Despite all the advances in equipment and technology to improve care, leaders should remember that staff and their relationships have the greatest influence on performance. Researcher Jody Gittell, PhD, professor of management at Brandeis University’s Heller School for Social Policy and Management, documented that high-performing nursing homes have as their foundation high-quality working relationships among the staff.
They found that residents’ experiences are powerfully shaped by relationships among staff and that the relationships among the staff that work closest to the residents matter most.

Communication Key In Relational Coordination

The interdependent nature of caregiving work requires what Gittell calls relational coordination (RC). The theory of RC is that the effectiveness of care and service is determined by the quality of communication among staff.
The quality of staff’s communication depends on their relationships with each other. This theory is highly applicable to the nursing home environment, where tasks employees perform are closely interrelated.
Their interdependence forces staff to work with one another, but if their relationships and communication are weak, then residents’ needs will fall through the cracks and may cause staff conflicts.
Leaders’ actions directly shape how well people work together. Effective leaders know the importance of communication and put in place the systems through which people communicate, such as through morning stand-up meetings and shift huddles. Leaders develop people’s communication and critical thinking skills so they know what to share and why it’s important. And effective leaders look for ways that make the work environment one that supports good communication.

For example, eliminating overhead paging so there is less sensory overload enables staff to communicate directly with each other in a more thoughtful way.
Systems that support RC among staff are the key to their success, whether it’s stabilizing operations, generating continuous quality improvement, or implementing culture change.

Five Practices That Support RC

Following are five specific RC practices that provide the organizational foundation for success in any improvement effort:

Relationship-Building Rounds. It starts with communication through rounds. Leadership makes rounds to check in on people, not to check up on people; foster relational coordination; and demonstrate active caring and listening. Maintaining a regular, timely, positive, problem-solving presence fosters quality communication and positive relationships. While it’s a good sentiment to say, “my door is always open,” requiring staff to come to you with a problem is not as effective as staff knowing they can count on you being present, asking how things are going and what they need.
Rounding several times a day helps leaders mitigate staff concerns while they are still small matters, instead of having unchecked problems mount up into major conflicts and relationship breakers by day’s end.
Whether working to stabilize a troubled building or launching a new area of improvement, rounding provides the regular positive presence that allows leaders to keep a finger on the pulse of the organization, catch problems early, and intervene effectively.

Consistent Assignment. When staff work with the same residents and co-workers day to day, they are able to establish deep relationships. However, if assignments are perceived as “unfair,” problems can emerge. Current best practice involves engaging the staff in figuring out the best balance so that assignments are fair and work both for residents and for staff. Ask staff to rank residents by degree of difficulty, in physical and non-physical care. For residents that everyone finds very challenging, consider pairing up and engage all disciplines and departments in problem-solving individualized solutions.

Many organizations that intend to have consistent assignment struggle with what to do when they have an unscheduled absence. It’s better to localize the disruption through an all-hands-on-deck approach on the short-handed unit, because pulling a nurse assistant away to cover for the absence actually doubles the disruption by affecting two units. To solidify consistent assignment, monitor how many people now take care of a resident and how many times staff are pulled away from their assignment because of an absence elsewhere.
Maintaining consistent assignment is easier with systems that make the daily staffing math work out. For example, in a “four on, two off” schedule, three staff can share two resident assignments, with one person serving as the consistent back-up for the other two.
 ■ Huddles. Have the huddles the same time every day so staff can count on them and be on time. Start and end on time, and be brief and on target. When starting with a huddle, consider using the elements of Stop and Watch, the early warning tool developed by INTERACT II as a guide for what to cover.
One way to get started is to use a huddle to let staff know about any new residents expected or to check in on newly arrived residents. It may be best to huddle on an area that needs work, such as which residents are most at risk for re-hospitalization and what can be done to monitor and safely care for them.
At Rosewalk Village of Indianapolis, staff huddle in a small back room and use a white board to note any significant information they need co-workers to know.
Consider involving other members of the care team. In a 10- to 15-minute gathering at change of shift, the nurse assistants at an Augusta, Maine, nursing home discuss each resident’s risks, status, and pertinent events of this shift, including quality-of-life events. Nurses identify any acute medical changes and the follow-up plan and address any changes or additions to the plan of care. Several times a week, social work, activities, rehab, and dietary staff join the huddle to discuss needs, risks, and preferences.
At a nursing home in South Bend, Ind., the management team takes its stand-up out to the units for a huddle to discuss the 24-hour report twice a week. Use the huddles for teachable moments.
When staff share information, it’s crucial to let them know why what they said is important, what they should look for in their care, and to follow up with them as the situation develops. This creates a continuous learning process in which staff get better at catching situations early and knowing how to think them through together.
When first starting a huddle, some staff may not know what to share about a resident.

Involving Dedicated Nurse Assistants in Care Planning. Once consistent assignment is in place, it will become evident that nurse assistants have a lot to offer. They really know their residents. This knowledge is valuable, but it has to be easy for them to share and comfortable to participate.
Consider relocating the care planning meeting near where the residents and nurse assistants are located. Let them know when residents are in their assessment reference date period, and, during the shift huddle on the day of the meeting, let the nurse assistants know what time the care plan meeting will occur.
Educate them about what information to share in the meeting. Families really appreciate being able to talk directly with their loved one’s primary caregiver.

Unit-based Quality Improvement. With huddles in place, when faced with a problem, leaders should consider taking the issue to the unit and getting the staff involved in identifying the root causes that may be evident.

Leaders can model effective, respectful group problem solving by setting guidelines such as “no finger pointing.” Then use this approach as a platform for enhancing everyone’s critical thinking and problem-solving competence. Stay with it because some staff members may not be comfortable at first. Recognize that “it takes a village,” and that many problems are not just the domain of the nursing staff.

Systems Drive Outcomes   

Wherever improvement efforts are focused, systems shape the outcomes. The better staff work with each other, the better they can care for residents. It sounds so simple, but RC doesn’t happen by itself. It occurs when leaders put the systems in place to generate “timely, accurate, problem-solving” communication; help staff to develop the skills needed to make the most of these systems; and create an environment that supports staff to talk issues through and problem-solve together.
Whether struggling to improve from a one-star rating, reducing antipsychotics, decreasing re-hospitalization rates,or working on culture change, success will come when systems that support and foster RC among staff are used and when those systems are backed up with a leadership approach that brings out and supports what staff have to offer.
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David Farrell, Barbara Frank, and Cathie Brady are co-authors of “Meeting the Leadership Challenge in Long-Term Care: What You Do Matters.”