for the Long-Term Care Industry
Jack Cooper
WESTERNCONNECTICUTSTATEUNIVERSITY
John J. Cronin
WESTERNCONNECTICUTSTATEUNIVERSITY
Administrators, directors of admissions, and corporate offices of nursing promised by advertising or other marketing communications,
homes must become better marketers to survive sweeping changes in the the effort will fail. Also, employees transmit information about
industry. An essential part of their marketing effort has to be what is termed the nursing home to the community, including prospective
“internal marketing.” Internal marketing consists of an effort by the organi- residents, by what is commonly called “word of mouth
adver-zation to train and motivate its employees to provide better service. Internal tising.” This information is passed on via a grapevine or
net-marketing must precede conventional net-marketing campaigns if the latter are work of friends and acquaintances. Through it, the staff
com-to succeed. Negative staff attitudes will affect quality of care, and negative ments are propagated to the public regarding fellow staff
word of mouth communication by patients and staff to the community will members, the management, and the type and quality of care
negate the effects of the marketing campaign. A survey by the authors shows provided to the patients. It is essential that marketing
pro-that education and advancement of nursing assistants has been neglected. grams attempt to manage this communication network just
They recommend the internal marketing efforts focus on those nursing as they use the mass media. The way to manage word of assistants. J BUSN RES2000. 48.177–181. 2000 Elsevier Science mouth advertising is to ensure that the staff is satisfied,
moti-Inc. All rights reserved. vated, trained, and loyal. In short, nursing home management
can only create effective marketing programs by first conduct-ing what is called “internal marketconduct-ing,” and by focusconduct-ing that internal marketing on nursing assistants.
T
he spread of managed care and the competition being encountered from hospitals and home health-careagencies will drive nursing home management to prac-
Marketing by Nursing Homes
tice more sophisticated marketing in the future. TechnologyNursing homes have historically relied on the social worker and the present alternative care models encourage provision
and/or admissions person employed by the individual home for geriatric care in the home, short-term respite care, and
to market their services, plus the occasional physician referral others models of care. Competition for patients is intense,
(Molloy, 1994). These professionals receive little, if any, train-and more effective marketing is essential for survival; however,
ing in marketing during their formal education, and certainly the nursing home industry has had little experience with
mar-none on internal marketing (Robbins, 1997; Grant, Kane, keting in its 30-year history. When the typical nursing home
Potthoff, and Ryden, 1996). Little marketing effort is made has designed a marketing campaign in the past, one of the most
to fill nursing home beds, and little is done to promote the important ingredients has been actually left out: the employees.
image of the nursing home. Even less is done to promote Employees affect the success of marketing campaigns in
word of mouth advertising through the caregiving staff. two ways. First, they are essential to the delivery of health
As reported in Hospital Marketer Study Archives, 83% of care to the patients. If they fail to deliver the quality of care
marketers that were surveyed reported that they received the least support from nurses (16%), physicians (14%), and other
Address correspondence to Dr. Jack Cooper, Western Connecticut State Uni- staff (13%) (Cooper, 1994). A 1993 survey of top-level nurses versity, 181 White Street, Danbury, CT 06810, USA.
showed that nurses in long-term care institutions spend less
An earlier version of this paper was presented at the Fourteenth Annual
Conference of the American Association for Advances in Health Care Re- time on marketing than do nurses in acute or home care (Scalzi search, Jackson Hole, Wyoming, March 9–11, 1995, and was included in the
1995 Proceedings of that association. and Wilson, 1993). When we consider that, in the nursing
Journal of Business Research 48, 177–181 (2000)
2000 Elsevier Science Inc. All rights reserved. ISSN 0148-2963/00/$–see front matter
home, nursing staff can constitute over 80% of the total staffing, cording to Kotler (1994): “it makes no sense to promise excel-lent service before the staff is ready to provide it” (p. 22). He the consequences of this lack of support become apparent.
Of particular importance is that over 70% of the nursing quotes Leonard Berry (1986): “the most important contribu-tion the marketing department can make is to be excepcontribu-tionally staff are nursing assistants (Tellis-Nayak and Tellis-Nayak,
1989). Nursing assistants constitute 43% of all full-time equiv- clever in getting everyone else in the organization to practice marketing” (p. 470). The concept of internal marketing is alents of those who provide care (Older Women’s League,
1988). Nursing assistants are those caregiver staff with little particularly applicable to service institutions (Berry, 1997) and, therefore, to nursing homes.
formal education, but most hands-on responsibilities for the
patient. In the state surveyed in this research (Connecticut), Internal marketing is a relatively new concept, but it is being adopted in other industries (see Cahill, 1996, for recent for example, these assistants to nurses receive 27 hours of
classroom training and 27 hours of on-the-job training. Both case studies), and it has already been practiced with success by some organizations in the health-care field. For example, the training and the job itself generally consist of taking
tem-peratures and other vital signs, feeding and bathing the pa- Virginia Blood Services, a not-for-profit organization in Rich-mond, Virginia reports successfully using an internal market-tients, and toileting and dressing them.
ing program to reposition itself for the 1990s (Bak, Vogt, George, and Greentree, 1994).
Internal Marketing
Health care is being swept by a wave of mergers,downsiz-ing, reorganizations, and layoffs. Nursing homes are not im-Marketing efforts by nursing homes that communicate only
mune to this trend and must be able to cope with the tensions with the external world, while caregiving personnel are left
and low morale that result. Internal marketing can maintain to conduct business in the same old way, are unlikely to
a customer-focused culture during such trying times. Research succeed in meeting their objectives. The target audiences will
shows that customer satisfaction rates are significantly higher receive conflicting messages. Advertising and public relations
in organizations where employees are aware of their impact will be telling them that the nursing home has improved, but
in delivering good service (Stershic, 1994). those in the market who have contact with the staff will
Nursing assistants and others who come into direct contact perceive that nothing has changed, and word of mouth
adver-with clients should be the primary focus of internal marketing. tising will tell the entire target audiences that nothing has
Nursing homes that adopt internal marketing will open up a really changed.
new channel to the community, one that costs relatively little. For many products and services, the relative influence of
Internal marketing also will improve the nurturing and reha-word of mouth communication greatly surpasses the influence
bilitative care provided to the residents, and has the potential of advertising (Aaker, Batra, and Myers, 1992). Advertising is
to increase staff loyalty and decrease staff turnover. 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
The Role of the Nursing Assistant
of all word of mouth is negative, and negative word of mouth isIt has been clearly established that when the elderly patient is given higher priority and assigned a greater weight in decision
admitted to a nursing home, the nursing assistant is the primary making (Engel, Warshaw, and Kinnear, 1994). The impact
caregiver. A study that was recently completed in the state of of word of mouth on the success of marketing programs is
Connecticut exposed one of the weaknesses of the marketing particularly critical for the launch of a new product or service.
function in nursing homes: the absence of training in internal As Shimp (1993) says, “Unfavorable word of mouth can have
marketing for nursing assistants. Nursing assistants in nine devastating effects on adoption” of new products or services
nursing homes, ranging in size from under 60 to over 500 (p. 187). Clearly, the management of the nursing home must
beds, were surveyed. There was a mix of proprietary and non-do whatever is possible to create positive word of mouth; this
proprietary facilities, and unionized and nonunion employees. can be done through an internal marketing program.
Internal marketing does not consist simply of finding ways
Demographics
to use staff to promote the services of the nursing home,
how-ever. That will come about as part of the process, as a result The nursing assistants in this study averaged 37 years of age, of effective internal marketing. Internal marketing consists of were predominantly female, with an average of 12 years educa-an effort by the orgeduca-anization to train educa-and motivate its employees tion and 9 years working experience as a nursing assistant. Half to serve its clients well (Gro¨nroos, 1984). It is more of a of them were married and were the primary wage earner in their families. Thirty-two percent were single parents. The com-management function than a marketing one, but is called
“marketing,” because it is an essential component of, and a position of the study participants is quite similar to the state and national demographics of nursing assistants as reported necessary precondition to, the marketing campaign of any
ac-Table1. Attitude Pairing Questions
Job Knowledge
30. Inmy first several weeksas a nursing assistant, I found working To determine the nursing assistants’ job knowledge, the
Pal-with dementia (Alzheimer’s)-type patients rewarding ... 5 4 3 2 1 ? more Facts on Aging Quiz, consisting of 25 true–false ques-31. Presently, as a nursing assistant, I find working with dementia
tions, was utilized (Palmore, 1997, 1981a, 1981b). The results
(Alzheimer’s)-type patients rewarding ... 5 4 3 2 1 ?
show a disconcerting lack of ecumenical knowledge about the aged. The Palmore questionnaire was administered with the
32. Inmy first several weeksas a nursing assistant, I found dementia inclusion of an “I don’t know” option (?) to reduce guessing.
(Alzheimer’s)-type patients difficult to provide care for .. 5 4 3 2 1 ? Overall, the respondents did poorly. Of the total of 25 ques-33. Presently, I find dementia (Alzheimer’s)-type patients difficult to tions, the average respondent gave 11 correct answers, 3 “I provide care for ... 5 4 3 2 1 ?
don’t know’s,” and answered the rest incorrectly (Table 3). These findings are an indication that internal marketing is
34. Inmy first several weeksas a nursing assistant, I had a positive needed. In addition to the direct benefits of improving the
attitude toward giving care to dementia (Alzheimer’s)-type patients knowledge of the staff, supplying education through ongoing ... 5 4 3 2 1 ? programs will show the staff that the management cares about 35. Presently, I have a positive attitude toward giving care to
demen-them. As in the well-known Hawthorne Studies
(Roethlis-tia
berger and Dickson, 1939), recognition of the importance
(Alzheimer’s)-type patients ... 5 4 3 2 1 ?
of the staff through special programs will result in better performance and better attitudes of the staff toward the
institu-36. Inmy first several weeksas a nursing assistant, I felt that dementia
tion. Table 4 references a comparison of mean correct
percent-(Alzheimer’s)-type patients took up time better spent with more alert
age scores to the Palmore Facts on Aging Quiz as obtained
patients ... 5 4 3 2 1 ?
in five different studies.
37. Presently, I feel that dementia (Alzheimer’s)-type patients take
up time better spent with more alert patients... 5 4 3 2 1 ? 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
Job Satisfaction
on the quality of patient life in the nursing home. Additionally, The nursing assistants in the study reported that working with
the inadequate care that results from this lack of knowledge their patients is as difficult today, after an average of 9 years
has an adverse impact on the nursing assistants’ perception of employment in this field, as it was during their initial days
of the management of the institution. This adverse perception in the field. Years of experience have not made it easier to
colors the word of mouth advertising they generate and re-provide for the needs of their patients. However, when
work-duces the probability that any marketing program initiated ing with patients who may often be confused and sometimes
by the nursing home will be successful in changing community combative, they display a widespread, manifestly positive
atti-attitudes or the image of the institution. tude toward performing their duties. Table 1 provides the
Seventy-six percent of the nursing assistants in this study attitude pairing questions. Table 2 demonstrates a comparison
stated that they learned most about their jobs from other of initial attitudes with current attitudes.
nursing assistants after completion of nursing assistant train-Analysis of the attitude questions shows that early
re-ing. The evidence of limited knowledge of the aged population warding or positive attitude responses toward dementia
pa-in general, as well as of specific patient diagnoses uncovered tients are essentially the same as those attitudes held presently.
in this study indicates that on-the-job training is inadequate. The t-test analysis showed a highly significant relationship
As additional evidence is the fact that there is a 70 to 100% between their early attitudes toward the patients they care for
turnover rate among nursing assistants in all nursing homes and later attitudes (t value5 5.13, 4.28, and 4.19,
respec-(Older Women’s League, 1988). Clearly, there is a need for a tively, with a low 1.0 for pairing #4, which reversed the
different approach to caregiver education in the nursing home. positive focus of the question).
A Model Internal Marketing Program
Table 2. Attitude Comparison Thornton (1994) has stated, “In-service education programs
Question t-Test p-Value need to be expanded to introduce employees to the role of marketing and to reinforce the vital role all staff play in creating
30/31 5.13 and shaping the reputation of a facility” (p. 38). We now
32/33 4.28
suggest a model for how this can be done.
34/35 4.19
A desire to have more input in patient care matters was
36/37 1.00 0.1587
Table 3. Palmore Facts on Aging Quiz
1. The majority of old people are senile (i.e., defective mem- 14. The reaction time of most old people tends to be slower than
ory, disoriented, or demented). the reaction time of younger people.
T F ?a T F ?
2. All five senses tend to decline in old age. 15. In general, most old people are pretty much alike.
T F ? T F ?
3. Most old people have no interest in, or capicity for, sexual
relations. 16. The majority of old people report that they are seldom bored.
T F ? T F ?
4. Lung capicity tends to decline in old age. 17. The majority of old people are socially isolated and lonely.
T F ? T F ?
5. The majority of old people feel miserable most of the time. 18. Older workers have fewer accidents than younger workers.
T F ? T F ?
6 Physical strength tends to decline in old age. 19. Over 15% of the U.S. population are now age 65 or over.
T F ? T F ?
7. At least one-tenth of the aged are living in long-stay institu- 20. Most medical practitioners tend to give low priority to the tions (i.e. nursing homes, mental hospitals, homes for the aged.
aged, etc.) T F ?
T F ?
8. Aged drivers have fewer accidents per driver than drivers 21. The majority of old people have incomes below the poverty
under 65. level (as defined by the federal government).
T F ? T F ?
9. Most older workers cannot work as effectively as younger 22. The majority of older people are working or would like to have
workers. some type of work to do (including housework and volunteer
T F ? work).
T F ? 10. About 80% of the aged are healthy enough to carry out 23. Older people tend to become more religious as they age.
their normal activities. T F ?
T F ?
11. Most old people are set in their ways and unable to change. 24. The majority of old people report that they are seldom irritated
T F ? or angry.
T F ? 12. Old people usually take longer to learn something new. 25. The health and socioeconomic status of older people (as
com-T F ? pared to younger people) in the year 2000 will probably be worse or about the same as that of today’s older people.
T F ? 13. It is almost impossible for most old people to learn
some-thing new.
T F ?
aWe added this (?) option (“I don’t know”) to reduce guessing.
nursing assistants with further education and allowing them the nursing assistant’s discipline are necessary. This program will establish a pattern of expectations by and of nursing to make additional inputs to patient care matters, nursing
homes will be initiating an effective internal marketing pro- assistants, motivating them to move up a career ladder. Presently, it is extremely difficult for nursing assistants gram. Perceptions of the patients regarding quality of care
received will improve, and these patients will initiate positive to obtain education beyond their initial training. Often, a combination of work and family obligations prevent them word of mouth advertising as they communicate with family
and visitors, and these people, in turn, communicate with their from attending community colleges or similar educational programs. What is necessary is to establish a work experience friends and family, and so on. Advertising and public relations
messages intended to improve the image of the institution and college credit program within the nursing home, or nearby, with course work during normal working hours, or will be reinforced rather than negated. The message in the
external marketing campaign will be more believable, because when that is not possible, immediately before of after normal working hours. The program could be patterned on that of it will not conflict with the community’s actual experiences
when they come in contact with patients or staff. the State of New York Regents College and Examinations Program (University of the State of New York, 1987). An internal marketing program for nursing homes must be
built around training and advancement for nursing assistants. Success both in attracting new patients and in retaining current patients is and will be essential for survival in the Classroom training plus continued learning on the job through
Table 4. Comparison of Mean Correct Percentage Scores Cooper, Jack:Effects of Nursing Assistant Attitudes Toward Care of Alz-heimer’s PatientsUniversity Microfilms, Inc., Ann Arbor, MI. 1992.
Group n Mean % Correct
Cooper, P.:Health Care Marketing. Aspen Publishers, Gaithersburg, MD. 1994.
Nursing assistants 177 59
Engel, James F., Warshaw, Martin R., and Kinnear, Thomas C.:
Undergraduates 31 70
Promotional Strategy. Irwin, Burr Ridge, IL. 1994.
Undergraduates 87 64
Aides and orderlies 259 55 Go¨nroos, Christian A.: A Service Quality Model and Its Marketing
High school graduates 259 57 Implications.European Journal of Marketing18(4): 36–44.
61 Mean Grant, L. A., Kane, R. A., Potthoff, S. J., and Ryden, M.: Staff Training and Turnover in Alzheimer Special Care Units.Geriatric Nursing. 17(6) (1996): 278–282.
Kotler, Philip: Marketing Management, Prentice Hall, Englewood
we cannot expect to compete successfully for the elderly pa- Cliffs, NJ. 1994.
tients who are finding health-care options in other caregiving Molloy, George E.: How to Market Specialized Care.Nursing Homes
(April 1994): 32–37.
arenas and in our competitors’ facilities.
Older Women’s League/American Federation of State, County, and
This positive attitude is encouraging, considering that the
Municipal Employees, AFL-CIO:Basic Facts About Chronic Care
management of nursing homes provides nursing assistants
Workers, Washington, DC. 1988.
with few rewards. There is little, if any, in-service education
Palmore, E.: Facts on aging: A short quiz.Gerontologist17(4) (1997):
and practically no chance for advancement. The majority of
315–320.
the nursing assistants in this study, more than 82%, reported
Palmore, E.: Facts on aging quiz: A review of findings.Gerontologist
they felt intrinsically rewarded by their work and wished to
20(1) (1981a): 669–672.
remain in nursing. However, they would like to have
advance-Palmore, E.: More on Palmore’s facts on aging quiz: A review of
ment opportunity. Clearly, there is fertile ground here for findings.Gerontologist21(1) (1981b): 115–116.
internal marketing. The very thing that nursing assistants Robbins, A.: What a nursing assistant knows.The American Journal want, advancement, can be used to motivate them to improve of Nursing97(7) (1997): 1939.
the service they provide. Roethlisberger, Fritz G., and Dickson, William J.:Mangement and
the Worker, Harvard University Press, Cambridge, MA. 1939. Scalzi, Cynthia C. and Wilson, David L.: Analysis of job functions
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