TeamSTEPPS Long-Term Care: Specialty Scenarios
Staff Roles
- Clinical Staff
- Nonclinical Staff
TeamSTEPPS Team Skills
- Team Structure
- Leadership
- Situation Monitoring
- Mutual Support
- Communication
The matrix directly below indicates which scenarios are appropriate for use by: (a) staff role, and (b) specific tools for each TeamSTEPPS team skill. Use this matrix as a roadmap to identify which scenarios are most relevant to your training audience.
Specialty Scenario Matrix
| Staff Role and Corresponding Scenarios | ||
|---|---|---|
| TeamSTEPPS Skill | Clinical Staff Licensed nurses, Nursing Assistants, Rehabilitation Staff, Physicians, APRNs/PAs |
Nonclinical Staff Administration, Dietary, Housekeeping, Laundry, Maintenance, Social Services, Therapeutic Recreation |
| Team Structure | 1, 2, 3 | 1, 2, 3 |
| Leadership | 4 | 4, 5, 6 |
| Situation Monitoring | 7, 8, 10, 11 | 8, 9, 10, 11 |
| Mutual Support | 12, 14, 15, 17, 19, 20, 21, 22, 23 | 13, 15, 16, 18, 19, 22, 23, 24 |
| Communication | 25, 26, 27, 28, 29, 30, 31, 32, 33 | 28, 30, 33 |
Customizable Content
Team Structure
Scenario 1
Appropriate for: Clinical and Nonclinical Staff
Department: Entire Nursing Home
A multi-team system (MTS) includes several components:
- Core Team
- Coordinating Team
- Contingency Team
- Ancillary Services
- Administration
Example: A Multi-Team System in a Nursing Home
Here we see an example of an MTS in a 120-bed long-term care facility. In this example, the Core team consists of: nurses (e.g., charge nurse, medication/treatment nurse), nursing assistants, restorative aides, attending physicians, and APRNs/PAs. The Coordinating Team consists of: the nursing supervisor or unit manager, unit secretary, and dietitian. The Ancillary Services Team includes rehabilitation therapy staff, social services, and therapeutic recreation staff. The Support Services Team consists of dietary, laundry, and housekeeping. The Contingency Team consists of the nursing home's emergency response team, care planning team, and quality improvement teams. Administration consists of the medical director, the director of nursing, and the administrator.
Team Structure
Scenario 2
Appropriate for: Clinical and Nonclinical Staff
Department: All Departments at the Unit Level
A multi-team system (MTS) includes several components:
- Core Team
- Coordinating Team
- Contingency Team
- Ancillary Services
- Administration
Example: A Multi-Team System on a 30-Bed Long-Term Care Unit
Here we see an example of an MTS on a 30-bed long-term care unit within a 150-bed nursing home. In this example, the Core Team consists of: nurses (e.g., charge nurse, medication/treatment nurse), nursing assistants, restorative aides, attending physicians, and APRNs/PAs. The Coordinating Team consists of: the nursing supervisor or unit manager, unit secretary, and dietitian. The Ancillary Services Team includes rehabilitation therapy staff, social services, and therapeutic recreation staff. The Support Services Team consists of dietary, laundry, and housekeeping. The Contingency Team consists of the nursing home's emergency response team, care planning team, and quality improvement teams. Administration consists of the medical director, the director of nursing, and the administrator.
Team Structure
Scenario 3
Appropriate for: Clinical and Nonclinical Staff
Department: All Departments at the Unit Level
A multi-team system (MTS) includes several components:
- Core Team
- Coordinating Team
- Contingency Team
- Ancillary Services
- Administration
Example: A Multi-Team System on the Cardiac Rehabilitation Unit
Here we see an example of an MTS in the Cardiac Rehabilitation Unit. In this example, the Core Team consists of: the consulting cardiologist, the charge nurse, nursing assistants, and the physical therapist. The Coordinating Team consists of the house supervisor/unit manager and the cardiac rehabilitation program manager. The Ancillary Services Team includes social services, dietary, rehabilitation therapy aides, and housekeeping. The Contingency Team consists of the nursing home's emergency response team. Administration consists of: the medical director, the director of nursing, and the administrator.
Leadership
Scenario 4
Appropriate for: Clinical and Nonclinical Staff
Department: Nursing, Housekeeping, Dietary
The second shift team working together on the secured dementia unit has been reporting gastrointestinal symptoms for multiple residents. During a huddle, the team leader identifies that most of the residents are sick. She informs the team that infection control and housekeeping have been alerted and dietary will be delivering extra fluids to the unit. The team is informed that the evening meal will be restricted to in-room dining only and group activities have been canceled. She checks in with how the team is feeling and reviews with the team the symptoms to monitor.
Instructor Comments
- Effective team leadership results in having team members who know their roles and responsibilities. Essential Information is shared and feedback is sought by the leader.
Skills Needed
- Team structure: Identify a leader, identify goals and vision, assign roles and responsibilities, share information among team members, and provide feedback.
Potential Tools
- Huddle, Collaboration, Feedback, Task assistance
Leadership
Scenario 5
Appropriate for: Nonclinical Staff
Department: Dietary
The dietary department huddles to discuss the evening's event, a family/resident holiday meal. Everyone is invited and more than 100 attendees are expected this year. It is their biggest event yet. During the huddle, the team leader updates the department staff on the expected attendance and the different dining rooms and common areas that will be used for seating to accommodate everyone. He confirms with the team their assigned dining room or common area for which they are responsible during the event and reviews the list of tasks and duties to be accomplished. The team is also updated on the non-dietary staff assigned to assist with the event. The team leader checks in with the team for questions and clarifies erroneous information.
Instructor Comments
- Effective team leadership results in having team members who know their roles and responsibilities. Essential Information is shared and feedback is sought by the leader.
Skills Needed
- Team structure: Identify a leader, identify goals and vision, assign roles and responsibilities, share information among team members, and provide feedback.
Potential Tools
- Huddle, Collaboration, Feedback, Task assistance
Leadership
Scenario 6
Appropriate for: Nonclinical Staff
Department: Maintenance
The maintenance team gathers for a huddle during a snowstorm on the first shift. The department head updates the team on the changing weather forecast, which is now predicting up to 12 inches of snow, with the heaviest snow falling during the change of shift. The department head gives the workers their assignments: shoveling, plowing, deicing walkways. He also gives the "snow rides" assignments, which involve maintenance staff picking up other staff members who cannot drive to work due to the snow. The department head also checks in with the team to be sure they have the equipment they need and proper snow gear to stay dry and warm and that their own families are safe.
Instructor Comments
- Effective team leadership results in having team members who know their roles and responsibilities. Essential Information is shared and feedback is sought by the leader.
Skills Needed
- Team structure: Identify a leader, identify goals and vision, assign roles and responsibilities, share information among team members, and provide feedback.
Potential Tools
- Brief, Huddle, Collaboration, Feedback, Task assistance
Situation Monitoring
Scenario 7
Appropriate for: Clinical Staff
Department: Nursing
Mary, a nursing home resident, falls while trying to walk independently. She suffers a head laceration and a possible fractured hip. The nursing assistant, charge nurse, and supervisor all respond to Mary's cry for help. Jean, the supervisor, completes her assessment. She directs Ann, the nursing assistant, to retrieve 4x4 gauze from the treatment cart and tells Jerri, the charge nurse, to maintain C-spine precautions until EMS arrives. Noticing her confused expression, Jean tells Jerri, "Place one hand on each side of Mary's head and keep it in straight alignment with her spine."
Instructor Comments
- Reinforce the point that monitoring of both the resident and team members supports the maintenance of situation awareness. In this case, it involves observing others and using clear communication. Monitoring is a powerful agent in responding proactively to a situation.
Skills Needed
- Situation monitoring: Assess status of resident and team and progress toward the goal. Cross-monitoring.
Potential Tools
- Call-out, Task assistance, Collaboration
Situation Monitoring
Scenario 8
Appropriate for: Clinical and Nonclinical Staff
Department: Entire Nursing Home
A powerful storm has downed trees and power lines across the city. A fallen tree has blocked the main road to and from the nursing home, preventing anyone from leaving or coming to work. Everyone is pitching in to help where they can. Social workers are passing water pitchers and afternoon snacks. A nursing assistant is leading an impromptu sing-a-long with a group of residents. Nurses are assisting with toileting, and housekeepers and administration are answering call bells. The director of nursing and assistant director of nursing are rounding and offering suggestions on what staff can do to help on the various units and offering assistance as needed.
Instructor Comments
- All staff are using situation monitoring to assess the status of the residents and the team. Everyone has put the safety of the residents ahead of their usual roles and responsibilities.
Skills Needed
- Situation monitoring: Assess status of residents and team and progress toward the goal. Mutual support: Provide task-related support and verbal support. Communication: Offer information.
Potential Tools
- Task assistance, Collaboration, Cross-monitoring
Situation Monitoring
Scenario 9
Appropriate for: Nonclinical Staff
Department: Housekeeping
Mary, a housekeeper, walks onto Unit 3 to get some extra supplies when she notes that Carol, the Unit 3 housekeeper, is rushing down the hall. Mary asks Carol, "What is the problem?" and she states, "I have a flood in the Room 316 bathroom and it is heading into the hallway." Mary states she will call maintenance and will be down in a moment to place caution signs in the hallway and alert the staff. Carol says, "Thank you," as she heads into the room to deal with the issue. Mary alerts everyone she needs to and then checks with Carol to make sure everything is under control prior to leaving the unit.
Instructor Comments
- In this scenario, Mary goes out of her way to assist a fellow team member deal with a crisis. She is aware of the environment, changes her priorities to prevent a flood and potential injury to other staff members and residents, keeping her goal to ensure resident safety in focus.
Skills Needed
- Task assistance. Shared mental model. Communication.
Potential Tools
- Collaboration, Task assistance, Cross-monitoring
Situation Monitoring
Scenario 10
Appropriate for: Clinical and Nonclinical Staff
Department: Entire Nursing Home
The STEP process involves ongoing monitoring of the:
- Status of the resident.
- Team members.
- Environment.
- Progress toward the goal.
Example:
The social worker notes that a resident in the end stages of Alzheimer's disease shows facial grimacing and restlessness. She thinks this could indicate an increased level of pain that cannot be communicated (STATUS).
The resident's nurse is busy helping another resident (TEAM MEMBERS).
It is shift change, and everyone is busy, so the social worker checks the medication record and notes that the resident is overdue for his morphine (ENVIRONMENT).
The social worker notifies the incoming nurse of her concern (PROGRESS).
Situation Monitoring
Scenario 11
Appropriate for: Clinical and Nonclinical Staff
Department: Entire Nursing Home
The STEP process involves ongoing monitoring of the:
- Status of the resident.
- Team members.
- Environment.
- Progress toward the goal.
Example:
The dietary aide is on the first floor delivering snacks when she notices a resident attempting to wheel herself out the front door. The dietary aide puts her snacks down and asks the resident if she needs help. The resident responds with a very confused answer that does not make any sense (STATUS).
The aide looks around to see if any nursing staff are around. Not seeing any staff, she asks the resident if she could help her back to the unit. Upon return to the unit, the aide realizes all the staff are providing care. She takes the resident into the dining room with her and helps her to a table (TEAM MEMBERS).
The aide goes down the hallway and finds the therapeutic recreation director. She explains her concerns. The therapeutic recreation director takes the resident into a program that was just going to start (ENVIRONMENT).
The aide finishes delivering the snacks and checks on the resident, who is now in the group activity smiling and singing (PROGRESS).
Mutual Support
Scenario 12
Appropriate for: Clinical Staff
Department: Nursing
Two nursing assistants are at the desk during a brief lull in a busy shift. They notice another nursing assistant racing busily between resident rooms and the supply area, glancing over at them as she passes. Nursing Assistant #1 says to Nursing Assistant #2, "Let's see if Maureen can use some help." Nursing Assistant #2 replies, "My resident will be back from rehab in just a few minutes, and I hate to get tied up. Besides, Maureen doesn't usually accept help from anyone." "Come with me," says Nursing Assistant #1. "I'll show you how it's done." Nursing Assistant #1 approaches Maureen and says, "Maureen, I can see you're busy. I have about 5 minutes before my resident gets back from rehab. I can take Mr. Rappaport and Mrs. Papa to the morning coffee and news program for you if that helps." "Thanks," says Maureen, "that would be great. They love to go and the program is starting shortly. Now I can help Mrs. Cortes finish getting ready for her doctor's appointment."
After Maureen leaves, Nursing Assistant #1 says to Nursing Assistant #2, "The key to offering assistance is being clear about how much time you have and what tasks you're able to pick up."
Instructor Comments
- In this scenario, Nursing Assistant #1 demonstrates that clear communication about time availability and specific assistance offered facilitates successful task assistance. Situation awareness and situation monitoring are combined with mutual support to reinforce a teamwork skill through peer coaching.
Skills Needed
- Task assistance. Situation awareness. Situation monitoring. Communication.
Potential Tools
- Feedback, Collaboration, Delegation, Cross-monitoring
Mutual Support
Scenario 13
Appropriate for: Nonclinical Staff
Department: Social Services
A resident with dementia had been admitted to the short-term unit for rehab after a hip fracture and is now being transferred back to her assisted living facility. The social worker for the short-term care unit has discussed this move with the resident's family and they are in agreement. When the time comes to transfer the resident and her belongings, another resident on the unit begins making suicidal threats and the short-term social worker is paged to the resident's room. The social worker from the long-term care unit walking in the vicinity of the short-term unit hears the page and offers to take over the transfer of the resident.
Instructor Comments
- In this scenario, the short-term unit social worker steps in to assist in a crisis situation. She is aware of the environment and adjusts her priorities to help ensure that the resident has a smooth transition from the current care area to the next, all the while maintaining the goal to ensure resident safety.
Skills Needed
- Task assistance. Situation awareness. Situation monitoring: Assess environment. Communication.
Potential Tools
- Task assistance, Feedback, Collaboration
Mutual Support
Scenario 14
Appropriate for: Clinical Staff
Department: Nursing
A staff development nurse watches a nursing assistant use a mechanical lift to transfer a resident from the bed to a chair. The nurse pulls the nursing assistant aside and reminds the nursing assistant on the proper positioning of the lift pad, showing the nursing assistant which landmarks to use. She explains how the resident's position can affect the function of the lift and can also cause friction and sheer to the resident's skin when not positioned properly.
Instructor Comments
- In this scenario, situation awareness and situation monitoring are combined with mutual support to reinforce a teamwork skill through situational learning.
Skills Needed
- Situation awareness. Situation monitoring: Assess environment. Communication: Offer information.
Potential Tools
- Collaboration, Huddle, Feedback, Task assistance, Cross-monitoring
Mutual Support
Scenario 15
Appropriate for: Clinical and Nonclinical Staff
Department: Administration, Social Services
The administrator, director of nursing, and social worker are meeting with a resident's family to discuss a recent complaint. The social worker addresses the family's concerns and feelings and offers a solution. The family feels their concerns were both heard and addressed to their satisfaction. After the family leaves, the administrator praises the social worker for remaining calm with the angry family, addressing their concerns related to both facts and feelings and offering a solution that worked for all involved.
Instructor Comments
- The administrator provided feedback that was timely, specific, related to behavior, and considerate.
Skills Needed
- Communication. Mutual support. Team structure.
Potential Tools
- Advocacy and assertion, Feedback, Conflict resolution, Collaboration, Debrief
Mutual Support
Scenario 16
Appropriate for: Nonclinical Staff
Department: Dietary
A dietary director is watching the food service line and notes that the staff member assigned to complete the tray check is only looking at the diet and not the adaptive equipment. The dietary director takes the opportunity to explain the importance of not only making sure that the correct diet is on the tray but also ensuring that the resident has all the special tools he or she needs to this meal by him/herself. The staff member did not realize the importance of including adaptive equipment, as he thought extra supplies were kept on the unit.
Instructor Comments
- A strong team structure uses feedback to improve future performance. In this case, a transfer of knowledge has occurred through the processes of situational teaching and learning. The use of feedback will improve the knowledge base of the team in a supportive environment. It also improves the quality of awareness that this worker will have in future situations involving adaptive equipment.
Skills Needed
- Team structure. Communication. Mutual support. Cross-monitoring.
Potential Tools
- Debrief, Collaboration, Feedback
Mutual Support
Scenario 17
Appropriate for: Clinical Staff
Department: Nursing, Medicine
A resident on the subacute unit has been cleared for discharge following a myocardial infarction 3 weeks ago. Before discharge the nurse checks the resident's vital signs one last time. The nurse finds it unusual that the blood pressure and heart rate are substantially elevated. Despite concerns, the nurse discharges the resident because the attending physician said he is well enough to go home. Besides, the attending physician is also the facility's medical director. He is well respected at the facility.
Instructor Comments
- In this scenario, the nurse fails to advocate for the resident. He misses an opportunity to avoid a potential complication in the resident's condition, thus putting the resident's safety in jeopardy. Failure to advocate for the resident is frequently identified as a primary contributor to clinical errors.
Skills Needed
- Mutual support: Conflict resolution. Communication. Situation monitoring. Situation awareness.
Potential Tools
- Advocacy/assertion, Two-challenge rule, CUS, DESC script
Mutual Support
Scenario 18
Appropriate for: Nonclinical Staff
Department: Dietary
A high school senior working in the dietary department is wheeling the steam-tray table down the hall after dinner. Ahead of her she sees a nursing assistant escort a resident into his room and close the door. As she passes the room, she hears a raised voice and believes it to be the nursing assistant. She feels she should knock on the door or tell someone, but doesn't. She says to herself, "No, I'm just in high school and working in the kitchen. It's not my place. Plus, who would believe me?"
Instructor Comments
- This scenario illustrates that everyone on the resident care team has an obligation to advocate for the resident. Team members should always feel their input is valued, regardless of their level in the organization, age, or education.
Skills Needed
- Mutual support. Communication. Situation monitoring. Situation awareness.
Potential Tools
- Advocacy/assertion, Two-challenge rule, CUS
Mutual Support
Scenario 19
Appropriate for: Clinical and Nonclinical Staff
Department: Social Services, Nursing
Ann Tayner is the social worker assigned to work on a busy subacute rehabilitation unit. She recently attended an educational session on resident safety and the importance of hand washing. She noticed that the APRN, Joyce Tsu, went from resident to resident without washing her hands. Later that morning, she encounters APRN Tsu in the corridor and addresses her, saying that she attended the hand-washing seminar and noticed that Ms. Tsu did not always follow procedure. APRN Tsu appears surprised by the comment but sheepishly agrees that hand washing is very important and she will be more careful.
Instructor Comments
- Point out that challenging a team member's position is an integral part of teamwork. All members of the team and support staff have a responsibility to advocate for resident safety even if it may lead to a conflict or differing positions. In this case, situation awareness was used to identify the problem and advocate for the residents.
Skills Needed
- Situation awareness. Situation monitoring: Assess environment. Mutual support: Resolve conflict. Communication: Offer information.
Potential Tools
- Advocacy/assertion, Feedback
Mutual Support
Scenario 20
Appropriate for: Clinical Staff
Department: Nursing
A nurse and nursing assistant are conducting a skin assessment on a newly admitted resident. The nursing assistant thinks she sees a reddened area on the coccyx that the nurse may have missed. What should she say?
Possible Answers:
- Opening: Say the person's name to whom the concern is addressed: "Dianne…"
- State concern: An owned emotion: "I thought I saw redness on the coccyx as we were turning Mrs. Levine over."
- State the problem: Real or perceived: "I can't be certain but it looks like she may have a reddened area."
- Offer a solution: "I can help you turn her back over to recheck the area."
- Obtain an agreement: "When she is turned, I can show you the area that I thought looked reddened."
Instructor Comments
- In this scenario, the nursing assistant, using cross-monitoring and situational awareness, should question the nurse when she is concerned about a missed reddened area. The possible answers provide a structure for such a conversation.
Skills Needed
- Mutual support. Communication. Situation awareness.
Potential Tools
- Assertive statement, Two-challenge rule
Mutual Support
Scenario 21
Appropriate for: Clinical Staff
Department: Nursing
A subacute resident is receiving IV therapy and rehabilitation for an infection in her right knee joint. The nursing assistant places a blood pressure cuff on the resident's arm that has the central catheter line. The nursing assistant realizes the IV line is in this arm and stops. As she removes the cuff, the nurse, seeing what she has done, reprimands her in front of the resident, stating abruptly, "You can't take a blood pressure in that arm! The resident has an IV in that arm." The nursing assistant is embarrassed but does not speak to the nurse about the situation.
Later that day, the same nurse asks another nursing assistant for an update on one of his residents. The nursing assistant proceeds with the update but is unable to recall the resident's intake at breakfast and lunch. Another nursing assistant who knows this information because she too worked in the dining room chooses not to share it with the nurse for fear he will reprimand her for interrupting.
Instructor Comments
- Point out that challenging a team member's position is an integral part of teamwork. Every attempt must be made to resolve personal conflict as it will interfere with work and undermine quality and resident safety.
- Ineffective team leadership results in having team members who do not speak up or challenge when appropriate. In this case, mutual support is lacking; however, skill in conflict management could enhance team development.
- Effective teams resolve conflicts constructively rather than allowing interpersonal issues to persist without resolution. Failure to share information has a detrimental effect on resident care and may result in inadequate plans of care.
Skills Needed
- Team structure: Identify barrier to team effectiveness. Mutual support.
Potential Tools
- Collaboration, DESC script, Conflict resolution
Mutual Support
Scenario 22
Appropriate for: Clinical and Nonclinical Staff
Department: Maintenance, Nursing
A maintenance request to fix a window unit air conditioner was submitted 2 days ago by the charge nurse. While in the resident's room, the nurse realizes it is warm and the air conditioner still isn't working properly. She checks the logbook and sees that the maintenance request has not been completed. She does not know that a new unit is being delivered today. Worried about the comfort of her resident, who has difficulty breathing in warm weather, she raises her voice at the director of maintenance in front of staff and residents, criticizing his work ethic.
DESC:
- D "I (maintenance director) realize that you (nurse) are worried about the resident's ability to breathe comfortably in this warm weather and I am sensing that you don't think I have addressed your concern about her air conditioning problem."
- E "When you accuse me of not addressing the needs of residents, especially in a timely fashion, it embarrasses me and makes me very frustrated."
- S "If you have a question about my performance, I would appreciate your asking me about it before jumping to conclusions."
- C "Having a conversation with me would be better because I would feel less embarrassed and would be able to supply information. Can we agree to follow such a procedure if this happens again? In the meantime, I can add a "pending" column to the logbook to communicate such information."
Instructor Comments
- This example shows a good approach to conflict resolution and use of the DESC script.
Skills Needed
- Communication.
Potential Tools
- Conflict resolution, DESC script
Mutual Support
Scenario 23
Appropriate for: Clinical Staff
Department: Nursing
A nurse feels that a resident has abdominal distension and pain secondary to a distended bladder and needs a catheter. The nurse calls the attending physician and receives the order. When the in-house APRN later realizes that the attending was called instead of her, she raises her voice to the nurse in front of staff and the resident. How could the DESC script be used here?
DESC:
- D "I (nurse) am sensing that you (APRN) are upset with me for calling Dr. McEleney about the catheter for your resident instead of you."
- E "When you question my judgment in front of others, it embarrasses me and makes me very uncomfortable. It also undermines my credibility with the resident."
- S "If you are concerned or have a question regarding my performance, I would appreciate it if you would speak to me in private."
- C "A private conversation would be more beneficial to me because I would feel less embarrassed and would be able to ask questions and supply information. Can we agree to follow such a procedure if this occurs again?"
Instructor Comments
- This example shows a good approach to conflict resolution and use of the DESC script.
Skills Needed
- Communication.
Potential Tools
- Conflict resolution, DESC script
Communication
Scenario 24
Appropriate for: Clinical and Nonclinical Staff
Department: Dietary, Housekeeping
A resident newly admitted to the nursing home has a severe allergy to nuts and the entire staff was notified. During an evening social, the resident is observed by the housekeeper snacking on the hors d'oeuvres. Knowing the resident's severe allergy to nuts, she approaches the dietary aide and asks if any of the hors d'oeuvres were made from ingredients containing nuts. The dietary worker shrugs and walks away. Sill worried, the housekeeper approaches the dietary aide and says, "I'm concerned. Mrs. Martin has a severe allergy to nuts. I'm uncomfortable with her eating the hors d'oeuvres without knowing for certain there are no nuts used as ingredients. I think this could be a safety issue for her." Alerted by the use of CUS, the dietary aide approaches the chef to discuss ingredients.
Instructor Comments
- The use of the keywords concerned, uncomfortable, and safety alerted the dietary aide to the importance of the housekeeper's worries.
Skills Needed
- Mutual support. Communication. Situation awareness.
Potential Tools
- CUS, Two-challenge rule
Communication
Scenario 25
Appropriate for: Clinical Staff
Department: Nursing
Beth is taking her mother, Margaret, a long-term care resident who is wheelchair dependent, out for the afternoon to attend a family gathering. As the nurse is signing out Margaret for the leave of absence, she tells Beth, "Your mother is at risk for pressure ulcers now that she uses the wheelchair. Her skin is intact and she will be fine as long as you reposition her at least every 2 hours." Later that evening, during evening care, the nursing assistant reports that Margaret has an open area on her coccyx. The nurse calls Beth. Beth, sounding confused, says, "How could this have happened? I did just as you said. I turned her chair every 2 hours!"
Instructor Comments
- Poor information transfer and an inadequate handoff create a poor outcome for this resident. In this case, the increased risk for skin breakdown is not adequately communicated to the family. The use of medical jargon prevents the family from understanding the nurse's intended meaning. Medical staff should always clarify instructions and meaning prior to the family assuming responsibility, as in this handoff.
Skills Needed
- Situation monitoring. Communication. Team structure.
Potential Tools
- Advocacy/assertion, Collaboration, Handoff, Check-back
Communication
Scenario 26
Appropriate for: Clinical Staff
Department: Rehabilitation
A physical therapist has been treating a subacute resident's broken wrist, which resulted from a fall. The resident is being discharged home today yet still suffers swelling in the wrist despite using a splint. The physical therapist recommends ice treatment to decrease inflammation. He tells the resident to apply an icepack to her wrist but does not provide detailed instructions. Later that evening, the hospital calls the nursing home, yelling that the resident is in the emergency room with frostbite to her hand and wrist and such swelling that her wedding ring had to be cut off to prevent loss of circulation.
Instructor Comments
- In this scenario a shared mental model is not developed because information regarding the resident's plan of care is not communicated to the entire team (including the resident). Residents and families may be too intimidated to ask clarifying questions and can misinterpret information that we as medical personnel feel are simple. Residents and families are important members of the team and must be communicated to in ways they understand. This lack of information and the inability to provide an accurate handoff resulted in a poor outcome for this resident.
Skills Needed
- Communication. Handoff, Situation monitoring
Potential Tools
- Check-back, Collaboration, Communication, Handoff
Communication
Scenario 27
Appropriate for: Clinical Staff
Department: Nursing
An 89-year-old female resident with Alzheimer's disease has been living at the nursing home for many years. The family decides they no longer want aggressive measures taken and request that the resident's code status be changed to Do Not Resuscitate (DNR). The evening shift documents in the progress note that the family (and designated health care agent) requested that the resident's status be made DNR. The evening shift does not relay the information during shift change or on the 24-hour report, or notify the attending physician. The day shift does not read the night shift's notes because of several immediate emergencies. The family, who had been keeping vigil at her bedside, leaves to go home to shower and eat. Upon return, they find the staff attempting CPR. The resident is successfully resuscitated but now lies in a vegetative state. The family is very unhappy and considering legal action.
Instructor Comments
- In this scenario, a shared mental model and an advocate are lacking. Breakdowns in communication processes failed to keep the team informed of new information. No leader was designated and no team actions were taken to identify and determine whether the resident's status was DNR. The team missed opportunities to communicate information and create a shared mental model by not conducting a brief or huddle.
Skills Needed
- Mutual support. Team structure. Communication. Shared mental model.
Potential Tools
- Brief, Huddle, Handoff, Communication
Communication
Scenario 28
Appropriate for: Clinical and Nonclinical Staff
Department: Nursing, Dietary
Jack, a newly admitted resident to the subacute unit, is at the nursing home for rehabilitation following hospitalization for an acute episode of congestive heart failure. The dietitian orders a low-salt diet and speaks with Jack and his wife about the importance of eating low-sodium foods and not adding salt to any foods. They agree and say they have been following those recommendations as given by their doctor. Jack says that he misses foods such as ham but is thankful he can still eat bacon. This is an example of inadequate verbal communication with residents/families.
Instructor Comments
- This is an example of ineffective communication with residents/families and the lack of a shared mental model. Residents and families are an important part of the team and clarifying information may be necessary to ensure that they understand the plan of care. Jack's response is an opportunity to clarify the plan of care and provide additional information and teaching.
Skills Needed
- Communication. Situation awareness.
Potential Tools
- Advocacy/assertion, Check-back, Communication
Communication
Scenario 29
Appropriate for: Clinical Staff
Department: Nursing, Medicine
Christine, a resident who takes warfarin, is noted to have a bloody nose, bleeding gums, and a large bruise on her arm. The nurse reports these findings to her physician. He orders a CBC and INR and assumes she understands his intent to have these labs drawn stat. The nurse orders the labs to be drawn on the next lab day, 2 days from now. This is an example of inadequate verbal communication between nurse and physician.
Instructor Comments
- This scenario illustrates the lack of a shared mental model by the team. The doctor fails to communicate his entire order and the nurse fails to question the physician or clarify the order with a check-back. A stronger team structure with expectations for mutual support will result in a shared mental model and prevent future occurrences of this problem.
Skills Needed
- Mutual support. Team structure. Situation awareness.
Potential Tools
- Collaboration, Delegation, Prioritization, Task assistance, Cross-monitoring
Communication
Scenario 30
Appropriate for: Clinical and Nonclinical Staff
Department: Nursing, Housekeeping
The nonverbal cues a nurse gives when assessing an injury would quickly tell another nurse the severity of the situation and might lead to proactive action. Likewise, the nonverbal cues on a housekeeper's face might communicate the urgency of the situation and need to interrupt a nurse who is with a resident's family members.
Instructor Comments
- In these examples, situation awareness was used to identify problems and communicate a shared mental model for the team.
Skills Needed
- Situation awareness. Situation monitoring: Assess environment. Mutual support. Communication: Offer information.
Potential Tools
- Advocacy/assertion, Feedback
Communication
Scenario 31
Appropriate for: Clinical Staff
Department: Nursing
The nonverbal cues a resident gives while receiving care would quickly tell a nursing assistant the resident is in pain and care should stop. Likewise, the nonverbal cues on a family member's face during a care plan meeting might communicate that they don't understand something, prompting the team to pause and address the family member's questions.
Instructor Comments
- In these examples, situation awareness was used to identify problems and communicate a shared mental model for the team.
Skills Needed
- Situation awareness. Situation monitoring: Assess environment. Mutual support. Communication: Offer information.
Potential Tools
- Advocacy/assertion, Feedback
Communication
Scenario 32
Appropriate for: Clinical Staff
Department: Nursing, Medicine
A nurse is accepting a telephone order from a physician: "Give amoxicillin 875 mg every 12 hours for 7 days." The nurse verifies and validates the order by recording it directly into the chart and reading it back to the physician: "Okay, Doctor, that was amoxicillin 875 mg every 12 hours for 7 days?" The physician acknowledges the information with a check-back, "Yes, that is correct."
Instructor Comments
- The nurse's use of a check-back to verify the medication order allows the team to share the same mental model and prevents a medication order error for this resident.
Skills Needed
- Communication.
Potential Tools
- Check-back
Communication
Scenario 33
Appropriate for: Clinical and Nonclinical Staff
Department: Dietary, Rehabilitation
A resident having difficulty swallowing is assessed by speech therapy. The speech therapist communicates to the dietitian, "A mechanical soft diet and honey thick liquids will prevent Mr. Garrant from aspirating and improve his experience during meals." The dietitian confirming what she heard correctly says, "So that was a mechanical soft diet with honey thick liquids for Mr. Garrant?" The speech therapist acknowledges the information with a check-back and says, "Yes. That's correct."
Instructor Comments
- The dietitian's use of a check-back to verify the new diet order allows the team to share the same mental model and prevents a diet order error for this resident.
Skills Needed
- Communication.
Potential Tools
- Check-back
