Session 1

Improving Patient Safety in Long-Term Care Facilities, Module 2

Introduction

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?

Mrs. C

  • What needs to be communicated?
  • By and to whom?
  • How?
  • When?
  • Where?
  • 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 with others.

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 communication.

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 problem.

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 solution.

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 with:

  • 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.

Message

  • Deliver a clear message.
  • Deliver a usable message.

Receiver of Information

  • Listen:
    • Actively.
    • 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 correctly.

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 is important.

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:
    • Gender.
    • Age/generation.
    • Language.
    • Culture.
    • Status.
  • 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 communication:

  • 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.
Current as of June 2012
Internet Citation: Session 1: Improving Patient Safety in Long-Term Care Facilities, Module 2. June 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ptsafety/ltcmod2sess1.html