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Discussion

Caring for and caring about part 3: using an adapted model of care to manage change

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Care homes should move towards a remedial approach of caring for residents. This article supports managers in embedding organisational change

Abstract

This last in a three-part series discusses how care home managers can use the adapted Caring For and Caring About (CFCA) model to lead organisational change management to develop a remedial culture.
Part 1 of this series explored the nature of the caring relationship and outlined the CFCA model, which staff can use to move from a protective focus of “caring for” to a remedial focus of “caring about” residents. Part 2 showed how staff can use the model in practice to promote a remedial care approach.

Citation: Wild D et al (2012) Caring for and caring about part 3: Using an adapted model of care to manage change. Nursing Times; 108: online issue, 10 April.

Authors: Deidre Wild is senior research fellow (visiting), Faculty of Health and Life Sciences, University of the West of England, Bristol; Ala Szczepura is professor of health services research, Warwick Medical School, University of Warwick, Coventry; Angela Kydd is senior lecturer, University of the West of Scotland, Hamilton Campus, Hamilton, Scotland; Sara Nelson is research fellow, Faculty of Health and Life Sciences, University of the West of England, Bristol.

Introduction

This is the final article in a three-part series on the Caring For and Caring About (CFCA) model designed to promote remedial care practice in care homes for older people. Part 1 described the model, the rationale for its development and care relationship requirements to make it work (Wild et al, 2012a). Part 2 focused on using the model in practice to encourage appropriate remedial care for the major disablements of late life, such as continence promotion, remobilisation, confidence-building and motivation (Wild et al, 2012b).
This final article offers support to care home managers who wish to use an adapted version of the CFCA model for organisational change. In this, “caring for” and “caring about” are still the essential conceptual approaches, but the processes described reflect the journey towards developing a remedial culture as an integral element of a quality-improvement initiative.

The need for remedial care

The need for changes in practice in all types of UK care home is illustrated by the findings of a large health census of residents in one provider’s homes; a considerable overlap was found in dependency between those in nursing homes and those in residential homes (Bowman et al, 2004). Assessment and regulation were described as poorly matched to the overall care needs of residents, of whom 71% were incontinent, 76% had impaired mobility and 78% had at least one form of mental impairment.
Such findings could suggest that the embedded care approach places emphasis on “caring for” residents (doing something for, to, or on behalf of, or looking after) rather than a remedial approach of “caring about” (enabling, encouraging, deferring to) that seeks to improve residents’ function. It could be argued that, as a higher number of beds are in residential homes with no onsite registered nursing requirement (Care Quality Commission, 2011), and staffed by social support carers with limited healthcare knowledge, that remedial care deficits would be an expected outcome in these settings. Other limiting factors could lie in the ad hoc nature of community nursing input (Goodman et al, 2005), and insufficient access to other NHS expertise (Lievesley et al, 2011).
A literature review on caregiving by staff in care homes highlighted: the limited subscription to evidence-based practice; the need for further role development of home managers as change agents; and the importance of investing in care staff development as a precursor to changing a task-oriented care culture (Szczepura et al, 2008).

CFCA as an organisational change model

The adapted CFCA model for organisational change management (Fig 1) shares a similar visual format to that of the CFCA model of remedial care presented in the two previous articles (Wild et al, 2012a; 2012b). It also retains the emphasis on “thinking” before “doing” in terms of decision-making for managing change. The model’s elements are labelled A to H with each representing a part of the management journey towards achieving remedial quality-improvement (QI) goals (H) agreed at the outset with staff (A). As with the original model, the thoroughness of the preparatory phase (A) will dictate the potential for success and if incomplete or rushed, it could jeopardise managers’ credibility and staff commitment.
As shown, each of the “managing caring for” and “managing caring about” approaches has a “high” and “low” level within its inter-dependent circle. Where both circles overlap is the crucial decision-making hub (F), in which the appropriateness of the management changes from one caregiving approach to the other (transition) are considered using findings from audit and other tools for monitoring progress (G1) and including external professionals’ feedback on performance (G2). There is no restriction on adding new 
tools or other knowledge at G to support the decision-making of zone F, which includes staff.
If at the outset “managing caring for” is high (B), then it is likely that staff’s ethos is to work to routines shaped over time and aimed at containing rather than diminishing disability. The greater the emphasis on “caring for”, the less management leadership is given to promoting “caring about” (D). However, this does not mean that both forms of care management do not co-exist, just that wittingly or unwittingly, one is more likely to be dominant than the other.
For example, a dominant “caring for” approach is legitimate and essential to meet needs arising from illness. However, when caregiving becomes overprotective and inappropriate by denying opportunities for individual residents to self-help, managers need to challenge the logic of this approach with staff and promote “caring about” ways of working using remedial skills.
As “managing caring about” increases (E) and progress towards the agreed strategic goal (H) is regularly reviewed (G), any focus on “managing caring for” should diminish (C), with staff becoming more active in negotiating the appropriate input of remedial care with individual residents.
If change falters, as the model’s two-way horizontal arrows indicate, the dynamic between the two management approaches may need to be revised and even temporarily reversed in order to identify new strategies to re-strengthen and encourage “caring about”. Importantly, underpinning the use of this model are two resources for sustaining change: the need for time (particularly during the preparatory phase) and patience (particularly after implementation) to enable it to become embedded practice within ways of working (Nelson et al, 2009a).

Preparing for organisational change

Managers as change-agents

Described by Nelson et al (2009b) as “the bridge or barrier” to successful innovation in care homes, home managers’ role is further complicated by a situation whereby they may choose to lead, but staff will decide whether or not to follow according to their perceptions of their manager’s credibility as a leader (Kouzes and Posner, 2011). Thus preparing for change should begin with home managers gaining insight into their credibility as perceived by staff. In seeking this, managers should be open to inviting peer review for self-improvement and ongoing mentorship as a support. This could have the added benefit of setting a precedent to make the appraisal of staff performance across the change process a similarly constructive rather than threatening activity.
The following list are qualities and attributes for home managers seeking to be a change agent (in bold) and some positive responses (in italics) that staff could make towards them:
Credible leadership Follows
Knowledgeable educator Learns from
Visionary strategist Confident in, Motivated by
Shares and listens Feels included, Has ownership
Innovative Sees change as progress
Hands-on style Has trust in, Sees as a role model
Relationship builder More support, More expertise
Most of all, being visible to staff and residents, with involvement in hands-on caregiving, will inevitably enhance managers’ standing with staff more than being remote and office-bound. Other attributes include having a thorough knowledge of residents’ care needs, wants and potential for improvement and a commitment to staff (and own) training and maintaining competencies.

Involving staff

In preparing for change, all staff levels need to be involved from the outset in developing a vision of what a remedial care home could be like. This should be followed by preparing a mission statement of what would need to be done to turn the vision into a reality. Finally, a values statement of the conduct to be adhered to by those involved in achieving the vision should be defined, as it will help to maintain group harmony by setting the tone and context for their future behaviour (Gottlieb, 2007). Through this type of inclusive process, staff are more likely to commit to both the vision and mission with a sense of ownership before starting the process of developing the strategy for change.
For managers and staff, knowing what happens now and why is both the springboard for change and the basis on which its success can be gauged. By mapping residents’ assessed level, range and type of needs against staff caregiving responses to meet them, and against the profile of staff skills and learning (given collectively in Fig 1 at A as “scope”), the level of demand on caregiving activity and the adequacy of staff skills to meet these can be gauged. Review of past audit and regulatory outcomes is a further addition to homes’ care history.
By taking time to understand staff’s current interactions between themselves and with residents and within their ways of working (including their use of material resources and the physical environment), future interventions become more transparent (Scott et al, 2008). Dialogues with staff could involve simple questions such as: “What do we need to learn and do to change X aspect of caregiving to achieve the quality-improvement goal Y?” This could then progress to the more complex and probing questions of: “If we change X, what else could be positively or negatively affected during the course of progress towards the achievement of Y?” and “How can we reduce the potential for harmful effects?” A simple SWOT analysis (strengths, weaknesses, opportunities and threats) by all or a representative group of staff is a useful exercise to provide and explore general perceptions of current and future caregiving approaches in practice.
Through such techniques, managers and staff will be able to identify the first change and go some way to second-guessing some of the common inhibitors towards it at the outset and during its progress. Examples of inhibitors found in recent studies are shown in Box 1 to illustrate some of the issues that could emerge.

Box 1. Research findings on inhibitors to upskilling social care staff

Resistant attitudes

  • Some staff did not want to change ways of working or learn new skills as they thought these were already adequate
  • Some believed they were too old to change
  • Only when staff could see the result of improved care did change become positively accepted

Lack of focus in education

  • The content of formal courses was insufficiently related to hands-on practice
  • The system of assessment and supervision of competencies was weak

Lack of resource

  • Staff perceived they did not have time for what they saw as “extra” work or learning
  • A belief that upskilling with healthcare skills created a need for more manpower

Lack of professional standing

  • Lack of understanding of accountability and liability
  • Sense of being a professional inside the home but less so in the eyes of those external to it
  • Social support care staff lack a professional framework, body and registration

Ineffective management

  • Some home managers subscribed rhetorically to change but did not have the experience or knowledge to lead implementation with staff
  • An office-bound, remote management style tended to leave staff feeling unsupported
  • Although a vision and strategy for quality improvement for the home, staff and residents was written by management, only in one in four of the homes was this fully shared with and understood by staff
  • Few reciprocal links between homes and wider NHS or other providers’ networks were established to support or sustain change
  • The value of audit as evidence was not fully recognised by managers

Sources: Wild et al (2011); Nelson et al (2009b)

Managing organisational change

Changing staff roles and ways of working

Changing ways of thinking will open minds to new ideas but is also likely to raise the question of resources. Given the current financial climate, it is likely that changes will largely be confined to using the same resources but in a different way. Remedial care depends on establishing strong one-to-one carer and resident interdependent relationships, with a continuity of dedicated time provided from one caregiver to another across shifts over the 24-hour day (Wild et al, 2012a).
The crucial change will move away from horizontal working, where staff work together to complete a series of tasks across a number of residents, towards vertical working with individual staff members being responsible for a small caseload of residents jointly involved in the process of achieving remedial goals (Wild et al, 2012b).
Essential to organising work in this more person-centred way is the manager’s role in matching caregivers’ skills to support residents’ own efforts towards QI goal attainment. However, if one-to-one care cannot be consistently provided across shifts to meet a remedial care goal, a skills learning cascade system should be activated to ensure that enough staff are adequately upskilled before embarking on remedial change. When changing practice from an excessively protective “caring for” approach towards a more hands-off but therapeutic “caring about” approach, it is important to retain the key quality of empathy. Since this cannot be taught, it is crucial that there is tangible evidence of this in both new and existing staff.

Staff motivation and incentives

A further important aspect relevant to workforce development is managers’ understanding of what motivates staff and which incentives they are most likely to appreciate. Haslam et al (2009) found that most care workers’ self-identity and motivation stemmed from their close identification with other colleagues. Furthermore, because carers demonstrated a sense of altruism towards their care work, they responded to work-related issues from a perspective of what was good for the group rather than for themselves as individual care workers. Monetary reward was not seen as a high priority. Some have suggested that managers should commit to developing a culture that encourages staff productivity and high morale based on staff’s personal sense of meaning and purpose given to their work rather than by externally imposed motivators (Morrison et al, 2007).
Upskilling and changing ways of working may destabilise some staff members’ sense of comfort and morale due to the loss of familiar routines and partnerships. This can result in initial resistance to change (Bozak, 2003). However, upskilling the carer workforce can lead to benefits for residents such as: improved quality of life; increased activity and stimulation; positive interactions and relationships with other residents and staff; and more appropriate and directed care (Fleming and Taylor, 2006; Smith et al, 2005; Proctor et al, 1998).
Keeping the vision and strategy alive, by managers leading from the front with hands-on visible support and adhering to values, will do much to bridge “what was” towards “what could be”, in terms of changing the approach to caregiving. By adopting a constructive management style such as “appreciative inquiry” (Cooperrider et al, 2008), managers can seek and build on the best in staff, their homes and wider systems rather than focusing on what is wrong with them. By doing so, staff resistance to change and negative “groupthink” (Janis, 1972) could be reduced.
Most of all, managers should not underestimate the time needed to support and understand staff as people as well as workers when they are undergoing change, even when enhanced by new remedial role titles (such as social care support therapist) and with mutually agreed job descriptions.

Developing the home

Transforming the home’s culture

Manthey (2002) suggested that changing practice alone will not change culture if unsupported by a climate in which innovation is encouraged and those innovating feel empowered. This echoes work by Banks (2006), who argued that day-to-day care in care homes must have a focus on applying moral philosophy in practice situations - that is the value bases that inform decisions in practice (see Wild et al, 2012b). Nolan et al (2008) noted that in transforming a home’s culture, education appears to be desirable but not pivotal to changing it. Other influential factors were: raising the home’s role and status; adopting a person-centred approach to care; and acknowledging the importance of all those who live, visit or work in the home.
Jost and Rich (2010) found that inspirational and credible leaders who communicated with staff and listened to the story of change as it unfolded and recognised new opportunity, had the most influence in changing culture. Thus, managers act as guardians of their homes’ past and future. On the one hand by capturing and reflecting the achievement of change over time and on the other, by translating this into a representation of the home’s caregiving culture as one of aspiration to improve residents’ health, sense of wellbeing and autonomy.
As Fig 2 shows, the two CFCA models represent mechanisms to support a learning culture that embraces:

  • Remedial caregiving practice;
  • Remedial care management.

Both are presented as separate but complementary journeys.

New enterprise opportunities

Care homes in the independent sector are run as businesses where surplus income must be made. Seeking new enterprise opportunities is therefore important for viability but this has to be cost-effective. Encouraging a remedial care approach is likely to require selected key staff to acquire an appropriate level of remedial knowledge and expertise in practice. However, care home staff can be isolated from other homes, and are largely excluded from mainstream care systems (the NHS) by different conditions of employment (Davies, 2001).
To overcome these constraints, developing a local network of like-minded care homes working towards remedial care could provide economies of scale through shared development costs and joint delivery of formal courses supported by hands-on learning provided by local NHS sources of expertise (Wild et al, 2005). Also, once key staff have been assessed as competent, they could take on the role of cascading their learning not only to in-house novice staff but also as “visiting remedial skills disseminators” for staff in other networked homes.
When the vision for the home becomes established practice, fresh enterprise opportunities could arise as the home’s reputation grows. For example, if a home is aspiring towards becoming a centre of remedial care excellence, it could participate in a “hospital to home” scheme. In this, hospitals discharge older patients earlier to remedial care homes than to their own homes, thus relieving pressure on acute hospital beds while increasing occupancy in care homes. These temporary residents would receive more intensive remedial goal-oriented care supported by NHS community therapists, with the objective of handover to community care support in their own homes within 2-10 weeks. Remedial day and short-stay care schemes with specialist care, such as dementia and stroke, could also be options.
In these ways, delays in permanent admission to care homes would enable many older people to remain longer with community support in their own homes with associated savings for social and health budgets. The added value in terms of enterprise-building for these care homes could lie in their recognition as a respected major resource through closer partnership working with NHS community and acute care staff.
However, close partnerships between care homes and local NHS community health professionals will not arise by chance but need joint vision, mission and values to be engineered and nurtured by influential managers of both sectors. In taking this further into developing strategy, “cross sector” (NHS commissioner and provider managers with independent-sector counterparts) reciprocity would become accepted as a logical “whole-system” partnership approach. For example, access to high-quality remedial homes could provide the NHS, local universities and colleges with inspirational placements for students from many health and social care disciplines. In return, lectures and dissemination of best practice by the educational institution’s staff could be open not only to their students, but also to able care home staff. Furthermore, if NHS managers can change the ways of working of visiting community therapists and community and specialist nurses to include mandatory skills dissemination to and supervision of care staff, then high-quality continuity in remedial practice could become a reality.

Conclusion

This series has highlighted care homes as a major long-term resource for the NHS but one that has perhaps been underestimated in terms of its value and potential.
Currently, once placed in a care home, older residents seem to suffer from a prevailing ageist assumption that they are on the fringe of entitlement to NHS services. However, in reality, as residents they still have the same rights to these services as they would have if they were in their own homes. Home managers are crucial in ensuring not only that these residents’ rights are exercised but also in encouraging continuity for remedial care initiatives.
The CFCA organisational change model offers a conceptual guide to the dynamic process of moving from a culture of “caring for” to one of “caring about” and is underpinned by shared decision-making between managers with staff. In addition, the model contains a useful by-product in its emphasis on evidence-based practice informed by scoping exercises, and the ongoing use of audit and assessment. The cumulative outcomes from these information sources can be used to provide a reliable picture of the home’s performance against national standards for registration and ongoing compliance with the Care Quality Commission.
In making the change towards a remedial care culture, new business opportunities for care homes could arise with minimal investment. However, this relies on the sector taking the initiative by looking outwards for more support and expertise as well as inwards in terms of embracing change towards a new vision. By putting into place the quality improvement attributes, given as a checklist in Box 2, care home managers and staff could build the culture that older residents need and deserve.

Box 2. Remedial care home culture

The remedial care home culture would have:

  • Developed a vision, mission, values statement and strategy
  • Inclusive feedback and discussion to inform decisions between staff and managers
  • Hands-on, visible and knowledgeable management that leads change by example
  • An internal professional framework for staff that underpins accountability, liability and responsibility
  • Created a learning environment in which staff are upskilled/updated using ongoing supervision for remedial practice supported by online access to learning materials, cross-sector and inter-sector reciprocal teaching and learning, student placements, and “expert” NHS dissemination/support for remedial practice
  • Adopted ways of case-working that are appropriate to the remedial caregiving relationship
  • Established cross-sector reciprocal partnerships with wider health and social care systems for innovations of mutual benefit
  • Internal pride in remedial care achievements and have gained external respect as a major health and social care resource

Key points

  • The CFCA organisational change model offers a conceptual guide to the dynamic process of moving from a culture of “caring for” to one of “caring about”
  • All staff levels need to be involved from the outset in developing a vision of what a remedial care home could be like
  • Given the current economic climate, it is likely that most change will involve using the same resources but in a different way
  • Developing a local network of like-minded care homes working towards remedial care could provide economies of scale
  • In moving towards a remedial care culture, new business opportunities for care homes could arise with minimal investment

 

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