1. Abrahamson, Kathleen PhD, RN
  2. Davila, Heather MPA
  3. Hountz, Diane DNP, MS, RN, ANP


Staff engagement and input are crucial to project success.


Article Content

The Quality Assurance and Performance Improvement program, an Affordable Care Act initiative, requires nursing homes to develop, implement, and evaluate specific quality improvement (QI) efforts based on the needs of their facility. Most direct resident care such as assistance with eating, bathing, and mobility is provided by nursing assistants (NAs) under the supervision of licensed nurses. Thus, NAs often have unique knowledge of residents and are aware of weaknesses in care or organizational processes.

Figure. Kathleen Abr... - Click to enlarge in new window Kathleen Abrahamson, PhD, RN
Figure. Heather Davi... - Click to enlarge in new window Heather Davila, MPA
Figure. Diane Hountz... - Click to enlarge in new window Diane Hountz, DNP, MS, RN, ANP

Staff engagement is known to increase the likelihood of QI success. In nursing homes, nearly all changes driven by QI in work processes, schedules, approaches to care, or documentation will either affect or be carried out by NAs. Thus, including NAs in QI efforts is crucial to their success. Here are several ways nurse leaders can include NAs in nursing home QI efforts.


The message from leaders matters. Health care staff perceive leadership support as important to QI success. Change that disrupts long-standing work processes is particularly hard to adapt to, especially for direct care providers who have little power to control their daily work routines. Nurse leaders such as directors of nursing and charge nurses can acknowledge that QI often demands more work initially. Communicating the rationale for changes and the project's potential long-term benefits can increase staff acceptance, as can listening to feedback when changes are difficult. And sharing project successes lets NAs know that their input and efforts have improved care in a way that's valued. Likewise, staff frustration can develop when change processes with positive effects are later disregarded by leaders.


Relaxing role boundaries. The organizational culture in many nursing homes is hierarchical, role dependent, and resistant to change. NAs do a tremendous amount of physical and emotional caregiving, often with inadequate time and resources. Shifts in organizational culture that decrease rigid role boundaries and flatten hierarchies can empower NAs and other team members to propose changes to improve resident lives.


Improved care quality can also increase staff satisfaction and retention. Allowing for flexible scheduling of tasks such as bathing and meals empowers NAs to negotiate routines with residents directly. Initiatives such as the INTERACT program's Stop and Watch documentation provide a structure for NAs to communicate changes they observe in residents' conditions to licensed nursing staff.


We observed an example of successful NA involvement at a local facility struggling to attain compliance with the documentation of resident weights, a task assigned to NAs. In response to a survey to describe problem areas and suggestions to improve them, NAs suggested that a visual cue could remind them which patients were to have daily weights. A reminder tag with a red scale on it was placed in a spot visible to NAs when daily weights were needed for a resident. The NAs also decided it would be more consistent if patient weights were done at the same time every day, during morning vitals.


QI ambassadors. NAs have the most frequent direct contact with family members and residents. If a trusted NA positively presents changes in care processes to a family member or resident, it can set a positive tone throughout the facility.


NAs know where the quality gaps lie. If given the opportunity to contribute, they can have valuable input into areas most in need of improvement. Providing opportunities for NAs to take risks in their thinking without criticism is an important step toward learning from their caregiving wisdom and communicating that they are crucial members of the QI team.