Long-Term Care Survey Alert

Do your nursing assistants "see no evil, hear no evil" when their coworkers sometimes behave inappropriately toward residents?

This "code of silence "can pave the way for an incident that causes serious harm to a resident. At that point, staff usually do come clean to surveyors or investigators about what they have observed all along, opening a Pandoras box of survey and liability issues.

Under F226, facilities are required to implement written procedures and conduct training to encourage staff to report abuse or neglect. As part of this training, "staff must understand their obligation is to protect residents, not fellow coworkers," emphasizes Beth Klitch, principal of Survey Solutions Inc. in Columbus, OH.

Informing staff of the legal consequences of not reporting can help drive home the complicity of silence. "The administration should teach staff that they are mandatory reporters who will lose their license or certificate if they dont report abuse," adds Kathy Hurst, principal of Hurst Consulting Group in Chino Hill, CA.

Yet even when staff are aware of their responsibilities to report resident abuse and neglect by their coworkers, the code of silence can bedifficult to break for a variety of reasons, experts caution.

"The obvious abuse and neglect cases do get reported, such as someone being really verbally mean or physically abusive to a resident," notes Karen Clay, a long-term care consultant with Landmark Health Solutions in Haverhill, MA.But CNAs face more dilemmas around the subtle forms of neglect or abuse, she says, such as not changing someone because it takes a two-person assist or not answering the call light of an onerous resident. "Those are the kinds of situations that would require CNAs to challenge their peers, which is difficult to do," she says.

Part of the answer is better supervision, which takes the onus for reporting peers off the CNAs shoulders. "Since peer review is so difficult, the nursing supervisor must step in and identify this subtler form of neglect, which requires nurses to be aware of and supervise the residents routines," Clay affirms.

Supervision can only go so far, however. CNAs need to internalize a standard of care and conduct that protects residents, which is a process that requires positive mentoring. "You have to take advantage of that teachable moment when you catch the CNA in the act of not providing the care required by a resident," Clay says. "If you can have the CNA look at it from the bigger picture of what it means for that resident in terms of outcomes, or what it feels like to the resident not to get their basic needs met, that will work better than taking a shaming approach."

A lot of facilities do empathy-building exercises with CNAs that focus on human rights and sensitivity to other peoples needs. Clay, for example, conducts exercises where CNAs are given a flash card that tells them a need they must convey without speaking to the other CNAs in the audience, such as "Im thirsty," or "Im lonely." This type of activity helps CNAs identify more closely with the frustration of elderly residents who are struggling to communicate basic needs.

Teaching CNAs to understand and deal positively with abusive or very demanding residents also helps staff view such behavior in a more clinical context, rather than taking it personally.

One phenomenon that contributes to the code of silence, in fact, is the notion that abusive or difficult residents "deserve" more subtle forms of retaliation or neglect. Administrators reinforce this rationalization when they dont help nursing staff deal with such situations.

"If administration sees a resident who provokes staff with acts of verbal or physical abuse, they should intervene with behavioral strategies, educating staff and watching whom they assign to the resident," says health care attorney Marie Infante of Mintz Levin Cohn Ferris Glovsky & Popeo in Washington.

Facilities can also take steps to dismantle the "them vs. us" mentality where CNAs see themselves as a group relegated to the lesser tasks in a facility while administrators and professional staff carry on with the "important" business.

"Mutual goal setting among all levels of staff is a good start in that direction," says Clay. "Sometimes when people are working towards the same goals, the differences in job position and culture become less important." Administration can help by developing regular forums to include CNAs in important decisions affecting the work and care environment, starting with care planning conferences.

It also helps to regularly ask CNAs about their professional goals and weave those into an overall objective of the facility for example, if a CNA says she wants more training in restorative care, the administration might fit that individual aspiration into its efforts to strengthen the facilitys restorative program.

The administration can also help everyone in the facility develop a sense of unity by hosting regular social events for everyone the kind that people really enjoy.

For example, Clay recalls working in one large nursing facility where administrators threw a large party every three months at a local establishment. "The facility paid for a disc jockey, management made snacks and everyone brought their own beverages, so it was a low-cost event," she reports. "Everyone came to the parties the CNAs, kitchen staff, the management, rehab staff, even the medical director. As a result, we developed such closeness as a group. Interdepartmental cooperation was high and turnover was low," she says.