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Over the next month, the PHI Expert Interview series will bring you insights from four senior PHI staff. They’re an impressive group - among the nation’s leading experts on long-term care’s direct-care workforce - and collectively they’ve spent decades studying the challenges facing the workforce and how to address them. We think you’ll be interested in what they’ve learned.

The One Thing You Need to Make Culture Change Work

Sue Misiorski, PHI’s Director of Organizational Culture Change, has been making nursing homes better places to live and work for more than 20 years. A registered nurse, she started her career as a CNA and later became a director of nursing and vice president of nursing for an innovative nursing home chain.

Sue is also one of the pioneers of the Pioneer Network, the people behind the concept of culture change. She was president of the Pioneer Network for three years, and she wrote its handbook on how to implement culture change: Getting Started: A pioneering approach to culture change in long-term care organizations.

The Pioneers have worked hard to keep the concept of “culture change” flexible. They say that it’s a journey, not a destination, and that it can start almost anywhere. In keeping with that philosophy, Sue and her PHI colleagues start with an organizational assessment when they work with an employer, learning about that particular organization’s needs and goals rather than trying to impose a cookie-cutter solution.

But Sue has learned that one thing must be in place before an organization can embark on its culture change journey. “Relationships have to be healthy and strong, with a high level of trust and honesty and respect,” she says. And that means all relationships - between frontline workers and the people they assist, between workers and their supervisors, and between workers in different departments.

No teamwork, no change

“We often get called into an organization as consultants after changes have already been attempted and met with a lot of resistance,” says Sue. “We hold focus groups with all kinds of staff in all departments, all shifts. We ask them a series of open-ended questions, and we listen. And based on what we hear, we can often figure out that there’s a problem with relationships that need to be grown and healed in order to move forward.”

“Let’s say, for example, that you want to change how you serve food in your nursing home - away from institutional tray service to a more homelike dining style. If your nursing assistants and your nurses are not in a good relationship with the dietary department, the teamwork that’s required just isn’t in place.”

Developing a core set of skills

Building good relationships “isn’t simply intuitive,” says Sue; it requires a core set of skills. Sue and her PHI colleagues have identified those skills and developed adult learner-centered ways of teaching them, working some into published curricula.

Communications skills, says Sue, boil down to “a combination of self-awareness and self-management.” PHI’s communication skills training for direct-care workers and other non-management staff includes:

• Active listening, or making sure you truly understand what someone else is saying;
• Pull-back, which means maintaining emotional control in stressful situations;
• Problem-solving by exploring options; and
• Appreciative inquiry, which is a means of approaching other people and one’s work from a positive perspective, identifying strengths and opportunities rather than weaknesses and problems.

Supervisory and management staff learn coaching supervision, which includes all the same skills as well as “how to present a problem without blame or judgment,” says Sue.

Cross-functional teams, where direct-care workers, supervisors, organization leaders and others work together to implement a change, can also foster better relationships - though not without a little assistance. Team members from different levels of the organizational hierarchy are generally unused to working together, so a newly formed team often requires support and training in order to learn how to communicate with one another. “Otherwise, what often ends up happening is that a couple of people do most of the talking,” says Sue.

From that, great ideas are born

Once good relationships have been formed, everything else becomes possible, says Sue.

To keep people talking, she and her colleagues often help organizations start learning circles, bringing staff from all departments together with clients to talk about how they want to live and work together. “From that, great ideas with a lot of energy behind them are born,” says Sue.

“There are so many wonderful opportunities: consistent assignment, changing caregiving practices and routines to be person-directed and less institutional, breaking the larger organization into smaller neighborhoods, changing how you serve meals, changing how you bathe people, changing how you administer medications, changing how activities happen.

“There isn’t a department that can’t be included in what happens next.”

Interview by Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org