cultivating positive attitudes in nursing home staff

Cultivating Positive Attitudes in Nursing Home Staff Patients need kind and respectful treatment from care givers.

MARSHA GOODWIN JULIE TROCCHIO

When asked what constitutes quality care and which factor is most important in creating a good nursing home environment, residents often men- tion the attitudes of staff, especially those ofnursing assistants(l). Recur- ring themes in responses about staff attitudes include "being kind and considerate," "friendly," and "listening to complaints."

The emphasis residents put on staffattitudes suggests, first, that they have a major impact on the quality of daily life and, second, that the pro- motion of positive staff attitudes is an area in which nursing homes may fall short. However, nursing assistants in long-term care facilities can be encouraged to exhibit behavior that reflects positive attitudes toward the residents with whom they work.

Neglect of the Affective Domain

Over the past ten years, most texts and curriculum guides that have been developed to teach nursing assistants how to do their jobs contain excellent suggestions for teaching the cognitive component: theories of aging, the aging process, basic anatomy and physiology, patients' rights, and so forth. Most instructors' guides include satisfactory ways ofevaluaiing whether students have mastered facts--for example, paper and pencil tests, oral quizzes, and writing as- signments.

Similarly, most curricula present

Marsha Goodwin, RN, C, MSN, is chief of evaluation and training, Office of Geriatrics and Extended Care, Veterans Administration, Washington, D.C.Julie Troechio, RN, MS, is director, Delivery of Services, American Health Care Associaton, Washington, D.C.

adequate information on psychomotor skills: how to measure vital signs, bed making, skin care, and feeding a patient. These skills lend themselves to simple evaluation; for example, an instructor using a skills inventory can "check off ' students who demonstrate skill proficiency.

Where most, if not all, texts and curriculum guides fail is in recogniz- ing the importance of the affective domain in teaching and learning. Bloom's three handbooks on the classification of educational goals, well known to nurse educators, focus on the cognitive, psychomotor, and affective domains. The third hand- book on affective domain includes a discussion of how values, attitudes, and emotions are learned. Although not consciously learned, they are the most deeply ingrained aspects of lifelong experiential learning.

In-service directors in nursing homes often neglect these important aspects of learning and focus only on teaching theory and skills. "Be nice to residents" sounds too basic to teach and almost condescending; yet, cordiality is what residents want most from nursing staff. Nursing assistants may be asked to demonstrate how they perform a procedure, but are they ever asked to demonstrate how they wish a resident "good morning"?

It is difficult both to teach and evaluate attitudes, possibly because many educators believe that attitudes cannot be changed or that they should not be changed through formal teaching. On the other hand,

• the noted theorists Martin Fishbein and Icek Ajzen wrote an entire text on attitude formation and attitude change as observed in overt behavior(3), and they are not the only ones who have tackled the subject.

Attitudes can be assessed and modified through teaching and can be objectively evaluated by observ- ing a set of specific behaviors. Nurs-

ing assistants can be told from the outset that they will be expected to demonstrate behavior that shows kindness and respect. Passing proba- tion will depend on whether they are able to demonstrate the expected behavior. Nursing assistants must also be told that actions indicating disres- pect and rudeness are grounds for discipline or dismissal.

Moreover, residents and their families must know that courtesy and respect are basic standards of practice. If residents are not satisfied with the behavior of any care giver, they must know how to bring the problem to the attention of someone who can take appropriate action.

Resident council and family meetings can help residents to do this by reinforcing the fact that staff is expected to show courtesy and kindness and that the facility administrator wants to know ifa staffmember is behaving poorly.

Training Techniques During orientation and in-service

training, numerous techniques can be used to shape the type of behavior that projects positive attitudes toward nursing home residents.

• S imu la t ion Games. Game-like activities can be enjoyable and pro- ductive ways of influencing attitudes. For example, "Into Aging" as- signs participants ages and disabili- ties and has them move from independence to dependence and through various aspects of social and health-care programs(4). As game players become increasingly "sick" and "dependent," they are treated with increasing paternalism. They become subject to the whims of care givers and are given a taste of what it may feel like to be a nursing home resident. Discussions following the game playing let staff members ex- plore their feelings and discuss how their experience with the game can influence their work with residents.

32 Geriatric Nursing January/February 1987

SKILL AND ATTITUDE CHECKUST Skill Demonstrated Attitude Demonstrated

lask Admitting and Orienting a Patient Measuring the Patient's Temperature Measuring the Patient's Pulse and Respiration Weighing the Patient Use of Bed Cradle and Foot Rest Applying Elastic Bandages Using Safety Restraints Testing the Urine for Sugar and Acetone Washing and Filling Water Pitchers Moving a Patient in Bed Moving a Patient from Bed to Chair Moving a Patient from Bed to Stretcher Assisting a Patient to Walk Range of Motion Exercises

Yet No Yet N0

• Living in a Nursing Home. An ambitious but often successful approach to influencing staff attitudes is inviting staff members to act as nursing home residents for a few hours or few days. These volunteers may eat all meals and be subject to such procedures as being fed, having vital signs checked, and being bathed. Using this program, two facilities can team teach by having staff from one facility act as residents in the other.

• Skills Checklists. A new dimen- sion can be added to the standard practice of checking off those skills that nursing assistants successfully demonstrate. Supervisors can ob- serve and record the context in which the skill is performed.

For example, in addition to assess- ing whether the nursing assistant can satisfactorily take a blood pressure, the supervisor observes whether he or she showed respect for the resident through such behaviors as introduc- ing himself or herself to the resident, saying good morning, explaining what he or she will be doing, perform- ing the test gently and, following the procedures, asking if the resident needs anything.

During the bath demonstration, the supervisor watches for such non- verbal cues as the nursing assistant's tone of voice, look in the eyes, and touch. Existing skills checklists can be adapted to include the affective domain simply by adding an "attitude" column (see checklist).

• Group Meetings. Small group staff meetings that are regularly scheduled can focus on attitudes. Staff can be encouraged to discuss both positive and negative feelings about residents and attitudes toward their jobs. This process will convey to staff members that their opinions are important and that dealing with attitudes and feelings are part of being on staff. Structured group sessions must include discussions on how attitudes affect resident care and the quality of resident life and how staff can show behavior that will have a positive effect on residents.

• InvolvingResidents. Perhapsthe most valuable teachers in the affective domain are residents themselves. Individual residents or small groups of residents can present information to new staff. Just as depart- ment heads represent their depart- ments and describe their functions at

orientation sessions, residents can be invited to these meetings to contrib- ute their perspective.

Not all residents will be comfort- able in the role of lecturer, but those who were formerly teachers or have some background in speaking can be identified to do the job. Ifan individual resident cannot be found, a small panel, perhaps representing the resident council, could be used to present the resident view. The panel could discuss such topics as quality care, what they value in staff members, or what makes a good or bad day in the nursing home.

Another approach might be to as- sign new staffto interview individual residents. Staffmust be instructed to ask open-ended questions and listen to what residents have to say about nursing home life and what they like about the facility. This assignment will help staff develop listening skills as well as gain greater understanding of the residents' perspectives.

Attitudes and Skills

Helping nursing assistants to develop positive attitudes and respectful behavior toward elderly and disabled nursing home residents

Geriatric Nursing January/February 1987 33

must be an important consideration throughout the orientation and edu- cation program. Some subject areas are especially appropriate for reinforcing the need to be sensitive to the needs ofresidents.

• Basic Skills. Whenever a nursing procedure is taught, certain behaviors need to be reinforced. First, nursing assistants must always ad- dress the resident by the name he or she prefers and must introduce or identify themselves. Nursing assistants must always tell the resident what procedure is to be performed and anything else the resident needs to knowmperhaps how long it will take or what to expect. The assistant talks to the resident during the procedure and does not watch television or gossip with another worker. This way of treating residents may not come naturally to nursing assistants, so it must be reinforced each time a procedure is taught and reviewed.

• Admission. Perhaps the most important part of the admission process is for staffto appreciate how crit- ical a time this is for the new resident and his or her family. Nursing assistants can help the resident feel more positive about the admission by showing concern for his or her feelings and individuality. Nursing assistants need to learn the resident's likes and dislikes, what the resident perceives as his or her greatest problem at the time, and what the resident expects from the nursing home and its staff. Residents will have an easier time adjusting to the admission when staff is sensitive to their feelings and concerns.

• Care Planning. In some facilities, involvement of nursing assistants in the care-planning process is limited to carrying out specific procedures listed on the Kardex. A better systemmone focusing on a resident- centered, team approach--involves nursing assistants in each step of care-planning: assessment, problem identification, goal setting, imple- mentation, and evaluation.

As active participants in the care- planning process, nursing assistants learn that an individualized approach is required to meet each person's needs. Care givers will learn that how they approach the resident

(their attitude as reflected in their behavior) can be as important or more important than the physical tasks they perform.

• T imeManagement . Seminarsin time management have recently gained popularity among executives. Actually, no one needs more help in planning the minutes ofthe day than a nursing assistant who has eight or ten residents to care for and a long list of unit tasks. These care givers must be taught that talking and laughing with residents is not only permissi- ble, but part of their work. Residents need the staffto take time to listen to them and to respond to them as indi- viduals.

One nursing home addressed this need with a program called "1:2:1"(5). Each staff member, from nursing assistant to housekeeper to administrator, could voluntarily be assigned a resident. A period of time each week would be put aside for vi- siting with the resident and identify- ing special needs. Eventually, each resident had an advocate, someone within the home who felt responsible for that person's well-being. An addi- tional bonus of this program was that staff members became more sensitive to the needs of all residents as they learned of the feelings and needs of one individual.

• Resident Councils and Activi- ties. Resident Councils are more than social clubs, and activities are more than mildly interesting hob- bies. Resident councils are vehicles for those living in nursing homes to have some independence and the op- portunity to make decisions. It is important for nursing assistants to un- derstand the significance ofthe council. Once they do, they will be more apt to appreciate the need that all residents have to be treated with respect and be given opportunities to make choices. Nursing assistants, with the council's permission, can sit in on meetings in order to gain in- sight into the council process.

Similarly, activity programs allow residents to keep up with pastimes and avocations following admission. An awareness of the need to continue lifelong interests wiU lead to an ap- preciation of the individuality of each resident. Further, if nursing as-

sistants believe residents' activities to be important, they will help them get to scheduled activities as well as make it possible for residents to en- gage in these pursuits in the nursing unit. For example, care givers will re- member to turn on a radio, make sure a book is nearby, or put sewing within reach.

Caring for One Another

Professional nurses can promote, positive attitudes and behavior by setting an example for nursing assistants. First, nurses must act as role models. When nursing supervisors show respect for the fights of residents, assistants will learn what kind of behavior is expected and needed. Nurses ought to know at least as much about residents as the nursing assistants who work with them on a daily basis.

Second, nurses must demonstrate respect for one another and all nursing assistants. Supervisors must con- stantly seek ways to enhance the self- esteem of each staff member. They reinforce positive behavior and give praise whenever it is due.

Working in a nursing home is difficult, often frustrating work. Supervi- sors need to tell staffthat their work is appreciated, their feelings are important, and that they are contribut- ing to the quality of life of each resident. It will be difficult for nursing assistants to maintain a positive attitude toward residents without re- ceiving nurturing from those around them. Nurses can demonstrate the value of compassion and caring by focusing it first on nursing assistants. In such a supportive environment, positive attitudes and behavior will develop and flourish.

References 1. National Citizens' Coalition for Nursing Home

Reform. A Consumer Perspective on Quality Care: The Residents'Point of View. Washinglon, DC, The Coalition, 1985.

2. Bloom, B.S., and others, eds. Taxonomy of Edu- cational Objecti*'es; the Classification of Educa- tional Goals" Itandbook I. Cognitire Domain. New York, Longmans, Green & Co., 1956.

3. Fishbein, M. and Ajzen, I. Belief, Attitude. Inten- tion. and Beha~'ior: An Introduction to Theory and Research. Reading, MA, Addison-Wesley Publishing Co., 1975.

4. Reif, S.D., and Hoffraan, T.L lntoAging:A Sim- ulation Game. Thorofare, N J, Charles B. Slack, 1978.

5. Dolan, M.B. The 1:2:1 program. Am.IIealth Care Assoc.J. 5:75-78, Mar. 1979

34 Geriatric Nursing January/February 1987

cultivating positive attitudes in nursing home staff

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