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a Department of Sociology, University of North Texas, Denton, TX
Correspondence: Dale E. Yeatts, PhD, Department of Sociology, University of North Texas, Denton, TX 76203. E-mail: yeatts{at}scs.cmm.unt.edu.
Decision Editor: Nancy Morrow Howell, ACSW, PhD
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Abstract |
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 TOP Abstract Definition and Rationale for...Identification and Study of...Impacts of SMWTs on...Factors Affecting SMWT...Implementing SMWTs in the...References |
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Key Words: Nursing homes • Long-term care • Employee turnover • Health care • Self-managed work teams • Employee satisfaction
Nursing homes have historically had high levels of turnover, especially among those who work most closely with the residents—the certified nurse's aides (CNAs). Researchers have reported turnover of nursing personnel averaging around 100% and as high as 400%, with CNAs leaving at consistently higher levels than licensed nursing staff (Cohen-Mansfield 1997
; Kettlitz, Zbib, and Motwani 1998; Turkington 1992). The effects of high employee turnover include a reduction in the quality of health care for residents as well as added administrative costs to the nursing home (NH) for recruitment and training of NH staff (Caudill and Patrick 1991–1992; LeKan-Rutledge, Palmer, and Belyea 1998; McAiney 1998). CNAs typically provide 80–90% of the direct care to residents of long-term care facilities (Burgio and Burgio 1990; Pillemer, Hegeman, Albright, & Henderson, 1996; Smyer, Brannon & Cohn, 1994). When the continuity of care is not maintained owing to constant turnover, there is less likelihood that the staff are aware of the many needs and preferences of the NH residents. This negatively affects the residents' health care. At the same time, high turnover rates also result in increased costs for recruitment and training. One study found that facilities can pay over $2,200 to replace one CNA (Cohen-Mansfield 1997).
Binstock and Spector 1997 recently conducted an in-depth study funded by the Agency for Health Care Policy and Research to identify the five highest priority areas for long-term care. One of the five areas they identified was a lack of knowledge about effective management strategies for improving NH quality. An examination of management practices currently used in NHs finds that they are typically very traditional, with a clear hierarchical structure and chain of command. Thomas 1994, in his assessment of NH management, has noted that nursing homes have inherited a style of management practice that essentially differs little from that of an "Army regiment." He has noted that NHs often try to promote warm, nurturing bonds between staff and residents while maintaining a paramilitary command structure and that although this can be done, it will never be done well. Tightly restricting the workers' daily routine with rules and regulations can be expected to spill over to the treatment of residents. Less-than-effective management practices that have negative impacts on employee morale and satisfaction can be expected to result in high turnover and, subsequently, reduced quality of health care (Caudill and Patrick 1991–1992; McAiney 1998; Robertson & Cummings, 1996).
One approach to managing staff that has been found to have positive effects on staff turnover and work performance is the use of self-managed work teams (SMWTs). In this article, we define and provide the rationale for SMWTs, examine major factors found to affect their performance, and describe steps that can be taken to implement SMWTs.
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Definition and Rationale for SMWTs |
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TOPAbstractDefinition and Rationale for...Identification and Study of...Impacts of SMWTs on...Factors Affecting SMWT...Implementing SMWTs in the...References |
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; Johnson and Johnson 1994; Wellins, Byham, and Wilson 1991). SMWTs were originally introduced into manufacturing settings to address a variety of workplace issues, including employee performance, satisfaction, and turnover. They have since begun to be used in other settings, such as public agencies (Yeatts and Schulz 1998) and health care settings (Becker-Reems 1994).
The self-managed work team is uniquely different from the interdisciplinary work team. Unlike SMWTs, interdisciplinary work teams have been growing steadily within the NH environment. The interdisciplinary work team in the NH setting (referred to as a task team in the manufacturing setting) is typically made up of a small group of professionals from differing disciplines (e.g., physician, nurse, and social worker) who come together to address a specific task such as a resident care plan (Siegler, Hyer, Fulmer, and Mezey 1998). This may be their only reason for meeting. Once the task is complete, the team disbands until another task arises. In contrast, the members making up an SMWT work together daily, depend on each other to get their work done, and routinely make management decisions related to their work.
The establishment of SMWTs in a NH environment can take a variety of forms. For example, an SMWT might consist of a group of CNAs responsible for serving a specific group of NH residents (e.g., residents living on one wing of a NH facility). These CNAs would work as a team and make management decisions related to their team. Such decisions might address who would care for which residents on a given day, when to bathe residents during the day, and who would work or not work on Christmas Day. These are decisions that may have previously been made by their supervisor—typically a registered nurse (RN) or licensed practical nurse (LPN; also referred to as licensed vocational nurse). This subsequently frees up a portion of the RN's and LPN's time to be devoted to other activities. An SMWT can work closely with other SMWTs and, where one team follows or precedes another team on a work shift, the teams can develop information-sharing and coordination activities that can enhance the provision of health care to their shared residents. Of course, some decisions must be left to the team's RN or others as specified by state and federal regulations. But even in these cases, a highly supportive team would provide assistance to the RN or others so that the best decisions would be made.
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Identification and Study of SMWTs in a NH Setting |
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After this initial data collection, three SMWTs were selected for in-depth study. The NH administrator and director of nursing assisted in identifying one SMWT that was performing at a particularly high level and a second that was performing at a particularly low level. Performance was considered to be high where the administrator and director of nursing perceived the NH residents served by the team to be receiving a relatively high level of care. These perceptions were based on the director's assessment of the residents. Both the high-performing team and the low-performing team consisted of three CNAs. Both teams were supervised by an RN and were responsible for caring for approximately 30 residents, and all team members and RNs were female. The teams were expected to make decisions such as who would serve which residents, the procedure that would be followed in serving the residents, and who would get off on major holidays.
The third team was a management SMWT for the facility and consisted of eight members: the NH administrator; the directors of nursing, social work, and mental health; the assistant directors of nursing and social work; and the managers of grounds and dietary. All three teams were observed performing their responsibilities multiple times as well as observed during team meetings. Each team member in the three teams, as well as the teams' supervisors, were interviewed in person, with each interview lasting roughly 1 h (17 employees total).
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Impacts of SMWTs on Turnover and Health Care |
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TOPAbstractDefinition and Rationale for...Identification and Study of...Impacts of SMWTs on...Factors Affecting SMWT...Implementing SMWTs in the...References |
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; Hitchcock and Willard 1995; Orsburn, Moran, Musselwhite, Zenger, and Perrin 1990; Wellins, Byham, and Dixon 1994). Further, case studies have shown that the decisions made by SMWTs can be extremely effective because those making the decisions—the team members—are the persons most knowledgeable about the work (Buchholz, Roth, and Hess 1987; Ray and Bronstein 1995). A comparison of the high- and low-performing CNA teams supported this earlier work, although more rigorous study is needed to confirm or refute these initial findings. Members of the high-performing team were deciding who would serve which residents and what specific services the residents should be provided. The information they used for making these decisions came directly from their experiences working with the residents as well as from the RN/supervisor. On the other hand, members of the low-performing team were given much less opportunity to make such decisions. The supervising RN was found to make decisions for the team without consulting team members and subsequently without taking advantage of the added knowledge the CNAs could bring to the decision-making process.
SMWTs have also been found to reduce employee turnover because job satisfaction increases (Bullock, Friday, and Belcher 1997; Hitchcock and Willard 1995; Lawler 1992; Wellins et al. 1991). Dawes 1981(p. 272), in her discussion of empowering CNAs, has noted that "the opportunity to participate in a team approach almost automatically will confer upon the aide a new dignity and will formalize respect for her and her work in a way that speaks much louder than words." Again, the data collected provided initial support for these previous studies. In-person interviews found that the team members of the high-performing team had a much higher job satisfaction level. This appeared to be the result of their higher involvement in decision making and higher level of team cohesion and cooperation. Relatively high job satisfaction, in turn, appeared to be related to reduced turnover, with the turnover rate of the high-performing team much lower than that of the low-performing team. Further, it is interesting to note that the annual turnover rate for the whole nursing home was roughly 20%, which is far below the reported national average for NHs (Cohen-Mansfield 1997; Kettlitz, et al. 1998). The NH administrator attributed this low rate in part to the higher overall job satisfaction that had been achieved through the use of SMWTs.
In sum, a comparison of the case studies suggests that SMWTs in the NH environment may have positive effects. The service to residents appeared to be positively affected when team members were able to discuss resident desires and needs among themselves and to easily communicate these to their supervisors. Team members of the high-performing SMWT reported that the ability to participate in the decisions related to their work greatly increased their job satisfaction and desire to come to work. However, on a more cautious note, additional rigorous testing is needed to substantiate or refute these initial conclusions.
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Factors Affecting SMWT Performance in the NH Setting |
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, who has examined those factors that enhance SMWT performance within hospital settings. A second exception is the work of Neuhaus 1990; however, this latter work has focused more on work teams in general rather than SMWTs.
The work of Becker-Reems and Neuhaus, along with that of others (Campion, Medsker, and Higgs 1993; Cohen 1994; Gladstein 1984; Hackman 1988; Pearce and Ravlin 1987; Salas, Dickinson, Converse, and Tannenbaum 1992; Tannenbaum, Beard, and Salas 1992; Yeatts and Hyten 1998), has suggested a variety of factors important to SMWT performance, including management support, interpersonal processes, and decision-making methods and processes. Each of these appeared to be important to the SMWTs examined in the NH setting.
Management Support
Previous research has found that management support is crucial to the success of the SMWT (Parker and Price 1994; Sims and Lorenzi 1992; Yeatts and Hyten 1998). It has been reported that the single most influential support provided by management is the unspoken message that it is the team that holds primary responsibility for monitoring its performance and that the manager can be counted on to help the team whenever possible. Of course, this does not mean that the manager never monitors the team's performance. However, it clarifies for the team that it is up to the team members to see that the work gets done and done well.
In the NH environment, interviews and observations showed that the RNs/supervisors of the high- and low-performing teams supported the teams very differently. The RN of the high-performing team turned over most of the day-to-day decision making to the team. Further, she was willing to help the CNAs with their tasks whenever help was needed. In-depth discussions with the CNAs suggested that the participation in decision making by the team members enhanced their self-image, their self-confidence, and their desire to continue in their current jobs and appeared to result in more positive interactions between team members and with the residents they served. On the other hand, the RN of the low-performing team seemed to typically fall back into a traditional role of making the decisions herself and telling the CNAs what they were to do. Not surprisingly, the CNAs in this team did not show the same high level of job satisfaction and enthusiasm for their work.
An examination of the third SMWT (made up of the NH's managers) found that the NH administrator acted more as the team leader than the team manager. She routinely took the role of discussion facilitator, encouraging different views and prompting the team members to weigh various alternatives' strengths and weaknesses. This again appeared to have positive effects on the team members and appeared to allow for more different ideas to be considered than when a single individual makes the decisions with little or no input from the rest of the team.
The Decision-Making Methods and Processes
A decision-making method refers to the sequence of steps (or lack of steps) that a team follows before making a decision. The decision-making process refers to the means by which the team selects a choice once the decision-making method has been completed, such as the use of consensus and majority vote. In the low-performing SMWT there was almost no decision-making at the team level, with decisions being made by the RN. As the RN described it, "The main difference between before and now is that now I provide explanations of what's happening, why decisions are being made."
In the high-performing SMWT, all three CNAs were typically involved in decision making. To make a decision, they typically followed a sequence of steps including (a) the considerations of several alternatives; (b) weighing the pros and cons of each; and (c) selecting the best one. This usually occurred at the beginning of a shift and during the day at impromptu meetings when a decision needed to be made. Observations of these meetings showed that team members held a high level of respect for one another and one another's viewpoints. They listened to one another and did not appear afraid to disagree when they held a different view. The result of their participation in decision making appeared to be heightened self-esteem, more involvement in the day-to-day decisions related to their work, cohesion among members, and job satisfaction.
One issue of concern that has been reported in previous studies is the time-consuming nature of team meetings. Observations showed that impromptu meetings occurred very efficiently and in a timely manner. For example, when deciding how to address a desire/need of a resident that had become apparent, the CNAs typically had a "stand-up" meeting where they clarified the issue, considered the pros and cons to various alternatives, and then selected a solution, all within roughly 5 min. If more time was needed, the team members deferred making a decision until more time could be applied to the problem (such as revisiting the issue during a slower part of the work day).
In the management SMWT, much more time was typically devoted to the decisions made. The typical sequence was the same as that used by the CNA team—clarify the problem, identify all possible solutions, weigh the strengths and weaknesses of each, and then select the best one. However, these procedures often took many days rather than a few minutes. All the team members were involved, and the administrator typically did not express a view but instead facilitated the team's consideration of the pros and cons of each. Team members showed no concern with voicing an opinion different from that of others and expressed a high respect for others even when they held very different views. In some cases, the administrator asked the team members to write down possible solutions to a problem. These were then grouped together and considered one by one. Each team member appeared to contribute unique information and subsequently enhance the quality of the decisions made.
The decision-making process used by the high-performing SMWT and the management SMWT was typically consensus (i.e., making a team decision that all team members were willing to support and no team member opposed, Yeatts and Hyten 1998). In the case of the low-performing team, the team members were rarely involved in the decisions made.
In the high-performing SMWT, if a consensus could not be reached, the RN typically attempted to help the team achieve consensus and, failing this, made the decision for the team. This process appeared to work well. In the management team, the administrator always sought consensus. If it could not be reached, the administrator typically set aside the issue rather than make a decision that some team members would disagree with. Several members of the management team were unhappy with this process. They expressed a concern that in some cases decisions were never reached and actions were never taken because a consensus could not be reached. They believed this sometimes had negative consequences for the NH.
Interpersonal Processes
Much of the research on work teams has focused on the interpersonal processes that occur within the team (Holt 1990; Johnson and Johnson 1994; McGrath 1964). These include processes such as communication, coordination, conflict, cooperation, and trust. There were clear differences observed between the high- and low-performing teams in this regard. The low-performing team expressed much lower trust and reported lower cohesion between team members, and in some cases team members complained about others on the team or the RN/supervisor. The CNAs expressed more feelings of being on their own and not having the support of their team members. Communication was relatively low as the RN/supervisor did not encourage participation in decision making. This relatively low interpersonal process appeared to be strained further by the inconsistent attendance among the team members and personal problems outside of work that appeared to draw attention and energy away from building interpersonal relationships at work.
An examination of the high-performing team found that two of the CNAs had known each other before working at the nursing home. The three CNAs periodically found time to get together for recreation outside of work, and the RN/supervisor joined them on occasion. This familiarity appeared to build trust. Team members believed that others on the team would look out for their welfare and assist them in time of need. Team members sought and valued approval from one another and attempted to obtain approval by performing high-quality work and assisting others on the team. A similar high level of interpersonal processes appeared to exist within the management SMWT. Team members highly respected one another and sought their approval by performing their work at a high level, even when this meant working overtime without additional pay. Unlike the low-performing team, a majority of the management team members had worked together for several years and spent considerable time outside of work enjoying each other's company.
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Implementing SMWTs in the NH Environment |
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TOPAbstractDefinition and Rationale for...Identification and Study of...Impacts of SMWTs on...Factors Affecting SMWT...Implementing SMWTs in the...References |
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; Orsburn et al. 1990), as well as our own experiences, have suggested that implementing high-performing SMWTs is not easy. In the traditional NH environment, those making management decisions do not typically share their authority. Interpersonal relationships between RNs, LPNs, and CNAs are authoritarian in nature and frequently adversarial. These conditions do not lend themselves to an easy transition to a teamwork environment, where team members are happy to assist one another and everyone's opinions are valued and considered before decisions are made.
Research has clearly demonstrated that training is a key component to an effective transition (Becker-Reems 1994; Yeatts and Hyten 1998). When it is combined with ample and knowledgeable coaching and facilitating, the culture of the organization can be changed. Ample here refers to regular and even daily coaching of team members to help them recognize when they have slipped back into the old way of thinking and doing. Knowledgeable refers to the coach's understanding of how team members must think and behave in order to create the environment and team culture desired.
When implementing SMWTs, the first step that should be taken is for the administrator and top management (e.g., the director of nursing) to become more educated on the advantages of SMWTs and what it takes to make them effective (helpful publications include Becker-Reems 1994; Larson and LaFasto 1989; Thomas 1994; Yeatts and Hyten 1998). It is helpful to visit other facilities that have implemented SMWTs and look at how they are organized and function, how they were implemented, and what hurdles had to be overcome before positive results emerged.
The next step is to begin feeding information about the positive impacts of SMWTs to all of the facility's staff. This information should include how SMWTs are organized and how they operate day to day. A steering committee should then be organized—made up of the administrator, director of nursing, other directors, and persons who can represent the facility's RNs, LPNs, and CNAs. The steering committee would, after a thorough education, begin to determine how the SMWTs should be organized and function within their facility. Simultaneously, a person (or persons) in the facility should be singled out to become the leader or "champion" for SMWTs. This person would receive intensive education on the topic, attend seminars and conferences, and visit other organizations that have implemented SMWTs. The facility's team champion would be responsible for initially educating the steering committee about SMWTs and later being directly involved in training staff—that is, helping them to see the advantages of SMWTs and to understand the first (or next) steps that must be followed to allow for their successful implementation. The success of the SMWTs will depend on the level of attention that each team receives. Some may need little and be found to already operate much like an SMWT. However, many may need almost daily attention, through facilitation and coaching, to successfully transition to an effective SMWT.
Received for publication June 2, 1999. Accepted for publication December 2, 1999.
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This article has been cited by other articles:
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  D. E. Yeatts and C. M. Cready Consequences of Empowered CNA Teams in Nursing Home Settings: A Longitudinal Assessment Gerontologist, June 1, 2007; 47(3): 323 - 339. [Abstract] [Full Text] [PDF]
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J. Rabig, W. Thomas, R. A. Kane, L. J. Cutler, and S. McAlilly Radical redesign of nursing homes: applying the green house concept in tupelo, Mississippi. Gerontologist, August 1, 2006; 46(4): 533 - 539. [Abstract] [Full Text] [PDF]
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D. E. Yeatts, C. Cready, B. Ray, A. DeWitt, and C. Queen Self-Managed Work Teams in Nursing Homes: Implementing and Empowering Nurse Aide Teams Gerontologist, April 1, 2004; 44(2): 256 - 261. [Abstract] [Full Text] [PDF]
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