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Healthcare Training Institute - Quality Education since 1979

Instructor’s Guide
for CD Inservice Training

Table of Contents | NCCAP/NCTRC CE Booklet | Administrator Post Test

Introductory Commentary
Activity Director and Staff:

Wouldn’t it have been great if you could have purchased this Manual and CDs and have them act like a magic wand to gain support for your program from all staff in your facility?  I mean, seriously, just think for a minute.  Aren’t we all hoping for some magic that will instantly make our jobs easier regarding providing appropriate quality activities for each and every resident in our facilities?  Magic is great.  Let’s see.  How could it work?  You could merely ruffle through the pages of this Manual and a magic powder could be dispersed, which instantly permeates its way through every corridor in your facility, putting smiles on all staff members’ faces and making words like “Yes, I will do that” come out of their mouths.  Be honest with yourself.  When you purchased this course dealing with gaining staff support, at a certain, perhaps unconscious level, isn’t that what you were hoping for? 

Here’s the problem.  If in the back of your mind you have unrealistically high expectations for this material, that it will somehow magically resolve your support issues with little or no effort on your part, you may as well stop reading right now.  Why waste your time?  You can return the course for a full refund, so you are not out any money.  And most important of all, you are not out the time you would have wasted playing the CDs and reading this Manual.  So take about ten seconds and be honest with yourself.  Are you expecting magic?  Have you already decided this course belongs in the trash can?  Is it just another worthless piece of literature you have purchased that doesn’t know your residents in your facility, and certainly doesn’t know your staff and the kind of challenges you face in gaining support?  The ball is in your court. What do you plan to do?  Continue with your unrealistic, pie-in-the-sky expectations that will let you off the hook and put another “notch in your belt,” so to speak, to proclaim another unusable, impractical approach that “won’t work in my facility!”  Take ten seconds and think.

Did you take the ten seconds, or did you just read on?  Here’s my point.  Since I wrote the course, I happen to know this is probably the most concrete, practical material written to provide you with specific how-to’s regarding your getting support for your Activity Program.  In the pages of this Manual, and on the CDs, when you finish, you will have a whole truckload of very specific things to do regarding getting support.  However, unless you are Bill Gates and have a photographic memory, reading through this Manual once and working through the exercises once will be tantamount to, or the same as, hoping for magic fairy dust.

Here’s the way it works.  What you get here are a lot of really, really good ideas.  Why are they really, really good?  Not only because they work, regarding getting staff support, they are presented to you in enough specific detail and provide you with numerous quotes of scripts to use with staff.  In short, I not only tell you what to do, but I tell you exactly how to do it.  I try to make getting support in your facility as simple as I can, by providing you with as much specific, step by step information as I can. 

Here’s your challenge.  And if you are hoping for magic fairy dust, this is where your bubble will be burst.  These ideas are simple, but they may not be easy for you.  How long have you worked in your facility?  Two hours?  Two days?  Two weeks?  Two months?  Two years?  If you have been in your facility for two years, you have established a pattern of communication with other staff members over that two-year period of time.  Thus, these simple ideas may not be easy for you to implement, because you have built up a habit or pattern of interaction with certain unsupportive staff members.  Thus, prior to purchasing this course, since you were not sure how to gain their support, you ignored their actions, and thus have created a pattern of communication accepting their lack of support.  In the closing commentary I will talk about courage, because courage is exactly what it may take to break out of established ways of interacting with staff, which in the past has shown your acceptance of their lack of support.

By the end of this course, you will have the tools you need to gain staff and department head support.  However, it is up to you to add the courage it may take to interact with certain staff members differently than you have in the past.

Independent Training Tool:  The purpose of Part I is to facilitate your providing an Independent Inservice Training to Activity Staff. By “independent”, I mean the Reproducible Inservice Training Note Taking Booklet and CD are coordinated in such a way as to enable you to give the booklet and CD to an Activity Staff member for them to listen to and complete independently. 
1. You might assign them the listening to of one or two tracks per training session to accommodate their schedule. 
2. By their listening to the CD independently, you are not repeatedly taking your time for this training. 
3. The trainee is instructed to pause the CD frequently to allow time to write answers to the questions below, which appear in their Note Taking Booklet.
4. The content below contains the answers to the questions presented in this Reproducible Inservice Training Note Taking Booklet.
5. This Instructor’s Guide facilitates your discussion with Activity Staff following their listening to pre-assigned CD Tracks and completion of that portion of the Note Taking Booklet.

CD Track #1
Two Magic C’s to Get Your Administrator’s Support

What are three specific areas relating to support for your program?
1. Surveyors look for all staff to be involved in the provision of activities
2. Medication, shower, and therapy treatment schedules are to be scheduled in such a manner as to accommodate residents’ attendance at activities
3. Surveyor guidelines specifically reference the need for residents to be transported to and from activities

Who are the key individuals in your facility from whom you need support?
1.
2.
3.
4.
5.

Here are six quotes from the surveyor guidelines regarding activities that you can use to build your case.
1. "All staff are responsible for providing activities." 
2. "Activities can occur at any time and are not limited to formal activities being provided only by activities staff, and can include activities provided by other facility staff, volunteers, visitors, residents, and family members." 
3. "If not contraindicated, time the administration of medications, to the extent possible, to avoid interfering with the resident's ability to participate or to remain at a scheduled activity." 
4. "Transport for residents who need assistance to and from activities should be provided." 
5. "The facility may need to consider accommodations in schedules, supplies, and timing in order to optimize a resident's ability to participate in an activity of choice." 
6. "Altering a therapy or bath/shower schedule to make it possible for a resident to attend a desired activity that occurs at the same time as the therapy session or bath is recommended." 

Sample CMS Guidelines to Present
to your Administrator and Director of Nursing

Even though they are aware of these, you are in a more knowledgeable position to make Culture Change requests when you have the printed word of CMS substantiating the validity of your request.  Search Google for updates.

F248 INTENT: 483.15(f)(1) Activities
“Non-traditional Approaches to Activities
Surveyors need to be aware that some facilities may take a non-traditional approach to activities.  In neighborhoods/households, all staff may be trained as nurse aides and are responsible to provide activities, and activities may resemble those of a private home.  Residents, staff, and families may interact in ways that reflect daily life, instead of in formal activities programs.”
   -“Activities can occur at any time, are not limited to formal activities being provided only by activities staff, and can include activities provided by other facility staff, volunteers, visitors, residents, and family members.  All relevant departments should collaborate to develop and implement an individualized activities program for each resident.”

   -“Some medications, such as diuretics, or conditions such as pain, incontinence, etc. may affect the resident’s participation in activities.  Therefore, additional steps may be needed to facilitate the resident’s participation in activities, such as:
   -“If not contraindicated, timing the administration of medications, to the extent possible, to avoid interfering with the resident’s ability to participate or to remain at a scheduled activity; or
   -“If not contraindicated, modifying the administration time of pain medication to allow the medication to take effect prior to an activity the resident enjoys.”
   -“Transporting residents who need assistance to and from activities (including indoor, outdoor, and outings).”
   -“For the resident with varying sleep patterns, activities are available during awake time.  Some facilities use a variety of options when activities staff are not available for a particular resident: nursing staff reads a newspaper with resident; dietary staff makes finger foods available; CNA works puzzle with the resident; maintenance staff takes the resident on night rounds; and/or early morning delivery of coffee/juice to residents.”

CD Track #2
Developing Clout with Nursing

Why should you meet with your administrator before scheduling a meeting with your DON?
Meet with your administrator so that you can indicate his or her support when you tell the DON the specifics of what you need to have happen in order for your department to be in compliance with federal guidelines.

Rate on a scale of 1-10 how likely it would be to get the following response from your DON if you have not met with your administrator first.  1 indicates highly unlikely, 10 indicates highly likely.
"Well, you know we were short-handed yesterday.  So that's why Mary Sue the CNA on A-Wing just didn't have time to transport Esther.  And you know, those shower schedules are set and we just have to take the residents when it's their time for a shower.  We're so short-handed!  How can my CNA's be expected to have time to give yarn winding to a resident?!"

1          2          3          4          5          6          7          8          9          10

What four points should you include in a brief document regarding Culture Change guidelines to hand to your DON during your initial meeting?
1. Transporting residents
2. CNAs doing activities with residents
3. Shower, medication, and therapy schedules coordinating with residents’ attendance at activities
4. Any other guidelines which you feel require the support of nursing

CD Track #3
Conquering your Conflict Avoidance

What kind of relationship do you have with your administrator?  Your DON?

Who is a staff member who you are uncomfortable around?

Do you feel fearful when there might be a potential for conflict with this person?

Envision your administrator.  Let's give your administrator the name Mr. Smith.  If your administrator is a female, you might transpose this in your mind to Ms. Smith, and change my pronouns from he's and him's to she's and her's.   Envision where this meeting will take place, perhaps with your Mr. Smith sitting behind his desk, and you in a chair across from him.  You have been smart enough, as mentioned on the previous track, to of course schedule an appointment with your Mr. Smith.  Next, imagine how you are feeling before you start this conversation.  Envision this scene seated across from your administrator, ready to discuss activity department compliance with federal guidelines. 

How did you feel before you started this conversation regarding activity department compliance with your administrator?  Nervous?  Anxious?  Afraid?  Even nauseous?  Or happy, relaxed, and at ease? 

The Two-Screen Technique
Think back to a time when you had a conflict with the first people in your life whom you viewed as authority figures.  Describe this incident:

Envision one scene of conflict from your past on the left side of your TV screen, perhaps with a thin line dividing the left and the right half.  Then on the right side of the screen, envision at whatever angle you would like, your future meeting with your administrator.  Now, envision your television screen. 

Create a statement based on reality using the word “not”:

Create a statement of reality, in other words facts about the present:

Envision the split screen with your photo of a past conflict on the left, and perhaps a live videocam shot of your future meeting with your administrator on the right.  State the "not statement" that the person on the left, using his or her name, is not your administrator.  Then, create a reality statement.  Repeat this until you are comfortable.

CD Track #4
Priorities & Strategies for Your Wish List

What are the three steps in attainting staff support that have been covered so far?
1. Meet with your administrator to clarify his or her ideas concerning Culture Change compliance
2. Acquire a hard copy of CMS Guidelines
3. Meet with your DON and provide him or her with a copy of the CMS guidelines

What are three criteria you might use to set priorities for your wish list?
1. The resident who is the most in need
2. The easiest victory first
3. The least supportive staff member first

What are your priority goals?
1.
2.
3.

Sample Format for a Listing of Residents to be Transported

How might you acquire the names of the charge nurses?

Record the names of the charge nurses below:

CD Track #5
How to Get ‘Em to Follow Through!

 Step 1: Set your request

Step 2: Discharge negative emotions on a regular basis

Step 3:  Know what you will say

One wish list item for which you have noticed a pattern of noncompliance:

Below, create a list of incidents of noncompliance to present to your DON:

Step 4: Practice or rehearse your presentation to the DON

Step 5: Meet with your DON to cooperatively create an action plan for compliance

Step 6: Repeat steps 1-5 until you get compliance

CD Track #6
Five Ways to Gain Respect

What can you convey by maintaining positive eye contact?
By maintaining eye contact, you communicate respect and interest in the other person, respect and interest for your own message which you are conveying, and respect and interest for the ideas of the other person.

What two things can you achieve by directly facing the person you are speaking to?
1. Establish an effective line of communication
2. Show interest in the other person, which make them more receptive to your own needs
How might a staff member perceive you if you stand too close during a conversation?
The other staff member might perceive you as threatening

If you stand too far away?
The other staff member may see you as unsure, insecure, and threatened, which can create an atmosphere of distrust

Record a pleasant or happy memory that can help you achieve an inner smile:

What three things should you consider when assessing a recording of your own voice?
1. Tone
2. Inflection
3. Volume

CD Track #7
Getting PT, OT, and Speech Schedule Coordination

Name a therapist or other staff member who intimidates you:

An opportunity to be casually friendly:

Write a statement of what you are not intending:

What are the first three steps in establishing a relationship with one of the Therapies or another staff member?
1. Schedule a meeting
2. Provider him or her with a hard copy of the guidelines regarding the alteration of therapy schedules to make it possible for the resident to attend activities
3. State empathy with his or her situation
4. State what you are not intending

CD Track #8
Grumbling, Complaining, & Over Apologizing

What is the first criterion to think about when considering a department head's or staff's positive or negative reaction to your requests for change?
How your request appears to them.

Think of a specific staff member.  How might your requests regarding optimizing a resident's ability to participate in an activity of choice may look to that staff member, if not presented in light of regulatory guidelines?

What is the first unsupportive reaction you may receive?
Grumbling, the staff member may comply with your request and is not openly aggressive to you at the time, but begrudges, resents, and grumbles about you, either to your face or to others.

Which staff members may grumble when you request a change?

What is a second unsupportive reaction you may receive? 
Guilt trips or complaining

What is a third unsupportive reaction you may receive?
Over-apologizing

What is an effective way with dealing with this third unsupportive reaction?
An effective way of dealing with an over-apologizer is to let them know that you aren’t upset at them, and they don’t need to feel so sorry about an issue which has already happened.

What is a fourth unsupportive reaction you may receive?
Revenge

CD Track #9
6 Proven Steps to Getting Cooperation

Name a resident you wish transported:
The CAN involved:
The staff member you will approach if the resident is not at the activity:

What are the five steps regarding what to do when staff does not follow through?
1. Timing your request
2. State your observation in a factual, friendly manner
3. Active listening
4. State the reasoning or “why” behind your request
5. State your expectation
6. Escalate

CD Track #10
Levels of Emphasis

“Do I pout, give negative looks, or slip sarcastic remarks into conversations about other departments when they do not comply with my requests?” 

“When the other staff member’s behavior doesn’t change, do I get angry and perhaps end up acting more aggressively than what I wish I would have?” 

What is Emphasis Level One?
Being Understanding.  Being Understanding occurs when you make your request in a civil tone of voice, giving the other staff member the benefit of the doubt, assuming the best about them.  You assume the best both regarding their intentions as well as their reaction to your request. 

Write an example of how you might use Emphasis Level One:

What is Emphasis Level Two?
Repeating followed by Deflecting: at Emphasis Level Two, you add a slightly more serious tone to your voice.  You may want to ask for a response at Emphasis Level Two so you can figure-out why the other staff member did not comply with your request the first few times when you were understanding.

What is meant by Deflecting?
Deflecting is a two step process where you precede your side of the situation with an acknowledgement regarding what the other staff member said.  After acknowledging the other staff member’s side of the situation, you then restate your request.

Write an example of a Deflecting statement:

Write an example of complete statement you might use at Emphasis Level Two:

What is Emphasis Level Three?
At Emphasis Level 3, the Advising Level, the motive is to advise the other staff member so they can make an informed decision whether they wish to comply with your request or to continue partial or total noncompliance.  Telling the other staff member ahead of time, rather than springing the consequence on them without advising them first, is actually doing them a favor, and this needs to be reflected in your attitude. 

Sample Advising Statements:
State, “I feel uncomfortable that Mr. Jones is under the impression that his Activity Department is making headway complying with CMS guidelines.”  At this point, you might add:
#1. “I’m not sure what to do.  Do you think I should talk with him?”
or #2.  “I feel he needs to be made aware of the situation, and I would like to schedule a meeting with the three of us.  When is a good time for you?”
or #3. “I know you have had a hard time of it this month.  But I feel I am in a real bind, because right now, Rebecca, I feel like I’m not doing my job. 

Write an example of a statement you might use at Emphasis Level Three:

CD Track #11
Obstacles to Gaining Staff Support

What are the two main pay-offs for not being assertive?
1. safety
2. praise

What are the pay offs or rewards if you act non-assertively and do nothing if the resident is not transported?
1.
2.
3.

What possible reason do you have for rocking the boat in your facility?

What is catastrophic thinking?
Catastrophic thinking occurs when you work yourself up to thinking a situation is much worse than it is.  When you catastrophize, you are always asking yourself “What if…?”, and scaring yourself with irrational, worst-case-scenario answers.

What is the worst thing that could happen when you request a change in your facility?

What forms of catastrophic thinking can you recognize in your thought habits?

CD Track #12
Overcoming Uncertainty

What are four types of powerlessness statements?
1. False uncertainty statements
2. False inability statements
3. Faultless apology statements
4. Self-mocking statements

What phrase is associated with each type of powerlessness statement?
1. “I think”
2. “I’ll try”
3. “I’m sorry” for something you didn’t do, or was out of your control
4. “I’m so stupid”

Do any of the four types of powerlessness statements apply to you?  Which ones?

What changes in your pattern of speaking might you consider?

CD Track #13
Commit to Change

What are three questioning concerning the first step in your commitment to change?
1. What is my goal?
2. What do I have to do to get it?
3. Am I willing to do it?

Below, write your answers to each question:
1.

2.

3.

What is the second step in your commitment to change?
Become successful at becoming imperfect.

CD Track #14
6 Steps to Success

Step 1: Observation

Sample Staff Support and Cooperation Log:

What is a staff support Situation that occurred today and who was involved?

What was your attitude and that of the other staff member involved? 

What was my behavior and that of the other staff members?

What do you feel were some obstacles involved? 

Has there been any progress with this person?  Or how would I define the problem? 

Step 2: Setting Goals

Staff you feel may be dismissing you:
1.
2.
3.

Small goals to maximize my chance of success with this staff member:
1.
2.
3.

Step 3: Concentrating on a Specific Situation
Describe how you handled a particular incident in which you feel you did not receive support:

Step 4: Reviewing Responses
How did you react in the incident you described above?  What emotions did you feel?

How did the other staff member react?

Step 5: Observe an Effective Model
Who will you observe? 

What can you learn that fits your style of relating to people?

Step 6: Alternative Responses
What are some alternate responses to the situation you described above?