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Healthcare Training Institute - Quality Education since 1979

Section 10
Track #10: Levels of Emphasis

Table of Contents | NCCAP/NCTRC CE Booklet

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Note-Taking Exercise

“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?

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

What is Emphasis Level Two?

What is meant by Deflecting?

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?

Sample Advising Statements:
State, “I feel uncomfortable that Mr. Jones is under the impression that his Activity Department is not 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:

Transcript of Track 10

Any time you rock the boat or the status quo, a certain element of risk is involved because you are unable to predict each individual staff's reaction.  The best track proposed is the Broken Record Technique. 

On this track, we will discuss three Emphasis Levels for tactfully requesting change.  Clearly, you will see this track is so content-dense that you will want to replay it several times, write scripts, and practice them in front of a mirror or with a partner at each Emphasis Level.  Since this track describes a core behavior change, you will need to take whatever steps you deem appropriate to make this level of Emphasis thought process second nature.

How can you tell what actions are necessary for what situations?   In other words, if 25% of the residents on your list are transported, when in the past none were transported, do you take action, or wait to see what happens next week?  How much emphasis do you place on partial compliance to your requests?

One method you might consider is to decided what level of Emphasis is appropriate.  In order to do this, you need to decide what is your bottom line of acceptable action.  For example, if you post a list of ten residents, and two are transported, is this acceptable to you?  There are no hard and fast rules here.  On some days, you may think two is great, and on other days two is unacceptable.  The crucial point here, however, is being extremely sensitive to your internal emotional barometer;  rather than waiting until your resentment has built up in you and your department, and negative emotions take over.  If you wait until it’s your last straw, you’re more likely to blow the situation out of proportion, express your exasperation to the other department head, and make the transporting situation, for example, worse.  Agree?

I feel because Administrators usually hire Activity Directors with strong Amiable-type personalities, Activity Directors oftentimes tend to be timid. Your timidity may start out by expressing your discontent non-verbally when, for example, the shower schedule is not changed.  By non-verbally, I mean ask yourself the following question.  “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 you get angry and perhaps end up acting more aggressively than what you wish you would have?” 

Assessing the right Level of Emphasis allows you to respond to a situation in a way that makes it more likely for you to get what you want, which is staff support and cooperation.  Assessing the right Level of Emphasis is a way of fine tuning the Broken Record Technique explained on the last track.

There are Three Emphasis Levels for making your request.  Emphasis Level One is 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.  In “being understanding” you can assume part of the responsibility for their noncompliance by stating, for example, “Perhaps it would help if I divided the list of residents’ names on separate post-its for each CNA.”  Or you can give them a way out regarding their noncompliance by stating, “I know Effie’s daughter was really upset at the time residents were to be transported, and she was talking to several CNAs when they were supposed to be transporting.”

When you hear the Music, turn your CD player off, and role play in your mind your use of  Emphasis level one, being understanding, when your request has not been acted upon. 

Emphasis Level Two is Repeating followed by Deflecting.  Emphasis Level Two is used when staff members do not cooperate with the request you set at Emphasis Level One. If you recall, in Emphasis Level One, you gave the department head the benefit of the doubt. Using Emphasis Level Two instead of giving up or reacting in anger, you simply repeat your request to the other staff member, and of course you remain polite.  However, 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.

 At Emphasis Level Two, you recap the history of your request.  You might state in a calm, matter-of-fact tone, “For the past three Wednesdays, I have sent an email and put a post-it at each nurse’s station providing the list of residents to be transported by the CNA responsible for them.  However, Sara was the only nursing assistant of the four that transported the two residents she had on her list.”

After repeating your request and recapping the history of your request, you may need to deflect arguments or excuses the other department head or staff member may come up with.  Deflecting is a two step process where you precede your side of the situation with an acknowledgement regarding what the other staff member said.  This acknowledgment is described in detail on the previous track and is called active listening.  After acknowledging the other staff member’s side of the situation, you then restate your request.  The main purpose of acknowledging or repeating what the other staff member said, by repeating what they said, you short circuit their excuse-making.  However, by acknowledging or repeating their side of the situation, you are not conceding the validity of your request.  In short you don’t get bogged down in a discussion regarding reasons why they did not comply.  So when they say “we were busy and short” the first words out of your mouth are, “yes, Rebecca, I know you were busy and short that day.”

By repeating their excuse, you simply avoid their entire point and restate your request for residents to be transported; or the schedule to be changed; or the CNA to provide the activity.  After you repeat their excuse, you may need to deflect.  Deflecting is particularly effective when the other staff member tries to discount your request, by saying something like "Oh you’re just making a big deal over nothing."  You can deflect by saying in a calm, even, unemotional tone, “It may seem like ‘not a big deal’ to you, however I don’t want my department to receive a CMS deficiency.” 

Deflecting can also help when the other staff member gives you reasons for their behavior, like “We’re too busy and working short-handed”.  As mentioned earlier, first acknowledge by repeating their “busy and short” excuse.  You can then deflect the “busy and short” litany by stating, “You may see this transporting, schedule change, or activity involvement as being not as important as resident care tasks, however I see it differently.”  Then, repeat your request.  You state in a calm, even tone, once again, “Sara was the only nursing assistant of the four that transported the two residents she had on her list.  Is there something I can do differently to get residents transported, schedules changed, or CNAs involved in activities?”

When you hear the Music, turn your CD player off, and role play in your mind your use of Emphasis Level 2, repeating their side of the situation followed by deflecting or stating your side of the situation, when your request is not acted upon. 

Level of Emphasis 3 is Advising.  After Emphasis Level One, Being Understanding, and Emphasis Level Two, Repeating followed by Deflecting.  a more serious and emphatic Emphasis Level is Level Three.  Most staff support, ideally, can be acquired at Emphasis Level One or Two.  However, sometimes, as we all know, words are not enough, and action is called for.  At Emphasis Level Three, you let the other department head or staff member know what you will do if they don’t change their behavior.  This Advising Level, however is not a threat, because your motive is not to scare, or strike fear into the heart of the other staff member, trying to intimidate them into making the change you requested.  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.  It is crucial you convey in your words and manner of speaking that they are backing you into a corner and are leaving you with no choice.  Basically, you’re giving them a last chance to modify their behavior.  For example, you state to the director of nursing, “Rebecca, we’ve talked about these issues for the last two months.” Then at this point, you need to state very, very specifically, exactly what “these issues” are, using staff member’s names, and exact areas of noncompliance.  For example, you state, “I have only seen one CNA, Sara, give an activity that has been left in the room to a resident.”  Be sure you have notes with dates, times, and lists of residents and staff members as appropriate.  Don’t rely on your memory.

Next, 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. 

Another course in this series is entitled, “Facility Team Work, ‘The Impossible Dream”: How to Make it Come True!”  If you have taken this course, you will know the best approach depending upon whether your director of nursing’s teamwork style that of an amiable, driver, analytical, or expressive.  If not, use your gut-level feeling regarding which approach feels the most appropriate.

 Be careful, however, not to say you’re going to do something you never end up actually doing.  If you don’t follow through, Rebecca will know that you don’t mean what you say, and she will definitely feel freer to continue to ignore your requests in the future.  Agree?

When you hear the Music, turn your CD player off, and role play in your mind your use of Emphasis Level three, which is Advising the staff member regarding your escalating their lack of follow through via informing a higher level in the facility, to use when your request is repeatedly not acted upon.  MUSIC

Creating a conscious awareness of these three Emphasis Levels does more than just help you to act wisely and make your actions escalate gradually as needed; it also improves your credibility, showing that your request for CMS Compliance is important to you, because it is important to your residents’ well-being.  Consciously applying levels of emphasis is especially helpful if you have in the past had a reputation for accepting a lack of follow-through regarding your requests. 

On this track, we discussed the three Levels of Emphasis.  The Levels of Emphasis were, Being Understanding, Repeating followed by Deflecting, and Advising.

What is the Gem of an idea that you received from this track?   This track is so content dense I am sure you will want to strongly consider replaying it more that once to actually implement some of the specific techniques suggested.  Remember just listening won't change anything related to your goal of gaining cooperation from staff.  So when will you replay this track?  Turn the CD Player off and write “replay track 10” in your planner now. 
                                                                    
On the next track, we will discuss obstacles to gaining staff support.