Culture Change in Long Term Care

Culture is a word we hear a lot and goes hand in hand with the concept of culture change.  In this article I’d like to touch on how to facilitate culture change and why it is beneficial to your long term care setting.  Let’s face it, aged residential care in New Zealand is changing rapidly and this impacts the experience of residents, staff and visitors to long term care settings. It impacts their desire to be in your care facility or to move somewhere else. This applies to be both residents and staff.  Families often choose the care provider for their elderly relatives.  What do they perceive when they visit you?

There are also barriers and challenges to creating and sustaining a definable and deliberate culture. The experience of the residents and staff is a result of the culture (behaviours) which should be aligned to your organisation values, mission and goals.  There are well publicised workforce shortages and high turnover of staff. Long term care is also in the middle of change from paper-based systems to electronic storage and management of information. The environment in which care is being provided is also changing through new construction of buildings from a institution to non-institutional. The atmosphere being created by those within the long term aged care residential setting is changing to a more relaxed feel.

Nursing care  and direct support is now also being provided within retirement village studios, apartments, villas, homes.  This means a change of not only the context of care.  Ensuring person centred care where each individual feels seen, heard and respected takes consistent focus and strong leadership.  Not always easy in a industry that is changing in so many ways. I wrote in a previous article on workplace culture that behaviours could be a better point of focus rather than simply focusing conversation on culture as a concept.

The behaviours which support a culture you can be proud of and one that sets you as an industry leader, require a long term focus and not just a one time exercise.  The strong leadership needed along with education and ongoing communication is key to setting a desirable culture.  Have you aligned your staff, management and Governance behaviours with your organisation vision and mission statements?  Behaviours reflect actions and they can be optimal actions, good actions, poor actions or non-action.  All will have an outcome which impacts the residents experience and determine how they feel about residing in your long term aged residential care setting.

For change to occur there needs to be a focus on improvement, a reason to change which residents and their families see as beneficial.  We tend to stick to doing what we’ve always done unless we can see a personal gain or something which provides a sense of satisfaction on a personal level.  What’s in it for me?  Culture change is not something that’s going to be achieved from a top-down approach. It’s going to take engagement from all levels of the organisation and create wins for those involved. Without perceived gains or wins, people stay stuck in old habits which don’t fit the new expectations of those seeking care and support.

If you’re the manager or CEO and delegate a ‘change management’ process to someone else, then expect to check in later to find wonderful results without your direct involvement and engagement, you may be disappointed.  Culture change is a team effort. To achieve change, everyone needs to participate.  They need to believe in the outcomes you’re trying to achieve with whatever strategies or initiatives you put in place.

Who is going to lead change?  There is an old saying that everything flows from the top down and this is also true of culture.  If the Board are dysfunctional then there should be no surprise when staff working at all levels of the organisation are dysfunctional. How is communication about strategies of change being done to gain buy-in? How are you going to measure your change initiatives to find out if you’ve been successful?  How are you going to ensure the desired culture is maintained?  There are a number of tools (mostly overseas based) which can be used to start this process. Here is a free online culture change assessment tool you could use.

What is the experience of your resident and your staff on a daily basis?  Would they recommend you to others in a way to reflects loyalty to your care facility as a preferred place to live or work? If not, what are you going to do about it?

Great audit result

Hi Gillian,

Great  news, we did very well with the audit.

The Lead Auditor tells us she cannot see we have any corrective actions to complete!

Also she acknowledged a CI  from one of the Quality Improvements I completed. She was very impressed with the Quality and risk management systems via your Policies and procedures and says we are using your systems to the max.

Well, where would we be without your Policy and Procedures, they are great to work with – thank you.

kind regards

Rose Kennedy (Dixon House – Greymouth)

Spiritual care and Pastoral Care

As we age, the need for spiritual care and pastoral care often come to the fore.  This is particularly so as people near the end of their life.  The need for comfort and peace of mind on a holistic basis.  Let’s firstly lets define the difference between these two concepts.

Pastoral care is an ancient model of emotional and spiritual support that can be found in all cultures and traditions. It has been described in our modern context as individual and corporate patience in which trained pastoral carers support people in their pain, loss and anxiety, and their triumphs, joys and victories. Spiritual care attends to a person’s spiritual or religious needs as he or she copes with illness, loss, grief or pain and can help him or her heal emotionally as well as physically, rebuild relationships and regain a sense of spiritual wellbeing.

For most of human history, in all major religions, an ultimate goal of spiritual practice was accomplishing a good death. When this goal was held in common by the whole society, spiritual care could focus on the interaction between a dying person and his or her caregivers.

A number of clergy have commented to me that spiritual care is not recognised by many aged care facility staff as important. They have frequently commented on services being interrupted by staff activity, or being asked to hold services or provide pastoral care in areas of the facility that are very close to the main entrance or actually in main thoroughfare areas. This is not respectful of the needs of the residents who choose to attend, or the need to peace and calm to receive spiritual care. In learning more about the importance of these concepts, it may support good holistic care for residents if you were to discuss with the clergy and pastoral care workers whether the circumstances being provided for them to support residents are appropriate.

To read more on this topic go here.

 

Critical thinking – the foundation of good nursing practice

There are lots of ‘trendy’ words in each work environment but one of the most important concepts which appears to be increasingly missing particularly in aged care nursing is that of critical thinking and reflective practice. Critical thinking is the core foundation of good nursing practice.

It is essential to evaluate what is occurring clinically for those in care and regularly reviewing what is being done for each individual resident along with what else needs to be done in order to provide the best care. The skills of critical thinking may not be instinctive for example for those nurses coming from a schooling system which promotes ‘rote’ learning and deters from challenging senior staff.  To question another may be seen in some settings as disrespectful however in the field of clinical care, to challenge and question is essential.  The attributes of those who critically think and reflect on nursing practice and care outcomes use evidence-based practice (EBP) guidelines including current EBP policies and procedures to form decisions.

Some of the skills of critical thinking are more important than others and certainly the ability to reflect while communicating with other members of the team is essential to safe and person centred care.  The nurse who has developed critical thinking skills is able to interpret, understand and explain the meaning of information. This can be event based or data based eg; reading lab result forms. Investigating possible interventions based on the information at hand and analysing which will achieve a desired outcome is also part of reflecting and critically evaluating a clinical scenario.  Assessing the value of information to determine it’s relevance, reliability and credibility in relation to a particular clinical presentation is also necessary.

There are potential barriers to optimising clinical outcomes by clinical staff when a pre-determined bias or fixed mind-set are applied to a set of data or resident clinical presentation. It’s only in the bringing together of information through evaluation, analysis, communicating, referencing EBP guidelines and a growth mind-set that care can be optimised.

Click here to read more on critical thinking.

 

 

Workplace Culture

Workplace culture is a term bandied around a lot but what does it actually mean and how can it be measured?  When I ask staff at facilities during training sessions what they see their point of difference is, they frequently reply saying ‘we’re friendly’, or ‘we care’ or ‘we provide a homely environment’.  While these are all nice to have, they would actually be expected as a basic standard.  They are not specific and not anything different to the care facility down the road.

Mary Barra, Chairwoman and CEO of General Motors (GM) states that at GM, they prefer to talk about behaviours rather than culture as behaviours can be changed very quickly and are apparent straight away. She talks about the need for rapid change with the inclusion of technology and advancements in artificial intelligence being used more frequently.  While those are starting to be present in some aged residential care settings, what is true of both GM and aged care is rapid change and the need to adapt quickly.  This isn’t going to happen by accident and needs clear direction, guidance, leadership and engagement of all those involved.

Mary Barra also refers to bringing products to market that bring people freedom, rather than talking about cars or transportation. She focuses on the outcome for their clients.   What is the key outcome you’re wanting to provide for those in your environment and how is that defined in your values?  How is it implemented by your staff and how do you measure success on those outcomes?

managers oath as I’ve mentioned before is a good place to start in defining the governance or leadership direction of organisations. Values and key performance indicators (KPIs) or quality objectives / measures need to align to this.To ensure consistent progress regular review of those KPIs or quality measures needs to occur and acted on according to the outcomes.  Policies and procedures to guide consistent best practice are an important part of ensuring clear direction for staff while setting parameters for performance.  Information reduces confusion and promotes change. Practice creates confidence not only in the staff but also in the resident and those observing their care.

Policies and Procedures folders

Policies & Procedures

Policy No. Titles for residential care service policies and procedures
CSM Care Services Manual introduction page
CS1 Admission to hospital for medical emergency
CS2 Adverse Health Policy
CS3 Anti-coagulation monitor
CS4 Warfarin blood monitoring results
CS5
CS6 Bereavement / Termination Care policy
CS6 A Bereavement notification form (and resource material)
CS7 Blood Glucose monitor form
CS7 A Blood sugar levels record sheet
CS7 B Diabetes Testing and Treatment sheet
CS7 C Blood glucose monitor form
CS8 Blood sugar equipment check
CS9 Blood sugar testing
CS10 Case Conference for care plan review forms
CS11 Care Plan Review Schedule
CS11 A Doctors Visits Schedule
CS12 Catheter management policy
CS12 A Catheter change schedule
CS13 Continence management policy
CS13 A Continence assessment form
CS13 B Continence Voiding Chart and Bowel chart
CS14 Clinical Management Policy (includes resource directly and key responsibilities)
CS14 A Robinson’s Resident Acuity & Clinical Risk Assessment
CS15 Challenging behavior assessment form
CS15 A Behavior monitoring chart
CS15 B Challenging behavior assessment form
CS16 Diversional Therapy – Quality of life policy
CS16 A Diversional Therapy – Residential profile
CS16 B Diversional Therapy – Care plan
CS16 C Diversional Therapy – Activities attendance register
CS16 D Diversional Therapy – Care plan evaluation form
CS16 E Sample Activities Calendar
CS17
CS18
CS19 Falls Prevention Programme
CS19 A Falls Risk Assessment – Coombe’s Assessment Form
CS19 B Repeated Falls Analysis – Accident Summary
CS19 C Resident Mobility Assessment Chart
CS19 D Resident Mobility Guide Form
CS19 E Post Falls Investigation Form
CS20 Fluid Balance Chart
CS20 A Daily Fluid Balance Chart (more reflective of hospital level care)
CS21 Handover sheet
CS22 Health status and clinical risk assessment policy
CS22 A Health status and clinical risk assessment form
CS23 ‘Health Promotion’ Initiative Planner
CS24 Lab form – Pathology report storage sheet
CS25
CS26 Long Term Care Plan (Including InterRai prompts and Evaluations)
CS26 A Short term care plan for acute issues
CS26 B Treatment Sheet
CS26 C Daily Care Summary (for inside wardrobe reference in resident room)
CS27 Care Plan multi-disciplinary review policy (and associated form)
CS28 Administration of medication policy – different version supplies for those using Medimap / 1 Chart
CS28 A Administration of medication procedure – different version supplies for those using Medimap / 1 Chart
CS28 B Glucagon Administration
CS28 C Blister pack contents verification
CS28 D Medication competency assessment forms
CS28 E Insulin competency assessment form
CS28 F Medication changes / order notification
CS28 G Medication order sheet – supplied for non-electronic system users
CS28 H Medication Signing sheet – supplied for non-electronic system users
CS28 I PRN medication signing sheet – supplied for non-electronic system users
CS28 J Medication error analysis form
CS28 K  Medication error analysis form
CS28 L  Respite / short term resident medication signing
CS28 M  Self Medication resident initial competency reviews
CS28 N  Self medicating – shift by shift verification
CS28 O Medication Returned to Pharmacy form
CS28 P Medication Key Holder Register
CS28 Q Injection Register form
CS30 Nebulizer usage and maintenance policy
CS31 Neurological Recordings policy
CS31 A Neurological Observation sheet
CS32 Podiatrist Service agreement
CS33 Pain Management policy
CS33 A Pain – Detailed Assessment form
CS33 B Pain – Review Assessment form
CS33 C Pain – ABBEY pain scale (for non-verbal resident)
CS33 D Pain – ABBEY pain scale reviews form
CS34 Personal hygiene and grooming policy
CS35 Pharmacy Service Agreement
CS36 Temp, Pulse and Respirations monitor form
CS36 A General Recordings record (optional use)
CS36 B Weight and Blood Pressure Monitor form
CS36 C Blood Pressure Monitor form
CS37 Pressure Injury Risk policy
CS37 A Pressure Injury Clinical Procedures
CS37 B Pressure Injury risk assessment form
CS38 Nursing (care) progress notes form
CS38 A Pressure Note Writing Guidelines
CS39 Medical Notes progress forms
CS40 Restraint / Enabler use policy and procedure
CS40 A Restraint / Enabler Authorisation form
CS40 B Restraint / Enabler Monitoring record
CS40 C Restraint / Enabler Register
CS40 D Restraint / Enabler Assessment prior to use
CS40 E Restraint / Enabler monitoring guidelines
CS40 F Restraint Approval Group Review meeting
CS40 G Restraint / Enabler Review form
CS41 RN – Medical practitioner communication
CS42 Sleep and Comfort policy
CS42 A Sleep Monitor form
CS43 Turn Chart for bed-ridden resident
CS44 Weight Management policy
CS44 A Weight Monitoring chart
CS45 Wound Management policy
CS45 A Wound care plan / dressing schedule
CS45 B Wound care competency assessment
Policy No. Title for residential care food services policies and procedures
FSM Food Services Manual introduction page
FS1 Admission Food & Nutrition Information
FS1 A Breakfast Order forms
FS2 Food brought into the facility
FS3 Food Safety policy
FS4 Food Services for the Elderly
FS4 A Food & Nutrition guidelines for the older person
FS4 B General tips for helping older persons eat etc.
FS4 C Ageing Process and Care Provisions Issues
FS4 D Eating Difficulties – Dry or Sore Mouth
FS4 E Fluids – Preventing Constipation
FS4 F Food and Medication Interactions
FS4 G Vitamin and Mineral Supplements
FS5 Food Services Questionnaire for Residents
FS6 Safety Checklist for Kitchen Services Areas
FS7
FS7 A Sample Menu – Winter 1
FS7 B Sample Menu – Winter 2
FS7 C Sample Menu – Winter 3
FS8 Microbiological Data Sheets – food Safety
FS9 Food services ordering and monitoring
FS10 Food services preferred suppliers
FS11 Food/fluid Intake Chart
FS12 Resident Food / Fluids Preferences at a glance form
FS13 Food Services Staff Responsibilities
FS14 Food Storage Policy
FS15 Food Thawing Policy
FS16 Meal Service Policy
FS16 A Resident Meal Receipt Verification Form
Policy No. Policy Title for Residential Care Service Delivery policies and procedures
SD1 Acquisitions Order Form
SD2 Common Abbreviations
SD3 Communication Policy
SD3 A   –  Sensory Communication Policy
SD4 Clinical documentation and report writing policy
SD5 Day Care Policy
SD5A Day Care – Client Care Plan
SD6 Family / Whanau / Resident Representative Contact sheet
SD7 Reassessment Referral Policy
SD8 Resident Inquiry for Admission Form
SD8 A Resident Inquiry for Admission Form (alternative form)
SD9 Resident Medical File Checklist
SD10 Transfer / Discharge of Residents Policy
SD10 A Transfer / Discharge Form
SD11 Medical Services Contract
SD12 Authorised Signatures register
SD13 Change of Resident Status Notification
SD14 Internal Telephone Numbers Listing

Electronic records and computer use in residential care facilities

I remember years and years ago hearing about the coming of the paperless society!  Do you recall that?  Have we achieved it?  If anything, we’re surrounded by more and more paperwork.  I receive enquiries on a regular basis from disgruntled nurses that are bogged down in paperwork and wanting to know if there is a simpler way to do things that will allow them time to get back to hands-on nursing; spending time with their residents.

I’m more than happy to help you with freeing up your time and still achieve all the necessities of documenting service provision.  One way to do this is using smart computer software.  I realise that up until recently our industry has not been ready for this however with the surge in uses of Facebook and other social networking sites, computers are not as intimidating as they once were!

I’m committed to getting your nurses back on the floor while working on the basis of continuous improvement and providing excellence in care based on evidence based practice.  In order to help me develop the tools you need I’d appreciate you taking a few minutes to complete this quick and simple survey.

Thank you for your time and look forward to getting a solution that will allow you to get out of the office and back to your residents!