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Healthcare Training Institute - Quality Education since 1979

Section 9
Track #9: 6 Proven Steps to Getting Cooperation

Table of Contents | NCCAP/NCTRC CE Booklet

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Note-Taking Exercise

Name a resident you wish transported:

The CNA involved:

The staff member you will approach if the resident is not at the activity:

What are the six steps regarding what to do when staff does not follow through?

1.

2.

3.

4.

5.

6.

Transcript of Track 9

On the last track we discussed four unsupportive reactions you may receive.  They were grumbling; attempts at guilt or complaining; over-apologizing; and open revenge.

So what happens if Ella is not transported to the activity?  What do you do if the list you posted at the nurses' station is ignored?  The person you approach next is determined by the size of your facility, the organizational structure, and your personal relationship with the noncompliant individual involved.  In this case, the CNA Julie.  If you have an informal structure in your facility, approaching the CNA directly may be appropriate.  When you hear the musical tone, turn the CD player off, and think of a resident you wish to have transported, the CNA involved, and who you would approach if your Ella is not at the activity.  Julie the CNA?  The charge nurse?  The director of nursing?  Who? 

Perhaps you have such a large facility and high turnover rate that you do not know the name of the CNA, which is mentioned on previous tracks as an additional goal for you.  However, for the purposes of my illustration, let's say you've deemed it appropriate to approach your Julie, who is your Ella's CNA.  Here's a six step method regarding what to do when staff does not follow-through.

The first step is timing, if your Julie is in the midst of, for example, catching a resident before she falls to the floor, clearly whatever you say will be met with a lack of receptivity.  Evaluate your Julie's facial expression, body language, and what she is doing.  Let's say, for example, that Julie is changing a bed.

The second step is, in a friendly factual manner, to state your observation.  Calmly say, with an even unemotional tone in your voice, “I noticed Ella was not at the Sing-a-Long this afternoon.” 

The third step is Active listening.

Another way to deal with lack of cooperation is Active Listening.  Active Listening is a process where, as the other person talks, you rephrase their statements to assure you understand their meaning.  Rephrasing what they have just said allows Julie the CNA, Misty the Charge Nurse or Ashley the Speech Therapist to know that you have heard them and understand what they are trying to tell you, or, if you misunderstand what they are saying, active listening allows the other staff member to correct your misunderstanding.  Conveying your understanding to the Julie, Misty, or Ashley in your facility helps them to become less defensive if they are feeling territorial about your request. 

Setting aside your own agenda of requesting a schedule change when you feel the Charge Nurse or Therapist is defensive or attacking, and listening-- I mean really listening can have a very calming effect to reduce their defensiveness.  Agree?

If you are not willing to listen, unfortunately, what usually happens is they get upset and the situation worsens.  When you actively listen, it helps you to stay calm, and it lets the other person know that you want to understand their side and work the situation out.  The key to active listening is simply to rephrase what you think they have just said.  You might state to the Speech Therapist, "So there is a grouping system you do not wish to disrupt for billing purposes."  Or to the Charge nurse, "So the person passing medications followed the old schedule once again, and thus gave Harvey his meds that make him sleepy just before the activity."  If they agree you have heard them correctly, what can you do about the situation so your department is in compliance with Federal Guidelines?  Present the other person with the facts.  You state, “If Harvey's or Lillian’s attendance records are analyzed based on federal guidelines, I will be out of compliance and could receive a deficiency.  How can you help me out here?  I know Mr. Smith, the administrator, has expressed a concern as well."  Now, the preceding may not be your style of communication with this particular staff member, but you can play this track several times and shift my suggestions around to fit your style and your relationship with the other staff member.  Remember from track one, that it is not you, the activity director, that is begging “Please change Lillian’s or Harvey's schedule."  If you become committed to playing each track of this CD set often, and taking the actions suggested or a version of these suggested actions that suit you better, then you have developed a position of influence by referencing Federal guidelines, as well as your administrator's interest in compliance with these guidelines.  Agree?

Let’s say, for example, Julie the CNA attempts to guilt-trip you by complaining that Ella's roommate was incontinent.  Great guilt trip, right?  I mean, how could you expect Julie to leave Ella's roommate in feces!  However, if you cannot come up with an answer for Julie's complaints or guilt trips as to why Ella wasn't transported, then you have conveniently created an escape hatch for the CNA, Julie, or the charge nurse or the director of nursing every single week not to comply with your request! As stated on the previous track, they may respond by grumbling, attempts at guilt or complaining, over-apologizing, and even open revenge.  What's your solution!?

Step four is state the reasoning or the “why” behind your request to, in this case, transport Ella while trying to create empathy in the receiver of your message.  The following sample, of course, will vary greatly depending upon your personality and your relationship with your Julie.  You might state using her name, "Julie, this puts me in a real bind.  Regulation guidelines state that nursing is to transport residents to activities.  Since Ella was not at the Sing-a-Long, I was unable to mark her attendance on my attendance record.  This creates a problem for me complying with her plan of care."  When you go to step five, do not allow Julie Pause to provide more excuses.

Step five is where you state your desired expectation.  Be friendly, firm, concise, and extremely clear. Obviously, since you have no official line of authority with the CNA, elect not to go immediately over her head by talking with the charge nurse or D.O.N. or administrator.  Continue by asking, "Are you on A wing tomorrow?"  If she indicates yes, state the facts of the situation by stating, "Ella is on the list to be transported to the lounge at 1:30."

#5 Broken Record
  So you're thinking, “what happens if Ella is not the lounge the next day either?”

Along with timing, stating your observation, active listening, and stating the reason why; use of the Broken Record Technique can be an effective method to gaining support.  Consider using the broken record technique when someone is dragging his or her feet in following through.   The term “broken record” refers to those old vinyl records before tapes and CD's came along.  If the record had a deep enough scratch in it, the same words of the song would play over and over again.  Well, that is what you need to do.  Repeat the above statements about compliance, the administrator interested in compliance, and the resident’s interest in attending an activity over and over again to the non-compliant staff member.  Repeat the message regarding compliance and administrative support with a calm, factual non-apologetic delivery over and over with the same calm inflection until the uncooperative behavior stops.  The next track outlines the Broken Record Technique in more detail.

If it does not stop, the other alternative is to decide at what level above them in the facility would be the next best step to ask for advice. 

This brings us to step 6, escalation. When escalated to a high level, after repeated lack of transportation, for example, the last step is to talk with the person directly above that staff member.  The care plan conference might provide a vehicle for this.  But then again, you are calling out, so to speak, the director of nursing in front of the other department heads, indicating CNAs are not doing their job.

Another higher level is your corporation.  Your corporation writes the CNA job descriptions and periodic reviews happen.   Think how different things would be if, when Julie, the CNA, was hired, she had been presented with an employee’s manual and written job description from her first day on the job, she is trained to transport residents to activities, and provide residents with individualized activities that have been left in their room after residents are dressed.  Charge nurse job descriptions suggest arranging shower and medication schedules to optimize attendance at activities, etc.  The periodic evaluation upon which CNA and charge nurse raise is based includes the preceding items.

An aside might be added here that Cathy Zugel, the author of this course, was an Activity Director that also had problems with CNAs transporting residents.  Cathy gave pieces of leftover birthday cake to the CNAs whether they had transported or not.  Some never did transport, but when new CNAs were hired, they saw the posted list and transported.  After two months of only the new CNAs transporting residents, two of the CNAs that had been there for years started transporting residents.  The moral of this story, don't set yourself up to fail by looking for instant results.  Change takes time.  Set small goals, one person at a time. 

On this track, we discussed three ways to deal with lack of cooperation:  timing of your request, stating your observation, active listening by rephrasing, giving the reason for your request; use of the Broken Record Technique by repeating your request, and escalating.

On the next track, we will discuss three risk levels.