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Healthcare Training Institute - Quality Education since 1979

Section 5
Track #5: How to Get 'Em to Follow Through!

Table of Contents | NCCAP/NCTRC CE Booklet

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Note-Taking Exercise

Step 1: _______________

Step 2: _______________

Step 3:  _______________

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: _______________

Step 5: _______________

Step 6: _______________

Transcript of Track 5

On the last track'', I suggested you create a priority wish list for staff support from your director of nursing.  But what happens if, or when, there is no follow-through?  The CNA is not giving yarn-winding to the resident she has just dressed, the charge nurse is aware that you or she has posted a list of residents to be transported behind the nurse's station, but your list of residents to be transported is ignored;

So now you are in what you may term the "uncomfortable position" of requesting more follow-through. 

What you can do next is actually a 5-step process for getting the next layer of follow-through that you want.  These steps are:  Set Your Request, once again Get Support, Discharge Strong Emotions, Know What You Will Say, and Debrief.

Technique:  Maintaining Boundaries
Here is how these five guidelines worked for Wendy, regarding her request for further follow-through

The first step is to set your request. When talking with or about someone who has not followed through, you need to be clear about the nature of the lack of follow-through. 

Casually, talk to the CNA first, and ask a question.  "Could you give Lillian the yarn-winding that's here in this bag taped to her night stand, after Lillian is dressed?"  Or, how about saying this?  "I noticed Henry was not at the sports discussion group."  The CNA replies, "Oh, gosh.  He really didn't want to go.  Plus, we're short-handed, and I didn't have time to take him."  Or how about this reply, "Honey, you can't expect shower and medication schedules to accommodate your activity program!"  Now, several weeks have past since your meeting with your administrator and director of nursing.  You have, in a low-key manner, mentioned, or stated on several occasions your request to the CNA and charge nurse regarding the preceding

The second step is to, on a regular basis, discharge negative emotions that may be accumulating.  You may have self-talk like, "They know what they're supposed to do!  I told them several times!  They're just not doing it!  I'll receive deficiencies at survey time!  Plus, several residents are becoming more disoriented due to lack of stimulation!"

 It’s no use to confront someone while angry, especially an administrator or someone of authority or CNA or charge nurse or anyone, as far as that goes, especially if you're seeking support.  Would you agree?  That’s why you must get rid of your feelings of anger or frustration or even hurt by talking them out with a friend or writing them down, whatever works best for you, maybe punching a pillow at home. Once you are calm and ready to fix the problem, instead of just getting mad at it, you can now take tactful action.  Kind of a nice phrase, isn't it?  Tactful action.  Say that with me, three times.  Tactful action.  Tactful action.  Tactful action. 

So, after you have made your request and discharged negative energy, the third step is to Know What You Will Say.  By planning what you will say beforehand, you can avoid a variety of problems, from backing down to losing your temper.  Sound logical?  Having a mental script helps you to be truthful and get your point across, without downplaying your feelings or embellishing the lack of follow through.  Simply and respectfully state your problem and what you would like the other person to do to change the situation.  Be prepared to accept blame if you are in error.  For example, could the transport list be located in a different place at the nurse's station?  Be made larger?  Be organized differently?
 
Here's how you will know what to say.  Let's take one of the 3 wish list items previously mentioned.  After you notice a pattern of several CNAs not providing residents with activities, make a list of residents' names and the specific activity that has been left in their room, as well as the name of the charge nurse on that shift, or whomever is the level directly above those specific CNAs.  In addition to having your specific facts neatly listed, perhaps in a Word or Excel document, you will also be in a position of more clout, or power, if you have noted the days and the times that you have reminded each of these CNAs to provide the resident with the activity.  Go to your director of nursing, for example, and discuss a strategy for compliance with the request she had agreed in a previous meeting was important. Also, it might not be a bad idea to once again have a copy of the surveyor activity guidelines, in case she has misplaced hers.  Remember, your administrator, who is at the top of the nursing home pyramid, as stated in track 1, is motivated by the two C's of census and compliance.  Those regulatory guidelines are your best friend.  It is not you, Wendy or Karen or Cathy, the activity director, who is stating, "Lillian, Effie or Hester needs to be involved.  It is compliance with the federal guidelines."  So start off by saying something like, "I know we have a survey in six months.  I have a concern about activity department compliance."  Provide your D.O.N. with a copy of the guidelines once again.  However, this time, provide her with the list of residents, activities left in the residents' rooms and CNAs who are not providing residents with activities after they are dressed, etc.  Of course, some of this might be handled at a care plan conference, if appropriate.  But since you are calling out the nursing department for not doing their job, this might be a tactical error on your part to do this in front of other departments.  If you have a list of several residents, it's not like you're just singling out Susie, the CNA. 

The fourth step is to practice or rehearse your presentation to the D.O.N.  This meeting is extremely important to build this key cornerstone for activity program support.  Be sure to spend some time role-playing in your mind or with another person.  Prior to the meeting, be sure to visualize this meeting resulting in the most positive outcome.

The fifth step is to have the meeting with your director of nursing and ideally walk away with an action plan which is developed cooperatively with her.  After you have cycled through several of these meetings with your director of nursing, listing names of staff and residents, etc, I think after a while it will become apparent that CNA job descriptions need to be changed so that from their first day of employment, a CNA knows that doing activities with residents and transporting residents is part of their job.  Also, charge nurse job descriptions need to be changed so that shower and medication schedules are designed to accommodate residents' preferences for attending activities.  However, if you start off talking about changing job descriptions, it will be met with much resistance until people see a need.  That need is pointed out by YOU and the resulting lack of staff follow-through.  On a less grand scale than that of re-writing corporate job descriptions, perhaps the director of nursing could now request charge nurses sit in on your meeting with her.  You would then provide information regarding lack of follow-through by CNAs in a three-way meeting between yourself, the charge nurses, and the director of nursing. 

Step six is to repeat steps one through five over and over and over again until you get compliance.  If after several months you feel you are still just getting lip service from your director of nursing, who do you go to?  Of course, your administrator.  Your Mr. Jones is definitely highly motivated by complying with regulations.  You may have to outline with dates and times of meetings the steps you have taken to attempt to draw your department into compliance.  Also, the name-dropping of family member's names, as disgruntled family members' will probably stimulate additional motivation from your administrator regarding census, or having a filled facility.  Perhaps you might suggest the director of nursing sit in on the latter half of your meeting with the administrator.

So there you have it.  Do you see how you now are in a position of power, clout, or influence in your facility?  It took a while to get here, many months and several meetings, as well as listings of staff and residents' names.  So you have an administrator who is motivated by census and compliance, you have federal guidelines, you have lists of residents that needed transporting or room activities for residents to do; you have specific dates, times and names when you have reminded CNAs of what you have requested; you also have specific dates and times of your meetings with your director of nursing, and charge nurses.  Now there you sit in a three-way meeting between you, your administrator and your director of nursing.  In my opinion, your Mr. Smith has no option but to say to your director of nursing, "How can we get this done?  How can we support activities?"  Granted, this takes several months, but you have to do your part, and perhaps you are in one of those, non-profit homes where all staff will happily comply, and your past four to six months of meetings, lists, and requests are not needed.  But I have painted a course of action for receiving no compliance, because that has been my experience in numerous homes.  Of course, eliminate any of these steps as needed

Now that I've outlined a general game plan for you, so to speak, let's talk about some specific ways for you to polish your interactions with these key people.  Sound good?  The next track will deal with how you look to other people and how to present yourself in the most credible, professional manner.  You may already know this, or be doing it.  So consider the next track a review.