Case Study: Mrs. C
Mrs. C is 85 years old; she has lived at the Manor Nursing Center for about a
year. Lisa and Anne are the nursing assistants on duty on Mrs. C's unit today on
the evening shift, and Linda is the licensed nurse. Lisa and Anne know that Mrs.
C has recently learned that her daughter, who lives in another State, is seriously
ill. After the evening meal, Lisa notices that Mrs. C is not her normal self.
Usually talkative, she is suddenly not talking much. She is also limping for an
unknown reason and seems very upset and angry. Lisa tries to talk to Mrs. C but
doesn't get much response. When she arrives to help Mrs. C prepare for bed, she
finds Mrs. C already asleep on her bed, still in her clothes. When she wakes Mrs.
C up to help her change and wash before bed, Mrs. C seems disoriented and says
something rude to her.
What needs to be communicated? By and to whom?
How? When? Where? How do you know when the
communication has worked?
- What needs to be communicated?
- By and to whom?
- How do you know when the communication has worked?
In answering these questions, think about specific things that
specific people should do: What should Lisa do next? What
can Anne do? What can Linda the nurse do? Should Linda
call Mrs. C's attending doctor? What should they tell the
night shift licensed nurse and nursing assistant when they
come on duty?
Detecting and reporting changes in a resident's condition
are the centerpiece of high quality care, and they are key to making sure
residents are as well as they can be. In your work you probably notice changes
in, for example, a resident's behavior or ability to do certain things. This is very
important. Often, changes can be detected just because you notice something out
of the ordinary.
The next important step is knowing how and when to report such changes.
Reporting changes is necessary for quality resident care, and that means working
Reporting changes involves a number of skills, including:
- Communicating what you have noticed to other members of your care team.
- Working together with team members to identify what the change might mean.
- Working with team members to take action to make sure residents are safe and getting the care they need.
A Safe Environment
- Reporting changes helps keep residents safe.
- Learning and experience are what make safety possible.
- Openly reporting anything that might affect a resident's well-being is essential for a safe environment.
- Change in a resident's condition should be reported openly, whenever it happens.
Front-line workers often know the resident better than anyone else, even—insome situations—the resident's family. As the "eyes and ears" of the entire care team, your skills in recognizing and communicating changes in the resident's condition are extremely important. For these reasons, using your skills to communicate changes across the care team may be the most important thing you can do for residents.
Learning to effectively communicate changes in a
resident's condition also depends on the care team
working well together. So being a good team
member and helping others to be good team
members are also important when it comes to
When team communication is poor, people often
say they don't feel they are heard, especially by
their supervisors. So pay attention to them if there
are people who report to you. Make sure you are
listening and that they are heard and feel heard.
Good communication skills help team members work with others toward
the goals they share for good resident care, and this is how things get done.
Communication about care is one important way for team members to learn
about their roles on the team, as well as the goals and ways of working on the
team. Communication teaches team members how to come to agreement and
how to achieve common goals. Team communication has to occur from the
leader of the team to all team members and also among all team members.
Research shows that teams with better communication provide better care.
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Working Toward a Safe Environment
Reporting changes helps keep residents as safe as possible. Residents are most
safe—protected from harm or injury—when it is normal and accepted that care
providers openly report anything that might affect a resident's well-being.
Reporting Changes in a Resident's Condition
- Detecting and reporting change is essential to patient care.
- Reporting changes is necessary for quality resident care.
- Reporting involves the following skills:
- Communicating what you have noticed to the care team.
- Working together to identify what the change might mean.
- Working with the care team to take action to make sure the resident is safe.
Sometimes people worry about reporting a change because they feel that
something has gone wrong, and they wish it was not so. But, you must report
the change, since the resident cannot be helped if no one knows there might be a
Learning and experience are what make safety possible. This involves getting
information and seeing how things work, noticing when they aren't working
right and understanding how to prevent that from happening, and knowing how
to recover when things do go wrong. So an environment where people openly
report anything that might affect a resident's well-being, and where they are
supported for reporting openly, is a safe environment.
An experienced care team has seen sick
people get well with good care. They have
also seen things go wrong in the care
system. Team members have learned how
to avoid those situations, and when they
can't be avoided, to fix them as well as
they can. But they can only do so if they
have the information that comes from
reporting. You can help everyone work
toward having a safe environment by
reporting resident change openly,
whenever it happens.
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Communicating About Unwanted Events
One of the most important ways that experienced care team members have
learned to improve safety is by learning to communicate openly with each other
when something happens. This may not be easy. When things go wrong or look
as if they nearly did, we tend to feel embarrassed and worry that if we report
the problem, our job performance could be questioned or we might be punished;
and, we don't want to get anyone else in trouble. This is particularly true if a
supervisor needs to be involved. As a result, things that might affect a resident's
safety may go unreported or not be discussed.
Not being able to talk about how things did or could go wrong holds back our
own learning. Learning is much harder if we can't see what happens when things
go wrong for others or can't get feedback when it happens to us. Everyone –
residents and staff—benefits from an environment that supports discussion and
learning from unwanted events that happened or nearly happened.
We all care about the residents in our nursing center. To make sure they stay safe,
we have to move beyond blaming anyone, to being able to openly share
experiences—good and bad. It is true that you may come across a situation in
which a care provider's actions are not well-intended; that person may have to be
identified and possibly removed from the setting. But that is very unusual.
Usually, when things go wrong it is because a provider
was too tired, distracted, didn't know the system, or
the teamwork was not smooth. Sometimes systems
create "an accident waiting to happen." These kinds of
problems can be fixed best if discussion is encouraged,
and the care team can work together to figure out a
Communicating About Unwanted Events
- Learn to communicate promptly and openly when something happens that might affect a resident's well-being.
- Move beyond blaming anyone to being able to openly share experiences.
- Show you care by speaking up.
Caring means speaking up. Residents expect and
deserve a safe environment but often cannot speak for
themselves, so it is up to members of their care team to
speak for them. While that's easier for some of us than for others—especially on
sensitive matters that we think might cause blame—it is something we all have
to learn to do.
It helps to have tips and tools for speaking up. In particular, it helps to be familiar
- What information you need to share with the rest of the team.
- Who you need to share the information with.
- How to best communicate with that person or those people.
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Communication: A Skill You Can Learn
What is communication? It helps to think about it in three parts:
communication is made up of a giver, a message, and a receiver.
Communicating well involves:
- Expressing yourself (the sender) in a way that you will be "heard" (understood) by other people.
- "Hearing" how other people (the receivers) answer. Really listening will let you know if you have gotten your message across.
One kind of communication is "verbal." Verbal communication involves
speaking and listening to speech. With verbal communication, things can
sometimes get in the way of your message. Certain words may mean one thing to
you and something else to the other person. Sometimes one person uses "jargon"—words that are specific to what they do—that other people may not know. How
quickly we speak, or what kind of accent we have, can also affect how the other
person receives what we say.
A second kind of communication is "non-verbal." This has to do with our
facial expression, how we move our hands, if we look the other person in the eye,
how close we stand to the other person, etc. This kind of communication can
either help get a verbal message across or get in the way.
Who is responsible for communicating change in a
resident's condition? We all are. Good communication is
part of a safe environment. Good communication is a skill
you can learn.
Stages of Communication: Giving and Receiving
Three Parts of Communication
Giver of Information.
- Prepare the message.
- Find a suitable setting.
- Deliver a clear message.
- Deliver a usable message.
Receiver of Information
- Without judgement.
- Focus on the main point.
There are three stages for giving information.
Get ready—What information do you want to give and to
whom? Is it an emergency, urgent, or routine?
Give your information—Keep it short, clear, and to the
point. Sometimes, depending on how the other person seems
to be receiving it, you may have to change your presentation
while it is happening, or repeat it in a different way.
Check to see if it worked—Follow up to make sure that
your message is understood.
There are also three stages for receiving communication.
Listening—Focus on the person you are listening to. Let him or her know you
are paying attention. You may want to ask questions to be sure you understand
Responding—It can be helpful to repeat, in different words, what the other
person said to you to show them that you understood. Think about how to give
information back to that person in a give-and-take until you are both sure that
you heard it right.
Following up—The next step is being clear about what will happen after the
message is given and received. What do you need to do or need the other person
to do? How soon? Does everyone agree on the plan?
Barriers to Communication
Sometimes communication may not go well or may break down completely.
What gets in the way of good communication? People may be afraid to speak
up. They may not know who should be getting the information. They may be
shy, or find it hard to communicate when they are under stress or talking with a
superior. They may worry that the receiver does not think what they have to say
We all have different ways of communicating. It is important to understand how
differences can become barriers that keep our message from getting through.
Gender differences—Many people believe that there are differences between
men and women in the ways that they communicate.
Generational differences—Our age (i.e., the generation we grew up with) also
influences our communication. This is because language changes over time, and
each generation may use different words to say the same thing (e.g., new words
come into general usage, while others fall by the wayside and may even become
unacceptable as time goes by).
Language differences—This can be about speaking in different languages, such
as English or Spanish, or using jargon. When people are not speaking in their
first language it can be hard to communicate. Jargon can also be a barrier, since
it is not always understood by the listener.
Cultural differences—These can be our beliefs about other groups of people,
our values, or what we think is acceptable or unacceptable behavior. Getting to
know how our coworkers communicate in their own way—how they talk, what
they feel uncomfortable saying—is important, but it can be difficult to achieve.
Status differences—When licensed nurses and doctors are valued as equal
professionals, communication is better. But when licensed nurses are seen as people who "take orders" from doctors, communication is more difficult. The same holds true for communication between nursing assistants and licensed nurses.
Interpersonal issues—Sometimes team members have differences that have led
to negative feelings between them, and they may prefer to avoid communicating
with each other. When this happens, communication about patient care issues
may be compromised.
Environmental or system barriers—More attention needs to be given to the
very detailed processes through which licensed nurses and doctors communicate.
In long-term nursing centers, many of these exchanges take place over the phone,
complicating things even more.
Workload issues—If you (or another member of the team) are overwhelmed
with work, it may be hard for you to find the mental energy necessary to
communicate well. You may feel that you can't spare the time to
follow good communication practices.
Sometimes we face several communication barriers at the
same time. For example, two groups of professionals who often
face communication difficulties are licensed nurses and doctors.
While all the barriers listed above may be involved, those
related to "status" and "systems" are most likely to come into
play at the same time.
Barriers to Communication
- Differences in:
- Interpersonal issues.
- Environmental or system barriers.
- Workload issues.
We may face several communication barriers at the same time.
In summary, early recognition of changes in a resident's
conditions is essential to his or her safety and well-being.
Appropriate action can't be taken if team members notice the
changes but are not able to communicate about them. For good
- Be aware of and have ideas about how to work around barriers.
- Give clear messages.
- Focus your attention on what the other person says by actively listening.
- Be aware of nonverbal signals, both given and received.
- Give and ask for feedback—this makes a positive outcome for the resident more likely and can improve future communication.
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