Interviews were conducted with a total of 13 staff members—two managers, three licensed practical nurses, and eight HCAs. Because there were two distinct lines of inquiry, results are presented separately for the components.
Expanded feedback report
The Expanded Feedback Report was developed in hopes of providing additional information and/or support to a facility that had expressed considerable interest in understanding more about the research that had been done and using it to improve care at the facility (Restwood).
The DOC indicated that the variable ‘evaluation’ (feedback processes) that had been reported in the FAR several months earlier was not as helpful as it could be because labels did not provide any intuitive guidance about what a low (or high) score meant. The scores on individual items, as opposed to derived variables, were seen as more meaningful in some cases. Two additional variables not included in the FAR, ‘Formal Interactions’ and ‘Informal Interactions,’ were included in the expanded analysis, and the DOC commented that it was necessary to distinguish these two variables from ‘Informal Data Review’ and ‘Formal Data Review’ that were reported as part of Feedback Processes on the FAR. Hence, using unique and descriptive variable labels is helpful.
Overall, the DOC found the FAR presentation of comparative results via bar graphs of the variables understandable and helpful. However, the DOC commented that the meaning of quadrant type graphs in the Expanded Feedback Report, which depicted inter-relationships among variables, was difficult to grasp. These graphs depicted three variables in a two-dimensional space. Two variables were plotted on the horizontal and vertical axis, respectively, and the third variable was incorporated through varying sizes of dots (large if above the median on the third variable and small if below; Figure 1). In addition, the dot that reflected Restwood was shown as a large red diamond on the quadrant graphs. Hence, there were three dimensions that varied (color, shape and size) and it was not clear to the DOC which, if any, of these dimensions were meaningful when trying to compare Restwood to the other facilities. The ability to quickly glance at and get an ‘impression’ from the size and scatter of the dots (above or below the median) showing mean scores on the graph was appealing, but it was difficult to interpret with confidence the key message from these quadrant graphs.
The organization of the results in the Expanded Feedback Report was not ideal from the DOC’s point of view. In one section, the report provided scores on all variables (e.g., burnout, culture, evaluation) for Restwood and compared them to the scores from the best performing facility, and in the next section of the report provided scores on all variables and compared them to the mean scores on all facilities in the province. The DOC was primarily interested in examining how the Restwood score on each variable (e.g., burnout) compared to the best performing facility, then to all facilities in the province, and finally to Restwood over time. The DOC would have preferred to have the three comparisons (Restwood to best performing facility; Restwood to provincial mean; Restwood compared to itself a year earlier) presented for each variable rather than presenting the comparisons for all the variables to one comparator (e.g., best performing facility). The dimension of interest was the substantive variable itself (e.g., burnout) rather than the other comparison group (e.g., provincial mean).
Staff engagement with the research process
Four themes emerged from the data: sharing feedback reports from the TREC study; the meaning of TREC to staff; understanding organizational context; and using the study feedback for improvement at Restwood. Each theme is described below.
Theme one: Sharing feedback reports from the TREC study
The TREC study feedback reports had been shared with staff (poster) and management (FAR) at the facility prior to the case study [12, 13]. According to staff interviewed for the case study, the FAR had not been widely shared with staff. The FAR was seen as very helpful and informative by the DOC and most of the results resonated with the experiences of management in the facility (e.g., exhaustion score from Maslach Burnout Inventory). The DOC indicated that the language was quite clear on the FAR with the exception of ‘Feedback Processes.’ It was only after the exact detailed wording of items used to capture feedback processes was shared with the DOC that the DOC understood what the Feedback Processes bar graph meant.
Two back-to-back feedback sessions were previously held with frontline staff to present and discuss the poster that showed selected findings from the HCA survey [12]. The poster was then left in the facility (on the table or posted in the staff room) for all staff to see it. However, only one-half of respondents interviewed during the case study reported ever having seen the poster. Most of those who had seen it did not recall discussing it with anyone. Although specific knowledge of TREC results was not high, most staff members were aware of ‘TREC’ (calling it by name) and greeted the interviewer with obvious knowledge of why she was there. The DOC was engaged in TREC at a more concrete and focused level than were staff (as illustrated above in discussion of the Expanded Feedback Report).
Theme two: The meaning of TREC to staff
Three themes emerged from staff perceptions of the TREC study. First, TREC provided an avenue through which to express or demonstrate hope and a desire for change and a better future at the facility. As one staff member stated: ‘If we’re not given an opportunity to talk, nothing will ever change.’ Another staff member indicated: ‘I appreciate this research so much…at a very minimum it is addressing that there are issues in long term care…which is the first step. We need buy-in from the community.’
Second, seeing results of the survey (even if for the very first time during this interview) provided a fresh lens through which to think about the current situation at Restwood. One staff member stated that the ‘exhaustion (burnout) finding for our facility is frightening’ (Figure 2). Staff were making connections in new ways. For example, looking further at the fact that the TREC study is interested in exploring the variable ‘organizational slack,’ another staff member highlighted the connection between slack and the exhaustion results (which were high for this facility).
A third and dominant theme, particularly as reflected by HCAs, was that of feeling undervalued and not listened to as staff members, and TREC provided a means of having one’s voice heard. For example, one respondent started energetically speaking even before signing the consent form about ‘being glad that someone was talking to them as they spend all their time with the residents.’ Another comment (from someone who reported having seen the HCA poster on the table) was ‘I was interested that someone is taking an interest in what is happening in our facility. To talk about the different issues that there are… it seems you work and no one pays attention.’ The fact that someone external was ‘listening’ or ‘paying attention’ to what was happening was hopeful to staff.
Theme three: Understanding organizational context
The importance of understanding organizational routines and the impact of corporate restructuring were key themes emerging from the case study. Even equipped with the results of the TREC survey, which identifies potential areas where improvement efforts could be targeted, it is necessary to understand more about the ‘ground’ or ‘base situation’ that exists in the facility in order to strategize about how best to initiate change. The following outlines some observations from the case study that partially characterize the current situation at Restwood.
Staffing profiles
HCAs were the vast majority of staff caring for residents compared to licensed nursing staff. Nursing staff were designated ‘in charge’ but often had less exposure (from a time point of view) to residents or to the facility operations generally than did HCAs. There were no full-time registered nurses in the facility. Therefore, some of the licensed practical nurses worked in various roles, sometimes in direct resident care and sometimes in the charge role.
Communication routines
Regular staff meetings were held, although the frequency and attendance at these meetings was not reported consistently by all respondents. There were (at least) two streams of communication—one that related specifically to residents and another that related to other issues (policies, organizational changes). Verbal updates supplemented by brief written notes were done at shift change. Only one respondent mentioned communication books as a mechanism whereby information was shared.
Organizational change
The ownership of Restwood had recently changed and the effects were evident from comments made by staff during the interviews. The new ownership brought with it a high-level commitment to a particular person-oriented approach. While the new ownership was not the only prevailing influence, it contributed in a major way to some observations; for example, staff attributed almost all changes that occurred in the facility (often described in a negative way as ‘rules’) to the person-oriented approach philosophy. One staff member stated: ‘POA [person-oriented approach] is not a new philosophy. But now that it’s been thrown down here with directive ‘we’re doing POA now’; now you have to do it; there’s a hard edge to it.’
However, some aspects of the person-oriented approach were deemed positive, such as a more homelike environment in the dining room. While the Restwood facility has been in existence for many years, the facility was rarely mentioned by name in interviews. There was very little evidence of ‘pride of identity’ with the Restwood facility (despite notable commitment to the well-being of residents). Staff expressed caring deeply about the residents and expressed an awareness that meaningful engagement with others makes a big difference in the quality of life for residents.
The energy of art
There was a summer art project lead by a young ‘artist-in-residence’ that had recently occurred in Restwood. This artist was in Restwood for several weeks, and there were many paintings on the walls in the dining room and hallways. These had all been painted, framed, and hung during the recent project. A small room off the larger activity room was used for the art project. At the time of the case study, a large ‘Art Room’ sign in hand-printed letters still hung, and tables were situated around the periphery of the room with various art supplies visible. Every HCA interviewed talked about this art project positively and with a high degree of energy:
…we had a summer student absolutely phenomenal.. she brought more joy to the lives of residents than our recreation program.
A lady who lives here had never been given the opportunity to paint. This was the first time in her life… her artwork is amazing… she shakes. She can hardly hold a cup… but somehow she paints a beautiful picture… to come for one summer in a matter of three or four months… it doesn’t take much.. If you come into a facility like this and introduce something like this… it is going to be successful. Don’t know why people are afraid to introduce programs… these people need something… if it’s more interesting than sitting in a chair, it will fly…
Staff had a strong commitment to addressing the needs of the residents as illustrated through their reaction to the art project. Not only did this art experience generate much energy among the staff, the staff commented on how happy they were when the residents were happy and engaged in activities.
Theme four: Using the study feedback for improvement at Restwood
To date, only the DOC has been involved with using the results from TREC. While there were no examples of direct action taken as a result of the research results, one action—the practice of doing annual performance reviews for all staff—was ‘spurred on’ by the TREC project. Initiating annual performance reviews (which had not been done historically) had been targeted as an objective for 2009, but participation in TREC provided further impetus as attention was focused on specific aspects of importance to staff (e.g., job satisfaction, receiving recognition for work done). The DOC anticipated that the research results would provide valuable information on which to base changes in the facility.