Nursing and culture change leaders at PHI training

National leaders in gerontological nursing education and culture change participated in a two-day PHI Coaching Supervision^SM seminar in New York City in early June.

The long-term care nurse leaders convened to experience the PHI Coaching Approach^SM to Supervision firsthand and discuss its implications for successfully fulfilling the nurse’s role.

PHI has been documenting and field-testing its Coaching Approach to Supervision with long-term care providers for the past four years, with funding from The John A. Hartford Foundation and The Atlantic Philanthropies.

“It is a tribute to PHI and the work you have done that you were able to bring together such a distinguished group,” said Amy Berman, a program officer at The John A. Hartford Foundation who attended the program.

Spreading the PHI Supervision Approach

Sara Joffe, PHI organizational and executive coach and director of the Center for Coaching Supervision and Leadership, and Susan Misiorski, national director of PHI Training & Organizational Development Services, taught the seminar with PHI Certified Coaching Trainers Anna Ortigara of the Green House Project and the Pioneer Network and Joanne Rader of Rader Consulting and the Pioneer Network.

Rader has supported PHI by bringing the PHI Coaching Approach to Supervision (pdf) to colleges of nursing. Ortigara has partnered with PHI to bring the PHI Coaching Approach as applied to three key areas — supervision, leadership, and clinical partnership — to the Green House Project.

Every Organizational Level Would Benefit

“This coaching supervision class was remarkable,” Ortigara said. “These are the leaders who can bring coaching skills to undergraduate nursing students as well as long-term care provider sites. It can change the way nurses are engaged in empowering relationships with care teams.”

The seminar participants’ primary interest was in the application of coaching skills for nurses in the field.

The nurse’s role as supervisor of nursing assistants is critical to the delivery of high quality care, yet nurses receive little formal training in this non-clinical aspect of their role,” said Assistant Professor Elena Siegel of the Betty Irene Moore School of Nursing at the University of California, Davis. “It’s wonderful to see how PHI’s Coaching Supervision program is supporting nurses’ development in this area.”

There was also a high level of interest and excitement in the relevance of this approach for culture change efforts in nursing homes.

“PHI has an exceptional approach to helping organizations on their culture change journey,” said Pioneer Network Executive Director Bonnie Kantor. She continued:

One of the core values of culture change is that “relationship” is the fundamental building block of a transformed culture. I think that the skills, attitude, and knowledge gained through the training could assist care providers at all levels of the organizations in creating the kind of caring, effective, and efficient culture that we all desire.

The group of seasoned professionals also found the discussions, small group exercises, and skill practice sessions to be highly relevant to their own personal and professional lives.

The PHI Coaching Approach draws upon the skills of active listening, self-awareness, self- management, and clear communication without blame and judgment. When practicing these skills in the classroom setting and back on the job, participants learn a dramatically different way to support individuals and teams than that offered by traditional supervisory approaches.

– by Susan Misiorski, National Director of PHI Training & Organizational Development Services

Konrad is one of the authors of the Workplace Interventions, Turnover, and Quality of Care Report (pdf) released in June 2009 that details the effects of three distinct workplace interventions aimed at improving staff turnover rates and quality of care in North Carolina’s nursing homes.

These interventions include:

• The WIN A STEP UP program, a partnership of UNC’s Institute on Aging (IOA) and the North Carolina Department of Health and Human Services. The program addresses nurse aide recruitment and retention by providing education, training, and monetary rewards for aides who complete it. It also requires PHI Coaching Supervision^SM training for nurse aide supervisors at participating homes.
• Quality improvement collaboratives (QIC), in which groups of nursing homes work together with the statewide Quality Improvement Organization to improve specific quality indicators like reducing pressure sores or eliminating use of restraints.
• Culture change initiatives, grant-funded programs that enable nursing homes to implement changes designed to make their environments more homelike.

From 2004 to 2007 these programs were implemented at various nursing homes in North Carolina and then analyzed by IOA using quality indicators from the Nursing Home Compare (NHC) data set provided by CMS. In the end the results were clear: staff turnover and quality of care were both improved.

Of the three interventions, WIN A STEP UP proved to have the most direct impact on staff retention.

“WIN A STEP has a threefold approach,” says Konrad. “One is recognition of the workers. The second is skills training and career building, which involves [financial] rewards. … The third part is an accountability commitment.”

The result, he said, is an increase in team spirit between frontline workers and supervisors, improvement of clinical skills, and improvement of “soft skills” such as communication and interpersonal dealings, all of which leads to improved retention rates and quality of care, as seen in, for example, an observed decrease in incidents of dehydration and pressure sores.

A Virtuous Circle

“I don’t think you can improve quality without reducing turnover,” Konrad said. “And the relationship seems to go both ways. That is, frontline workers and supervisors don’t want to work in a place that doesn’t have high quality, so both contribute to raising that quality.

“Furthermore, as a nursing home improves its quality it builds commitment in the staff. So it can be a virtuous circle, although we see the opposite process occurs too often in some nursing homes.”

Konrad emphasized that none of the positive results reported in the study should be taken as cause for complacency. “We still have an unacceptably high turnover rate in North Carolina,” he says. “Unless the kind of changes we saw with WIN A STEP UP and other such things are institutionalized and carried on, turnover can go right back up.”

The paper summarizes a 2008 expert panel discussion convened by the Hartford Institute for Geriatric Nursing in collaboration with the Coalition for Geriatric Nursing Organizations and the Pioneer Network.  PHI Director of Organizational Culture Change Susan Misiorski represented Pioneer Network and PHI at the discussion.

Written by a team of 10 expert authors, the report examines the direct impact on nurses of the culture change model’s dominant themes — e.g., autonomy in personal choices for the residents, consistent staffing, and a less vertical organizational approach.

“The goals and philosophy of culture change and the goals of nursing are highly compatible,” the authors announce in the executive summary, since the “fundamental principles of nursing care support and incorporate resident-directed care.”

They say providing effective clinical care according to a resident-centered model “requires intensive nursing participation,” and therefore “core competencies for nurses in a resident-directed environment, and articulation of the essential role nurses play in helping to lead culture change efforts, are necessary.”

Recommendations

The paper includes a set of six recommendations, two of them regarding practicing nurses in nursing homes and the other four aimed at academic programs that prepare professional nurses:

• Develop and distribute a Statement of Goals for Practicing Nurses in Culture Change Nursing Homes.
• Develop competencies for nurses practicing in culture change nursing homes.
• Conduct a comprehensive review of culture change content in pre-licensure (associate degree and bachelor of nursing) nursing programs.
• Disseminate existing tools/resources on culture change and nursing’s role in culture change to academic nursing programs, including strategies for incorporating this content into the curriculum.
• Create new tools/resources based on the competencies for nurses in nursing homes.
• Identify research priorities for examining the role of nurses in nursing home culture change.

The paper identifies PHI’s coaching approach to supervision as one model for moving nurses beyond the traditional autocratic leadership structure, thus enabling them “to be a transformational leader and move culture change closer to its goals.”

At the upcoming annual Pioneer Network Conference, August 12-14, Misiorski and other experts  involved in developing the paper will offer three presentations dealing with the role of nursing in culture change.

Misiorski says the conference sessions are designed to share more detailed information with nurses working in organizations that are implementing culture change. Sessions will explore nurses as person-centered care experts and role models, as team builders and leaders.  “The role of the nurse in culture change goes far beyond medications and treatments, and we are excited to bring forth the full value of the nurse in the care team,” says Misiorski.

For more about bringing the coaching approach to nursing and to learn about PHI’s customized training and skill development for nurses regarding person-directed care, visit PHI Training & Organizational Development Services .

Over 50 participants from as far away as Oregon and North Carolina traveled to Pennsylvania to deepen their coaching supervision skills and share lessons learned. Trainers were able to connect with others who were at various stages of implementing coaching supervision, and to participate in skill-building workshops.

“We are growing so rapidly,” said CCSL Program Manager Makeeda Womack. “This was perfect timing to bring together trainers and reflect on the personal and organizational impact of using coaching supervision.”

The PHI Center for Coaching Supervision and Leadership, funded by the John A. Hartford Foundation and The Atlantic Philanthropies, is working with 42 long-term care organizations to transform how frontline staff are supervised and supported. In addition to training trainers in how to deliver the PHI coaching curriculum, CCSL works with executive leaders to support coaching throughout their organizations. The coaching approach strengthens communication and problem-solving skills, and reduces the time supervisors and managers spend “putting out fires.”

“Being a part of that whole experience was very positive,” said trainer Sherry Hill from Pennsylvania. “I learned a lot from others sharing their stories.”

To find out more about PHI’s coaching supervision training, email: consutling@phinational.org.

Aaron Toleos, Online Communications Director
atoleos@phinational.org