Background
An increasing number of older people requiring complex care
A decreasing workforce that is inadequately prepared
Staff and skill mix as a solution?
Methods
Context: Living labs in elderly care
Study description
Team | Start situation | Changes in staff mix | Changes in skill mix |
---|---|---|---|
1 (retirement home) | 31 team members, mainly nursing assistants level 1 and 2. | − Educating nursing assistants from level 1 to level 2. − Adding 3 nurses (level 4). − Tighter collaboration with other disciplines and clients’ family | - Role enhancement - Role enlargement |
2 (care at home) | 8 team members: 5 nursing assistants level 2 and 3, 3 nurses level 4. | − Nursing assistants level 1 and 2 gone. Adding 3 nursing assistants level 3. | - Role enhancement - Role enlargement |
3 (nursing home) | 30 team members: nursing assistants level 2 or 3, and nurses (level 4). | − Adding 2 nurses (level 5). − Educating nursing assistants from level 2 to level 3 − Tighter collaborationwith other disciplines and clients’ family | - Role enhancement - Role enlargement |
4 (care at home) | 14 team members: 1 nurse (level 4), 8 nursing assistants level 2 and 3, 3 casemanagers, 1 geriatric specialist, 1 psychologist. | − No change in staff mix, but the team members split from 1 into 2 teams. − Tighter collaboration with other disciplines and clients’ family. | - Role enhancement - Role enlargement |
5 (nursing home) | 51 team members: all nursing assistants level 3. | − Diversifying the team by downgrading nursing assistants to level 1 and 2, by hiring group assistants, and by letting go of some nursing assistants level 3. − Adding nurses (level 4 and 5). − Tighter collaboration with other disciplines and clients’ family. | - Role enhancement - Role enlargement |
6 (nursing home) | 29 team members: mainly nursing assistants level 2 and 3. | − Adding 4 nurses (level 4). − Educating nursing assistants from level 2 to level 3. − Tighter collaboration with other disciplines. | - Role enhancement - Role enlargement |
7 (retirement home) | 36 team members: nursing assistants level 1, 2 and 3. | − Adding 2 nurses (level 4). − Tighter collaboration with other disciplines and clients’ family. | − Role enhancement − Role enlargement |
Data collection
Data analysis
Main theme | Subtheme | Subtheme | Subtheme | Subtheme |
---|---|---|---|---|
Staff and skill mix | Qualification level | Competencies | ||
Communication | Collaboration | Coordination | ||
View of care | Care for the individual client | Role of informal caregivers | ||
Autonomy | Professional conduct | Getting and using professional autonomy | ||
Team culture | Role of the team captain/leader | Development and learning | Willingness to change | Ability to change |
Results
Changes in staff and skill mix
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Educating existing personnel so that they obtained a higher qualification level, in order to cope with the increasing complexity of their clients’ health care problems.
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Adding one or more higher-qualified health care workers (e.g. a nurse or specialist nurse) to the team, in order to cope with the increasing complexity of their clients’ health care problems.
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Adding lower-qualified health care workers to the team (e.g. a nursing assistant level 2), in order to ensure personal attention for clients.
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Seeking tighter collaboration with other disciplines (e.g. a general practitioner, psychologist or physiotherapist), so the team became multidisciplinary.
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Seeking tighter collaboration with clients’ family or other representatives, so they were seen as part of the team that cares for the client.
~ Team captain, team 1.
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Higher-qualified health care workers (e.g. a nurse or specialist nurse) were thought to add coaching, coordinating, and signaling competencies to the team.
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The role of existing team members was enhanced (role enhancement). For example, team members were trained in their knowledge of and dealing with older people with dementia, or trained to coordinate care.
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The role of existing team members was enlarged (role enlargement). For example, team members were trained in their knowledge of and dealing with patient-centered care, in coordinating and coaching other team members, in collaborating with clients’ family members (or other representatives), and/or the use of new digital information systems at work.
“I wish that it was clear to everyone where we are at and especially what the role of the higher-qualified nurse is, because that is sometimes unclear to me. And that the atmosphere at work stays fun, also for the clients. They live here after all. They shouldn’t suffer when there are frictions amongst personnel, because they notice everything. So yes, clarity, it’s mostly clarity… what do we do, what don’t we do?”
~ Nursing assistant, team 6
“Some employees experience a year of training as intense. A lot of lower-qualified staff is around 50 years old, and have to go back to school for a year, next to their work. […] Older employees are used to getting classical education. Now they have to make a portfolio, and work with the computer. It sounds strange to us, but there are a lot of employees who have problems with the computer. And who experience that as a barrier. […] What also stops them, is that they don’t get extra salary so why would they do this extra education?”
~ Team captain, team 6
~ Team captain, team 3.
“I like the fact that I can approach the higher-qualified nurses with questions, ask them for information, and ideas on how I can do something. She coaches me on the job. I really like that. It is nice to be able to rely on a higher-qualified nurse when something is up with a client.”
~ Nursing assistant, team 3
“Many of our employees have downgraded in function, there are a few new employees coming and a few employees are going to leave. We have definitely changed as a team, and team members experience this positively. There is a new way of working. We have a team where all kinds of staff levels are represented, with nursing assistants of level 1, 2 and 3. Level 4 are our higher-educated nurses. In terms of team composition, we are nearly where we wish to be.”
~ Team captain, team 5
Experience of the influence of staff and skill mix on quality of care, quality of life, and job satisfaction
Quality of care
~ Team captain, team 1
“I believe there is added value when there is a higher-qualified nurse in the team. The quality of care is higher, there is earlier signaling of clients’ problematic behavior, of clients dying, of multicomplexity, both physical and cognitive. We also use higher-qualified nurses to improve our team, to support lower-educated nurses.”
~ Team captain, team 6
“I do experience that quality of care improves with a higher-qualified nurse in the team, when the team supports the addition of that nurse. But some team members think: do we need this? Do we have to? What is the added value of a higher-qualified nurse in the team? Can’t we do those tasks ourselves? As long as the team members don’t see this added value, adding a higher-qualified nurse gives irritation or friction in the team.”
~ Physiotherapist, team 3
“We are searching as a team. I came here in a chaotic situation and that chaos is still here, in my experience. That makes it very hard to finds my place in the team. A lot of things are unclear. Materials that we need are not available. And how am I going to fulfil my role as a higher-qualified nurse? My role is still in the starting blocks. We are working on it, but it’s a real searching process.”
~ Nurse, team 6
Quality of life
~ Nursing assistant, team 1.
~ Casemanager, team 4.
~ Family member, team 6.
~ Nursing assistant, team 3.
~ Family member, team 5.
Job satisfaction
~ Nursing assistant, team 2
“I enjoy going to work. The past half year I enjoyed going to work a bit less because there were hassles, but I said to myself, it is my choice, what I choose to find important. […] The thing with change, I realise, is that change is difficult for people.”
~ Nursing assistant, team 7
“There is a lot of negativity in the team. I was on holidays for 1,5 weeks, and I did not look forward to going back to work, because of all the things that have changed again… that is how I feel.”
~ Nursing assistant, team 7
“We communicate differently with each other now, and we understand each other better. We also dare to talk to each other about things that are not going so well, which really improved the atmosphere in our team. Since a couple of months, I really enjoy going to work again!”
~ Nurse, team 4
~ Nursing assistant, team 1.
~ Nursing assistant, team 3
“Caring for older people is very special. They deserve good care. However, we have to spend a lot of time behind the computer, filling in forms. We forget what it’s all about: the older, care-needing individual.”
~ Nursing assistant, team 5
Contextual conditions
“There is better communication, team members more openly talk to each other, and not just during official meetings, but also during the workday. And not just about care for the client, but also getting to know each other’s’ area of expertise, what they do during a workday, and how they can use each other’s’ expertise. That kind of dialogue was never there before. It sounds very black and white, but I think that is a real difference.”
~ Nurse, team 4
In successful teams, team members tended to have a similar view of care and explicitly discussed this. In all teams, a shift from a task-oriented towards a patient-centered view of care was observed. In a patient-centered view of care, the needs and wishes of clients are central, and clients, their family, and other informal caregivers are more involved in the provided care [25]. However, many team members indicated that they sometimes found it difficult to translate a patient-centered view of care into their day-to-day work (e.g. how to actively involve clients and their families in daily routine).
“Satisfied clients is my most important goal of the day. That is where the change is going, the change I’ve been seeing in this profession as an “older” employee. The change from “the doctor or nurse will tell you what’s good for you and everything is decided for you” to more autonomy for clients. I am all for this, but sometimes it’s difficult to know how we can incorporate this autonomy for clients into the daily routine.”
~ Nursing assistant, team 3
“Team members do see themselves as a professional, but I believe that it’s possible to get much more out of this, to make them even more aware that they are a professional. For example, team members feel very differently about our quality register. Some team members love it, and experience it as part of their professional development. Others think it’s nonsense, and experience it as another task to do.”
~ Nurse, team 5
~ Team captain, team 3
“Some team members noticeably find it very difficult to deal with change. You hear a lot of: ‘yes but this, yes but that…’ I find that very disappointing. […] Change is always difficult for some people.”
~ Nursing assistant, team 7