Organizational approach to preferred view

Organizational culture shapes care in our communities. The concept of preferred view, which we looked at in February’s column, p. 16, applies to the organization as a whole, as well as to the individuals both working and living in it. Having a clear sense of the organization’s preferred view, often revealed in the mission and values of the community, can bring out the best in all its members and guide internal organizational alignment and culture change.

In “Using Strengths-Based Practice to Support Culture Change: An Australian Experience,”

1 in the book

Culture Change in Long-Term Care, Peta Slocombe recounts the story of Mary, a caregiver who had entered the field later in life after an experience reading to a vision-impaired elder. Mary was a patient, caring person and she found the pleasure that she took from this job so rewarding she decided to work in the field. However, Mary was experiencing difficulty at work because a woman with Alzheimer’s was taking off her clothes after Mary helped her shower and dress, and the woman’s daughter would visit and think that nobody was taking care of her mother. The daughter complained to management, and Mary’s supervisor responded with more and more constraints on Mary and the frontline staff, requiring increased paperwork and regulation along with adapting a defensive stance. Slocombe recounts: “As the organization attempted to manage the [preferred view] gap and dealt with staff morale issues by increasing regulation and reviewing procedures, staff came to feel more and more despondent and unproductive. They felt that the imposition of these policy changes meant that management saw them as to blame for the complaints or at the very least deficient.” This widened the gap for Mary and many of her coworkers.

The solution here is to regroup and revisit the “positive intentions and resources of the organization” and work to bring them in line with “the staff’s preferences to be caring, flexible, and client-centered.” Implementing top-down or punitive solutions rarely work as they take the focus off the individual’s ability to bring their own strengths-based solutions to the table. The worker gets the message that she is seen as noncompliant, uninformed, rebellious, or uncaring. This widens the gap between how she sees herself (cooperative, caring, and responsive) and the way she is being seen and treated by management.

Professional development as well as problem-solving when a client, resident, or staff member is dissatisfied is most effective when the focus is on reaffirming the positive intentions and viewpoints of both the organization and staff, as opposed to workshops that point out or suggest deficiencies by implying a lack of skill or motivation.

Brainstorming and team-building sessions in which employees identify specific behaviors that express their commitment to the values of the organization are especially helpful. For example, if the organization has pledged to treat everybody with respect, what does this look like? People are generally very good at identifying these behaviors, especially when they are personalized in a golden-rule-type framework.

Christine Mour, Community Leader (formerly titled Administrator) of St. Elizabeth Rehabilitation and Nursing Center in Baltimore, who studied preferred view in the Master’s degree program at the Erickson School, has spent the past five years using organizational preferred view techniques in order to change the model of care from institutional to person-centered at St. Elizabeth. She stresses the importance of honoring the good work people are doing, and have been doing, so that they do not feel criticized or implicated in the need for change. The preferred view of St. Elizabeth did not change, she says, as it has been and will always be a place with caring intentions. The story of the original St. Elizabeth, whose mission was to care for the needy, guides their work, but inspiration to change the way they carry out this vision came from becoming aware of wanting a more person-centered environment. “The worst thing you can do is tell people to change and then they feel like they have been doing it wrong for 30 years,” Mour says. “Acknowledge and celebrate the way you did it and bring people’s gifts and talents to the table to get to the next level.”

At St. Elizabeth, getting to the next level meant an overhaul. Mour says she knew there was a view in the wider community that their organization was “hierarchical and stodgy,” and she was uncomfortable with that. There was a wide gap between how she and her team viewed St. Elizabeth and how it was perceived in the world.

She and her team had a view that “embraced elders as individuals,” and brought each community member’s strengths and preferences to the forefront. Identifying each person’s preferred view and lining it up with the organizational preferred view to bring parallel effectiveness in executing the mission did not come without growing pains. In switching from an institutional to a social model, some positions changed but, working from an honest and sometimes difficult conversation with each person about preferred view, many are happier working at St. Elizabeth than ever before.

Mour tells the story of one of her nurse-managers, a person who had worked at St. Elizabeth before and returned to a position during the culture-change efforts. She was used to being in charge, to informing residents of how they would be cared for. She was comfortable with her place in the hierarchy. But nurse-manager positions were eliminated, Mour recounts, and replaced with laypeople to guide each neighborhood in the new community model. “She will tell you she had to do a lot of soul-searching, to figure out her new role,” Mour says of the nurse, “and now she says it’s the best thing that ever happened because she did not go to nursing school to chase down lost hearing aids.”

The nurse has a new administrative position off the floor and spends half her time working directly with elders and the other half reviewing charts to evaluate outcomes. She has time to really care for individuals and think hard about whether their work together has been effective. She is contributing to the success of St. Elizabeth, and both the organizational and individual preferred view are honored with a very narrow gap.

Smart management retained a valued employee because they made sure to work with her to discover her preferred view and thus her best possible contribution in the post culture-change organization. “She feels she is doing work that she became a nurse to do,” Mour says. And that is the best possible outcome. LTL

Judah L. Ronch, PhD, is the Dean of and professor at the Erickson School, University of Maryland Baltimore County, which offers undergraduate and Master’s degrees in Management of Aging Services as well as online and live Executive Education programs and customized industry training. He can be reached at

JudahRonch@UMBC.edu.

REFERENCES

1. Using Slocombe P. Strengths-Based Practice to Support Culture Change: An Australian Experience. In: Weiner AS, Ronch JL, eds. Culture Change in Long-Term Care. Binghamton, NY:Haworth Press; 2002:307-23.

Long-Term Living 2011 March;60(3):16-18

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