Affirmation of Program Goals
The evaluation has supported the goals of this program. The qualitative and qualitative data affirmed the need for a training program to he lp build the leadership and management capacity of the LVNs in California nursing homes. Previous research has identified the lack of adequate and appropriate supervision of CNAs by charge nurses as a major contributor to staff turnover,
instability in the workforce and ultimately poorer quality of care. This study found that LVNs do not recognize themselves as managers and leaders of their units. They have no formal training in this area and no professional association that helps them to define this role. Most see themselves as floor nurses who are primarily responsible for “passing meds” and helping to ensure resident safety.
The attitude of many RNs toward the LVNs that they are “lesser nurses” further discourages efforts on the part of LVNs to assume any leadership role. While the scope of practice in California does not identify management as a core responsibility of the LVN, most of these nurses do become charge nurses on their units and are responsible for the activities on the floor and CNAs who provide most of the direct care. One of the major successes of this pilot program was the recognition by many of the LVNs that they were leaders and that they had a
responsibility to manage their units, to communicate with and mentor the CNAs and to develop a team approach to service delivery.
Content of the Training
A second lesson learned was the importance of certain aspects of the training program. The information about leadership, particularly the scenarios that highlighted why and how LVNs are (or could be) leaders on their units, provided the “a-ha moment” for a number of the participants. Some were natural leaders who simply had their roles better articulated. Others recognized for the first time the potential to develop their leadership skills and found the training and booster sessions helpful in laying out steps for successful management of the unit.
The module related to the teaching/mentoring role was found to be very effective in providing the LVNs with an overview of the difference between “command and control” supervising and a coaching approach. Through scenarios and interactive role playing, the participants learned how to use “teachable moments” on the floor with CNAs to help the direct care staff better perform hands on care and communication with residents. DSDs in the pilot facilities noted that they observed a number of the LVNs in their facilities coaching CNAs following the training.
A final module, added to the training program after the first booster session, focused on how LVNs can communicate better with upper management. While the initial training primarily addressed communication with CNAs, many of the participants noted that they were more uncomfortable expressing concerns to their DONs and administrators. In response, additional materials were developed, including scenarios and some role playing activities, to help the LVNs formulate and express their concerns to upper management in a way that they could be heard and acknowledged.
Natural Mentors
One assumption in developing this program was that indigenous LVN leaders could help disseminate and sustain the program within each facility. While the pilot was not intended to develop a mentor program, e a number of natural mentors who participated in the program were observed. These LVNs were more vocal in the training and booster sessions, volunteered for role-playing activities and seemed intuitively to understand the teaching/coaching role. In subsequent conversations with the facilities’ leadership teams, they also mentioned the potential
role of these natural leaders in helping to take the training program to other incumbent LVNs as well as newly hired charge nurses. Suggestions for management on how to formally utilize these natural mentors should be considered in future nurse leadership programs.
Lack of Facility-Level Implementation Plan
As was previously highlighted, the project team met with the upper management of each facility to discuss the program’s goals and objectives and to ask them to consider how they would help the LVNs implement what they had learned once they were back at the nursing home. Despite multiple conversations, one of the lessons learned is how difficult it is for DONs and
administrators to create the infrastructure and ongoing support that maximizes the potential for implementation, diffusion and sustainability. Several of the administrators did provide some acknowledgment of the training and support for the LVNs, but this occurred on an ad hoc basis rather than in any type of formal, consistent manner.
None of the managers set any real expectations for the LVNs prior to their attending the training program and few provided concrete follow up. There seemed to be some cognitive dissonance between what upper management felt they were doing and what they actually did to support the program. That is, several administrators expressed significant interest in and enthusiasm for, the training program and believed that they were supporting staff to implement what they had learned. The LVNs were told about the program prior to their attending the sessions and were asked how they liked it following the training. For the most part, though, that was the extent of support. This lack of formal acknowledgement and infrastructure was expressed by some of the LVNs who attended the booster sessions. While they now recognized their leadership and supervisory roles, they were not certain how to execute their newly acquired skills within their organizations.
It is clear to the project team that replication of the training program should include more specific involvement of the facility’s management group. A management-oriented module should be incorporated into the program to assist management in developing a formal implementation plan with input from and ownership by all staff. The plan should include policies and procedures that will support the new LVN roles, including new job descriptions, criteria in performance evaluations, inclusion in orientation programs and in-services and other mechanisms for supporting the LVNs and holding them (and others such as the DONs)
accountable. In order to implement and sustain this type of program, there must be opportunities for encouragement to provide “teachable moments” where LVNs can work with CNAs and others on their units to build teams and to help their staff perform efficiently and effectively. Incumbent and newly hired LVNs should be exposed to this program and the natural mentors who emerge should be used to help sustain the training and skills and expertise acquired.
The Essential Role of the DSD
Another lesson learned is the current and potential role that DSDs play in training LVNs to be better leaders and unit managers and in supporting them as they work with CNAs to build teams and create a healthier work/care environment. Despite the fact that California mandates the DSD position, these individuals appear to be seriously underutilized, particularly as it relates to
both the CNAs and the LVNS and, in most cases, were respected and trusted by both levels of staff. DSDs, therefore, could be the glue that supports the LVN training program and that creates the pivotal link between the LVNs and upper management.
Unfortunately, the DSDs are often spread too thin. The project team believes their fulltime role should be as a staff educator and that they should focus on leadership/management training as well as clinical issues, infection control and other topics generally addressed through in-services. California does require DSDs to obtain limited hours of training on how to fulfill their DSD responsibilities. One way to strengthen the LVN training program could be to incorporate this training into the DSD training to help DSDs become ongoing trainers and sustainers in this area.
Cultural Diversity
Recognizing that California is a very diverse state, the project team expected to find cultural diversity issues and challenges in developing this program. Focus groups with CNAs and LVNs, interviews with management and the training and booster sessions with the LVNs underscored the need to address ethnic and cultural diversity in the leadership training program and in the implementation back at the facilities. The majority of the LVNs (as well as most of the DONs and many of the CNAs) employed by the pilot facilities were from the Philippines. Through observation of the nurses during the training sessions and conversations with facility
management, the project team learned that a number of cultural issues may impede the ability of these charge nurses to assert themselves in a leadership position. For example, the Filipino culture encourages deference to one’s elders and superiors. This, of course, would make it very difficult for an LVN to see him or herself as a mentor to a seasoned CNA. The LVNs also expressed discomfort in the notion that they should approach and even confront upper
management with their concerns about lack of support and their ideas about how to assume more of a leadership role. Some CNAs and LVNs from other backgrounds noted that the Filipino nurses often talked among themselves in their native tongue, a practice that created a sense of insecurity and discomfort among the non-Filipino staff. These examples underscore the
importance of including cultural competence elements in any leadership training program as well as in the application of this knowledge in daily practice on the unit. While it is helpful to have a general cultural diversity session as part of an overall leadership program, some organizations may need a stand-alone program targeting the specific issues faced in their facility and taught by a cultural diversity expert.