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Empowerment is a concept inextricably linked to nursing. With the highest priority placed on the dignity, respect, and preservation of life, nurses obtain enthusiasm and inspiration from assisting patients in maximizing their health - this necessitates empowerment of not only the client, but the nurse as well. In Ontario's long term care (LTC) facilities, an over reliance on the medical model, combined with budget restrictions, has caused registered nurses (RNs) to gradually be replaced by registered practical nurses (RPNs) and personal support workers (PSWs) as direct care staff. This had led to the disempowerment of workers and subsequent chronic absenteeism. Moreover, LTC residents are subjected to custodial care and treated as diagnoses, rather than as human beings.
Although numerous studies have shown that staff empowerment leads to improved patient outcomes (Stewart, McNulty, Griffin, & Fitzpatrick, 2010), its implementation is often not actualized. Without an adequate change theory to guide the implementation, the intended innovation may not succeed. The purpose of this paper is to hypothetically apply Havelock's (1973) change theory to the empowerment of direct care worker staff at Casa Verde, an LTC and retirement residence in Toronto, Ontario. Casa Verde is an infamous LTC facility due to a double homicide by a resident in 2 005. The coroner's inquest led to massive reform of all LTC facilities across the province due to violations of standards of practice. Incidentally, this is my current community clinical placement. My first hand experience testifies to the reality that empowerment of the staff is definitely lacking, causing consistent chronic absenteeism. Furthermore, families' have expressed complaint of inadequate and uncompassionate care, compounded by a lack of continuity.
To be empowered means that one perceives his/her work as meaningful and important, and that he/she is competent and valued as an employee (Bandura, 1997). Empowerment is dynamic in that it is based on mutuality between staff, management, and residents, with the locus of control within the culture and structure of not only the organization, but each member of the teams as well. According to Stewart, McNulty, Griffin, and Fitzpatrick, "Empowerment is also a psychological process, which occurs when one has a sense of motivation in relation to the workplace environment" (2010, p.27). With the traditional top down management style, issues of power and control can severely impede the dynamic change and potential of empowerment to capitalize on the uniqueness of individuals making up a team. With empowerment achieved, the not only will the staffs' attitudes, motivation, and job satisfaction improve, but moreover, the quality of care provided to residents will as well. Because direct care workers have less opportunity to communicate with the professional staff, they can inadvertently have a negative impact on the residents' quality of life. These workers do not feel their contributions to care are important or appreciated due to subjugation to a hierarchal system of health care.
Staffing paradigms need to change and emphasize interdisciplinary collaboration and communication, team interaction, cohesiveness, and team building. Similarly, Caspar and O'Rourke (2008) studied the relationship between care provider's ability to provide individualized care and feelings of structural empowerment. They found that access to empowerment structures (information, formal power, informal power, support, opportunity, resources) had a statistically significant, positive impact on the provision of individualized care by RNs, RPNs, and care aides. Thus, individualized care can be enhanced when direct care workers, non-RN staff included, have access to these empowerment resources. This raises the question as how to implement these structures.
Finally, in a study by DeCicco, Laschinger, and Kerr (2006), the perceptions of empowerment and respect was studied in Ontario's nursing homes by investigating the relationships between perceptions of psychological and structural empowerment, organizational commitment, and respect of RNs and RPNs to clients. Both groups had moderate levels of these factors, and interestingly, RNs had higher perceived levels of respect and empowerment than the RPNs. Access to opportunity was considered to be the most empowering factor, and the least empowering was access to resources (DeCicco, Laschinger, & Kerr, 2006). This raises the question as to whether we can increase empowerment of our direct care staff through increasing access to opportunities. Several researchers from the 1990s have focused on Kanter's (1977) theory of structural power in organizations to show that empowerment is a critical factor in the success of healthcare teams (Laschinger, &Â Shamian, 1994). Although empowerment is a necessity to productive work environments, few theoretical frameworks provide guidance for the implementation of empowerment as an innovation. To this end, Havelock's (1973) theory of innovation is used to hypothetically address the issue of disempowerment and chronic absenteeism in Ontario's LTC facilities.
Havelock's (1973) Change Theory
According to Havelock (1973), "there are two ways to look at stages of innovation. One way is to see it from the point of view of the people who are being changed, and the other is to see it from the point of view of someone who is trying to change someone else" (p.5). Change is often challenging because we are stuck in our conventional methods. It is easier to stick with what has worked, then to try something new and innovative. Havelock (1973) proposes two change innovation methods, the reflex response versus the rational problem solving method. The former is not likely to result in uptake of the innovation, while the latter can lead to lasting change. Furthermore, Havelock (1973) views change agents as having four possible primary roles: catalyst, solution giver, process helper, or resource linker.
Havelock (1973) summarizes three strategies for the uptake of an innovation. The first is problem solving, which posits that the innovation is an essential part of a problem solving process that is found in the change agent. The second is social interaction: this emphasizes the role of the social system in which the innovation is diffused. Third, research development and diffusion is guided by five assumptions: there is a rational for the innovation; planning is required; division of labour is necessary; the consumer is passive; and initial development costs are high but worthwhile (Havelock, 1973). With these change agent roles, strategies, and assumptions in mind, the change theory proposed by Havelock (1973) is used to show how an empowered health care team can provide improved client relations in LTC. This theory provides a simple six step sequence for leading to adoption of an innovation:
Establishing a relationship with the client system
Diagnosing the need for change
Acquiring the necessary resources
Choosing the appropriate strategy
Accepting and adapting the chosen solution
Guiding the client system in self renewal - the ability to change
Application of Theory
The first step is establishing a relationship with the client system (Havelock, 1973). Positive relationships are a key element to changing the environment. Because we are interested in unit level change as the initial pilot project, representatives from every shift and all job categories must be included (Lane, 1992). These members will form the planning committee for staff empowerment. Most importantly, the change agent, a staff nurse, will be asked to volunteer to fill a pivotal role. This nurse will then assist the committee in identifying the formal leaders, the informal leaders, and information re-layers (Lane, 1992). With structure issues addressed, the role of the change agent is clarified. According to Lane (1992), "the change agent should be friendly, familiar, responsive and rewarding â€¦ this person should establish a working atmosphere of reciprocity, openness, equalized power, minimum threat and involvement while guiding clients to realistic expectations of the change process" (p. 58). Therefore, we will require a nurse with a highly developed sense of rapport, trust, and leadership characteristics to provide an exemplary change agent.
During the empowerment committee's meetings, we will continue to maintain Havelock's (1973) principle of establishing relations by encouraging members to offer ideas and even confront each other when appropriate (Lane, 1992). This will lead to higher synergy among the group and the generation of further novel innovations to empower the staff. We must make sure that all of the staff conceptualize that we are all change agents. The committee's planning process will now consist of several meetings, and because this is a pilot project, we will begin with a weekly schedule, which will then change to biweekly, and monthly if appropriate. These meetings will be a half hour at first.
The second stage is diagnosing the need for a change (Havelock, 1973). At the first meeting, the issue of empowerment of staff will be raised by the change agent, and input of ideas through brainstorming will be encouraged. Nominal group technique will be incorporated to find the staffs' feelings on the issue of empowerment of staff to decrease chronic absenteeism. The personal issues of staff in providing quality patient care and organizational problems will be discussed and addressed, as well as problems they have in delivering it. Some of these issues may include different interpretations of client centered care, the staff to resident ratio, misunderstood rules and regulations, increasing staff through access to education, a participative management style, and strategies for quality improvement. In a study by Kuokkanen and Katajisto (2003), they studied five factors that impede and promote empowerment in the nursing environment. The main results were factors which increased empowerment were: career consciousness, job satisfaction, commitment, and further training. Therefore, considering organizational changes and personnel governance could be the means of empowering the staff at our LTC facility.
At the second meeting, the committee will provide a description of the proposed project based on the input from the first meeting, and how to address empowerment issues. This mutual goal will be further explored through brainstorming. As a group, we can then determine if the goals are feasible and reasonable for our staff to decrease chronic absenteeism and improve client-centered care. A study by Cready, Yeatts, Gosdin, andÂ Potts (2008) also found that empowered nurse teams, specifically certified nurse assistant (CNA) teams, could effectively provide improved care to clients. These empowered CNA teams, and the RNs who worked with them, reported better performance and improved attitudes towards work, and a subsequent decrease in thinking about leaving their work positions (Cready, Yeatts, Gosdin, &Â Potts, 2008). The incorporation of such teams is supported by the literature, and a plausible option for our LTC facility. Hopefully these kinds of solutions will be produced by the committee.
At the third meeting, "focus on diagnosis through input from the committee and process analysis of previous meetings' proceedings" (Lane, 1992, p.59), to address the relevant materials related to the diagnosis - chronic absenteeism from disempowerment. However, the change agent must be vigilant in the pitfall of over diagnosing the problem. The most parsimonious solution could be the correct one, and these goals must be expressed and developed by all involved. By the end of this third meeting, the committee should have identified its goals (Lane, 1992).
The third stage is acquiring the relevant resources (Havelock, 1973). This is where the committee members are delegated information searching tasks to seek solutions to the disempowerment issue. Several nursing resources, such as CINAHL, PubMed, Medline, the Registered Nurses' Association of Ontario (RNAO) Best Practice Guidelines (BPGs), and others will be used for the acquisition of relevant information - this will be a literature review of empowerment of staff and client centered care of residents in LTC facilities. Several information searching strategies will be generated, and the committee will be responsible for reviewing the contributions in the next stage. Stewart, McNulty, Griffin, and Fitzpatrick, (2010) assert that by providing access to support, information, opportunities to learn and grow, as well as resources, an empowering workplace environment is created. A common theme occurring in this research was the importance of psychological and structural empowerment. This relationship is linked to quality patient care, retention, work effectiveness, and cost effectiveness (Stewart, McNulty, Griffin, & Fitzpatrick, 2010). These concepts must also be integrated into our program in order for the change to be effective.
The fourth stage is choosing the appropriate strategy. After the resource findings are presented, members will review the materials, identify feasible options, and state the implications for action (Lane, 1992). A range of solutions should be created, such as education sessions on client centered care, best practice guidelines summaries, and other possible solutions. At the end of this meeting there should be several possible strategies for review and critique. According to the current literature, an excellent strategy is the incorporation of empowered work teams (Yeatts & Cready, 2007). These workers consist of frontline workers, such as RNs, RPNS, and PSWs, how do direct care and know the residents on a one to one basis. Because empowered teams will have similar responsibilities and skills, they each take on some supervisory responsibilities and provide recommendations for workers at the same level. Several studies have shown that these empowered teams with self direction, increased responsibility, and supervisory function have not only improved performance, but also much higher work satisfaction and decreased absenteeism (Yeatts & Cready, 2007). Furthermore, the decisions made by these teams often have more innovative solutions than management due to their knowledge of the work environment and process (Lane, 1992).
Transformational learning is another aspect of empowerment that might be addressed by the committee. Dingel-Steward and Lacoste (2004) report: "Nurses who are successful in transformative learning will feel empowered. These newly transformed nurses see themselves more as healthcare engineers rather than as direct care technicians"(p.212). Transformational learning must also be shared with the other direct care workers, not just RNs, for empowerment of staff to take effect. An empowered team is not synonymous with an interdisciplinary team. The former refers to a group who feels their contributions are worthwhile and appreciated, while the latter describes members from various professions (Lane, 1992). Indeed, an empowered team is more likely to occur when the members are from the same discipline and are self managed, with more decision making authority than found in interdisciplinary top down directed teams.
The fifth stage is accepting and adapting the chosen solution (Havelock, 1973). During this stage feasibility for the preferred solution is addressed, and the change agent is in charge of facilitating the review of the potential benefits, workability, and infusibility of each possibility (Lange, 1992). The group will be encouraged to implement this solution on a pilot basis. The committee must be encouraged to identify what improvements "would be the best one: one with the most benefits, the most workable, or the most diffusible" (Lane, 1992, p. 59). The pilot design and plan could be created using the plan-do-study-act (PDSA) small project implementation strategy (Langley, Nolan, Nolan, Norman, & Provost, 2009). A possible PDSA worksheet is provided in Appendix A (Institute for Healthcare Improvement, 2010).
The sixth stage is guiding the client system in self renewal - the ability to change (Havelock, 1973). This stage is crucial as it leads to empowerment and assimilation of the change. According to Lane (1992), the committee must: "identify innovators, resistors, and leaders on their unit and how they will involve the key persons" (p. 60). Lane (1992) provides several suggestions, such as establishing biweekly newsletters, a videotape of the project, or posters of the innovation. The change agent will be the resource person for evaluation of the pilot project. Quantification of empowerment could be achieved through a questionnaire, pre-test post-test design, where direct care staffs' knowledge of empowerment issues is measured through a true/false test. Thirty days post test, the same quiz could be used to see if their knowledge of empowerment strategies has increased, and whether this correlates with job satisfaction, improved attitudes, and other agreed upon correlates of empowerment. A similar questionnaire could be developed and measured among the residents, and in this case, a qualitative appraisal area would also be included. Also of importance, monthly quality control indicators (CQIs) reports of chronic absenteeism could show the effectiveness of the implementation of the empowerment innovations among our direct care workers.
Based on the application of Havelock's (1973) theory of change, it is predicted that the empowered teams should have several outcomes, which include but are not limited to: increased feelings of empowerment of teams; increased performance; improved attitudes; improved client centered care; and decreased absenteeism of staff. With Havelock's (1973) theory, it is apparent that the change agent is a crucial leader to communicate with the committee for implementation of the innovation. The participants in the committee will feel empowered due to the constant input and encouragement to contribute. Lane (1992) recommends continued reward of the members and recognition of contributions to the committee's processes. Whenever the reward comes from the improvement in the patients' quality of life, and increased feeling of dignity, the nursing perspective is actualized.
By implementing empowerment of staff through the process outlined in this paper, the quality of life, dignity, and integrity of the residents can be preserved and maintained. This involves changing the facility's culture through a six step process which will lead to empowerment. In summary, the plight of Ontario's LTC facilities can be reversed by incorporating a nursing model of empowerment among direct care workers, as opposed to the current reductionist medical model of treating residents as diagnoses. Overall, this paper has demonstrated that with empowerment through Havelock's (1973) theory of innovation, the six stages of planned change can be actualized through a caring and compassionate approach to health care.
PDSA Worksheet for Testing Change
Aim: To increase the empowerment of direct care staff at Casa Verde LTC & Retirement Home
Describe your first (or next) test of change:
When to be done
Where to be done
Invite all direct care staff for the first empowerment committee meeting
List the tasks needed to set up this test of change
When to be done
Where to be done
Invite all staff for empowerment committee meeting
Enquire if a nurse will become the overseeing change agent
Use nominal group technique for addressing empowerment issues
Brainstorm on possible solutions
Conduct literature review and research
Choose appropriate strategies - possible examples from current literature include: work teams, transformational learning, staffing, resident to staff ratio changes, autonomy, interdisciplinary collaboration, communication, team interaction, cohesiveness, team building, access to empowerment structures (information, formal power, informal power, support, opportunity, resources)
Implement change and evaluate
Predict what will happen when the test is carried out
Measures to determine if prediction succeeds
Direct care workers will increase their job satisfaction, work attitudes
Chronic absenteeism will decrease
The quality of care will improve
Chronic absenteeism will decrease
Quantitative questionnaires of residents
Qualitative appraisal of the improvements by residents
Quantitative questionnaires of RNs, RPNs, PSWs that measure work satisfaction and empowerment
Monthly CQI of chronic absenteeism