Policies and Practices Will Trump Your Rhetoric

The Atlantic recently published an enlightening article by veteran journalist Joe Williams, entitled, “My Life as a Retail Worker: Nasty, Brutish, and Poor,” where he writes about his experience working in a retail sporting goods shop after being laid off from Politico. It’s reminiscent of a phenomenal article Steven Lopez wrote in 2006: “Culture-Change Management in Long-Term Care: A Shop-Floor View,” which paints a similar picture of organizational rhetoric flatly denied by policy and practice.

Both articles highlight a common feature in highly bureaucratic organizations (which includes virtually all LTPAC providers): The rhetoric of person-centeredness, of genuine care about individuals, and of interest in the complexities of socio-economic conditions oftentimes falls flat in the face of organizational practices, strict “no-fault” policies, and unrealistic demands on individuals. In our work with providers, we constantly see discrepancies in the rhetoric of very caring leaders (We value our staff, we trust them to make good decisions, we put our residents first…) and the “machine” of the organization: inflexible attendance policies, collaborative discussions around all work issues except wages and working conditions, unrealistic labor demands on line staff… These two strong forces are like the legs of a person: if you don’t move too fast, you’ll probably drag each leg along without serious disruption. But try to run; try to walk quickly; try even to turn around: You’ll stumble and fall, like many well-intentioned providers.

Take this article published last month in McKnights. “Consistently assigning nursing home aides to particular residents could cause the aides to feel isolated and overburdened, suggests a study forthcoming in the Western Journal of Nursing Research.” Chris Perna, chief executive officer of the Eden Alternative, responded: “What the researchers can conclude is that the organizations involved did not do a very good job implementing these changes.” Pena went on to criticize the deployment of the program in the facilities studied, the sample size, and even that “the nursing homes in the study did not exemplify the principles of consistent assignment that Eden advocates.”

Pena is basically saying the organizations didn’t implement culture change correctly. It’s a common response to any criticism of the culture change framework, which intuitively feels right. And I get the feeling: my first job as a nursing home administrator was at a community lauded for it’s culture change practices, yet completely frenetic in staffing assignments. Through a long process, we developed a consistent assignment program that I felt was incredibly successful. From my vantage point as the administrator, I saw care outcomes were better (measure by incident numbers and the QI report), residents and staff were both happier (measured anecdotal and through satisfaction surveys), and absences were lower (measured through a detailed log we kept). But there was also roughness to this result. When a primary caregiver returned after a day off, they were invariably annoyed by small things the alternate did (or didn’t do). Teamwork was completely unaffected by consistency: those staff who helped extensive before consistent assignments continued to do so; and those who didn’t, didn’t. And the complaints about “certain groups of residents” intensified, as now it wasn’t luck if you were assigned “a hard group”– it was your fate. When we looked at outcomes on a microlevel, we found that one group consistently had lower staff satisfaction and higher turnover. Did we fail in our implementation? Did we not exemplify the principles well enough? No, I don’t think so. I think we discovered how life is infinitely more complex than a consistent assignment program can encapsulate. I think we discovered that our attendance policy was doing more harm to consistency than our staffing practices. And I think we discovered that not all CNAs want the same thing, not all residents want the same thing, and sometimes the competing priorities between administrators, staffing coordinators, line staff and residents mean that not everyone gets exactly what they want. And this is the heart of it.

The problem with culture change interventions, fundamentally, is that they are typically constructed in a vacuum of what could be. This is a great environment for designing a best practice, and a lousy environment for integrating real-world challenges. At the core of culture change philosophy is the tenet, “Know the person.” And it’s here where the tension is greatest. Know the person means consistent assignments are not best for all residents and all staff and all organizations. Neither is any other intervention. Programs must be designed locally and in context. And part of that context is the rest of the organization. What Lopez and Williams point out is that if your organization values people, don’t insist on policies that treat workers like criminals or children. If your organization demands loyalty, don’t stand behind policies that inflexibly respond to outcomes rather than processes. And if you care about doing the best work possible for residents, don’t create avenues for discussion that a priori exclude topics (like wages and working conditions).

Here’s a good way to start a more complex evaluation of culture change in your community: look at either your organization’s attendance or counseling policy. Does it reflect the person-centeredness of your organization? Does it reflect the values you expect line staff to show to your residents? Does it reflect your organization’s heart? Or is it formulaic, adversarial and reminiscent of the care processes your organization is committed to changing?


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