Long-Term Care Survey Alert

Some work cultures are a recipe for frustration and abuse. And if resident abuse occurs in your nursing facility, surveyors and malpractice attorneys may be looking closely to see if yours is one of them.

Nursing facility leadership at all levels can, however, go a long way toward preventing resident abuse and improving the quality of care by instilling a culture of caring that supports and empowers caregivers. "Administrators set the standard of caring in terms of their availability to and relationship with staff," says former director of nursing Myra Peskowitz, principal of The Peskowitz Group in Melville, NY.

That's why, in Peskowitz's DON days, she made sure she was a "safe person" to whom nursing staffcouldventtheirfrustrations,largeorsmall,such asrunningoutoftimeeveryshiftoroutoflinenatbath time. "Then I did everything I could to address the underlying issues," she tells Eli.

The DON's familiarity with the staff is also critical to heading off abuse or neglect of residents."A bigpartofabusepreventionisbeingpartofthefabric of what's going on not to be a spy, but just knowing who is having trouble at home or under stress at the time," Peskowitz adds.

Facilities where the DON knows the names of the certified nursing assistants and something about them personally have much lower staff turnover and often not a hint of abuse, says Darla Watson, director of clinical informatics for Mariner Post-Acute Network in Atlanta. "Everyone wants to be recognized it's a basic human need for all of us. The work CNAs do is very hard."

CNAs especially want to be treated as a key part of the care team, Watson says. In her experience, a lack of "valuing" the CNAs' contribution often translates into poor orientation and inadequate follow-up to make sure CNAs have what they need to do the job. In such a case, "the CNAs may not even get sufficient training to know what constitutes abusive behavior," she notes.

Some staff, for example, may have had parents who cuffed them around or often spoke to them in a rough manner, so they may not really understand that's in appropriate behavior.

A facility administration that proactively prevents resident abuse accepts and addresses the fact that many CNAs feel under siege on the home and work fronts. "It's easy to say, 'Leave your problems at home when you come to work,'" but this is difficult for some workers, Peskowitz notes.

In the workplace, too, abuse begets abuse. So one of the main ways an administrator can provide a supportive environment for staff is to help make sure they aren't the target of put-downs or outright verbal abuse from family members and residents. "The facility must take a stand that families cannot be abusive toward the staff," says Peskowitz. "Everyone has to follow a standard of conduct. You want to let families know that you are going to protect their family member but also that they cannot talk to staff in an abusive manner even if that means someone has to be present during their visits to the facility. It's too easy for everybody to criticize what the CNAs are doing."

Peskowitz believes it helps to set this tone during orientation of residents and families. "Emphasize that it's a team effort all the way," she notes.

CNAs also have to be protected from residents who provoke staff with racial slurs, abusive language or physical abuse. "If administration or even charge nurses become aware of a potentially volatile situation they should intervene with effective behavioral strategies, educating staff and monitoring whom they assign to the resident," suggests Marie Infante, a health care attorney with Mintz Levin Cohn Ferris Glovsky & Popeo in Washington.

The facility can also train staff to dea lwith the cultural stress that comes from caring for people from different ethnic,racial or socioeconomic groups.For example,empathy-building exercises,including videos and role playing, can help the staff bridge cultural differences by focusing on what everyone experiences  in common: grief, loss, loneliness, fear, growing older, the need to be accepted, etc.

Caregivers must also be taught to develop personal boundaries in caring for others and to find ways to replenish themselves lest they eventually feel "used up" and angry, which can lead to health problems and a greater potential for behaving in negative ways toward residents or families.

A "culture of caring" doesn't mean one where employees repeatedly reap the benefit of the doubt without bringing their performance up to par. "There does come a time when administrators must draw the line with an employee," observes Beth Klitch, president of Survey Solutions in Columbus, OH. "Once you work to help an individual overcome obstacles getting in the way of their getting to work on time or performing as well as they can and they still don't perform well then you have a whole different issue and set of required actions."