723889
research-article2017
QHRXXX10.1177/1049732317723889Qualitative Health ResearchPickering et al.
Article
Recognizing and Responding to the “Toxic” Work Environment: Worker Safety, Patient Safety, and Abuse/Neglect in Nursing Homes
Qualitative Health Research 1–12 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/1049732317723889 DOI: 10.1177/1049732317723889 journals.sagepub.com/home/qhr
Carolyn E. Z. Pickering1, Katie Nurenberg2, and Lawrence Schiamberg2
Abstract This grounded theory study examined how the certified nursing assistant (CNA) understands and responds to bullying in the workplace. Constant comparative analysis was used to analyze data from in-depth telephone interviews with CNAs (N = 22) who experienced bullying while employed in a nursing home. The result of the analysis is a multistep model describing CNA perceptions of how, over time, they recognized and responded to the “toxic” work environment. The strategies used in responding to the “toxic” environment affected their care provision and were attributed to the development of several resident and worker safety outcomes. The data suggest that the etiology of abuse and neglect in nursing homes may be better explained by institutional cultures rather than individual traits of CNAs. Findings highlight the relationship between worker and patient safety, and suggest worker safety outcomes may be an indicator of quality in nursing homes. Keywords quality of care; certified nursing assistant; turnover; patient safety; elder mistreatment; qualitative; grounded theory; North America Elder abuse is an act of harm, or a failure to provide a service, by a person in a trusted relationship with the older adult (Bonnie & Wallace, 2003b). Although no national prevalence data are available, surveys have found consistently high rates of abuse and neglect in nursing homes (NHs; Castle, 2012; Page, Conner, Prokhorov, Fang, & Post, 2009). For example, a survey of family members of residents in Michigan NHs revealed 21% of respondents reported their loved one experienced at least one incident of neglect by NH staff in the past year (Zhang et al., 2010). This rate of neglect is considerably higher than the rate found among community-dwelling older adults (5.1%; Acierno et al., 2010), and particularly troubling as neglect represents the failure or refusal to care for an older adult’s needs, which is the purpose of a NH. It is important to note that elder abuse and neglect only sometimes reaches the threshold of a criminal problem, but it is always a clinical problem. In the context of NH care, quality of care can be thought of as a spectrum ranging from anticipatory and preventive at the positive pole to abusive and neglectful at the negative pole. Within NHs, certified nursing assistants (CNAs) provide the majority of the direct hands-on care residents receive, making them the ideal target population for
interventions to reduce rates of abuse and neglect and improve quality of care. An ecological perspective suggests abuse and neglect are best understood in a bifocal perspective, with a focus on the older adult resident and CNA dyad as the central context in which care outcomes occur, influenced by the multiple contexts in which their interactions take place (Schiamberg et al., 2011). To date, variables including individual characteristics of residents (i.e., acuity, dementia) and facilities (i.e., profit status) have been suggested to affect resident outcomes (Harrington, Woolhandler, Mullan, Carrillo, & Himmelstein, 2001; Wan, Zhang, & Unruh, 2006), including abuse and neglect (Jogerst, Daly, Dawson, Peek-Asa, & Schmuch, 2006; Payne & Cikovic, 1996). Although these are important variables, other more modifiable 1
University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA 2 Michigan State University, East Lansing, Michigan, USA Corresponding Author: Carolyn E. Z. Pickering, School of Nursing, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA. Email:
[email protected]
2 contexts related to resident abuse and neglect should be further explored including an institutional culture of violence (Nelson & Cox, 2003). Surveys of patient safety culture within NHs report scores lower than those found in surveys of hospital settings, suggesting that residents of NHs may be at risk of harm related to poor patient safety practices driven by institutional cultures (Castle & Sonon, 2006). One of the primary missing links in our understanding of abuse, neglect, and care quality in NHs is the absence of variables related to the experience of the CNA (Schiamberg et al., 2012). Successful interventions to decrease abuse and neglect and improve care quality require attention be given to the CNA as well as the multiple and more distal contexts of the older adult resident/ CNA dyadic relationship, which contribute to care outcomes. These more distal contexts reflect existing connections—or absence of connections—to sources of influence on one or both participants in the older adult resident/CNA dyad, which in turn affects their interactions and the development of outcomes (Schiamberg et al., 2011). One such relevant distal context that may influence the older adult resident/CNA dyad is the CNA’s experience of workplace bullying. Workplace bullying consists of negative acts, which occur repeatedly and regularly over a period of time, in which the victim ends up in an inferior position (Einarsen, Hoel, & Notelaers, 2009). CNAs are subjected to aggressive actions and bullying from coworkers (Gates, 1999; Hall, Hall, & Chapman, 2009). There have been no prevalence studies on the experience of bullying between coworkers among CNAs in NHs, but a qualitative study of workplace violence experienced by CNAs suggests that CNAs come to accept violence as an everyday part of their work (Gates, 1999). Studies with registered nurses (RNs) have found rates of exposure to bullying in the last 6 months from 18.5% to 85% (Rodwell & Demir, 2012; Wilson, Diedrich, Phelps, & Choi, 2011). A mixed-methods study with RNs found that bullying is better explained as a feature of an organizational culture in which the behaviors are normalized and rationalized, rather than as discrete events resulting from conflict or work pressures (Hutchinson, Vickers, Wilkes, & Jackson, 2009). As such, it is not surprising that there is an observed relationship between nurse reports of workplace bullying and adverse patient outcomes (Hutchinson, Vickers, Wilkes, & Jackson, 2010; Wright & Khatri, 2015). This suggests that the distal context of workplace bullying may influence the interactions that occur in the older adult resident/CNA relationship in NHs, posing major concerns for patient safety and care quality. Therefore, guided by the ecological perspective, this study focused on the older adult resident/CNA relationship as the central context in which resident outcomes
Qualitative Health Research 00(0) occur, and moved more distally to examine the other important contexts that influence the quality of this caregiving relationship. To understand the impact the context of safety culture has on the dyadic caregiving relationship between CNAs and residents, we focused our research on bullying between CNAs as an indicator of an unsafe culture. We sought to understand how that context (negative relationships between a CNA and their coworkers and the culture that allows/uses bullying) influences the process of providing care to residents and related outcomes.
Design and Method The purpose of this grounded theory study is to explore, from the perspective of the certified nurse aide, how the context of workplace bullying affects their ability to provide care, including poor quality and unsafe care such as elder abuse and neglect, in NHs. Using grounded theory methods, we were able to examine how the CNA understands and responds to bullying in the workplace and what influences this process.
Sample The sample for this study came from the Florida CNA registry provided by the Florida Department of Health for every licensee current as of July 7, 2014, consisting of 94,805 licensed CNAs in total at the time. The initial eligibility criteria for the study included persons who (a) were certified nurse aides (per the registry), (b) were currently working in the NH for a minimum of 6 months, and (c) self-identify as experiencing workplace hostility or conflict. The reason these criteria were chosen was because 6-month duration is the standard for defining workplace bullying (Einarsen et al., 2009). Also, because it has been suggested persons who self-identify as bullying victims are a narrower group than the actual population of bullying victims (Lutgen-Sandvik, Tracy, & Alberts, 2007), we did not initially use the term bullying in the advertisement or eligibility screener. We instead listed types of bullying behaviors as examples of hostility or conflict found in the workplace, using items of the Negative Acts Questionnaire–Revised (a workplace bullying survey; Einarsen et al., 2009). Persons who could not participate in a 1- to 2-hour interview over the phone were excluded.
Recruitment and Data Collection Given the size of the registry (above 94K persons) versus our anticipated needed sample size (20–30), not all licensees would be invited to participate. To determine who to invite, the entire Florida CNA registry was sorted in excel using a random number generator, and personally identifiable
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Pickering et al. Table 1. Demographics of the Sample. Demographics (N = 22)
% (n); M (SD; Range)
Gender: Female Age Ethnicity Non-Hispanic White Latino Black Asian Married Have children Tenure as CNA
86.3% (n = 19) 33 (11; 21–54) 63.7% (n = 14) 4.5% (n = 1) 27.3% (n = 6) 4.5% (n = 1) 50% (n = 11) 54.5% (n = 12) 6.8 (6.6; 1.5–34)
Note. CNA = certified nursing assistant.
information was deleted, with the exception of email addresses that were used to send out recruitment emails. Recruitment emails were sent out following the order of the random number generator. All persons who responded to a recruitment email were screened for eligibility via email, and interview times were arranged. In total, 67 interview appointments were made, of which, only in 22 appointments did the participant actually call in. Interviews were scheduled at times convenient for shift workers including early mornings, late evening, and weekends. All interviews were completed by the principal investigator (PI; Pickering), and took place over phone using a secure third-party conference calling service that had no cost for the participant. Informed consent was obtained at the start of each interview. The average length of an interview was 72 minutes. Participants were reimbursed with a US$40 e-gift card for their time. The procedures were specifically designed so that no identifiable information would be collected, and as such, was deemed exempt by the institutional review board (IRB). Demographics of the sample can be found in Table 1. The final sample was mostly non-Hispanic White (63.7%) and female (86.3%) with an average age of 33 years having an average of 6.8 years experience as a CNA. A semistructured interview guide was used to direct interviews, with guiding questions evolving as data analysis and theoretical sampling progressed and new information was needed to best understand the phenomenon. The ecological perspective served as the conceptual lens in framing this exploration and development of the interview guide, which focused on different contexts (e.g., peer to peer, administrator to peer), which may affect the caregiving relationship. Theoretical saturation was reached at the completion of 22 interviews. Theoretical sampling is an important aspect of grounded theory, in which the researcher samples to obtain rich detail about all aspects of the emerging concepts and theory to obtain theoretical saturation (Morse,
1995). Following the recommendations of Morse (1995), our goal for theoretical sampling was not the frequency with which a pattern is represented but rather the completeness to which all variations have been explored (Morse, 1995). Accordingly, as the study progressed, the eligibility criteria were modified to allow for theoretical sampling. Although initially the research team was careful to not use the term bullying in the advertisement, eligibility screening, or the interview guide, participants repeatedly used the term themselves during our initial interviews and when responding to the recruitment email. This led the team to believe that bullying was colloquial enough of a term or pervasive enough of an experience among CNAs that it could be used in the study materials without introducing bias. Then, based on the emerging analysis as well as feedback received during recruitment, there seemed to be a link between bullying experiences and employment turnover. To explore this lead, eligibility criteria were expanded to licensed CNAs who had worked in an NH within the last 3 years. Then, we began to learn that participants typically described bullying starting on the first week (if not first day) of employment and on average took participants 3 months to notice the pattern of behaviors as bullying (compared with 6 months described in the bullying literature). Participants also described that they had colleagues who left the NH after making this realization. So with that, we again modified the eligibility criteria to currently working or had worked in an NH for a minimum of 3 months in the last 3 years to allow us to further explore whether and why some people leave the NH after recognizing the bullying when others do not. With each modification of the eligibility criteria, the research team also modified the interview guide to ensure these concepts and ideas were fully explored.
Ethical Considerations Doing research on elder abuse and neglect is difficult for a number of reasons, including the sensitive nature of the topic and practical limitations posed by mandatory reporting laws (Bonnie & Wallace, 2003a; Fulmer, 2008). Given the purpose of the study, we intended to directly ask about abuse and neglect, meaning it was probable that participants in the sample would disclose acts that would fall subject to the mandatory reporting law posing an ethical dilemma. Accordingly, the study procedures were carefully designed to protect the participants against this and maintain their anonymity by not collecting any personally identifiable information. Recruitment and enrollment happened through email, and the phone conversations took place with a third-party conference calling service so that the researcher would not have the participant’s name or phone number. The study was done in a different state where the PI was not a professionally mandated reporter
4 in the event a participant accidentally disclosed something identifiable. These procedures (email recruitment, phone interviews) have been used in other studies with elder abuse/neglect perpetrators with success and no reports of adverse outcomes (Pickering, Mentes, Moon, Pieters, & Phillips, 2015).
Analysis In doing grounded theory, constant comparative analysis is used as the technique for data analysis (Charmaz, 2006). Constant comparative analysis begins with lineby-line coding, intended to capture and condense meanings and actions as they emerge from the participants’ interviews. Gerunds are used as codes to keep the focus on the participants’ perspectives (Charmaz, 2006). As the data collection and analysis progress, significant or frequent codes may be termed “focused codes” and used to organize data into categories and subcategories. Axial coding is used to explore the properties and dimensions of categories, and theoretical coding is employed to understand the relationships between categories (Charmaz, 2006). These different levels of coding are used in pursuit of constructing a theory grounded in the participants’ perspectives of the phenomenon. Throughout the grounded theory process, the research team maintained memos. Memos can be analytic in nature, and document the researchers’ ideas about emerging categories and relationships (Lempert, 2010). In analytic memos, the researcher may pose and attempt to answer questions about the data to push and challenge their understanding of the emerging findings. One way we did that in this project was by use of situational analysis techniques, including constructing situational maps and social world maps, which are analytic exercises intended to help understand all the conditional elements of the experiences participants were describing (Clarke, 2005). These exercises helped guide the research team in our theoretical sampling. Self-reflexive memos were also maintained to help decrease potential biases of the researcher on the data (Morse, 2015). Analysis was led by the PI (Pickering), with input from other members of the research team. In the early stages of the project, the team members would read and code the initial interviews individually, then discuss their thoughts during team meetings. When the research team agreed focused codes had begun to appear, Dr. Pickering took over primary responsibilities of coding. As analysis progressed, Dr. Pickering presented her memos on the emerging analysis, and axial and theoretical codes were discussed, challenged, and debated at team meetings to ensure the completeness of the final theory. When the team had agreed upon axial and theoretical codes and
Qualitative Health Research 00(0) constructed a “code book” of definitions, both Dr. Pickering and Ms. Nurenberg reviewed and sorted all data into their respective categories. At a team meeting, they compared their final sorted data, with Dr. Schiamberg weighing in on any discrepancies.
Results The result of the analysis is a multistep model describing CNA perceptions of how, over time starting with their entrée to the NH, they recognized and responded to the unsafe work environment (Figure 1). Our participants described how, within a “toxic” work environment, bullying is one feature that contributes to the overall culture. Overtime, after repetitive interactions with the different features of the culture and learning the toxic workplace, participants went through a process of losing trust. Following this, participants then responded to their new understanding of their workplace culture by entering into a process of reconciling expectations, which involved adapting how they provided care to allow for working without trust. This led to the development of patient and worker safety outcomes (i.e., outcomes which represent actual or potential harm related to the adapted care strategies).
Step 1: Learning the Toxic Workplace Participants explained, when they started at the NH, it took time from them to recognize that their work environment was not “normal” and in fact “toxic.” Participants all had strong ideals for how proper quality care for residents should be delivered and expectations for what work in a NH should be like. Participants described experiencing repeated incidents with both the administrators and fellow CNAs that challenged their idea of standard of care for NH residents and how to deliver it. These behaviors performed by administrators and fellow CNAs served as formative experiences that shaped their understanding of the workplace culture. Data exemplars for Step 1 can be found in Table 2. Important to understanding the participants’ description of these experiences is that, per their descriptions, it appears within a toxic workplace, there is a confusion over hierarchy and job roles. Participants tended to call everyone who was not a CNA “administrator” or “management” (e.g., licensed practical nurses, RNs, activities director, social workers, the actual administrator). Participants rarely knew the actual job title or functions of other staff including nursing. With that, we use “administrator” in our description of the data to mirror our participants’ descriptions though administrator generally means anyone who was not a CNA.
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Figure 1. Recognizing and responding to the toxic workplace. Note. CNA = certified nursing assistant.
The experiences described in Step 1 include behaviors performed by administrators and by fellow CNAs. Participants described four distinct experiences involving administrators. First, inflicting overload were experiences in which they perceived administrators were demanding unreasonable tasks or had impossible expectations for what they wanted the CNA to be doing. Overload has to do with factors that directly affect the ability to do the CNA job well that are in control of the administrator, including resources/supplies, policies, staffing levels, equipment, and time. Next, participants described experiences of administrators mishandling critical incidents, which included incidents in which someone was harmed or at risk of being harmed (including the participant, a fellow coworker or a resident), and participants perceived the administrator either did not address the situation at all or handled it inappropriately by not addressing the underlying problem. Participants described administrators’ mishandling of critical incidents set a precedent for what would happen in the future, and left them feeling like they had no voice to advocate for themselves or residents. Playing favorites includes experiences in which participants perceived administrators allowed some CNAs to have special privileges that others did not that would thereby create unequal power among
CNAs. Finally, participants described how administrators engaged in belittling staff as a way of reinforcing CNAs had no power, by requiring them to do menial tasks outside of their roles, being overly critical, or through blatant displays of power. These experiences of belittling were described as unprovoked adding to their upsetting nature. In addition, salient experiences with fellow CNAs also challenged participants’ understandings of what it means to provide care to residents in a NH. Bullying as described by participants included perceptions of intentionally aggressive acts by fellow CNAs, including both direct and indirect acts. Participants described that bullying was repetitive and chronic in nature, and often involved more than one aggressor. Participants also described experiences in which they observed their fellow CNAs putting residents at risk by causing direct harm or risk of harm through poor quality and unsafe care. In total, this core set of experiences shaped participants’ understanding of their “toxic” workplace as exemplified by this participant’s description: It’s very toxic . . . the people are always talking about how there’s bad aides but they don’t get rid of them, that management expects everybody to do all these things, and they don’t follow up their promises . . .
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Table 2. Data Exemplars Step 1: Learning the Toxic Workplace. Category Inflicting overload
Mishandling critical incidents Playing favorites
Belittling staff
Bullying
Putting residents at risk
Exemplar They tell us this is a no-lifting facility, but you know, you can’t—you can’t find lifts half the time, or the patients don’t have a Hoyer standing lift ordered, and so you’re supposed to transfer the patient, but they don’t have it ordered, and so what are you supposed to do? You know what I mean? They kind of make it to where you don’t really have a choice. But then, if you lift somebody and hurt yourself, then you weren’t following policy. And when I was changing her one day, I noticed, you know, she was compacted. And I told them, and told them, and told them, and it was like nothing seemed to be done. I told the unit manager. I went above their head and told the DON. I told the social worker. And it seemed—nobody seemed to want to do anything about it. So um, the manager or the supervisor, she had her, her, her people, her picks. You know? They’d order food and be talking and he-he-he-ing and everything would be all good. “Let’s order some food.” “Oh, that’s all you all are doing down here, eating food.” What? Why just order people and then ask us if we want any pizza, you know? I still had the supervisor that was constantly riding me, riding us, I would say . . . she would do little stuff, come down and she would do a fire drill—I still didn’t understand—a fire drill at 2:00 AM in the morning. Who does a fire drill at 2:00 AM in the morning? These people are in the bed. Who is going to do a fire drill at 2:00 AM in the morning? And the same employee also would like to scare you all the time. I’d open the linen door closet, be gathering linen. He’d come and bang on the door to scare me. Or he’d come up behind me and poke me in the sides with two fingers just to hear me scream. You know, or come up by—He was constantly doing that, constantly. And then berating me all the time about, “You’re not doing this right. You’re not doing that right.” They would leave a lot of them just kind of, like sitting in the same spot the entire day, just sitting, watching the same TV show for the entire day. They’d get up to eat, and then some of them would be soaked through their clothes because they had been sitting there for so long.
Note. DON = director of nursing.
Step 2: Losing Trust Learning the nature of the workplace culture took some participants months and others only weeks. But, taken together, these experiences shaped how participants constructed their understanding of their workplace. Participants described these experiences to be highly distressing as they clashed with participants’ own understanding of what proper safe care for residents should entail. As a result, participants went through a process of losing trust in which they felt they could no longer count on their fellow CNAs or administrators to do the right thing as exemplified by this participant’s reflection: . . . At first, I thought it was just, you know, them making a point that they’re in charge. But when it kept going for more than a week or so, I was like . . . this isn’t right. And, unfortunately, HR covers for the DON, and it covers for the unit managers. It’s like they were all . . . there was nobody you could go and talk to, and feel safe about talking about them. There was no neutral party there.
Most but not everyone in the sample moved from Step 2 to Step 3. It appears after going through the process of losing trust, participants may reach a decision point. The few participants who left the NH at this point had described experiences under Step 1 that were particularly highly distressing (i.e., victim of attempted rape by a coworker,
which management ignored; advocacy being ignored leading to the preventable death of a resident). With that, we theorize that the severity of the distress experienced during the learning the toxic workplace step may affect CNAs decision to move forward. After losing trust, some CNAs cannot or will not reconcile expectations for care (Step 3) and instead respond by exiting the NH.
Step 3: Reconciling Expectations As this new understanding of their care environment clashed with participants’ own expectations for how care should work in a NH, participants went through a process of reconciling expectations to develop care strategies to enable working without trust in the toxic work environment. Accordingly, these strategies can be viewed as a compromise between the two conflicting agendas (participants’ ideals for care provision vs. reality of the toxic workplace) as explained by this participant: And, I mean, you’re not doing things the way that you’re supposed to but, you know what? You’re doing them the way things are done in nursing homes. That’s literally the way it’s done.
In reconciling expectations, participants developed new strategies to adapt to their workplace culture and
Pickering et al. lack of trust. These strategies are performed by the participant and involve behaviors in multiple relationships (administrators, fellow CNAs, residents). A key feature of these adaptive strategies is that participants strove to minimize exposure to personal harm, including both physical and mental injury as well as job security. As such, participants often found themselves having to put their needs to prevent personal harm over the needs of residents. Participants developed two strategies when interacting with administrators and fellow CNAs (keeping silent, forming alliances), and three strategies when interacting with residents (implementing workarounds, reprioritizing care activities, disengaging). First, participants modified their behaviors with administrators and fellow CNAs by engaging in a process of keeping silent. In keeping silent, participants knowingly chose to not go forward to administrators with important information relevant to patient or worker safety. Participants described how they would keep silent about a variety of safety issues such as work-related injuries, witnessing abuse/neglect of a resident, witnessing coworkers drink on the job and steal, and concerns about changes in a resident’s health. Participants kept silent because of past experiences they did not feel reporting would lead to any solution but may put them at risk for retaliation or being blamed. Participants also used keeping silent when interacting with their fellow CNAs. Typically, this manifested as a lack of advocacy for either themselves or their residents as described in this example: There was one lady (resident) who would always during breakfast or lunch or anything, who would always end up getting up and walking away from the table, and then we would have to sit her back down and get her, like, situated again . . . Well one of them [the bullies], which was the lady I was the most intimidated by, would always yell at her, saying “You know better. You need to sit back down right now.” And I always, always, always, wanted to stick up for her, and be like, “she doesn’t really know better. She doesn’t know that she’s supposed to stay seated.”
Next, participants also adapted by forming alliances. Forming alliances involved finding a coworker who, through a mutual understanding of the necessity of having a person to rely on, would become their workplace “team” or “buddy.” This could be a very healthy strategy for participants as having someone to count on for unwavering assistance relieved some of the stress of navigating the toxic environment on your own. The unwavering assistance includes not only assistance with resident care but also filled the social needs of having someone to help deflect bullies or administrators, discuss feelings or to “have your back” when questioned by administrators. For example, this participant explains the value he saw when forming an alliance with another coworker:
7 So, there was someone . . . in regards to the fact that I could count on him to physically help me transfer people and physically help me to do my work. I also had someone that I could, like, kind of confide in . . . talk to about my problems . . . it was cool to have it, like, both ways—someone I could talk to and someone I could count on to help me with my work.
However, when participants engaged in forming alliances, a feature of this alliance is the exclusion of all other coworkers. Some participants relayed that by refusing other coworkers, they were putting the residents at risk and could be seen as engaging in bullying themselves. This participant recalled a scenario when her resident care was affected because her work buddy went on a lunch break: I’m kind of in this dilemma, because it’s like, okay, I need to get this patient moved because if I don’t, you know, they’re going to be suffering. And I don’t want that for them. So I just said a prayer . . . I’m looking at the time. I know she has 30 minutes left till she comes back . . . let me just try and make my rounds and . . . when she comes back, ask her to help me . . .
Furthermore, in reconciling expectations for care, participants also had to modify how they interacted with residents by implementing workarounds, reprioritizing care activities, and disengaging. Implementing workarounds consisted of problem-solving caregiving strategies used to be able to meet the demands of overload and avoid bullies while not having to violate their other adaptive strategies. This included strategies to overcome lack of resources, staffing, and time. This also included learning to do things by yourself, such as transferring residents without assistance. Participants also adapted by making do with resources at hand, such as bathing residents with paper towels because there are no linens. Again, as implementing workarounds is a compromise, residents were often put at risk as explained by this participant who had to move a resident by herself: I figured out how to do it without hurting myself. I knew when I went in there I was going to be in there for at least about 25-30 minutes ’cause that’s how long it took me when it would normally take me about five or ten minutes [with assistance]. It took me longer because I had to do it by myself, but I got it done, and I didn’t have to ask nobody. Yeah, like MacGyver. Yeah, I just, I would tell them [the resident], “You know I’m sorry,” you know? . . . it hurt her to have to be moved because of the way her arms and her legs were [contracted] . . . when you’ve got two people you can do it a little bit faster . . . But it just, it didn’t always work that way.
Participants also adapted by reprioritizing care activities, in which participants performed what they perceived
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to be the essential activities versus all the needed care activities a resident may require. Reprioritizing care consisted of making choices about what care to do and what care not to do, based on the needs of the participant and expectations of the toxic workplace dynamics. One example of reprioritizing care that a participant gave included choosing to do showers over toileting because showers were counted by the administrators each morning and checked against the shower schedule. The participant was aware that skipping toileting could lead to falls, skin breakdown, and was unfair to the residents. However, not giving showers had consequences for the participant (i.e., getting in trouble with the administrator), whereas not providing toileting care did not. Common examples of care activities that participants reprioritized as nonessential included repositioning, ambulation, oral hygiene, and social support. Finally, participants used a strategy of disengaging, which consisted of removing themselves emotionally, and sometimes physically, from care. Disengaging was described as a sense of going through the motions and becoming more detached when providing care, and not taking the opportunities to form or strengthen relationships with residents. Participants described how, instead of explaining to residents the care tasks they were going to do, they would just go in and do them. Participants described how while care activities would get done, they would not be paying much attention to the resident and may miss important details about changes in a resident’s physical or emotional status. When emotionally removing yourself from the toxic workplace did not suffice, participants would describe hiding in bathrooms or closets for extended periods of time while at work or calling in sick. Participants often described disengaging as a need to “keep to myself” as a way of getting through the day as explained by this participant: If he would start teasing and stuff like that, it would put me in a negative mood and maybe I wouldn’t be able to give my all to my patients . . . I would just kind of keep to myself and maybe not pay attention to detail with the patients . . . as I should be because of how I am feeling . . .
Step 4: Development of Patient and Worker Safety Outcomes These strategies evolved out of participants’ perceptions of how to provide the best care possible, given the circumstances of the toxic workplace. Importantly, as these strategies were a result of reconciling expectations, they were perceived as a compromise to ideal safe care, and participants were highly aware of the potential impact to resident and worker safety that could occur through using these strategies. Participants described a variety of
Table 3. Patient and Worker Safety Outcomes. Patient Safety Outcomes Nutrition Pressure ulcers Incontinence Hygiene Falls Social isolation Contractures/sarcopenia/ mobility issues Missed nursing care Sleep quality Abuse Gross neglect Resident/resident aggression
Worker Safety Outcomes Absenteeism Turnover Injury Smoking Stress Nutrition Strains on family relationships Resident/staff aggression Anxiety Depression Self-esteem Presenteeism
outcomes representing actual or potential harm that could occur because of the culture and their adapted care strategies (Table 3). Participants explained how the strategies evolved out of reconciling expectations often involved not providing care activities as well as it should be done, not providing them in a timely manner or not providing them at all, which affected specific outcomes (pain, sleep) but could also be viewed as gross neglect. For example, this participant described how this process causes skin breakdowns: This person might have had a bowel movement, but you have to give somebody a shower. They’re sitting there in that bowel movement while you’re showering somebody. You just don’t have the time to get to them to clean them like they need to be. And, you know, that’s, a lot of times, where the breakdown comes in.
As such, these strategies that evolved out of reconciling expectations were not entirely successful in their goal of limiting personal harm, as participants were aware that many of the strategies put themselves at risk of adverse outcomes such as back injury from doing two-person lifts alone. In addition, participants found the experience of knowingly providing substandard and unsafe care to residents a great source of moral distress, which increased over time. Participants linked the moral distress to family strain, resulting from the carryover of stress to their home life. Participants also contributed the moral distress to difficulties with anxiety. Even as participants recalled situations from the past, the moral distress still bothered them, as this participant became emotional explaining what it was like: . . . when I look back at that, I feel so guilty, you know, because it’s like I’m allowing these women to . . . affect my work ability . . . I’m putting a patient in an uncompromising position because of how these women are treating me . . . it—it was just—it’s like, I—I just feel so horrible, and I feel
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Pickering et al. bad, and even if I think about it, I’m like, oh my God, I—I— just that experience, it was—it—no one should ever have to go through that. No one should ever have to feel the way that I feel and to be put in that position and to have that happen . . . It was so hard.
As a result, the majority of participants left the NH industry and many left the CNA profession entirely, attributing their decision to leave to the workplace culture, as highlighted by this participant: Every day, I am exposed to cutting corners. Every day . . . I’m risking my patients’ safety, and I’m not doing the level of care that I believe I should be giving each one of my patients . . . it’s always like this . . . I have to say I need to quit. I need to stop. I’m not going to work anymore . . .
Discussion Support From Previous Research In Step 1, participants described experiences with the workplace culture that aided them in learning the toxic environment. These data provide further empirical support for the content validity of the survey on patient safety culture. The experiences described within this step are conceptually similar or related to dimensions of the survey on patient safety culture, such as teamwork, communication, and nonpunitive response to mistakes (Sorra, Gray, Famolaro, Yount, & Behm, 2016). Based on our participants’ descriptions of their “toxic” work environment, it appears they would have likely had low ratings on the survey on patient safety culture. This provides further support for the assumption that bullying is a feature of unsafe or negative workplace cultures (Hutchinson et al., 2009), and suggests bullying may be prominent in facilities with low patient safety culture scores. Support for our findings regarding the adaptive strategies described in the process of reconciling expectations can be found in work done by Bowers (1992), who completed a qualitative study to understand how CNAs organize their work. Bowers described the themes of developing an organizational style, cutting corners and breaking the rules as necessary features of care provision for CNAs. Furthermore, Bowers (1992) described how a group of her participants had such high levels of distress over the contradiction of the care they wanted to do versus what they actually could do, it led to them quit. This is similar to the experiences described by our participants both at the decision point between Steps 2 and 3, and the ultimate formation of outcomes, which occurs at Step 4. Although it is positive that other empirical findings support our model demonstrating the validity of our findings, it is also disconcerting that in the 25-year span between studies, little has changed with regard to the distress
CNAs experience when trying to provide quality care in NHs.
Unique Contributions of This Research Use of the ecological perspective in understanding care quality. By focusing on the contexts that affect the older adult resident/CNA dyadic caregiving relationship, this work highlights the important relationship between patient and worker safety in the NH setting. Patient safety culture and worker safety culture are often treated as two distinct concepts, though emerging research has found perceptions of worker safety culture and patient safety culture to be positively associated (Mohr, Eaton, McPhaul, & Hodgson, 2015). The findings demonstrate that the workplace culture directly influences not only worker safety but also how workers deliver care, which ultimately affects patient safety and care quality. This suggests future research needs to take a broader look at institutional safety culture rather than patient safety culture as a discrete concept. Given the apparent relationship between worker safety and patient safety, it is possible worker safety outcomes may also serve as valid quality measures in evaluating care quality in NHs. Role of institutional culture. Importantly, the model describes how a negative institutional culture affects CNA care processes and how worker/resident outcomes are created. There is some emerging evidence that patient safety culture within NHs is associated with resident outcomes such as restraint use and falls (Bonner, Castle, Men, & Handler, 2009; Thomas et al., 2012). However, there is not a clear understanding of which care processes produce which care outcomes (Werner, Rita, & Kim, 2013). Findings from this work help fill the gap in the literature by describing processes used in adapting to a toxic workplace culture and highlighting etiologies for some important clinical outcomes, which represent the actuality of CNA care provision. These outcomes could serve as nurse-sensitive outcomes measures in future research (Nakrem, Vinsnes, Harkless, Paulsen, & Seim, 2009; Tolson et al., 2011). Future studies should explore the extent to which administrators and nurses perceptions of culture, care quality, and safety converge or diverge with the CNA perspective. Implications for policy intervention. The most commonly suggested interventions in addressing elder abuse and neglect in NHs target individual qualities of CNAs and include training and background checks, and neither intervention has been evaluated. Although participants in this study did engage in neglectful and sometimes abusive behaviors, they were often very aware of doing so. As a result, participants described high levels of moral
10 distress as they often found themselves in positions of choosing between the better of two bad choices when trying to deliver care, as demonstrated by the model. It appears that unsafe institutional cultures and related care practices may be more prominent risk factors for elder abuse and neglect in NHs than qualities of individual CNAs. Future research on prevention of elder abuse, neglect, and care quality should aim to develop packages of interventions that can address the issues, which arise across the ecological model—such as combining interventions to improve communication, reduce role ambiguity and bullying with alternate staffing or care delivery models. Furthermore, this work supports Bowers’ (1992) conclusions that more formal education and training for CNAs is not necessarily the answer to improving care quality in NHs and, in fact, more training on the importance of person-centered care may further exacerbate feelings of moral distress. However, because NH administrators do set most of the policies and procedures for their staff, shaping culture and care practices, better training and more rigorous licensing requirements for administrators may be beneficial. Another important policy implication relates to the findings on turnover, as quality of care is related to staff turnover in NHs (Trinkoff et al., 2013). Turnover is an outcome represented at two different points in the model. The data suggest early turnover (leaving after Step 2 instead of progressing to Step 3) is driven by highly distressing events such as negligent resident death. As such, high rates of early turnover, or turnover within the first 1 to 3 months of starting employment, may indicate the presence of unsafe culture and poor quality care. Future research to explore this hypothesis is warranted, as high rates of early turnover could serve as a “red flag” in identifying facilities that would benefit from more frequent surveying.
Strengths and Limitations of This Work An inherent limitation of qualitative work is the lack of generalizability. Future testing of the model, including relationships between our identified care processes and outcomes, is needed to understand whether the data in fact is representative of NHs lacking in patient safety culture. Furthermore, future research is needed to validate our assumption that bullying is a feature of NHs lacking in patient safety culture. With that, there are many strengths to the study design and strategies used to maintain rigor, reliability, and validity including the careful and methodical approach to theoretical sampling and saturation, the use of a conceptual lens (i.e., ecological perspective) guiding data collection and analysis, the peer review team analysis process, and the use of selfreflexive memoing to acknowledge and limit bias.
Qualitative Health Research 00(0) The use of email recruiting and phone interviews as recruitment and data collection procedures also has unique strengths and limitations. On one hand, these methods allowed people to participate in research who otherwise may not have been able to if required to do a face-to-face interview. The telephone interview allowed us to accommodate shift work schedules, and let the participant call in while their child was napping in another room or while they folded laundry. On the other hand, it did mean that only people with active email addresses and access to a telephone could participate. In addition, observation of the participant is often an important aspect of qualitative interviewing, which was lost through a phone interview. However, the dynamic of an anonymous phone interview has its own benefits. The layer of anonymity offered by the phone meant participants shared stories, particularly sensitive and incriminating stories, which they may not have otherwise. It was not uncommon for participants to sometimes start a story, pause, and then continue after commenting on how I (the researcher) had no idea who she (the participant) is or the facility she is talking about, thus feeling able to disclose the information. In addition, in some instances, when participants were describing a story they recalled, they wrote an email about it to a friend or detailed it in their diary, and then, while on the phone, retrieved the writings and read it to the researcher. This provided a rather unique opportunity, and rich detail, that could not have otherwise been obtained. Finally, though it may seem like establishing rapport and a trusted relationship with the participant would be more difficult on the phone, we generally did not find that to be the case. This may have been because (a) participants were in their own home (or familiar location) during the interview, which made them more comfortable; (b) participants were not distracted trying to read the researcher’s body language or facial expression; (c) this is generally a powerless group, which are often the subject of blame, and many participants commented they were happy to have the opportunity to tell their story; and (d) the PI is experienced in doing qualitative interviews over the phone.
Conclusion In short, using the ecological model as a lens has provided for a better understanding of the everyday experiences of CNAs, and the ways in which “toxic” or unsafe cultures affect care processes and outcomes. Findings highlight that the development of abuse and neglect in NHs, as well as an array of outcomes related to substandard care quality, arise not from individual traits or characteristics of CNAs but rather from an overall institutional culture. Findings also demonstrate that abuse and neglect within NHs is related to the same care processes as other
Pickering et al. outcomes commonly used as indicators of care quality, rather than distinct or separate etiologies. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a 2014 research grant from the American Nurses Foundation and the International Association of Forensic Nursing.
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Author Biographies Carolyn E. Z. Pickering, PhD, RN, is an assistant professor of nursing at the UT Health San Antonio School of Nursing. Katie Nurenberg is a senior nursing student at the Michigan State University College of Nursing, and a mentee of Dr. Pickering. Lawrence Schiamber, PhD, is a professor in the Department of Human Development and Family Studise at Michigan State University.
