Parkway Nursing Care is an organization facing a massive change. The company was founded in 1982 with just two nursing homes in Phoenix, Arizona. The company was very successful, and throughout the 1990s, it continued to turn a consistent profit while slowly acquiring or building 30 more units. This low-profile approach changed forever in 2003 when venture capitalist Robert Quine decided to make a major investment in expanding Parkway in return for a portion of its profits over the coming years. The number of nursing homes exploded, and Parkway was operating 180 homes by the year 2010.

The company now has 220 facilities in the southwestern United States, with an average of 115 beds per facility and a total of nearly 30,000 employees. In addition to health care facilities, it also provides skilled in-home nursing care. Parkway is seen as one of the best care facilities in the region, and it has won numerous awards for its achievements in the field.

As members of the baby boom generation become senior citizens, the need for skilled care will only increase. Parkway wants to make sure it is in a good position to meet this growing need. This means the company must continue expanding rapidly.

The pressure for growth is one significant challenge, but it is not the only one. The nursing home industry has come under increased government scrutiny following investigations that turned up widespread patient abuse and billing fraud. Parkway has always had outstanding patient care. No substantiated claim of abuse or neglect in any of its homes has ever been made. However, the need for increased documentation will still affect the company. As the federal government tries to trim Medicare expenses, Parkway may face a reduction in funding.

The Problem As growth continues, Parkway has remained committed to maintaining the dignity and health of all residents in its facilities. The board of directors wants to see a renewed commitment to the firm's mission and core values, not a diffusion of its culture. Its members are worried there might be problems to address. Interviews with employees suggest there is plenty to worry about.

Shift leader Maxine Vernon has been with Parkway for 15 years. "Now that the government keeps a closer eye on our staffing levels, I've seen management do what it can to keep positions filled, and I don't always agree with who is hired. Some of the basic job skills can be taught, sure, but how to care for our patientsa lot of these new kids just don't pick up on that."

"The problem isn't with staffit's with Parkway's focus on filling the beds," says nurse's aide Bobby Reed. "When I started here, Parkway's reputation was still about the service. Now it's about numbers. No one is intentionally negligentthere just are too many patients to see."

A recent college graduate with a BA in psychology, Dalton Manetti is more stressed than he expected. "These aren't the sweet grannies you see in the movies. Our patients are demanding. They complain about everything, even about being called patients, probably because most of them think they shouldn't be here in the first place. A lot of times, their gripes amount to nothing, but we have to log them in anyway."

Carmen Frank has been with Parkway for almost a year and is already considering finding a new job. "I knew there were going to be physical parts to this job, and I thought I'd be able to handle that. It's not like I was looking for a desk job, you know? After every shift, I go home with aches all overmy back, arms, and legs. I've never had to take so much time off from a job because I hurt. And then when I come back, I feel like the rest of the staff thinks I'm weak."

Year Number of Patients Injuries per Staff Member Incidents per Patient Certified Absences per Staff Member Other Absences per Staff Member Turnover Rate 2010 21,200 3.32 4.98 4.55 3.14 0.31 2011 22,300 3.97 5.37 5.09 3.31 0.29 2012 22,600 4.87 5.92 4.71 3.47 0.28 2013 23,100 4.10 6.36 5.11 3.61 0.35 2014 23,300 4.21 6.87 5.66 4.03 0.31 2015 23,450 5.03 7.36 5.33 3.45 0.28 2016 23,600 5.84 7.88 5.28 4.24 0.36 2017 24,500 5.62 8.35 5.86 4.06 0.33 2018 24,100 7.12 8.84 5.63 3.89 0.35 2019 25,300 6.95 9.34 6.11 4.28 0.35 "I started working here right out of high school because it was the best-paid of the jobs I could get," says Niecey Wilson. "I had no idea what I was getting myself into. Now I really like my job. Next year I'm going to start taking some night classes so I can move into another position. But some of the staff just think of this as any other job. They don't see the patients as people, more like inventory. If they want to work with inventory, they should get a job in retail."

Last month, the company's human resources department pulled the above information from its records at the board of directors' request. The numbers provide some quantitative support for the concerns voiced by staff.

Injuries to staff occur mostly because of back strain from lifting patients. Patient incidents reflect injuries due to slips, falls, medication errors, or other accidents. Certified absences are days off from work due to medically verified illnesses or injuries. Other absences are days missed that are not due to injuries or illnesses; these are excused absences (unexcused absences are grounds for immediate firing).

Using Organizational Development to Combat Stress and Improve Performance The company wants to use organizational development methods such as appreciative inquiry (AI) to change and re-energize its sense of mission. As the chapter on organizational change explains, AI procedures systematically collect employee input and then use this information to make a change message everyone can support. The human resources department conducted focus groups, asking employees to describe their concerns and suggestions for the future. The focus groups highlighted many suggestions, although they do not all suggest movement in the same direction.

Many suggestions concerned schedule flexibility. One representative comment was this: "Most of the stress on this job comes because we can't take time off when we need it. The LPNs [licensed practical nurses, who do much of the care] and orderlies can't take time off when they need to. Still, many of them are single parents or primary caregivers for their own children. When they have to leave for child care responsibilities, the work suffers, and there's no contingency plan to help smooth things over. Then everyone who is left has to work extra hard. The person who takes time off feels guilty, and there can be fights over taking time off. If we had some way of covering these emergency absences, we'd all be a lot happier, and I think the care would be a lot better."

Other suggestions proposed better methods for communicating information across shifts. Most of the documentation for shift work is done in large spiral notebooks. When a new shift begins, staff members say they don't have much time to check on what happened in the previous shift. Some younger caregivers would like to have a method that lets them document patient outcomes electronically because they type faster than they can write. The older caregivers are more committed to the paper-based process, in part because they think switching systems would require a lot of work. (Government regulations on health care reporting require that any documentation be made in a form that cannot be altered after the fact to prevent covering up abuse, so specialized software systems must be used for electronic documentation.)

Finally, the nursing care staff believes its perspectives on patient care are seldom given an appropriate hearing. "We're the ones who are with the patients most of the time, but when it comes to doing this the right way, our point of view gets lost. We really could save a lot of money by eliminating some of these unnecessary routines and programs. Still, it's something management always just says it will consider."

Staff members seem to want some way to provide suggestions for improvement, but it is unclear what method they would prefer.

Parkway has taken some initial steps in this new direction, but clearly, it has a lot of work left to do. A change management consultant has been brought in to help the company change its culture and respond to the stress that employees experience. Report as if it is for the leadership of a major corporation.

CC-30. What do the data on employee injuries, incidents, absences, and turnover suggest to you? Is there a reason for concern about the company's direction?

CC-31. The company will be making some significant changes based on the AI process, and most change efforts are associated with resistance. What are the most common forms of resistance, and which would you expect to see at Parkway?

CC-32. Given the board of directors' desire to re-energize the workforce, what advice would you provide for creating a leadership strategy? What leader behaviors should nursing home directors and nurse supervisors demonstrate?

CC-33. What are the major sources of job stress at Parkway? What does the research on employee stress suggest you should do to help minimize the experience of psychological strain for employees? a plan for how to reduce stress among employees.

CC-34. Based on the information collected in the focus groups, design a survey to hand out to employees. What sort of data should the survey gather? What types of data analysis methods would you like to employ for these data?