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Correspondence: Address correspondence to Paul Stolee, PhD, Southwestern Ontario Regional Geriatric Program, c/o St. Joseph's Health Care London, 801 Commissioners Road East, London, Ontario N6C 5J1, Canada. E-mail: paul.stolee{at}sjhc.london.on.ca
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Abstract |
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 TOP Abstract Design and MethodsResultsDiscussionReferences |
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Key Words: Organizational support • Delphi technique • Transfer of learning • Nursing home
The impact of continuing education in long-term-care facilities is largely uncertain, especially on a sustained basis. In our literature review of the effectiveness of continuing education in long-term care (Aylward, Stolee, Keat, & Johncox, 2003), we found that rigorous research in this area has been limited and that while transfer of knowledge may have been effective in the short term, there is little evidence for the sustained application of continuing education. Educational programs may increase knowledge, but this is only one of many factors affecting performance (Broad, 1997; Rummler & Brache, 1995). Evidence from a variety of settings (Daley, 1997; Escovitz & Davis, 1990; Koeck, 1998) suggests that organizational and system factors can facilitate or hinder knowledge transfer and sustained impacts of continuing education. Unfortunately, the majority of studies in long-term care do not consider organizational and system factors when planning and implementing continuing-education initiatives. This may account for the difficulties encountered in the sustained transfer of knowledge to practice. Our review (Aylward et al.) identified a need for further rigorous research on the effectiveness of continuing education in long-term care, with systematic attention to the role of workplace factors.
This article presents the results of two related studies that examined factors within the long-term-care work environment that affect the use of knowledge gained from continuing-education programs. Study 1 built on our literature review on the effectiveness of continuing education in long-term care and involved focus-group interviews with long-term-care staff and management as an initial exploration of the workplace factors affecting transfer of learning. Results from the literature review (Aylward et al., 2003) and from Study 1 were used to inform Study 2, a Delphi approach to validate and refine our list of factors that facilitate or hinder effective continuing education in long-term care.
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Design and Methods |
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TOPAbstractDesign and MethodsResultsDiscussionReferences |
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Separate focus groups were conducted with staff (three groups) and management (three groups), with a total of 35 participants. They ranged in number of years of service in long-term care from less than 1 year to 30 years (M = 9.9 years; SD = 5.9). Participants were employed in privately owned nursing homes (n = 21), publicly owned homes for the aged (n = 13), and a combined private/public facility (n = 1); they represented 25 facilities spanning five counties in southwestern Ontario. The number of participants in each of the focus groups ranged from five to seven (median = 6). Two focus groups (1 management and 1 staff; n = 13) were conducted in an urban setting and four (2 management and 2 staff; n = 22) in rural settings.
Of the 17 staff participants, 11 (65%) were registered nurses, 5 of whom were charge nurses or unit managers. The remaining staff participants were registered practical nurses (RPNs) (2), health care aides (3), and one position was unknown. Eleven (65%) of the staff participants worked in rural areas. Of the 18 management participants, 15 (83%) were registered nurses. Fourteen (78%) of the management participants held administrative or director of care positions. The remaining 4 participants held specialized coordinator positions (e.g., quality assurance, food services and nutrition). Eleven (61%) of the management participants worked in rural areas.
Procedure
The focus-group interviews were conducted within long-term-care facilities and were approximately 1.5 hr in length. All interviews were tape recorded. The interviews were conducted by a trained facilitator, who asked the following discussion questions, using predetermined probes as necessary: (a) Can you think of any factors in your work environment that hinder continuing-education programs from having an impact? (b) Can you think of any factors in your work environment that have helped continuing-education programs have an impact? (c) Thinking about your work environment, what are your ideas or suggestions to improve the impact or benefits of educational programs? (d) Thinking about your work environment, what, if anything, is unique to this environment that influences the effectiveness of continuing-education programs? (e) Is there anything else you would like to add?
Transcribed audiotapes and facilitator notes were analyzed using a qualitative naturalistic inquiry approach (Lincoln & Guba, 1985). Inductive analysis of the data allowed for the identification of themes recurring in the data without prior assumptions (Patton, 1990).
This study was approved by the Research Ethics Board for Health Sciences Research Involving Human Subjects, University of Western Ontario.
Study 2
A Delphi survey process was undertaken to develop a prioritized and comprehensive list of organizational and system factors important to the effectiveness of continuing education in long-term care. The Delphi technique is a structured process for obtaining consensus through iterative survey questionnaires (Boberg & Morris-Khoo, 1992; Dalkey, 1970). In this study, the initial list of factors was derived from the information gathered from several sources: (a) our review of the literature (Aylward et al., 2003); (b) a symposium on education and training in long-term care held in December 1998 with long-term care facility staff and management, provincial and regional health officials, and representatives from programs involved in providing education; and (c) the focus-group interviews, as described earlier.
Sample
Thirty-four experts in long-term care were invited to participate in this study. Thirty experts responded to the first questionnaire (88% response rate), representing four groups: long-term-care facility (staff and management) representatives (n = 12); provincial and regional health officials (n = 6); and representatives of programs involved in providing education (n = 12). Of these 30 participants, 27 responded to the second questionnaire (90% response rate; 11 long-term-care representatives, 5 health officials, and 11 education providers).
Procedure
Consistent with the Delphi methodology, participants received, by mail, a first survey in which they were asked: (a) to rate the importance of 38 factors potentially relevant to the effectiveness of continuing education in long-term care (1–10 scale; 10 = very important); (b) to indicate whether they felt the factor was modifiable in the current system; and (c) to suggest any other factors. Data collected from the first survey served as the basis for the second questionnaire, which included factors identified as modifiable in the first survey, the statistical ratings of importance for each of these factors, and new factors suggested by participants. As in the first survey, participants rated the importance of each factor. Mean ratings of items were used to determine relative rankings of importance and modifiability. Standard deviation was used as a measure of consensus. Sufficient consensus was achieved with two rounds of surveys as indicated by the consistency in responses between the two survey rounds and the low and relatively stable standard deviations of the most important factors.
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Results |
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Demonstrated practicality and efficacy was viewed as paramount to staff's willingness to implement new approaches. A rural staff participant commented:
If you get them [residents] feeding themselves or brushing their hair, in the long run they are going to be doing that for themselves. That's something that staff members won't have to do. It's going to save time later on. They [staff] don't see that. They just say let's get it done.
Resistance to change was seen as compounded by an undereducated workforce; the low educational requirements for positions such as health care aides have resulted in a work force that may not value continuing education. Staff participants suggested that management has failed to support health care aides' participation in continuing education in favor of registered staff. However, many believed that simply making continuing education available to health care aides would not meet the demands for more specialized and complex care, which requires better educated and trained professional staff, such as registered nurses. A rural administrator commented:
... the complexity of care that we are getting into, does it really warrant [only] the level of health care aide? And I know that the personal support worker program has increased the knowledge base and the training, but are we still reaching what we need as far as the level of professionalism and knowledge base? We're just getting into so much now that it's almost beyond their level.
Administrators were viewed as instrumental in creating a work environment conducive to change. A rural management participant commented: "If you don't have an administrator that is going to support it, you're not going to get the funding. You're not going to get the time and energy that is going to promote that education." Management support was described as including prioritization of new initiatives with funding for staff coverage, organizing staff schedules to allow attendance, and scheduling continuing education at optimal times. Management participants reported that union rules about overtime, scheduled breaks, and travel costs, and the lack of funding to cover overtime costs, hinder unionized staff members' participation in continuing-education programs.
A "whole-team approach" involving all staffing groups was identified as a vehicle for facilitating continuing-education initiatives by promoting clear communication, sharing knowledge about new approaches across different staff roles and shifts, and consultation between different disciplines (including physicians and pharmacists). In particular, management participants commented that continuing education for administrators increases their understanding of the particular health care issue, increases their support for change, helps them appreciate what effort and strategies are required to implement new approaches, and eases the development of new policies.
Consistent with a whole-team approach, participants identified the need for physicians to maintain a more active role in continuing-education initiatives. Participants cited examples of situations involving pain and symptom management and behavior management, in which they had learned about new medications or other treatments in continuing-education programs but their efforts to implement these were thwarted by physicians who were not familiar with the new treatments.
Lack of financial and physical resources, particularly in smaller facilities, was a pervasive theme underlying many of the factors. A rural management participant commented: "They [staff] come back [from continuing education] and say, ‘yeah, they had great ideas but to apply it here it's very difficult because we are a quarter of the size.’" In comparison to acute-care facilities, long-term-care facilities receive less money and operate with less management, less specialized equipment, and fewer professional staff members, despite the intensive care that is required. Pervasive under-staffing in long-term care results in higher workloads and less time for educational activities and implementation of new approaches. Participants indicated that all of these factors affect the utilization of continuing education, in that management has limited time and resources to develop and implement policy changes and has less money for covering clinical time while staff attends educational programs.
Management participants expressed frustration with their inability to cover positions when staff attends continuing-education programs: "... to take away two people to an in-service, that's 50% of that particular unit that you're pulling off. And we really are at a bare minimum, and ... to take one or two people has a tremendous impact." This impact is compounded in smaller facilities where staff often fulfills multiple roles (e.g., both front-line and administrative roles).
Participants in both rural and urban areas underscored the lack of physical space and resources in smaller facilities as a barrier to conducting educational programs and implementing some new care approaches. Smaller facilities may not have meeting rooms necessary for training, clerical support for producing materials, or the necessary equipment (audio-visual equipment, photocopiers) required to conduct training programs. Similarly, facilities may not have designated space or equipment for new physiotherapy or activitation programs.
Participants suggested that in order for continuing-education programs to be effective, facilities need access to expert mentors, resources, and follow-up support. Networking among facilities and with other community agencies to improve the dissemination of new information about implementation strategies was seen as particularly important for smaller facilities, which face unique issues when implementing initiatives. Other strategies to support continuing education included key expert contacts and resources for specific problem solving; these could be accessed via telephone (e.g., 1–800 numbers), e-mail, or informational web sites.
Study 2
In the first questionnaire of the Delphi survey, participants rated 49 factors and suggested an additional 15. In the second questionnaire, participants rated the importance of the 39 most modifiable factors from the first round, along with the 15 new factors. Table 2 presents the top 10 factors rated as important for the effectiveness of continuing education across all participant groups. The mean ratings were high; means ranged from 8.78 to 9.4; standard deviations were all less than 1.4. More than 80% of respondents indicated that these factors were modifiable. Management support was the top-rated factor relevant to the transfer of learning in long-term care, in both questionnaires. Two factors identified by participants in the first questionnaire (knowing change of practice supported and knowing patient care completed while training) made the top 10 list of factors in the second questionnaire.
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Discussion |
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In the United States, efforts have been made to improve quality of care in nursing homes through government regulation. As part of the Omnibus Budget Reconciliation Act of 1987, the Nursing Home Reform Act (NHRA) legislated requirements for care and staffing levels, including minimal standards for the training of health care aides (minimum of 75 hr and a passing competency test). There is evidence to suggest that NHRA legislation has resulted in improved quality of care including a decreased use of restraints (Marek, Rantz, Fagin, & Karejci, 1996) and catheterization (Mosely, 1996). Zhang and Grabowski (2004) suggest improvements resulting from the NHRA are due, in part, to higher staffing levels for those facilities that had substandard levels prior to the NHRA. These results suggest that quality-improvement strategies and related training initiatives are more likely to be effective if they have system-wide policy and regulatory support.
In the studies presented here, management support was perceived as essential to ensuring the success of continuing education in long-term care. Staff perceived management as unsupportive when access to continuing education was limited because of funding, staff coverage, or scheduling issues and when they were unable to implement learned care strategies in the workplace. Although some of the management participants in this study suggested that the lack of transfer of training is a result of resistance to change of the learners, the clear message from this research is that organizational support is much more important in affecting the success of continuing education. Organizational support is multifaceted and goes beyond simply supporting an individual's participation in continuing education. The list of factors important for the effectiveness of continuing education in long-term care identified in this research is consistent with organizational factors affecting performance identified by Rummler and Brache (1995) and adapted by Broad (1997), including clear performance specifications (expected outputs, standards); necessary support (resources, priorities, responsibility, authority, time); and clear consequences (reinforcement, incentives, rewards). These factors underscore the responsibility of organizations, not just trainers and trainees, in facilitating the transfer of new learning.
Management and organizational support is central to the development of a workplace environment that fosters innovation and change. Ross, Carswell, and Dalziel (2002) suggest that the relationship between staff training and quality of care is mediated by the quality of the organization; nursing homes that fail to provide adequate care have been found to have work environments that pay little attention to staff motivation, have inadequate planning, have few resources available to implement new programs, undervalue lower-level care providers, have low staff cohesion, and have staff focused on maintenance models of care. The Wellspring model, which is an alliance of nursing homes that have successfully enhanced the implementation of new interventions to improve quality of care, provides some insights into the clinical and organizational changes necessary to ensure the success of continuing education (Stone et al., 2002). Within the Wellspring model, collaboration between administration and staff to meet goals at both an organizational and individual level creates a work environment in which staff members are empowered to improve clinical care. Within the alliance, facilities share resources—including knowledge and experience—with front-line workers. Training is shared across facilities, giving staff opportunities to collaborate and consult on difficult clinical issues. Moreover, staff training occurs in cross-disciplinary teams, rather than being segregated by discipline. Staff members are responsible as a team to disseminate new information and ensure that new practices are incorporated into routine care. This collaboration is viewed as a way to decrease some of the hierarchical relationships that can act as a barrier to change.
Consistent with the Wellspring model, focus-group participants in this study did not view training as being in and of itself sufficient to ensuring knowledge transfer and competence. Key to change is the support and commitment from administration to empower staff to change practice. Focus-group participants emphasized the inclusion of all disciplines, including administration, in continuing education to ensure that all members of the facility are working toward common prioritized goals for resident care. The lack of shared vision at any level (administrative, medical, nursing, or front-line workers) was viewed as a significant barrier to change.
Efforts to improve quality and overall performance in long-term care need to address the organizational and system factors that can support change in a sustainable fashion (Beck, Ortigara, Mercer, & Shue, 1999). Some of the factors identified in our research (e.g., needs for resources, access to expertise, and changed attitudes toward the elderly population) suggest the need for system-wide changes. Some of these may be possible in the short term, but many will be more difficult to address. This study identified union policies as a potential barrier to staff participation in continuing education. The role of unions is a system factor that has not been well explored in long-term care and should be examined further.
In this study, focus-group participants emphasized the need for workplace environments to support staff efforts to try innovative approaches and to encourage the maintenance of new skills once education programs are over. Green and Kreuter's (1991) identification of factors relevant to behavior change in health promotion, namely enabling factors (which are the conditions and resources within the environment that allow, or enable, an individual to implement new skills) and reinforcing factors (those that provide an individual with cues or reminders to implement new skills or that reinforce the use of new skills), were identified in our studies as important to sustained transfer of learning in long-term care. Interventions that incorporate enabling and reinforcing factors are considered to be more effective in creating behavior change than programs that simply focus on the dissemination of information (Davis, Thomson, Oxman, & Haynes, 1992). In our literature review (Aylward et al., 2003), we found that the majority of education initiatives focused primarily on the dissemination of information, without any enabling or reinforcing strategies in the form of organizational or system support to facilitate the transfer of new knowledge or behavior in the workplace.
Enabling factors identified in the studies presented here included opportunities for bedside learning, incentives to attend continuing-education programs, easier access to continuing education, staff coverage to allow staff to attend continuing education without being stressed about the consequences of leaving their work, physical space necessary to implement new programs, and opportunities to assimilate new material and practice new strategies. Focus-group participants identified space issues and availability of resources as impacting a facility's ability to provide continuing education. Innovative solutions and partnerships will be necessary to overcome these issues. Resource barriers could be overcome by the development of collaborative relationships among facilities in close geographic proximity, or with similar resident populations, to share resources and continuing education, similar to alliances created in the Wellspring model. Similarly, collaborative partnerships with community and government programs and with staff unions could be established to develop continuing-education initiatives that are mutually beneficial and resolve some of the barriers to providing continuing education.
The studies presented here highlight the need for reinforcing factors such as access to expert resources and networking for ongoing support, consultation, and information sharing. Nurse practitioners working in long-term care have been found to play effective roles in the education of long-term-care facility staff, particularly through informal, "in the moment" teaching (Stolee, Hillier, Esbaugh, Griffiths, & Borrie, 2005). Where available, nurse practitioners could be utilized to provide education and reinforce new skills (Smith, 2004). Collaborative relationships among facilities to create a support system or network would provide staff with an opportunity to share lessons learned in the implementation of new care approaches and to problem solve difficult issues. Consistent with the Wellspring model, care teams could support the implementation process through mentoring opportunities within and across collaborating facilities and could link with other community agencies or services. Follow-up support and access to key expert resources for consultation and the use of new technologies (e.g., videoconferencing or web sites) could support facilities in efforts to implement new approaches and problem solve clinical issues. As an example, part of a comprehensive provincial strategy for Alzheimer's disease and related dementias (Ontario Ministry of Health and Long-term Care, 1999) includes the "Putting the P.I.E.C.E.S. Together" training initiative for long-term care. This initiative provides an intensive classroom program supported by on-the-job practical application of the curriculum and posttraining support in the form of workplace mentors, regional mentors (psychogeriatric resource consultants), access to information and networking via a training program web site, teleconferencing opportunities for coaching in the integration of new skills and knowledge into daily clinical practice, and a service that provides timely fax or e-mail advice on clinical and educational problems (McAiney & Stolee, 2003). In Ontario, the impact of the Putting the P.I.E.C.E.S. Together training initiative is likely enhanced by its link to an overall provincial strategy; however, it has not been accompanied by supporting regulatory changes.
A limitation of this research is the limited representation of the perspectives of health care aides, who provide most of the direct care in long-term-care facilities. Inclusion in the focus-group interviews was dependent on participation in regional continuing-education initiatives. Few health care aides attended these training programs. Future research should more closely examine the perspectives of health care aides on the relevance of training to their work, the training and supports they require, and the factors that facilitate or hinder implementation of new care approaches.
The results of the studies presented here add to a growing understanding of the workplace environment in long-term care and its impact on the potential success of continuing education and quality-improvement initiatives. There is a need for continued research to evaluate organizational and system-wide changes and their impact on staff competence and outcomes for long-term-care residents.
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Footnotes |
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1 Southwestern Ontario Regional Geriatric Program, St. Joseph's Health Care London, Ontario.
2 Department of Epidemiology and Biostatistics, University of Western Ontario, London.
3 Lawson Health Research Institute, London, Ontario.
4 Consortium for Practical Research in Care of the Elderly, Mount Hope Center for Long-Term Care, St. Joseph's Health Care London, Ontario.
5 Ottawa Hospital, Civic Campus, Ottawa, Ontario.
6 Planning, Accountability, and Evaluation Unit, Ontario Ministry of Health and Long-Term Care, Toronto.
7 Southwestern Ontario Regional Pain and Symptom Management Program, London, Ontario.
8 Department of Family Medicine, University of Western Ontario, London.
Decision Editor: Linda S. Noelker, PhD
Received for publication December 12, 2003. Accepted for publication September 27, 2004.
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