The Importance of Creating a Culture of Learning
Nursing represents the largest group of employees in nursing homes. Consequently, the quality of the services they provide has a significant impact on the quality of care that nursing home residents receive. Unfortunately, this workforce has little formal preparation in geriatrics and long-term care (LTC). In addition, the nursing workforce who are responsible for providing most of the direct care to residents have minimal educational preparation in general. Certified nursing assistants (CNAs) constitute nearly half of the LTC workforce and provide 2.3 hours of care per resident day, compared with 0.5 hours per resident day provided by registered nurses (RNs), and 0.7 hours per resident day by licensed practical nurses (LPNs).
In the report The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine (IOM) emphasized that nurses must achieve higher levels of education and training to respond to increasing demands. In 2008, the IOM released Retooling for an Aging America: Building the Health Care Workforce, a landmark report that outlined the critical shortage in the numbers and competencies of the workforce that cares for elderly persons.1 The need to enhance knowledge and competencies of LTC nurses is significant; however, there are several obstacles that must be overcome to achieve this end, including insufficient investment in education, insufficient leadership commitment, and insufficient personal responsibility.
Insufficient Investment in Education
Educational resources and teaching expertise are sorely lacking in most nursing homes. Most facilities lack libraries, computers, and Internet access. Staff development educators are primarily nurses with no formal preparation or experience in adult education; their ability to assess educational needs, plan programs, use various teaching methodologies, and bridge theory to practice is limited. Facility support for attendance at extramural programs is often limited to leadership staff. These factors, combined with a workforce who has had minimal experience in academic environments in which they could have gained an appreciation and skills for independent continuing education, result in challenges in sustaining and advancing competencies.
Insufficient Leadership Commitment
Over the past year, I have had the opportunity to consult on a project in which a group of nursing homes with 3-star ratings or less were provided onsite education and consultation to promote culture change and quality improvement efforts. The plan was to offer four full-day workshops annually, followed by implementation assistance from experienced nurse consultants. A component of the program was to provide several of the American Association for Long Term Care Nursing (AALTCN) certification programs to interested nursing staff free of charge. I believed this was an opportunity that a low-performing nursing home would enthusiastically embrace: free, quality education within their own facilities with implementation assistance from expert nurse consultants. I was wrong! Recruiting facilities to participate in the program was a challenge, as most didn’t think they could support having staff attend a full day class on four different occasions throughout the year. There was also the challenge of sustaining efforts in most of the facilities that did agree to participate, as leadership failed to find ways to allow frontline staff to take a full day off for educational purposes. An adjustment was made to break the sessions into multiple 1-hour sessions, which enhanced participation, although the ability to have staff attend the sessions even in 1-hour blocks remained a challenge. Unfortunately, the view that education is a burden rather than a necessity is hardly rare in many LTC settings. It should be mentioned, however, that the frontline staff who attended the sessions were interested, enthusiastic, and desirous for more educational opportunities.
Considering education as merely an expense rather than an investment may reflect the shortsightedness of nursing home leadership. Evidence exists that providing professional development opportunities reduces turnover and improves quality.2,3 With the current turnover rates of 39% for directors of nurses (DONs), 50% for RNs, 49% for LPNs, and 71% for CNAs, and with replacement costs averaging $5901 for an RN and $3940 for a CNA, there seems to be a strong business case for investing in education; however, without leaders who understand this and convey the value of education, staff fail to gain an appreciation for its importance.
Insufficient Personal Responsibility
Professionals who have been students in university settings often gain an appreciation of the need to take personal responsibility for lifelong learning. They realize the importance of joining professional associations, reading journals, and attending continuing education programs. Unfortunately, this personal commitment to sustaining and improving one’s competencies is uncommon among LTC nursing staff, as is exemplified by DONs, who represent the highest position in the nursing department. Most DONs possess basic nursing degrees. Survey data indicate that the education levels of DONs are as follows: 56% hold an associate’s degree or diploma in nursing, 30% a baccalaureate degree in nursing, 5% a master’s degree in nursing, and 13% a non-nursing bachelor’s or master’s degree. Approximately one-third of DONs hold some type of certification, with only 12% holding certification in nursing administration in LTC. Less than half belong to specialty nursing organizations.5 The percentage of nurses with degrees, certifications, and involvement in professional associations is significantly less for other levels of nursing in LTC. These realities present obstacles to nurses in satisfying the IOM recommendation that they engage in lifelong learning to gain and sustain the competencies needed to provide care to the populations they serve.
Creating a Culture of Learning
Limitations in the academic preparation of nursing employees, onsite educational resources, preparation of staff development educators, and support for education by leadership challenge the ability of facilities to provide care that is reflective of current best practices. Aggressive efforts to develop a culture of learning in LTC settings are needed and the initial action is for leadership to support this effort. Some ways to demonstrate this support include: assuring every job description includes an expectation of continuing education, supporting participation in educational activities for all levels of staff, recognizing continuing education efforts, and budgeting for educational activities and products.
Staff development directors need to enhance their competencies for their unique role. This includes an awareness of the principles of adult education, techniques for needs assessments, fundamendals of effective planning, and use of various approaches for presentation and evaluation. The AALTCN offers an LTC Staff Development Specialist Certification that provides this preparation, which has proved useful for many nurses in this role. More information on this certification can be found at www.ltcnursing.org.
A commitment to being a lifelong learner needs to be nurtured in all employees, which can be achieved by having employees recognize how quickly knowledge on geriatric care issues is expanding, helping employees develop personalized educational plans based on their individual needs and learning style, and rewarding their efforts. Knowledge and skills, particularly in healthcare, change too rapidly for anyone to think that education stops upon graduation. Nurses and their employers need to understand that time, effort, and money are necessary investments to ensure continued competency and that the demands of an increasingly complex resident population are met.
References
1. Committee on the Future Health Care Workforce for Older Americans; Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: The National Academies Press, 2008.
2. Utley R, Anderson R, Atwell J. Implementing transformational leadership in long-term care. Geriatr Nurs. 2011;32(3):212-219.
3. National Commission for Quality Long-Term Care.The long-term care workforce: can the crisis be fixed? www.ncqltc.org/pdf/ltc_workforce.pdf. Accessed March 29, 2012.
4. The Coalition of Geriatric Nursing Organizations. Hartford Institute for Geriatric Nursing Website. Published 2008. https://hartfordign.org/advocacy/cgno. Accessed March 16, 2012.
