theme in the same manner as the activity audits. The themes were rank ordered by frequency and documented by job title and wing location. Content analysis with all qualitative data was done by hand. Results Fifteen staff members including 7 nurses and 8 CNAs working on the 2 wings that comprised the Transitional Care Unit (TCU) of the
facility participated in LTC Team Talk. Only one participant was male and the age range was 22e58 years. Length of employment ranged from 1 to 25 years (see Table 1). Participation included debriefing session attendance, pre and post-program QWL survey completion, and focus group/interview participation. Nurses were included as participants due to the nature of their role as being teamed with individual CNAs based on patient assignment, necessitating continual interactions. This allowed for incorporation of their pre and post-program observations surrounding teamwork, communication, and CNA empowerment into the analysis of the project. Involvement of other team members in the intervention, such as therapists and social workers, was based on the CNAs’ decision to include them due to their more secondary or intermittent interactions. Quantitative findings The QWL survey results were entered into SPSS and evaluated by paired t-test of CNA pre-program to post-program scores (see Table 2). QWL survey scores results were significant in the categories of coworker and supervisor support (0.032) to the 0.2 and medium effect size measured at >0.5 for all categories: coworker and supervisor support (0.69), teamwork and communication (0.39), job demands and decision authority (0.23), wing characteristics (0.39) and job intentions (0.14).
Table 2 CNAs QWL survey subscale results by wing.
SW Pre-test Post-test NE Pre-test Post-test Cohen d SW NE Paired T test
Coworker & supervisor support
Teamwork & communication
Job demands & decision authority
Wing characteristics
Job intentions
3.2 4.3
3.0 4.9
3.1 3.6
2.5 3.5
2.7 3.8
3.6 3.9
3.3 3.1
3.3 3.4
3.1 3.2
3.4 3.5
1.5* 0.69 0.032***
1.4* 0.39 0.129
2.5* 0.23 0.188
1.2* 0.39 0.099**
1.6* 0.14 0.084**
Cohen d effect size: >0.2 ¼ small effect; >0.5 ¼ medium effect; >0.8 ¼ large effect; * ¼ >large effect. Significance: **
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Empowering certified nurse’s aides to improve quality of work life through a team communication program Erin E. Howe, DNP, RN, ANP-BC University of Rochester, School of Nursing, 255 Crittenden Boulevard, Rochester, NY 14627, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 June 2013 Received in revised form 1 November 2013 Accepted 10 November 2013 Available online 5 December 2013
The purpose of this pilot study was to explore the impact of a certified nurse’s aide (CNA)-led interdisciplinary teamwork and communication intervention on perceived quality of work environment and six-month job intentions. CNAs are frequently excluded from team communication and decision-making, which often leads to job dissatisfaction with high levels of staff turnover. Using a mixed quantitative and qualitative approach with pre- post-program design, the intervention utilized the strategy of debriefing from the national patient safety initiative, TeamSTEPPS. Inherent in the program design, entitled Long Term Care (LTC) Team Talk, was the involvement of the CNAs in the development of the intervention as an empowering process on two wings of a transitional care unit in a long-term care facility in upstate NY. CNAs’ perceptions of work environment quality were measured using a Quality of Work Life (QWL) instrument. Additionally, job turnover intent within six months was assessed. Results indicated improved scores on nearly all QWL subscales anticipated to be impacted, and enhanced perceived empowerment of the CNAs on each wing albeit through somewhat different experiential processes. The program is highly portable and can potentially be implemented in a variety of long-term care settings. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: CNA empowerment TeamSTEPPS Staff turnover
Introduction In this country, older adults are the fastest growing segment of the population with an anticipated census of 19 million people aged 85 or older by the year 2050 and nursing home costs expected to skyrocket to 540 billion dollars by 2040.1 The supply of CNAs available to provide quality care for our aging elders has become an increasingly urgent issue over the last two decades. Given the crisis of CNA turnover in long term care settings, identifying reasons for staff dissatisfaction and finding ways to improve retention should be a priority for health care administrators and nurse leaders. Staff turnover and job satisfaction are strongly tied to management support, job opportunities, workload, coworker relationships, communication, teamwork, and salary/benefits.2e5 Interventions identified to improve the complex construct of CNA job satisfaction involve a combination of extrinsic financial rewards, career opportunities and advancement, organizational culture, individual/ family factors and economic forces.2 The multitude of combinations incorporating these variables makes a challenging case for determining the most effective strategy for impacting global CNA job satisfaction. Yet a number of investigators have examined strategies designed to enhance work-place empowerment as a means to
E-mail address: [email protected]. 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.11.004
improve staff satisfaction and influence job retention.6e9 Few studies have explored the influence of empowerment on the CNA role, specifically. It is generally believed, however, that a combination of competence, autonomy and job meaningfulness contribute to feeling empowered in the workplace, which has been shown to enhance job satisfaction and retention of CNAs.10e12 The role of the certified nurse’s aide (CNA) as a primary provider of care in many health care settings is well established. This unlicensed position is critical in the nursing home environment, where CNAs are utilized to provide the majority of “hands-on” care.13 CNAs in nursing homes leave their positions at alarmingly high rates with turnover ranging from 70 to 100% annually. The cost to replace a single CNA is estimated to be greater than $4000.2 In addition to the financial costs, high rates of CNA turnover jeopardize quality of care. Health outcomes such as challenging resident behaviors, pressure ulcers, falls, and infection increase when CNA continuity of care to individual residents is interrupted.3 Failure of managers to recognize the impact of the CNA role on patient care and to institute measures to support, educate, and motivate their employees can lead to feelings of job dissatisfaction and ultimately a loss of quality caregivers.4 Approximately one year prior to development of this pilot study, CNAs in a long-term care facility in upstate New York were surveyed using a tool designed to assess psychological empowerment within the work environment.14 The results of that survey (N ¼ 12)
E.E. Howe / Geriatric Nursing 35 (2014) 132e136
revealed that the CNAs generally felt competent to do their work and found meaning in their jobs but they experienced little autonomy in their daily functioning, perceived having minimal impact on team decisions, and felt communication amongst team members to be poor. All of these factors were sources of disempowerment and job dissatisfaction. Based upon the literature regarding CNA job satisfaction and low perceived empowerment along with the communication issues identified by CNAs in the facility, a program entitled Long Term Care (LTC) Team Talk was developed that aimed to boost the CNAs’ sense of autonomy and empowerment, with the goal of potentially alleviating job dissatisfaction and turnover through a team communication approach. This pilot program, LTC Team Talk, was comprised of a communication and teamwork intervention led by the CNAs. The intervention consisted of a debriefing strategy, which is a simple mechanism that involves an informal and brief yet routine gathering of the team to discuss an experienced event. This method is an abbreviated version of what has been utilized in the successful national patient safety initiative, TeamSTEPPS, Team Strategies and Tools to Enhance Performance and Patient Safety as a way to improve the teamwork and communication of tiered groups of disciplines functioning in settings such as the operating or emergency room.15 This debriefing strategy is typically incorporated into a surgical setting, for example, as one of a number of peri-operative procedures designed to enhance patient safety and staff communication. Such fast-paced, acute environments often have a rigid hierarchy of authority and power, creating a vertical channel of downward communication. This type of structure often precludes a sense of egalitarianism and can hinder open communication to the detriment of teamwork and patient safety.16,17 Though this curriculum has not been studied in long-term care, nursing homes share the multidisciplinary and hierarchical nature of more acute care settings, which makes the TeamSTEPPS strategies, as used in the LTC Team Talk program, effective in this environment. Another key feature of the LTC Team Talk program involved the CNAs’ tailoring of the debriefing to meet their particular needs in the context of their respective units. The experiential process of the CNAs developing and then implementing this team communication program including making revisions to the process was assessed through post-program focus groups and interviews with the staff. The impact of the intervention on the CNAs’ perceived empowerment and quality of work life also was assessed. Methods Setting LTC Team Talk was implemented on a 68-bed sub-acute transitional care unit within a 362-bed, not for profit, long-term care facility in upstate New York. The unit was comprised of two separate wings (Northeast, NE and Southwest, SW) that constituted one entire floor with a similar population of rehabilitating elders. The program was approved by the University of Rochester’s Institutional Review Board and senior nursing home administrators prior to implementation. Other than to provide initial administrative approval, facility managers were not involved in the project so to protect the privacy and rights of the participants. Study design The study was a single group mixed quantitative and qualitative study with a pre-post-program design. The group was composed of staff on two separate wings within one transitional care unit that functioned independently of one another. Due to the distinctly separate geographical nature of the two wings, the intervention
133
was administered in two phases, first on the NE wing and then replicated on the SW wing. Pre and post-program surveys were obtained on both wings at the beginning and conclusion of the initiative on each side respectively. A second post-program survey utilizing a sub-sample of the group was administered eight weeks post-intervention to assess for preliminary indications of longerterm impact. Participants This pilot study utilized a nonrandomized convenience sample of CNAs and nurses on the two wings of the sub-acute rehabilitation unit. Inclusion criteria involved being a day shift CNA or nurse working more than 24 h/week on the rehabilitation unit. Exclusion criteria involved working primarily evening or night shifts, working less than 24 h/week, primarily working shifts on other units versus the rehabilitation unit, or not being employed as a CNA or nurse. Fifteen staff members were approached to voluntarily participate in the program and the study but were informed they could join LTC Team Talk but opt out of the study. All fifteen were eligible and agreed to participate in both LTC Team Talk and consented to the study. The participants were comprised of 8 CNAs and 7 nurses on the combined wings of this one unit. The four nurses and four CNAs on the NE wing and the three nurses and four CNAs on the SW wing were approached for participation during each wing’s routine monthly staff meeting. Informed consent forms were subsequently obtained by the organization’s nurse educator prior to administration of the pre-program Quality of Work Life (QWL) survey. Intervention The LTC Team Talk program involved regularly scheduled 5-minute debriefing sessions at the end of the day shift led by a rotating schedule of CNAs. The CNAs posed three questions to the staff during these sessions: 1) What went well today? 2) What can we improve upon? 3) What do we need in order to improve? Participants included CNAs, floor nurses and other interdisciplinary team members as invited by the CNAs. Each phase of the LTC Team Talk program last four weeks during which time the project director observed the debriefings and completed an activity audit form that documented attendance, question responses by staff, themes, notable staff interactions, and challenges encountered. Quantitative measures The QWL survey was administered pre and post-program as a validated 45-item Likert scale questionnaire modified from its original 65-item format that has been used previously to measure quality of work life for employees in health care organizations.18 The tool is composed of ten subscales, five of which were expected to be impacted in a positive direction by the intervention because they involved the key components of empowerment (competence, meaning, impact, and autonomy). These subscales included: co-worker and supervisor support, teamwork and communication, job demands and decision authority, characteristics of the unit and intent to leave/transfer units. The Cronbach alphas for these scale items were 0.91, 0.83, 0.58, 0.84, and 0.93 respectively. The remaining subscales were not expected to change with the intervention and included characteristics of the organization, staff
134
E.E. Howe / Geriatric Nursing 35 (2014) 132e136
training and development, patient/resident care, compensation and benefits, and overall impressions of the organization. The Cronbach alphas for these subscales were 0.84, 0.94, 0.93, 0.84, and 0.65 respectively.
Table 1 Summary of CNA age and employment in facility by wing.
SW NE
Years old
Years employed
30 46
2.8 14.3
Qualitative measures Activity audits were developed specifically for the debriefing sessions. Each audit included attendance, length of session, CNA leading the session and CNA timekeeper, a grid to record CNA and nurse responses to each of the three repeated questions (what went well today, what can we improve on, what do we need to improve) and a section for session themes. Focus groups were used at the conclusion of the program to evaluate the experience of the program and assess for feelings of empowerment. Two to three CNAs and nurses, in separate groups, were gathered to engage in the focus groups on the respective units. This arrangement was selected due to the scheduling challenge of convening a large group meeting during the day shift. The focus group was the CNAs’ requested method of evaluation as they expressed a preferred comfort level in speaking in small groups/pairs (as opposed to individually or in a larger group) and it was easier for them to simultaneously leave the floor in smaller numbers. These focus groups occurred based on staff availability during the day. The interview guide used during the focus groups consisted of ten open-ended questions pertaining to the staff’s feelings of empowerment. The questions were intended to address their sense of impact on the team, degree of job autonomy, experience of teamwork and communication on the wing both before and after the program, their perception of the debriefing sessions, how their day to day interactions with the team were similar and different and their description of their quality of work life. Quantitative data analysis Quantitative data was collected from participants via pencil and paper and included the demographic data of age, job title, and number of years employed in the current facility and the QWL survey. Data analysis involved the use of a paired t-test to compare the mean CNA scores pre and posttest on the following QWL subscales: Coworker and supervisor support, teamwork and communication, job demands and decision authority, characteristics of the wing, and intent to leave/transfer units. Qualitative data analysis Qualitative data was collected by capturing the themes discussed during the program and post-study focus groups. The study coordinator analyzed the data by first re-writing the activity audits as a transcript after each debriefing session. Staff expressions of recurrent issues were then labeled by category with the frequency of key words recorded. This content was then coded into themes. The data collected from the debriefing sessions via the activity audits were documented in table by role (CNA vs. nurse) and wing (NE vs. SW). The focus group responses were similarly transcribed immediately afterward by the study coordinator with key words noted and creation of codes by theme in the same manner as the activity audits. The themes were rank ordered by frequency and documented by job title and wing location. Content analysis with all qualitative data was done by hand. Results Fifteen staff members including 7 nurses and 8 CNAs working on the 2 wings that comprised the Transitional Care Unit (TCU) of the
facility participated in LTC Team Talk. Only one participant was male and the age range was 22e58 years. Length of employment ranged from 1 to 25 years (see Table 1). Participation included debriefing session attendance, pre and post-program QWL survey completion, and focus group/interview participation. Nurses were included as participants due to the nature of their role as being teamed with individual CNAs based on patient assignment, necessitating continual interactions. This allowed for incorporation of their pre and post-program observations surrounding teamwork, communication, and CNA empowerment into the analysis of the project. Involvement of other team members in the intervention, such as therapists and social workers, was based on the CNAs’ decision to include them due to their more secondary or intermittent interactions. Quantitative findings The QWL survey results were entered into SPSS and evaluated by paired t-test of CNA pre-program to post-program scores (see Table 2). QWL survey scores results were significant in the categories of coworker and supervisor support (0.032) to the 0.2 and medium effect size measured at >0.5 for all categories: coworker and supervisor support (0.69), teamwork and communication (0.39), job demands and decision authority (0.23), wing characteristics (0.39) and job intentions (0.14).
Table 2 CNAs QWL survey subscale results by wing.
SW Pre-test Post-test NE Pre-test Post-test Cohen d SW NE Paired T test
Coworker & supervisor support
Teamwork & communication
Job demands & decision authority
Wing characteristics
Job intentions
3.2 4.3
3.0 4.9
3.1 3.6
2.5 3.5
2.7 3.8
3.6 3.9
3.3 3.1
3.3 3.4
3.1 3.2
3.4 3.5
1.5* 0.69 0.032***
1.4* 0.39 0.129
2.5* 0.23 0.188
1.2* 0.39 0.099**
1.6* 0.14 0.084**
Cohen d effect size: >0.2 ¼ small effect; >0.5 ¼ medium effect; >0.8 ¼ large effect; * ¼ >large effect. Significance: **
