THE DON IN LTC Supporting an Endangered Species

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THE DON IN LTC Supporting an Endangered Species

• Janet Dykstra, MS, RN, CDONA-LTC
• Edie Cassel Walters, MBA, RN, NHA

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• VII.
• YESTERDAY,
• TODAY AND
• TOMORROW
• Culture Change, Workforce

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CULTURE CHANGE

• WHAT IS CULTURE?
• Behavior patterns
• Beliefs
• Institutions
• Products of human work and thought

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CULTURE CHANGE

• WHAT IS CULTURE?
• Every organization has a culture based on
  beliefs, values, attitudes and behaviors
• Culture is the predominating attitudes and
  behaviors of the group

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CULTURE CHANGE

• WHY DOES CULTURE NEED TO CHANGE?
• We evolved from acute care
• Focus illness, incompetence, dependence
• Restricted by assumptions on safety, financial
  issues, regulations

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CULTURE CHANGE

• Like it or not, communities for the aging are
  feared and avoided by many
• Elders have changed
• Healthier
• More assertive
• Higher expectations
• In general, more affluent
• Health care is more liberal (ex. Diabetic diet)

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CULTURE CHANGE

• CMS AND CULTURE CHANGE
• HANDOUT VIII A ARTIFACTS OF CULTURE CHANGE
• Guidance on social services, activities, etc.
• Still a struggle with individual surveyors

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RE-EXAMINE ASSUMPTIONS

• ABOUT THE RESIDENT
• Assume competence, ability, wellness,
  independence
• Resident-directed the resident (or family, if
  resident can not) makes decisions regarding his
  or her life and care
• Risk is part of life
• Growth and Learning

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RE-EXAMINE ASSUMPTIONS

• ABOUT THE ORGANIZATION
• Value person before tasks
• Staff want to make a difference
• Staff can and will be accountable
• Leadership coaches and mentors
• Avoid hierarchy and bureaucracy

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RE-EXAMINE ASSUMPTIONS

• ABOUT THE STAFF
• Staff are skilled in
• Person-centered care
• Communications
• Critical Thinking
• Teamwork
• Technical skills

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RE-EXAMINE ASSUMPTIONS

• ABOUT THE STAFF
• Permanent assignments
• Career ladders
• Competencies

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RE-EXAMINE ASSUMPTIONS

• ABOUT THE STAFF
• Education in
• Relationship building
• Team work
• Critical Thinking
• Behavior management
• Conflict management
• Customer service
• Quality improvement

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RE-EXAMINE ASSUMPTIONS

• ABOUT THE STAFF
• Education in
• Activity participation for all
• Abuse and neglect
• Care planning and documentation
• Specialized personal care techniques
• Safety, falls, restraint alternatives
• Cognitive impairment
• Restorative nursing
• Ethics and privacy

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RE-EXAMINE ASSUMPTIONS

• ABOUT THE STAFF
• Education in
• Time management
• Stress management
• End-of-life issues

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RE-EXAMINE ASSUMPTIONS

• ABOUT RELATIONSHIPS
• Encouraged and enabled among all participants
• Conducted with
• Respect
• Trust
• Compassion
• Patience
• Humor
• Hope
• Mutual (not necessarily equal) effort and
  appreciation

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RE-EXAMINE ASSUMPTIONS

• ABOUT THE ENVIRONMENT
• Should be home, not just home-like What was
  home like?
• Normal
• Spontaneous
• Diversity
• Comfort
• Flexibility
• Supports (subtle!) function and mobility
• Predictability and dependability security

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FACILITATE RELATIONSHIPS

• Encourage relationships among ALL stakeholders
• Make new friends and keep the old
• Relationships based on respect, trust, kindness,
  compassion, patience, humor, hope, mutual (not
  necessarily equal) effort and appreciation

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CULTURE CHANGE

• EXAMPLE ACTIVITIES DEPARTMENT
• It probably doesnt report to you
• Its success impacts your success and your
  surveys
• Nurses need to be involved too!

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ACTIVITY REGULATIONS

• Recognizing programs like Greenhouse
• Any endeavor other than routine ADL that is
  intended to
• Enhance well-being
• Enhance or promote physical, cognitive and
  emotional health
• Pleasure, comfort, self-esteem, education,
  creativity, success and independence

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ACTIVITY REGULATIONS

• Person-appropriate
• Personal identity and history
• Activities are appropriate when they are
  meaningful for a person, when the respect the
  persons age, beliefs, culture, values and life
  experiences.
• Nurses, especially CNAs, have good input on
  residents

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ACTIVITY REGULATIONS

• Some key words
• Meaningful
• reflect interests, enjoyable
• Produce something useful, sense of belonging
• Dignity
• Positive self-image
• Require thinking
• Gender specific
• Relate to previous work
• Physically active
• Community oriented

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ASSESSMENT

• Know all you can about the resident!
• WHAT IS THE KEY TO THIS RESIDENT?

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CARE PLANNING

• Link to MDS
• Individualized!!! (I statements)
• Specific but leave room for flexibility
• Person-appropriate

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CULTURE CHANGE
EXERCISE Give examples of culture change in

• Dining
• Interests and Pursuits
• Personal Care
• Personal Space
• Mobility

• Privacy
• Personal Affairs
• Environment
• Health Care
• Communication
• Volunteering

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CULTURE CHANGE

• A JOURNEY, NOT A DESTINATION
• THE PROCESS INCLUDES
• Defining the vision
• Confirming values
• A leader who will invest time, energy,
  enthusiasm, consistency, integrity, risk-taking

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CULTURE CHANGE

• A JOURNEY, NOT A DESTINATION
• THE PROCESS INCLUDES
• Identify WHAT will change
• Identify desired OUTCOMES
• Identify the process for each individual element
  of change

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CULTURE CHANGE

• A JOURNEY, NOT A DESTINATION
• THE PROCESS INCLUDES
• Identify who will be affected and how
• Make a plan
• Implement the plan
• Modify as needed
• Evaluate outcomes, make a new plan

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WORKFORCE ISSUES

• GENERATIONAL DIFFERENCES
• Generation X
• Family Merit Independence Information
• Generation Y
• Want answers, not commands.
• Want feedback, mentoring.
• Family first.
• Characteristics - Honesty, want challenge,
  committed, adaptable, innovative and

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GENERATION Y

• Millennials
• Echo Boomers
• Generation Next
• Boomlets
• Gen Y
• Net Generation
• Generation WHY

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Who are they?

• 60 Million born after 1980 through 1994
• Ages 13-27
• Will not follow advice or respond to authority
  without first knowing why and what is in it for
  them.

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Who are they?
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GENERATION Y

• Refuse to do the what before they know WHY
• Filter out anything without rationale
• They want answers, not commands
• Bright and discerning
• Difficult to understand
• Hard to manage and motivate
• Question previously unquestioned questions!

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GENERATION Y Demographics

• 1 in 3 is not Caucasian
• 2 in 4 come from single parent home
• 4 in 5 have working mothers
• Turnover rate
• 20-24 year olds is 54
• 16-19 year olds is 78

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GENERATION Y

• No recollection of the Reagan era
• Dont remember Challenger explosion
• Toddlers during Desert Storm
• Dont remember ET, Mr. T, McDLTs, PacMan,
  Mopeds, or who shot JR.

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GENERATION Y

• Never knew life without
• Cell phones, pagers, fax machines, vm
• Always had
• Minivans, bottled water, cable, overnight
  delivery, chat rooms, ATMs, VCR, PC, CD, MTV,
  CNN, SUV,TCBY!
• Never lived without
• AIDS, crack, terrorist attacks, a time when kids
  didnt shoot and kill other kids.

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GENERATION Y The Downside

• They are
• Impatient
• Desensitized
• Disengaged
• Skeptical
• Disrespectful
• Bluntly Expressive

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GENERATION Y - The Up Side

• They are
• Adaptable
• Innovative/Efficient
• Resilient/Tolerant
• Committed

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GENERATION Y What do they expect?

• Mentoring System
• Low stress and fun environment
• Schedule flexibility
• Team/partner working relationship
• Frequent constructive feedback and recognition
• Change-it is normal needs to be part of their
  work environment

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GENERATION Y How to manage them

• Lay out the big picture in small terms
• Revisit your rules
• Tune in to their frequency
• Get their heads in your game
• Be Flexible attendance punctuality
• Wage a battle against boredom

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GENERATION Y How to Manage them

• Unique talent to multi-task and digest
  information quickly
• Need new trends in training keep feeding them
  stimulation by teaching new skills
• Provide freedom to explore new methods for doing
  repetitive tasks show you how to increase
  productivity
• Involve them in new training systems
• Keep communication short and to the point
• Vary delivery method and content

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Never Think.

• Free Parking
• Free T shirts
• Facility Outings
• Promotions
• Will keep them if the leader treats them poorly.

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CAREER LADDERS

• Professional advancement
• CNA to LPN
• LPN to RN
• RN to BSN
• BSN to MSN
• Issues are cost, time, child care

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CAREER LADDERS

• Professional Nursing Assistants
• Like what they are doing
• Dont want to do anything else
• Do want to grow, learn, be respected

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CAREER LADDERS

• Research shows that the most important reason
  direct care professionals stay in their jobs is
  the relationships they have with residents.
  Compensation alone does not explain satisfaction
  or turnover.
• Direct care staff whose work is valued and
  appreciated by supervisors and who are listened
  to and encouraged to participate in care planning
  decision have higher levels of job satisfaction
  and are more likely to stay in their jobs.
• IFAS 2007

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CAREER LADDERS

• Career Ladders can
• Focus on perfecting clinical skills
• Focus on soft skills
• Communication
• Critical Thinking
• Teamwork
• Building relationships
• Customer service
• Leadership, mentoring, coaching

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CAREER LADDERS

• Career Ladders can
• Combine both
• Some soft skills
• Some clinical focus
• Systems and processes that are changing
• Systems and processes that are traditional
  challenges
• Restorative Nursing
• End of Life
• Abuse and Neglect
• Safety, falls, restraints
• Skin care

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CAREER LADDERS

• Benefits
• Buy-in and satisfaction
• Retention
• Improved outcomes
• Ready-made preceptors
• Issues
• Time for training initial and on-going
• Increase in rates for graduates

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SUPERVISORY SKILLS

• You cant focus on CNAs alone
• The biggest reason for turnover is poor
  supervision
• Have you promoted licensed nurses to supervisory
  positions without education and mentoring?

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CULTURE CHANGE

• Keep asking why
• Then ask why not?
• You can be
• A Victim This always happens to ME
• A Survivor Whatever will be, will be
• A Navigator Ill find a way

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CULTURE CHANGE

• MAKING CULTURE CHANGE HAPPEN
• Establish sense of urgency
• Form a powerful guiding coalition
• Create a vision
• Communicate the vision
• Empower others to act on the vision

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CULTURE CHANGE

• MAKING CULTURE CHANGE HAPPEN
• Plan for and create short term wins
• Consolidate improvements and make more change
• Institutionalize new approaches