Work in eldercare : staying or leaving : caregivers’ experiences of work and support during organizational changes

The overall aim of the present thesis was to reveal nursing home (NH) caregivers’ work experiences when receiving support through education and clinical supervision over a two-year period, while the workplace was undergoing organizational changes. The studies (I-IV) combine qualitative and quantitative methods in a longitudinal two-year follow-up project in three Swedish NHs (NH I - III), in which support was given to the staff at NH I-II. NH III was included as a comparison.

The thesis is based on interviews (I-IV) and self-assessment questionnaires (I), which were conducted at three occasions: at start, after 12 and 24 months at the respective NHs. As a result of political decisions, NH I was informed of organizational changes and pending financial cutbacks shortly after opening. The other NHs were informed at around 12 months. The numbers of caregivers willing to participate at start were 32, 21 and 22 at the respective NHs. No new participants were included to replace dropouts. Descriptive statistics (I) and qualitative content analyses (I-IV) were used. Study I focused on the organizational climate and the prevalence of burnout symptoms in the three NHs. The result from NH I revealed an improvement over time as opposed to NH II, which showed negative progression at 12 months, despite support. This corresponded to the time at which they received information about financial cutbacks. The improvement based on the interviews at NH I was not as distinct as that based on the self-assessment scores. The support given seemed to have helped the caregivers at NH I, but was not able to alter the situation at NH II. The development based on self-assessments at NH III was more constant throughout the study. Results from interviews at NH II and III were more in accordance with the scores.

In Study II, the caregivers’ work experiences at NH II, while receiving support through education and clinical supervision, showed that they valued the caring milieu and their own knowledge. The value of knowledge was related to their different backgrounds and to the knowledge gained through the support, and it seemed to be one factor underlying participants’ continued willingness to stay. In Study III, caregivers’ experiences and reflections on working at NH III, while under threat of organizational changes and termination notice, showed a transition from ‘having a professional identity and self-confidence’ to ‘being a professional in a threatening situation caused by someone else’. Finally they were ‘struggling to adapt to a changed working environment as a person and a professional’. The caregivers experienced a loss of pride and satisfaction. Included in Study II and III were interviews from those caregivers who had been interviewed on all three occasions. Study IV focused on what had caused caregivers at the three NHs to decide to leave their employment during the study period. Caregivers’ decisions to leave work could be encompassed in one main category: ‘Unmet expectations’. Their experiences were lack of encouragement, trust and professional development. Also reported were feelings of insecurity, different opinions on the care delivered, being disregarded and betrayed, followed by thoughts of leaving work and pursing other opportunities. It can be concluded that the changes at all three NHs seemed to have over-shadowed attempts to improve working conditions. Successful changes require a vision that justifies them. High-level decision-makers and managers ought to be conscious of the factors that facilitate or impede similar transitions. They should also focus on supporting caregivers during change processes, as the literature shows a risk for decreasing quality of care.

List of scientific papers

I. Fläckman B, Skovdahl K, Fagerberg I, Kihlgren M, Kihlgren A. (2008). Organizational climate and burnout in relation to changes in organization - caregivers self-assessments and experiences at nursing homes. [Submitted]

II. Fläckman B, Fagerberg I, Häggström E, Kihlgren A, Kihlgren M. (2007). Despite shattered expectations a willingness to care for elders remains with education and clinical supervision. Scand J Caring Sci. 21(3):379-89.
https://pubmed.ncbi.nlm.nih.gov/17727551

III. Fläckman B, Hansebo G, Kihlgren M, Kihlgren A. (2008). Struggling to adapt: caring for older persons while under threat of organizational change and termination notice. [Submitted]

IV. Fläckman B, Sørlie V, Kihlgren M. (2008). Unmet expectation: why nursing home staff leave care work. Journal of Older People Nursing. 3:55-62.