the importance of organizational climate to training needs...

109The Importance of Organizational Climate

The Importance ofOrganizational Climate

to Training Needs and Outcomes in Long-term Care

Training to improve the capacity of long-term carestaff to provide quality dementia care occurs withthe organizational context, which ultimately

shapes whether and how training content is integrated intoorganizational care processes and practices.1,2 Greenhalghet al3 apply Roger’s theory of the diffusion of innovationsto health services organizations,demonstrating how multi-ple dimensions of the organization affect the uptake anduse of new care practices. These dimensions range fromstructural characteristics, such as facility size or ownershiparrangement, to the absorptive capacity of the organiza-tion, which is the ability of it members to assimilate new

knowledge (eg, educational level of staff, the rate of staffturnover) and its members’ readiness for change in howcare is currently provided.

While multiple characteristics of the organization havethe potential to shape training,we can conceptualize thesecharacteristics within 2 broad domains. The first domainincludes the set of characteristics that are less amenable tochange by management at the local level. Examples mightinclude whether or not the organization is licensed as aresidential care/assisted living (RC/AL) setting or as a nurs-ing home (NH),or the mix of registered or licensed practical

RESEARCH

Efforts to improve dementia care through training occur in an organizational context that may enhanceor inhibit improvement. This article used linear mixed models to examine the relationship of contextualand organizational factors to baseline knowledge, work stress, and training outcomes of a dementia caretraining program. Data from staff (N � 678) in 16 long-term care settings indicate that such factorsrelated to both baseline training needs and training effects over time. On the basis of these findings,long-term care administrators are advised to consider the administrative climate, communication patterns,and the perceived need for training before implementing a training program.

Key words: assisted living, communication, management practices, nursing homes, staff trainingprograms

BY KIRSTEN N. CORAZZINI, PHD; ELEANOR S. MCCONNELL, PHD, RN, APRN, GCNS, BC; RUTH A. ANDERSON, PHD, RN, FAAN; DAVID REED, PHD; MARY T. CHAMPAGNE, PHD, RN, FAAN;

DEBORAH LEKAN, RN, MSN; JOHN S. PREISSER, PHD; DONALD BAILEY, PHD, RN; SHERYL ZIMMERMAN, PHD

Alzheimer’s Care Today 2010; 11(2):109–121

nurses relative to assistive personnel. These factors havebeen identified in prior research as having the potential toshape if and how dementia care training affects care practices.2,4 However, facility managers may have little orno control over these decisions, given that more than 50%of US nursing homes are chain owned, which decreasesthe autonomy of local-level administrators or managers.5

Thus, such decisions may be considered part of the facilitycontext that practitioners such as staff developmentnurses must keep in mind, but ultimately may have no au-thority to change.

The second domain includes the set of organizationalcharacteristics that comprise the organizational climate,and which managers at the local level have the ability todirectly shape and influence. Organizational climate is theshared perceptions by staff of management practices andprocesses that influence care practices.6 Therefore,climate has many dimensions,7 including administrativeclimate, leadership climate,tension for change in care prac-

tices, and communication patterns among administratorsand staff.Because these perceptions result from the qualityof relationships that staff members have with one anotherand with the administration, managers and supervisorshave the ability to directly affect and shape organizationalclimate. For example, including the value of dementia carein the agency’s mission and goals, and developing an em-ployee recognition program for staff members whodemonstrate exceptional dementia care skills, changesmanagement practices by making clear the expectationsfor outstanding dementia care.This change has the poten-tial to improve the relationships between staff and man-agers, as employees now are rewarded for qualitydementia care.As a result, the way in which staff membersintegrate dementia care training into their dementia carepractices will look very different in this new organiza-tional climate.

Dimensions of organizational climate,such as administra-tive climate, leadership climate, tension for change, andcommunication, have been related to aspects of organiza-tional performance. Administrative climate, as defined bySheridan et al,8 includes the following 4 key dimensions:(1) human relations, where management practices andpolicies are perceived as demonstrating a clear commit-ment to employee well-being and to good staff relation-ships; (2) laissez-faire policies and practices, wheremanagement policies and practices do not set forth clearexpectations or standards, and employee rewards and re-source allocation are not on the basis of consistent objec-tives; (3) status orientation, where status differencesemphasize a hierarchy and foster conflict; and (4) task ori-entation, where clear expectations are matched with re-wards based on individual performance. Administrativeclimate has been related to long-term care facility perform-ance such as whether or not a nursing facility loses certifi-cation to provide care8 and nursing staff turnover rates.6

Leadership climate is the shared perceptions by staff ofthe policies and behaviors of agency leaders and has beenmeasured in a variety of ways, both qualitatively and quantitatively.9,10 Leadership climate commonly has beenincluded as a subscale in measures of organizational climatein healthcare settings11; it is related to long-term care facil-ity resident outcomes and staff welfare.9,10 Tension forchange is shared perceptions among management and staffthat there is a need for additional training or programmingto address a particular care need.12 Tension for change hasbeen examined extensively in the human services sector inrelation to the effectiveness of programming for substanceabuse treatment,12 but has been relatively absent fromlong-term care research.Finally,communication patterns of

Alzheimer ’s Care Today | Apri l–June 2010110

Including the value of dementia care in

the agency’s mission and goals, and

developing an employee recognition

program for staff members who demon-

strate exceptional dementia care skills,

changes management practices by mak-

ing clear the expectations for outstanding

dementia care.This change has the poten-

tial to improve the relationships between

staff and managers, as employees now

are rewarded for quality dementia care.

As a result, the way in which staff mem-

bers integrate dementia care training

into their dementia care practices will

look very different in this new organiza-

tional climate.

111

staff, including the extent to which communication is per-ceived as open and accessible to all staff,13 whether sharedinformation is accurate,13 and whether information isshared in a timely manner,14 have been related to staffturnover in nursing facilities, as well as quality-of-care outcomes.6,9

Organizational climate emerges from the quality of therelationships of staff members with one another and withagency managers and administrators.6 Managers and ad-ministrators shape these relationships, in part, throughtheir management practices, policies, and procedures. Be-cause components of the organizational climate relate tothe uptake and integration of new care practices,managersand administrators have the ability to directly influence theoutcome of training programs through their managementpractices.The purpose of this article is to explore 4 aspectsof the organizational climate, including administrative cli-mate, leadership, tension for change, and communicationpatterns, and their associations with knowledge and workstress outcomes of the Foundations of Dementia Care(FDC) Training Program.15 Describing the relationships be-tween organizational climate and outcomes of the trainingwill facilitate managers and administrators in developingtools and strategies for improving the outcomes of this andother training programs and ensuring that staff knowledgeincreases and dementia care improves.

METHODS

Sample setting and design

Nurses and direct care staff members who participated inthe FDC evaluation program provided data for the study (N � 678); staff members were employed in 16 long-termcare facilities comprising 7 RC/AL settings and 9 NHs.All set-tings received the FDC program;half of the facilities receivedthe training first and the second half of the facilities receivedthe training following a 3-month lag corresponding to end ofthe posttraining data collection at the other sites.For the pur-pose of these analyses,data were pooled across all 16 sites.

Table 1 presents demographic characteristics of thesample, including both staff-level and setting-level charac-teristics.The majority of staff members were female (97%),functioning as unlicensed assistive personnel in nonsuper-visory roles (73%), consistent with long-term care facilitystaffing structures. Almost half of staff members (47%)were members of a racial and/or ethnic minority group.The mean age of staff members was 40 years and the staffhad been working an average of 4.3 years in the facility atthe start of the training program.

Participating facilities included for-profit, nonprofit, andgovernment-owned facilities, with 50% of facilities report-ing for-profit status.The average facility size was 211 beds.Facilities had been in operation for an average of4 decades, with an administrator who had been in the po-sition for an average of 6 years.The mean turnover rate forstaff was 35% over a 6-month period,ranging from facilitieswith very little staff turnover (4%) to one facility with

The Importance of Organizational Climate

Sample Characteristics (N � 678 StaffMembers, 16 Settings)

N (%) or Mean (SD)

Staff characteristicsFemale 655 (96.6%)Race/ethnicity

African American or black 318 (46.9%)White 344 (50.7%)Other 16 (2.4%)

Hispanic (not mutually exclusive) 4 (0.6%)Licensure/certification

None 35 (3.6%)RN 42 (6.2%)Licensed practical nurse 105 (15.5%)Medical assistive 139 (20.5%)

personnel/technicianCertified nursing assistant/ 357 (52.7%)

personal care assistantSupervisor 173 (25.5%)Age (y) 40.0 (13.1)Tenure in facility (y) 4.3 (5.7)

Setting characteristicsOwnership

For-profit 8.0 (50%)Nonprofit 7.0 (44%)

Government 1.0 (6%)Total number of beds 210.8 (221.7)Years in operation 39.9 (36.0)Administrator tenure 5.7 (5.1)Turnover rate (No. left in 35.1% (34.4)

6 mo/No. current) � 100Percentage of staff who are RNs 5.7% (5.3)

(full and part time)Percentage of staff who are 84.0% (12.1)

full timePercentage of residents who 55.0% (18.5)

have dementia

Abbreviation: RN, registered nurse.

TABLE 1.

widespread turnover (147%); facilities had proportionatelyfew professional nurses on staff (6%), largely relying on li-censed practical nurses and unlicensed assistive personnelto provide care. Dementia case mix was variable, rangingfrom 16% to 82% of residents reported as having dementia.

Measures

Measures are summarized in Table 2. Facility contextualvariables were operationalized as staff sociodemographiccharacteristics and facility structural and staffing charac-teristics. Staff sociodemographic characteristics included

whether or not the staff member self-identified as a super-visor, staff age, whether or not the staff member is of eth-nic minority status, and staff tenure in the facility. Facilitystructural and staffing characteristics included whetherthe facility is a NH or an RC/AL setting, how long the set-ting has been in operation under current ownership, therate of staff turnover in the 6 months prior to the start ofthe training program, the percentage of staff memberswho are registered nurses, and how long the current ad-ministrator has been in his/her position.

Organizational climate was operationalized as administra-tive climate, leadership climate, tension for change, and


Key Variables and Their Measurement (N � 678 Staff Members, 16 Settings)

Variable How Measured N (%) or Mean (SD)

Dimension of facility contextStaff type, supervisor Whether or not the staff member self-identified 173 (25.5%)

as a supervisorStaff age Age of staff member in years 40.0 (13.1)Staff minority status Whether or not the staff member is a member of a 334 (49.3%)

racial and/or ethnic minorityStaff tenure Length of staff employment at facility in years 4.3 (5.7)Facility type Whether or not the facility is a skilled nursing facility 9 (56.3%)

relative to a residential care/assisted living settingFacility operational tenure Years facility in operation under current ownership 39.9 (36.0)Staff turnover Rate of staff turnover in last 6 mo 35.1% (34.4)Professional nursing staff mix Percentage of nursing staff who are registered nurses 5.7% (5.3)Facility administrator tenure Length of current administrator’s tenure in years 5.7 (5.1)

Dimension of organizational climateAdministrative climate

Status orientation 5-point scale score, possible range 1–5 2.7 (0.7)Task orientation 5-point scale score, possible range 1–5 3.6 (0.6)Laissez-faire orientation 5-point scale score, possible range 1–5 2.6 (0.7)Human relations orientation 5-point scale score, possible range 1–5 3.5 (0.8)

Leadership climate 7-item summary scale score with possible range 7–35 28.1 (5.0)Tension for change Perceived staff training needs; scale score possible 38.1 (7.7)

range 10–50Communication patterns

Openness 5-point scale score, possible range 1–5 3.6 (0.8)Accuracy 5-point scale score, possible range 1–5 3.0 (0.8)Timeliness 5-point scale score, possible range 1–5 3.8 (0.7)

Training outcomes, baseline valuesKnowledge of “Improving Score on “Improving Communication” with residents 3.1 (1.1)

Communication” with dementia, possible range 0–5Knowledge of “Pain Awareness” Score on “Pain Awareness” of pain in residents with 3.3 (1.1)

dementia training, possible range 0–5Work events work stress Work Stress Inventory subscale score, possible range 1–5 2.0 (0.7)

TABLE 2.

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communication patterns. Administrative climate was meas-ured using the administrative climate scale of Sheridan et al,8

which has shown adequate reliability and validity with thispopulation and includes subscales of status, task, laissez-faire,and human relations orientation. Leadership climate wasmeasured using the Baldrige leadership scale,which has beenused extensively for organizational self-diagnosis of staff per-ceptions of leadership.16 It assesses issues such as the degreeto which organizational values guide how care is deliveredand whether leadership encourages employee learning.Ten-sion for change was measured with the Immediate TrainingNeeds subscale of the Organizational Readiness for Changescale.12 The scale has shown adequate reliability and validityin human services organizations and asks administrators to as-sess the degree to which staff members have training needsin a variety of areas including use of equipment and technol-ogy, procedures and regulations, and supervising and manag-ing other staff members. Communication patterns wereoperationalized as communication openness, accuracy, andtimeliness and were measured using openness and accuracyscales of Roberts and O’Reilly,13 and timeliness scales ofShortell et al,14 all of which have demonstrated validity andreliability in long-term care settings.

Outcomes of the FDC program included improvedknowledge in 2 of 6 areas—improving communication(immediately posttraining and 3 months later) and painawareness (immediately posttraining)—as well as in-creased work stress related to work events measured at3 months,as described elsewhere.15 Knowledge assessmentscales were developed by the FDC program evaluation re-search team.15 Work stress related to work events wasmeasured using the work events subscale of a modifiedSchafer and Moos work stress inventory that has demon-strated reliability and validity with this population.17

Analysis

The analysis explored the relationship of the 3 outcomes ofthe FDC (knowledge related to improving communicationand pain awareness, and work events work stress), with fa-cility context and organizational climate at both the indi-vidual staff member and facility levels. Specifically, linearmixed models measured the relationship between organi-zational climate and previously identified significant rela-tionships15 between the FDC and training outcomes ofknowledge and work stress, controlling for facility context.Linear mixed models were used to account for the nestingor clustering of staff members within the 16 settings,and toaccount for the repeated measures of staff members overtime,including pretraining,immediately posttraining,and at

3-month follow-up.Specifically, linear mixed models appro-priately estimate statistical significance both in relation tothe nested nature of the data and for repeated measures,even if data are not provided by a respondent at all data col-lection periods. Linear mixed model analyses were carriedout using PROC MIXED in SAS software, version 9.1.Descriptive statistics were generated with SPSS,version 16.

A procedure called “centering” was used to facilitate theinterpretation of the results.As an illustration of the proce-dure, the individual staff member’s score on the status orien-tation scale was centered by subtracting from it the averagestatus orientation score of all staff member participants inthat facility.Thus, someone who originally had a score equalto the average for all staff participants in a facility would havea score of zero after centering.A person with a below-aver-age score would have a negative score and a person with anabove-average score would have a positive score. Scores forfacilities were calculated in a similar manner.

All facility contextual variables were examined at the bivari-ate level with the 3 sets of outcome measures using Pearsoncorrelational analysis to identify potential predictors for


Optimizing the implementation of de-

mentia care training programs requires

that managers and administrators con-

sider the larger organizational context of

their agencies.While managers have little

or no ability to modify many aspects of

context, organizational climate is a

promising target for management inter-

vention.Management practices and

policies directly affect the quality of the

relationships among staff members. Staff

perceptions of management practices and

policies form the shared organizational

climate within which dementia care

is provided.

inclusion in the mixed models.A reduced set of facility con-textual variables were entered into the mixed models as a setin each of the 3 outcomes models, and a backward stepwisemodeling approach was used to remove nonsignificant facil-ity contextual and organizational climate variables until 3 fi-nal models were estimated.The final models are presented inTables 3 to 5; nonsignificant predictors remain in the modelif their interactive effects are significant.To clarify presenta-tion of findings, the tables summarize the models in relationto the facility contextual and organizational climate variablesonly and do not include predictors kept in the model to fullyspecify the mixed models’ fixed and random effects includ-ing whether or not the staff member was part of the first orsecond group to receive the training program.

RESULTS

Staff knowledge of “Improving Communication”

Both facility context and organizational climate related tostaff knowledge of content covered in the “ImprovingCommunication” component of the FDC (see Table 3). Ofthe 9 aspects of facility context entered into the model,whether the staff member was a supervisor, whether the

staff member was of racial and/or ethnic minority status,and the years the facility had been in operation under cur-rent ownership, were all related to knowledge of “Improv-ing Communication.” Staff members who self-identified assupervisors had greater knowledge at baseline relative toother staff members, whereas staff members who were ofracial minority status had less knowledge at baseline rela-tive to other staff members. Other staff characteristics, in-cluding age and tenure, were not significant.The numberof years that a facility had been in operation related to theamount of knowledge change in “Improving Communica-tion” immediately after training, such that staff in facilitiesthat had been in operation longer showed less increase inknowledge relative to others. No other facility characteris-tics, such as turnover, or staff mix, were significant.

Of the 4 aspects of organizational climate measured, in-cluding administrative climate, leadership climate, tensionfor change, and communication patterns, only administra-tive climate was related to knowledge in “Improving Com-munication.” Specifically, a task orientation administrativeclimate and a laissez-faire administrative climate related tobaseline knowledge of “Improving Communication.” Thegreater the degree to which staff members perceived thereto be task-oriented or laissez-faire climates in their


Relationship of Facility Context and Organizational Climate to Staff Knowledge of ImprovingCommunication in the Foundations of Dementia Care program (N � 678 Staff Members)

Relationship to Staff Members’ Knowledge of “Improving Communication” From Baseline Through 3-Month Follow-up

Predictor Estimate F df P

Intercept 3.46 … … …Time

Immediately posttraining 1.29 69.2 13 �.00013 mo posttraining 0.30 7.60 13 .02

Dimension of facility contextStaff type at baseline 0.44 30.5 1191 �.0001Staff minority status at baseline �0.48 32.5 1191 �.0001Facility operational tenure at baseline �0.002 0.97 12 .34Facility operational tenure immediately �0.01 6.88 13 .02

posttrainingDimension of organizational climate

Task-oriented administrative climate �0.47 37.8 1191 �.0001at baseline

Laissez-faire administrative climate �0.42 43.9 1191 �.0001at baseline

TABLE 3.

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agencies, the less their baseline communication knowl-edge compared to others.

Staff knowledge of “Pain Awareness”

Facility context related to staff knowledge in “Pain Aware-ness.” Of the staff characteristics measured, whether thestaff member was a supervisor,and whether the staff mem-ber was of racial and/or ethnic minority status,was relatedto baseline knowledge of “Pain Awareness.” Supervisorshad more baseline knowledge, and staff of racial and/orethnic minority status had less baseline knowledge.Thesefindings are similar to what we found for staff knowledgeof “Improving Communication.” None of the other staffcharacteristics were related to baseline knowledge of “PainAwareness.” However, age of the staff member was relatedto knowledge posttraining. Older staff showed less in-crease in knowledge of “Pain Awareness” immediately aftertraining relative to others.

Of the organizational climate measures, only administra-tive climate was related to knowledge in “Pain Awareness.”Both a human relations organizational climate and a lais-sez-faire administrative climate were related to baselineknowledge of “Pain Awareness.”The greater the degree towhich staff members perceived there to be human rela-tions or laissez-faire climates in their agencies, the less

their baseline “Pain Awareness” knowledge compared toothers.

Staff work stress

Facility context related to work stress. Specifically, supervi-sors perceived more work stress at baseline relative toother staff members, and older staff members perceivedless stress at baseline. No other measures of facility con-text, including other staff characteristics and facility char-acteristics, related to work stress.

Organizational climate related to work stress both atbaseline and posttraining. Of the dimensions of climatemeasured, administrative climate and communication re-lated to work stress. At baseline, staff members who per-ceived more of a status-oriented administrative climatereported higher work stress. By contrast, staff memberswho perceived more of a human relations administrativeclimate had less baseline work stress. Further, staff mem-bers who perceived more accurate and timely communi-cation patterns reported less baseline work stress.Importantly, the relationship between human relations cli-mate on stress changed direction following the trainingprogram; at 3 months posttraining, more of a human rela-tions climate related to increased stress.Tension for changealso related to more stress at the 3-month follow-up, such


Relationship of Facility Context and Organizational Climate to Staff Knowledge of PainAwareness in the Foundations of Dementia Care Program (N � 678 Staff Members)

Relationship to Staff Members’ Knowledge of “Pain Awareness” From Baseline Through 3-Month Follow-up



Immediately posttraining 0.75 20.9 13 �.001Dimension of facility context

Staff type at baseline 0.62 41.9 1172 �.0001Staff minority status at baseline �0.45 30.0 1172 �.0001Average age of staff members at baseline 0.02 1.07 11 0.32Average age of staff members immediately �0.07 6.37 13 0.02

posttrainingDimension of organizational climate

Human relations–oriented administrative �0.24 15.3 1172 �.0001climate at baseline

Laissez-faire administrative climate at baseline �0.35 25.2 1172 �.0001

TABLE 4.

that staff members in settings where administrators re-ported higher training needs had higher work stress post-training.

DISCUSSION

Optimizing the implementation of dementia care trainingprograms requires that managers and administrators con-sider the larger organizational context of their agencies.While managers have little or no ability to modify many as-pects of context, organizational climate is a promising tar-get for management intervention. Management practicesand policies directly affect the quality of the relationshipsamong staff members. Staff perceptions of managementpractices and policies form the shared organizational cli-mate within which dementia care is provided.This studylooked at 3 outcomes of a dementia care training program,including knowledge of communication, knowledge ofpain, and work stress, and related these outcomes to as-pects of agency context, including organizational climate.The findings highlight specific dimensions of climate that

are related to training outcomes; managers and administra-tors can use these findings to develop strategies for assess-ing their agencies before implementing training tomaximize uptake.These findings, implications, and strate-gies are summarized in Table 6.

Administrative climate relates to baseline staff knowl-edge, particularly administrative climates that staff per-ceive as having a laissez-faire, human relations, or taskorientation.The laissez-faire climate was related to lowerbaseline knowledge in both communication and painawareness. Staff members in the laissez-faire climate per-ceive a lack of clear expectations or standards and believestaff recognition is not closely linked to organizationalgoals. Because such a climate recognizes promoting staffon the basis of status or position, rather than actual clinicalexpertise or care provided, this climate is unlikely to sup-port and encourage learning about evidence-based de-mentia care knowledge. Managers in these higherlaissez-faire climates should be encouraged, therefore, tolink staff knowledge and performance to rewards and in-centives. Examples might include creating dementia care


Relationship of Facility Context and Organizational Climate to Staff Perceived Work EventsWork Stress (N � 678 Staff Members)

Relationship to Staff Members’ Perceived Work Events Stress From Baseline Through 3-Month Follow-up



3 mo posttraining 0.17 29.54 13 �.001Dimension of facility context

Staff type at baseline 0.30 31.4 972 �.0001Staff age at baseline �0.01 16.1 972 �.0001

Dimension of organizational climateStatus-oriented administrative 0.12 6.85 972 .009

climate at baselineHuman relations–oriented administrative �0.16 13.9 972 �.001

climate at baselineHuman relations–oriented administrative 0.18 16.65 972 �.0001

climate at 3 mo posttrainingAccuracy of communication at baseline �0.12 13.3 972 �.001Timeliness of communication at baseline �0.11 5.85 972 .02Tension for change—training need �0.002 1.95 12 .19

at baselineTension for change—training need 0.02 13.5 13 .003

at 3 mo posttraining

TABLE 5.

117The Importance of Organizational Climate

Overview of Organizational Climate Findings and Management Implications

Aspect of Findings: Relationship With Implications and Organizational Climate What It Means Training Outcome Strategies

TABLE 6.

Laissez-faire oriented administrative climate

Human relations–oriented administra-tive climate

Task-oriented administrative climate

Status-oriented administrative climate

Accuracy of communication

The extent to which administrative policiesand procedures may beunclear, or there maybe inadequateresources to do the jobor few incentives to doa good job

The extent to which administrative policiesand procedures showconcern for employeewelfare and fostergood staff relations

The extent to which staff job responsibilitiesregarding resident careare clear and linked tostaff recognition programs

The extent to which administration empha-sizes status differences;rewards are statusbased, rather thanmerit based

The extent to which staff members exchangeaccurate information,including accurateinformation aboutresidents

The more laissez-faire the climate:

• Less staff knowledgeabout “ImprovingCommunication” con-tent at start of trainingprogram

• Less staff knowledgeabout “Pain Aware-ness” content at startof training program

The more human relations the climate:

• Less staff knowledgeabout “Pain Aware-ness” content at startof training program

• Less staff-reportedwork stress at start oftraining program

• More staff-reportedwork stress at 3 moposttraining

The more task oriented the climate:

• Less staff knowledgeabout “ImprovingCommunication” con-tent at start of trainingprogram

The more status oriented the climate:

• More staff-reportedwork stress at start oftraining program

The more accurate the communication:


• Clarify policies andprocedures in ways thatsupport paying attentionto residents, especiallynonverbal cues.

• Develop rewards orincentives for staff mem-bers who developexpertise in caring forthose with dementia

• Review policies to deter-mine whether expecta-tions for staff competen-cies are sufficient

• Have knowledge expert-ise enhanced alreadystrong, supportive rela-tionships among staff inthe organization

• Encourage staff to lookbeyond what is writtenin their job description tolearn about and providequality dementia care

• Consider adding coredementia competenciesto job descriptions

• Reward staff membersfor what they do ratherthan for their title orposition

• When a staff member isproviding good care,recognize and rewardthat behavior

• Continue supportingthese effective ways ofexchanging informationso that staff membersobtain accurate informa-tion about residents

(continues)

specialist nursing assistant positions, where this special-ized knowledge is recognized with a distinct position andrewarded with higher wages, bonuses, or other benefitsvalued by staff.

Interestingly, both the human relations climate and thetask-oriented climate were related to lower baseline knowl-edge of pain and communication, respectively, perhaps indi-cating that an administrative focus on employee welfare orthe clarity of work tasks does not ensure a focus on evidence-based dementia care practices. Managers in ahigher human relations climate can build on the strengths ofhaving staff members who feel valued by administration toencourage advancement in dementia care knowledge andskills. Such agencies may have tuition reimbursement pro-grams and support flexible scheduling to accommodate em-ployee class schedules. By linking these policies to neededclinical expertise, managers can improve the quality of careprovided. Comparably, in task-oriented climates, managerscan build on staff adherence to job responsibilities and roles,to expand role descriptions that explicitly address core de-mentia care competencies and pathways for achievement.

The relationship of climate to work stress indicates thatmultiple dimensions of the climate may shape staff percep-tions of work stress. Staff members reported lower work

stress at baseline when they perceived that information isshared accurately and in a timely way and that administra-tors hold a high regard for employee welfare (contrastedwith status-oriented administrations). Following the train-ing,however,the effects of climate are more complex.Threemonths posttraining,staff reported higher work stress in set-tings where staff perceived a greater human relations cli-mate and where administrators reported higher trainingneeds (compared to other settings). Staff in these settingsmay have had unmet expectations of the utility and impactof the training.Alternately, it may be that necessary condi-tions for change did not exist. In agencies where administra-tors reported higher training needs, staff may have hadunrealistic expectations that all training needs would be ad-dressed with 1 training program; the program may have ex-acerbated perceptions of need across both administrationand staff levels.Managers in these climates should anticipatethe need to create a long-term vision or “big picture” fortraining and to build on training efforts in order to imple-ment and sustain practice changes. Simultaneously, man-agers should enact strategies that minimize work stress.

Other nonclimate, contextual factors that related totraining outcomes included facility and staff characteris-tics. While managers and administrators do not directly


Overview of Organizational Climate Findings and Management Implications

Aspect of Findings: Relationship With Implications and Organizational Climate What It Means Training Outcome Strategies

TABLE 6. (Continued)

Timeliness of communication

Tension for change—training need

The extent to which staff exchange informationin a timely way andcan anticipate receivingtimely informationabout residents

The extent to which the administrator perceivesa need for staff training

The more timely the communication:


The more the need for training:

• More staff-reportedwork stress at 3 mo posttraining

• Continue supportingthese effective ways ofexchanging informationso staff obtain timelyinformation about resi-dents

• Facilitate changes to theorganizational structurethat make it easier tochange care practices

• When a training need isidentified, do not rely onjust 1 approach ortraining program to meetthe need; rather, considermultiple approaches thatincorporate multiplelearning styles

119

influence these characteristics, they are nonetheless im-portant to note because they identify subsets of facilitiesor staff that may be at increased risk for not achievinglearning goals in training programs.

Facilities that had been in operation longer saw fewergains in knowledge about communication following thetraining.While we know that ownership stability is relatedto better resident quality of care in several ways, includingreducing turnover of direct care workers,10 it is possiblethat with stability comes less openness to learning aboutnew ways of providing resident care. Managers in suchagencies can build on the strengths of stability in owner-ship to foster innovation and continued learning amongstaff members for better care that incorporates newknowledge and new ways of giving care.

Staff members who were not supervisors or who wereof racial and/or ethnic minority status (irrespective of su-pervisory status) had, compared to others, lower baselineknowledge in both communication and pain. Gaps inknowledge related to supervisory status may reflect differ-ences in education and licensure (ie,we might expect thatsupervisors would have been exposed to additional educa-tion in dementia care),but gaps related to race or ethnicityindependent of supervisory status may indicate disparitiesin access to adequate dementia care training. Staff age re-lated to posttraining knowledge, in that agencies with ahigher average (mean) age of staff members saw fewerknowledge gains about pain.These findings highlight theimportance for managers to be aware of potential educa-tion disparities among staff members with regard to theknowledge they bring to the care setting,as well as the po-tential need for different teaching approaches that capital-ize on the strengths and needs of diverse adult learners.Reliance on a single training program or teaching ap-proach may undermine the effectiveness of the training indiverse audiences.

There are several limitations to this study, including howwe measured organizational climate. Specifically, we lim-ited ourselves to a narrow set of 4 aspects of climate, andmeasured these aspects using self-reported, survey instru-ments. Future research in this area should consider abroader, multimethod approach to measuring climate.An-other limitation to the study is how we only explored train-ing outcome measures of work stress and knowledge,rather than actual behavioral changes in providing care.Again, further research in this area should seek to explorethe effects of climate on behavioral change following train-ing. Both of these limitations may explain our failure toidentify significant relationships between leadership cli-mate and training outcomes, and possibly explain the lack

of relationships between other staff members and facilitycontextual factors and outcomes.

By carefully considering organizational climate and facil-ity context, managers implementing dementia care train-ing programs in the future can anticipate potential barriersto training uptake. Knowing this information allows man-agers to begin to implement changes in their practices andpolicies to ensure training success, and to tailor trainingprograms with specific populations or in specific settingsthat may need additional content to ensure that a commonendpoint or training goal is met across agencies. Ulti-mately, these strategies can assist in appropriately targetingscarce training resources and maximizing the likelihood oftraining uptake and application, to improve the quality ofdementia care.


Administrative climate relates to baseline

staff knowledge, particularly administra-

tive climates that staff perceive as having

a laissez-faire, human relations, or task

orientation.The laissez-faire climate was

related to lower baseline knowledge in

both communication and pain aware-

ness. Staff members in the laissez-faire

climate perceive a lack of clear expecta-

tions or standards and believe staff

recognition is not closely linked to organi-

zational goals.Because staff promotions in

such a climate are not linked to clinical

expertise or care provided, this climate is

unlikely to support and encourage

learning about evidence-based dementia

care knowledge.

Kirsten N. Corazzini, PhD, is Assistant Professor, DukeUniversity School of Nursing; and Senior Fellow, DukeUniversity Center for the Study of Aging and Human De-velopment, Durham, North Carolina.

Eleanor S.McConnell, PhD, RN, APRN, GCNS, BC, is Asso-ciate Professor, Duke University School of Nursing;ClinicalNurse Researcher, Durham Veterans Affairs Medical CenterGeriatric Research Education and Clinical Center; and Senior Fellow, Duke University Center for the Study of Ag-ing and Human Development, Durham, North Carolina.

Ruth A.Anderson, PhD, RN, FAAN, is Professor and Se-nior Fellow, Duke University Center for the Study of Ag-ing and Human Development, Durham, North Carolina.

David Reed, PhD, is a Senior Analyst, Program on Ag-ing, Disability, and Long-Term Care, Cecil G.Sheps Centerfor Health Services Research, University of North Car-olina at Chapel Hill.

Mary T. Champagne, PhD, RN, FAAN, is Laurel Chad-wick Distinguished Professor, Duke University School ofNursing; Senior Fellow, Center for the Study of Aging andHuman Development; and Professor of Medicine, DukeUniversity, Durham, North Carolina.

Deborah Lekan, RN, MSN, is Clinical Associate, DukeUniversity School of Nursing, Durham, North Carolina.

John S.Preisser, PhD, is Research Professor of Biostatis-tics, UNC Gillings School of Global Public Health;and Fel-low, Cecil G. Sheps Center for Health Services Research,University of North Carolina at Chapel Hill.

Donald Bailey, PhD, RN, is Associate Professor, DukeUniversity School of Nursing; Senior Fellow, Center forthe Study of Aging and Human Development; andClaire M. Fagin Fellow, Durham, North Carolina.

Sheryl Zimmerman, PhD, is Kenan Distinguished Pro-fessor and Director of Aging Research, School of SocialWork; Adjunct Distinguished Professor, School of PublicHealth;and Co-Director, Program on Aging, Disability, andLong-Term Care, Cecil G. Sheps Center for Health ServicesResearch, University of North Carolina at Chapel Hill.

This research was supported by grants from the Duke UniversityTrajectories of Aging and Care in Nursing Science Center (NIH1 P20-NR07795-01), the University of Iowa Geriatric NursingInterventions Research Center (NIH: P30-NR03979), the Univer-sity of Iowa John A. Hartford Center of Geriatric NursingExcellence, and the Alzheimer’s Association Medical and Scien-tific Division (grant IIRG-05-14332).

Address correspondence to: Kirsten N. Corazzini, PhD, DukeUniversity School of Nursing, Box 3322 DUMC, 307 Trent Dr,Durham, NC 27710 ([email protected]).

REFERENCES

1. Beck C, Heacock P, Mercer SO, et al. Sustaining abest-care practice in a nursing home. J HealthcQual. 2005;27(4):5–16.

2. Beeber AS. Challenges and strategies for imple-menting and evaluating dementia care staff trainingin long-term care settings. Alzheimers Care Today.2010;11(2):17–39.

3. Greenhalgh T, Robert G, Macfarlane F, Bate P,Kyriakidou O. Diffusion of innovations in healthservice organizations: systematic review and rec-ommendations. Milbank Q. 2004;82(4):581–629.

4. Beeber AS.Who attends training in long-term care?Understanding staff and facility correlates of atten-dance. Paper presented at: Annual Meeting of theGerontological Society of America; November2009; Atlanta, GA.

5. Kruzick JM. Ownership, chain affiliation, and ad-ministrator decision-making autonomy in long-term care facilities. Adm Soc Work. November2004;29(1):5–24.

6. Anderson RA, Corazzini KN, McDaniel RR Jr. Com-plexity science and the dynamics of climate andcommunication: reducing nursing home turnover.Gerontologist. 2004;44(3):378–388.

7. Neal A, Griffin MA, Hart PM.The impact of organi-zational climate on safety climate and individual be-havior. Saf Sci. 2000;34(1–3):99–109.

8. Sheridan JE,White J,Fairchild TJ. Ineffective staff, in-effective supervision,or ineffective administration?Why some nursing homes fail to provide adequatecare. Gerontologist. 1992;32(3):334–341.

9. Anderson RA, Issel LM, McDaniel RR Jr. Nursinghomes as complex adaptive systems: relationshipbetween management practice and resident out-comes. Nurs Res. 2003;52(1):12–21.

10. Eaton SC.Beyond ‘unloving care’: linking human re-source management and patient care quality innursing homes. Int J Hum Resource Manag.2000;3:591–616.

11. Gershon RR, Stone PW, Bakken S, Larson E. Mea-surement of organizational culture and climatehealthcare. J Nurs Adm. 2004;34(1):33–40.

12. Lehman WE,Greener JM,Simpson DD.Assessing or-ganizational readiness for change. J Subst AbuseTreat. 2002;22(4):197–209.

13. Roberts K, O’Reilly C. Measuring organizationalcommunication. J Appl Psychol. 1974;59:321–326.


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14. Shortell SM, Rousseau DM, Gillies RR, Devers KJ,Simons TL. Organizational assessment in intensivecare units (ICUs): construct development, reliabil-ity, and validity of the ICU nurse-physician ques-tionnaire. Med Care. 1991;29(8):709–726.

15. Zimmerman S,Mitchell CM,Reed D,et al.Outcomesof a dementia care training program for staff in nurs-ing homes and residential care/assisted living set-tings.Alzheimer’s Care Today. 2010;11(2):83–99.

16. National Institute of Standards and Technology, USDepartment of Commerce. Baldrige National Quality Program. http://www.baldrige.nist.gov/.Updated December 7,2009.Accessed December 7,2009.

17. Zimmerman S, Williams CS, Reed PS, et al.Attitudes, stress, and satisfaction of staff who carefor residents with dementia. Gerontologist. 2005;45:96–105.


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