Key to a successful management style and decision-making is making it clear to staff that they and their ideas are valued.

       Editor’s note: This is the sixth in a series of articles related to topics presented at the 2007 Symposium on Regulatory Issues for Management in Long-Term Care (SORIM LTC). For more information leading up to the 2008 conference, please visit www.SORIMLTC.com.

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aking things much harder than they need to be—it’s what we nurses do, right? Let’s see. I find myself once again the new Director of Nursing (DON) in a different facility, this time with a great office, including beautiful furniture and two windows. Good start. Still, I peek in the drawers to find the treasures of the former DON and find the usual paper clips, pens, pencils, rubber stamps, the keys to who knows where, letter openers, old memos, and files. But where are the instructions to this place?
       A DON rarely if ever gets an orientation to a new place. I’m lucky this is another site within my own company; some have to start all over again. Then there’s the book shelf that holds the multitude of binders that have things in them from maybe four DONs prior to me. They usually include the last three sets of policy and procedure, in-service stuff, old books, quality assurance (QA) memos, and documents of things that have been found and resolved, only to arise again and, if you’re lucky, be resolved again. The first days in a facility are challenging at best. You have to be many things to many people without a whole lot of information.
       This is the story of how a new management team identified problem areas and successfully changed outcomes by working with the staff—not changing existing policy and procedure. Most seasoned nurses are quick to look at systems, operational issues, policy, and procedure, but most of us have been around the block enough that we’re starting to realize things haven’t changed that much. Maybe we need to look at our staff’s attitudes and behaviors. New regulations just keep coming like a waterfall on a flood, but the guiding principles of the regulations haven’t really changed that much. The “new” is mostly the interpretive guidelines, and we need to make sure we’re meeting the surveyors’ expectations and delivering quality care. What we don’t need to do is pile on more policy and procedure, documentation, and QA monitoring until we’re sure that’s where we’re coming up short.
       Every facility’s DON role is different and often defined by the individual in the position, as are the management positions in the department. My Assistant DON (ADON) and I had worked together

Table 1

in the last facility and determined how we would run day-to-day operations. Upon arrival at the new facility, we knew that needed some tweaking, so we defined and outlined our roles and responsibilities (see Table 1).
       We did have the opportunity to do some homework prior to coming to the facility. We reviewed Quality Indicators (QIs) and Quality Measures (QMs) and met with management in the department as well as the Executive Director. Resident falls in the skilled care area were an issue and not proportional to the census and staffing patterns. The numbers were astounding; for example, there were 27 falls in 28 days in February of 2006. This was the place to start.

The Problem

       So what was the problem? We needed to find out, and so we set our sites on fall reduction as our first major goal. We met and talked with the staff as we made rounds in the Health Center. We observed the residents looking well cared for, the staff attentive, the doctors responsive. Fall-prevention practices (eg, alarms, mats, new patient lifts, etc.) were in place. The facility had the same policy and procedure as our prior facility did, so what was the difference? We quickly identified the following areas that we felt were major contributing factors:
• Apathetic and uninterested staff. We identified staff as not being utilized in the problem-solving process.
• Absence of management (not literally). Staff members were not given clear direction or held accountable for their performance.
• No sense of urgency. We would hear alarms ringing and see no one moving quickly to answer them.
• Layering incompetence. For example, there were four nurses and seven CNAs on the day shift for a census of 37 residents. Similar over-staffing was found on the evening and night shifts. The job was not getting done, so evidently more staff was added (under the mistaken assumption that it was numbers, not performance).
• Weak interdisciplinary team participation. This facility was fortunate to have an entire rehabilitation staff on site employed by the facility, as was the registered dietitian (RD) and a full-time nurse practitioner (NP). They were, however, extremely underutilized in the day-to-day operations.
       The staff was trying to be nice, and we knew they were sizing us up as we were them. One can only assume the staff was thinking: “Not only do we have a new DON, we have a new ADON as well. What kind of changes are ahead? What more will we be asked to do?” These questions had to be running through their minds. More than a third of the staff was employed by the facility for a long time (ie, more than five years). Eight nurses had been here 10-15 years. Many CNAs were here for 10-40 years. We knew they wanted to be here. Maybe this was just one more DON and ADON that were going to come in shake everything up only to leave in a short time, they might have thought. They had survived more than a handful of DONs and other managers in their time here. (How’s that go? Outwit, outsmart, and outlast?) They were still here. One can understand the apathy we observed; we had heard staff members were on eggshells worried they would be fired. They were, naturally, worried because there had been management changes. Fear abounded.

The Plan

       Our expectations were high, and that needed to be communicated clearly to all of the staff. We decided to bring the staff together for a meeting that would deliver the message of how things would be done going forward. We needed to heighten the awareness to the seemingly obvious issue of multiple falls. We asked the staff for their input on how we can reduce falls. It was apparent this was not how things had been done before. The staff seemed hesitant to share ideas. We wanted to foster a team approach to the problem. We knew some staff members who were not committed and that it brought the team morale down. We refused to be held hostage by poor performance and made this abundantly clear to all staff. It became clear which staff members were not a good fit.
       We knew we needed to thin the herd. For example, one evening we stayed to observe the responses to call bells and alarms. It was quickly noted that an alarm was sounding and that four staff members nearby did not respond with any sense of urgency. We spent that Friday evening with each of these staff members to convey and set our expectations. Our simple method with any disciplinary action:
1. State what happened.
2. State what should have happened.
3. State what will happen if it happens again.
       We find this method effective. For example: “Kim, an alarm sounded and we observed no sense of urgency on your part to check on the resident. We would expect that when an alarm is sounding, every staff member respond in a timely manner with a sense of urgency. Should we find in the future that the alarms are not answered promptly, we will start progressive disciplinary action.”

The Results

       The dramatic decrease in falls was immediate and sustained. We were amazed and pleased with the change. For the next several months, the fall rate decreased to a level proportionate to our census.

Figure 1

For example, we started working at the facility at the end of March 2006. The fall rate for April was eight and May six for a census of 37 residents. In September of 2006, we had a total of five falls, and our census was then in the low forties. Most recently in June of 2007, we had seven falls with a census of 43 residents. We’ve had our ups and downs as most facilities do, but we’ve definitely moved in the right direction (see Figure 1).
       In addition to our census increasing and our number of falls per month decreasing, we changed our staffing patterns by addressing poor performers and hiring thoroughly screened employees who care. We can teach someone to provide care, but we can’t teach someone to care.

The Bottom Line

       The bottom line is your staff is your richest asset and should be treated as such. Happy employees know what you expect of them. You have to get to know them as individuals and respect them. Keeping them interested is the key to your success. If they’re kept abreast of the issues you’re working on and involved in the process of improving them, they’ll feel part of the problem-solving process. Always praise the positive and give any attempt at problem resolution the attention it deserves. Encourage employees to give you ideas on how to improve performance on the unit. Be fair and consistent. Employees want to know they matter as much as the next, and if you’re consistent with this, they respect it.

Table 2

       In order to achieve this kind of participation, you must always make yourself available. Saying you have an “open-door policy” is not enough. Employees must feel confident that you value what they say. Addressing poor performance immediately is important. If you let things go and don’t address them right away, you lose momentum in building relationships with the good performers. They do keep track, so it’s important that you do, too. Praise good performance on the spot; praise loses its effectiveness if not done when the employee and others are mindful of the act. Be present, not just physically but mentally, and not just when problems arise. Employees want to know you’re involved in the day to day and are aware of their attempts and successes at problem resolution. If you assign a project or task to an employee, make the time to let him or her know you’re aware it was completed, and thank them. This keeps employees motivated. Employees want to know you’re paying attention to their performance.
       Encourage questions and be responsive to staff ideas and concerns. We’ve all been in the situation where you bring a problem to your boss’s attention and he or she says it will be taken care of. Following through is crucial to building trust with your staff. Being honest with your employees will show that you respect them.
       We all know there are some issues that cannot be resolved quickly. Communicating the progress or lack there of is appreciated by the staff. At least they know you’re working on the problem. We all experience setbacks. If you’ve been in long-term care long enough, you know problems will arise again. Be willing to try new things and communicate that if it doesn’t work, you’re willing to try something else. Sometimes managers are afraid to implement something new for fear that it won’t work. Just do it. If it doesn’t work, try something else. When things don’t go as planned, don’t blame. Learn from the mistakes and try another approach. Education should always be your first approach when problems arise. We always take the approach that perhaps the employee did not know or understand why something happened. But repeated mistakes or poor performance need to be addressed in a timely manner, as this is the type of thing that brings team morale down.
       CNAs are often treated like children and not utilized as the rich resource that they are. Interdisciplinary teams often include all members of the professional staff, for example the rehabilitation therapy (eg, physical, occupational, and speech) services, the RD, the NP, nurses, nursing management, the social worker, the activities director, and the dietary manager. They don’t, however, automatically include the person who spends the most time with the resident—the CNA. Especially with culture change, this is not the norm, but it still exists in many facilities. We all need to mindful that CNAs are a wealth of knowledge on our residents. We need to encourage them to talk directly to our interdisciplinary team members and participate in the meetings. Traditionally, every concern the CNA has goes to the charge nurse, and the information is disseminated to the other team members. Encourage direct contact in addition to notifying the charge nurse. This empowers the CNA to directly assist in meeting a resident need, bringing him or her some satisfaction. Job satisfaction is at an all-time high when employees know they make a difference and feel that they’re valued. These principles can be utilized to assist any team in achieving desired goals and outcomes.
       Lastly, DONs are sometimes led to believe that working the floor will help them develop a rapport and earn respect from the staff that they supervise. But the DON’s job is vastly different from that of a nurse who delivers direct care on the floor. The DON’s job is to have a view of the big picture at all times. It is impossible to have the big picture when you’re in it. When DONs are promoted from within, it’s often an easy transition from the office to the floor. But as you move from place to place, this is not always the case. Some DONs are tempted to jump in and work the floor to get an immediate fix on the current problem. This fix is temporary. Every successful team needs a capable and competent leader with responsibility for the overall team’s performance.
       To use an analogy, compare the DON’s role to that of the head coach of a football team. The coach at some point in time was a player and therefore has a thorough understanding of how the game is played. Moving forward, his leadership abilities were recognized, and he became a coach. The coach is responsible for recruiting the best players for all positions, ensuring they are competent and educated for their roles on the team. This includes building an adequate bench for times when substitutes are needed. So think of it this way: In a professional football game, when the field goal kicker gets hurt, who goes in to kick the field goal? It’s not the coach.
       DONs take the time to thoughtfully and strategically fill your bench with great players to back up for you when needed. If you do, your team members won’t be looking for you to jump in and play. They’ll be happy that they have a great team of good players willing to pitch in wherever the team needs them.

Conclusion

       We encourage you to include your staff members when problems, no matter how big or small, occur in your department. Remember: employees respond better to helping solve a problem rather than being handed another policy or procedure. Your role as the leader is to empower your staff to help in decision-making. Content employees stay with you, and in this business continuity is essential to your success.