Internal Marketing: A Competitive Strategy for the Long-Term Care ...

Internal Marketing: A Competitive Strategy for the Long-Term Care Industry Jack Cooper WESTERN CONNECTICUT STATE UNIVERSITY

John J. Cronin WESTERN CONNECTICUT STATE UNIVERSITY

Administrators, directors of admissions, and corporate offices of nursing homes must become better marketers to survive sweeping changes in the industry. An essential part of their marketing effort has to be what is termed “internal marketing.” Internal marketing consists of an effort by the organization to train and motivate its employees to provide better service. Internal marketing must precede conventional marketing campaigns if the latter are to succeed. Negative staff attitudes will affect quality of care, and negative word of mouth communication by patients and staff to the community will negate the effects of the marketing campaign. A survey by the authors shows that education and advancement of nursing assistants has been neglected. They recommend the internal marketing efforts focus on those nursing assistants. J BUSN RES 2000. 48.177–181.  2000 Elsevier Science Inc. All rights reserved.

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he spread of managed care and the competition being encountered from hospitals and home health-care agencies will drive nursing home management to practice more sophisticated marketing in the future. Technology and the present alternative care models encourage provision for geriatric care in the home, short-term respite care, and others models of care. Competition for patients is intense, and more effective marketing is essential for survival; however, the nursing home industry has had little experience with marketing in its 30-year history. When the typical nursing home has designed a marketing campaign in the past, one of the most important ingredients has been actually left out: the employees. Employees affect the success of marketing campaigns in two ways. First, they are essential to the delivery of health care to the patients. If they fail to deliver the quality of care Address correspondence to Dr. Jack Cooper, Western Connecticut State University, 181 White Street, Danbury, CT 06810, USA. An earlier version of this paper was presented at the Fourteenth Annual Conference of the American Association for Advances in Health Care Research, Jackson Hole, Wyoming, March 9–11, 1995, and was included in the 1995 Proceedings of that association. Journal of Business Research 48, 177–181 (2000)  2000 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010

promised by advertising or other marketing communications, the effort will fail. Also, employees transmit information about the nursing home to the community, including prospective residents, by what is commonly called “word of mouth advertising.” This information is passed on via a grapevine or network of friends and acquaintances. Through it, the staff comments are propagated to the public regarding fellow staff members, the management, and the type and quality of care provided to the patients. It is essential that marketing programs attempt to manage this communication network just as they use the mass media. The way to manage word of mouth advertising is to ensure that the staff is satisfied, motivated, trained, and loyal. In short, nursing home management can only create effective marketing programs by first conducting what is called “internal marketing,” and by focusing that internal marketing on nursing assistants.

Marketing by Nursing Homes Nursing homes have historically relied on the social worker and/or admissions person employed by the individual home to market their services, plus the occasional physician referral (Molloy, 1994). These professionals receive little, if any, training in marketing during their formal education, and certainly none on internal marketing (Robbins, 1997; Grant, Kane, Potthoff, and Ryden, 1996). Little marketing effort is made to fill nursing home beds, and little is done to promote the image of the nursing home. Even less is done to promote word of mouth advertising through the caregiving staff. As reported in Hospital Marketer Study Archives, 83% of marketers that were surveyed reported that they received the least support from nurses (16%), physicians (14%), and other staff (13%) (Cooper, 1994). A 1993 survey of top-level nurses showed that nurses in long-term care institutions spend less time on marketing than do nurses in acute or home care (Scalzi and Wilson, 1993). When we consider that, in the nursing ISSN 0148-2963/00/$–see front matter PII S0148-2963(98)00084-8

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home, nursing staff can constitute over 80% of the total staffing, the consequences of this lack of support become apparent. Of particular importance is that over 70% of the nursing staff are nursing assistants (Tellis-Nayak and Tellis-Nayak, 1989). Nursing assistants constitute 43% of all full-time equivalents of those who provide care (Older Women’s League, 1988). Nursing assistants are those caregiver staff with little formal education, but most hands-on responsibilities for the patient. In the state surveyed in this research (Connecticut), for example, these assistants to nurses receive 27 hours of classroom training and 27 hours of on-the-job training. Both the training and the job itself generally consist of taking temperatures and other vital signs, feeding and bathing the patients, and toileting and dressing them.

Internal Marketing Marketing efforts by nursing homes that communicate only with the external world, while caregiving personnel are left to conduct business in the same old way, are unlikely to succeed in meeting their objectives. The target audiences will receive conflicting messages. Advertising and public relations will be telling them that the nursing home has improved, but those in the market who have contact with the staff will perceive that nothing has changed, and word of mouth advertising will tell the entire target audiences that nothing has really changed. For many products and services, the relative influence of word of mouth communication greatly surpasses the influence of advertising (Aaker, Batra, and Myers, 1992). Advertising is often regarded as self-serving; whereas, friends and relatives who discuss the same product or service are seen as having nothing to gain, and therefore unbiased. More than one-third of all word of mouth is negative, and negative word of mouth is given higher priority and assigned a greater weight in decision making (Engel, Warshaw, and Kinnear, 1994). The impact of word of mouth on the success of marketing programs is particularly critical for the launch of a new product or service. As Shimp (1993) says, “Unfavorable word of mouth can have devastating effects on adoption” of new products or services (p. 187). Clearly, the management of the nursing home must do whatever is possible to create positive word of mouth; this can be done through an internal marketing program. Internal marketing does not consist simply of finding ways to use staff to promote the services of the nursing home, however. That will come about as part of the process, as a result of effective internal marketing. Internal marketing consists of an effort by the organization to train and motivate its employees to serve its clients well (Gro¨nroos, 1984). It is more of a management function than a marketing one, but is called “marketing,” because it is an essential component of, and a necessary precondition to, the marketing campaign of any service organization. Internal marketing must precede external marketing, ac-

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cording to Kotler (1994): “it makes no sense to promise excellent service before the staff is ready to provide it” (p. 22). He quotes Leonard Berry (1986): “the most important contribution the marketing department can make is to be exceptionally clever in getting everyone else in the organization to practice marketing” (p. 470). The concept of internal marketing is particularly applicable to service institutions (Berry, 1997) and, therefore, to nursing homes. Internal marketing is a relatively new concept, but it is being adopted in other industries (see Cahill, 1996, for recent case studies), and it has already been practiced with success by some organizations in the health-care field. For example, Virginia Blood Services, a not-for-profit organization in Richmond, Virginia reports successfully using an internal marketing program to reposition itself for the 1990s (Bak, Vogt, George, and Greentree, 1994). Health care is being swept by a wave of mergers, downsizing, reorganizations, and layoffs. Nursing homes are not immune to this trend and must be able to cope with the tensions and low morale that result. Internal marketing can maintain a customer-focused culture during such trying times. Research shows that customer satisfaction rates are significantly higher in organizations where employees are aware of their impact in delivering good service (Stershic, 1994). Nursing assistants and others who come into direct contact with clients should be the primary focus of internal marketing. Nursing homes that adopt internal marketing will open up a new channel to the community, one that costs relatively little. Internal marketing also will improve the nurturing and rehabilitative care provided to the residents, and has the potential to increase staff loyalty and decrease staff turnover.

The Role of the Nursing Assistant It has been clearly established that when the elderly patient is admitted to a nursing home, the nursing assistant is the primary caregiver. A study that was recently completed in the state of Connecticut exposed one of the weaknesses of the marketing function in nursing homes: the absence of training in internal marketing for nursing assistants. Nursing assistants in nine nursing homes, ranging in size from under 60 to over 500 beds, were surveyed. There was a mix of proprietary and nonproprietary facilities, and unionized and nonunion employees.

Demographics The nursing assistants in this study averaged 37 years of age, were predominantly female, with an average of 12 years education and 9 years working experience as a nursing assistant. Half of them were married and were the primary wage earner in their families. Thirty-two percent were single parents. The composition of the study participants is quite similar to the state and national demographics of nursing assistants as reported by the State of Connecticut’s Commission on Long-Term Care (1988) and by Older Women’s League (1988), respectively.

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Table 1. Attitude Pairing Questions

Job Knowledge

30. In my first several weeks as a nursing assistant, I found working with dementia (Alzheimer’s)-type patients rewarding ..... 5 4 3 2 1 ? 31. Presently, as a nursing assistant, I find working with dementia (Alzheimer’s)-type patients rewarding ............................. 5 4 3 2 1 ?

To determine the nursing assistants’ job knowledge, the Palmore Facts on Aging Quiz, consisting of 25 true–false questions, was utilized (Palmore, 1997, 1981a, 1981b). The results show a disconcerting lack of ecumenical knowledge about the aged. The Palmore questionnaire was administered with the inclusion of an “I don’t know” option (?) to reduce guessing. Overall, the respondents did poorly. Of the total of 25 questions, the average respondent gave 11 correct answers, 3 “I don’t know’s,” and answered the rest incorrectly (Table 3). These findings are an indication that internal marketing is needed. In addition to the direct benefits of improving the knowledge of the staff, supplying education through ongoing programs will show the staff that the management cares about them. As in the well-known Hawthorne Studies (Roethlisberger and Dickson, 1939), recognition of the importance of the staff through special programs will result in better performance and better attitudes of the staff toward the institution. Table 4 references a comparison of mean correct percentage scores to the Palmore Facts on Aging Quiz as obtained in five different studies. The low level of knowledge of nursing assistants about aged patients is cause for concern, these patients are the vast majority of those for whom these nursing assistants care. First, inadequate knowledge can lead to inadequate care (Cooper, 1992), and the type of care received has a significant influence on the quality of patient life in the nursing home. Additionally, the inadequate care that results from this lack of knowledge has an adverse impact on the nursing assistants’ perception of the management of the institution. This adverse perception colors the word of mouth advertising they generate and reduces the probability that any marketing program initiated by the nursing home will be successful in changing community attitudes or the image of the institution. Seventy-six percent of the nursing assistants in this study stated that they learned most about their jobs from other nursing assistants after completion of nursing assistant training. The evidence of limited knowledge of the aged population in general, as well as of specific patient diagnoses uncovered in this study indicates that on-the-job training is inadequate. As additional evidence is the fact that there is a 70 to 100% turnover rate among nursing assistants in all nursing homes (Older Women’s League, 1988). Clearly, there is a need for a different approach to caregiver education in the nursing home.

32. In my first several weeks as a nursing assistant, I found dementia (Alzheimer’s)-type patients difficult to provide care for .. 5 4 3 2 1 ? 33. Presently, I find dementia (Alzheimer’s)-type patients difficult to provide care for ............................................................... 5 4 3 2 1 ? 34. In my first several weeks as a nursing assistant, I had a positive attitude toward giving care to dementia (Alzheimer’s)-type patients ........................................................................................ 5 4 3 2 1 ? 35. Presently, I have a positive attitude toward giving care to dementia (Alzheimer’s)-type patients .............................................. 5 4 3 2 1 ? 36. In my first several weeks as a nursing assistant, I felt that dementia (Alzheimer’s)-type patients took up time better spent with more alert patients............................................................................ 5 4 3 2 1 ? 37. Presently, I feel that dementia (Alzheimer’s)-type patients take up time better spent with more alert patients................. 5 4 3 2 1 ?

Job Satisfaction The nursing assistants in the study reported that working with their patients is as difficult today, after an average of 9 years of employment in this field, as it was during their initial days in the field. Years of experience have not made it easier to provide for the needs of their patients. However, when working with patients who may often be confused and sometimes combative, they display a widespread, manifestly positive attitude toward performing their duties. Table 1 provides the attitude pairing questions. Table 2 demonstrates a comparison of initial attitudes with current attitudes. Analysis of the attitude questions shows that early rewarding or positive attitude responses toward dementia patients are essentially the same as those attitudes held presently. The t-test analysis showed a highly significant relationship between their early attitudes toward the patients they care for and later attitudes (t value ⫽ 5.13, 4.28, and 4.19, respectively, with a low 1.0 for pairing #4, which reversed the positive focus of the question).

A Model Internal Marketing Program Table 2. Attitude Comparison Question 30/31 32/33 34/35 36/37

t-Test

p-Value

5.13 4.28 4.19 1.00

0.1587

Thornton (1994) has stated, “In-service education programs need to be expanded to introduce employees to the role of marketing and to reinforce the vital role all staff play in creating and shaping the reputation of a facility” (p. 38). We now suggest a model for how this can be done. A desire to have more input in patient care matters was expressed by 79% of the study participants. By providing

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Table 3. Palmore Facts on Aging Quiz 1. The majority of old people are senile (i.e., defective memory, disoriented, or demented). T F ?a 2. All five senses tend to decline in old age. TF? 3. Most old people have no interest in, or capicity for, sexual relations. TF? 4. Lung capicity tends to decline in old age. TF? 5. The majority of old people feel miserable most of the time. TF? 6 Physical strength tends to decline in old age. TF? 7. At least one-tenth of the aged are living in long-stay institutions (i.e. nursing homes, mental hospitals, homes for the aged, etc.) TF? 8. Aged drivers have fewer accidents per driver than drivers under 65. TF? 9. Most older workers cannot work as effectively as younger workers. TF? 10. About 80% of the aged are healthy enough to carry out their normal activities. TF? 11. Most old people are set in their ways and unable to change. TF? 12. Old people usually take longer to learn something new. TF?

14. The reaction time of most old people tends to be slower than the reaction time of younger people. TF? 15. In general, most old people are pretty much alike. TF? 16. The majority of old people report that they are seldom bored. TF? 17. The majority of old people are socially isolated and lonely. TF? 18. Older workers have fewer accidents than younger workers. TF? 19. Over 15% of the U.S. population are now age 65 or over. TF? 20. Most medical practitioners tend to give low priority to the aged. TF? 21. The majority of old people have incomes below the poverty level (as defined by the federal government). TF? 22. The majority of older people are working or would like to have some type of work to do (including housework and volunteer work). TF? 23. Older people tend to become more religious as they age. TF? 24. The majority of old people report that they are seldom irritated or angry. TF? 25. The health and socioeconomic status of older people (as compared to younger people) in the year 2000 will probably be worse or about the same as that of today’s older people. TF?

13. It is almost impossible for most old people to learn something new. TF? a

We added this (?) option (“I don’t know”) to reduce guessing.

nursing assistants with further education and allowing them to make additional inputs to patient care matters, nursing homes will be initiating an effective internal marketing program. Perceptions of the patients regarding quality of care received will improve, and these patients will initiate positive word of mouth advertising as they communicate with family and visitors, and these people, in turn, communicate with their friends and family, and so on. Advertising and public relations messages intended to improve the image of the institution will be reinforced rather than negated. The message in the external marketing campaign will be more believable, because it will not conflict with the community’s actual experiences when they come in contact with patients or staff. An internal marketing program for nursing homes must be built around training and advancement for nursing assistants. Classroom training plus continued learning on the job through daily interaction with peers and supervisors in and outside of

the nursing assistant’s discipline are necessary. This program will establish a pattern of expectations by and of nursing assistants, motivating them to move up a career ladder. Presently, it is extremely difficult for nursing assistants to obtain education beyond their initial training. Often, a combination of work and family obligations prevent them from attending community colleges or similar educational programs. What is necessary is to establish a work experience and college credit program within the nursing home, or nearby, with course work during normal working hours, or when that is not possible, immediately before of after normal working hours. The program could be patterned on that of the State of New York Regents College and Examinations Program (University of the State of New York, 1987). Success both in attracting new patients and in retaining current patients is and will be essential for survival in the next decade. Without support from our nursing departments,

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Table 4. Comparison of Mean Correct Percentage Scores Group Nursing assistants Undergraduates Undergraduates Aides and orderlies High school graduates

n

Mean % Correct

177 31 87 259 259

59 70 64 55 57 61 Mean

we cannot expect to compete successfully for the elderly patients who are finding health-care options in other caregiving arenas and in our competitors’ facilities. This positive attitude is encouraging, considering that the management of nursing homes provides nursing assistants with few rewards. There is little, if any, in-service education and practically no chance for advancement. The majority of the nursing assistants in this study, more than 82%, reported they felt intrinsically rewarded by their work and wished to remain in nursing. However, they would like to have advancement opportunity. Clearly, there is fertile ground here for internal marketing. The very thing that nursing assistants want, advancement, can be used to motivate them to improve the service they provide.

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