Table 3 Local interaction strategies and exemplar quotations

Connection: Local interactions strategies that help individuals make and keep good relationships with co-workers and foster good teamwork; these lay the foundation for effective information exchange and problem solving about resident problems.

• Be approachable--Be open, listen, and respond to what people say

A rehabilitation therapist said, “If I have a positive relationship before a situation comes up, then I’m more likely to get a positive response from [the nursing assistants] out on the floor, too… They will stop me and they’ll tell me about issues.

Respect

Better care planning

Early detection of problems

• Pitch-in-- Go beyond regular duties to help others

I [nursing assistant] had one total care person and the rest just need some assistance which made my assignment easier. So I went down and gave a couple of showers and made a couple of beds for the other girls…They did not ask me, I just went ahead and did it.”

Teamwork

Staff well being

• Seek assistance-- Request help

An employee performance standard (employee handbook), “They are willing to ask for help and do not think they can handle every situation on their own. If they can’t get the needed result they will find someone else who can. They are primarily concerned about getting the right result for a resident.”

Patient safety/earlier detection of problems

• Reciprocate-- Give and take with others in a way that generates goodwill

A business manager says, “I give [my assistant] a lot of my work to help me out – AND we work together. She does things for me. I just don’t like telling her what to do. I said, ‘These are the things that have to be done, let’s work on it together.’ And I do that kind of thing. I think its being a team player and not just unloading everything on one person. … She had to leave early one day and I said, ‘Well, go, I’ll finish up.’ And I made her leave. You know, I believe you should be able to take the load over.”

Teamwork

Staff well being

• Show appreciation-- Express a positive opinion of other peoples’ actions

“If I [administrator] see things that are right…we write you up for that in a positive way…we try to focus on what you are doing right.”

Motivating

Empowering

Staff well being

Confidence

Satisfaction

• Give respect--Let others know you value them and their opinion

An administrator says that “to develop employees to their fullest potential and allow them to see the difference that THEY can make in people’s lives….by viewing every [resident] as an individual, whether [or not] they are capable of communicating with us to treat them with the dignity and respect that THEY deserve and to – to try to give them the best quality of life. I feel like if we treat our employees right, they’ll treat the residents right. But, we have to model the behavior that we want them to have. And, uh, so – and I think that starts with - with EVERYONE, but certainly with me. And so I do everything I can to encourage that behavior.”

Respect

Staff well being

Patient quality of life

• Say thank you-- Express gratitude, pleasure and satisfaction

“Staff like to be recognized…when [the administrator] goes in there one-on-one and says, ‘thank you for the hard work that you do’ and ‘can’t even pay you enough for the hard work that you do. We really appreciate it.’ The staff like that.”

Staff well being

Respect

• Give praise-- Let others know you admire the work they do

“It makes me [nurse] feel good when I do something good for a resident, like if something happens to them and I end up having to send them out…and someone will come to me and say, ‘You did a really good job. You knew to call 911, you knew to do this. You knew to do that.’”

Respect

Motivating Empowering

Staff well being

Satisfaction

• Coach/Mentor-- Guide, instruct, or train others; form trusting relationships

“I [nurse] use to get the worse nursing assistants. But what I would do was to…work with their strengths and whatever weaknesses. I would teach them. ‘You don't leave up a rail’…I will go back and check behind them. Before long they will pick up on these things”

Valuing Confidence

Better resident care

Patient safety

New Information Exchange: Local Interaction Strategies that help individuals give and get new information about residents to and from the right people, in a way that ensures everyone understands.

• Listen-- Hear with thoughtful attention

A nurse manager said, “Just let people know that they’re important [said with emphasis] and that what they have to say is important… Whether you can do anything or not, at least you’re listening! You know that you’ve heard what they’ve had to say.”

Staff feel respected

Valuing

• Give information-- Share information; give a report

After a CNA described how she solved a resident behavior problem, a researcher asked, “Did you share your strategy with anybody else?” The CNA said, “I did with another nursing assistant. She had [the resident] the next day and I told her what I did… she said okay and she tried the same thing and it worked.”

Teamwork

More consistency in resident care

• Receive information-- Graciously accept information

An LPN explained, “If you’ve got concerns or complaints, being able to go to someone and say, you know, ‘This is bothering me,’ or ‘I’m concerned about this.’ And, them at least addressing your concerns—that’s important. They may not do anything about it THEN, but then at least they LISTEN to you. I think that important.”

Potentially pick up resident issue

Staff feels respected

Staff well being

Valuing

• Explain-- Give more details to clarify what you mean

A housekeeping director said, “If you just say, ‘This is wrong you know, you better change this, it is not good,’ they [housekeeping staff] will just end up hating you…I explain to them, ‘This is what you need to do. Bring the trash can; put a lining on that trash can, so when you take off the diaper, drop it directly in…I give them several examples like that and that way they understand.’”

Staff well-being and efficacy

Better job performance

• Verify Meaning-- Make sure you understand information shared by others.

A nursing home administrator relayed a conversation with an employee who said, “I don’t understand why I’m submitting a doctor’s bill.” I said, “Prospective Payment System…” and I went through the scenario. She said “Now I understand.” That’s what I try to … I’ll look in your eyes; if I’m comfortable you got it, we move on with business. If not, I want you to think about it for a minute…

Delegated tasks more likely to be done properly

Cognitive Diversity: Strategies that help individuals notice changes in residents’ conditions and that they act on what they see and discuss multiple opinions to make good sense of the problem and ensure shared meaning of events.

• Pay attention-- Make a conscious effort to stop, watch and act.

“In the wheelchair…in front of the nursing station, one male resident had been snoring very loudly. A certified nursing assistant moved him and another resident in a geri-chair around and reclined both so they can sleep more comfortably. She then picked up a couple of paper towels that had fallen on the floor and went into a bathroom to throw them out and wash her hands.”

Better quality

Patient safety

Earlier detection

• Ask questions-- Ask for explanation when you feel uneasy about something and when you feel you were not heard.

A nursing assistant said, “I would…look at the chart. But…for me to really, really understand the resident - since that nurse knows that resident, I would rather go to [the nurse] and say, ‘Well, how about so and so, what kind of person is he?’ You know, ‘can he stand, can he sit?’

Patient safety

Better care

• Give feedback-- Provide others with useful opinions or reactions to their work

A physical therapist said, “If I hear of problems, I try to pull people in. For instance, we’re having issues with some restraint situations…And so, we’ve opened up some lines of communication.”

Patient safety

Better care

• Receive feedback-- Graciously accept others’ opinions about, or responses to, your work

A Minimum Dataset Nurse explained, “I have a particular resident who…filled my ears full yesterday and, you know, I explained to him that I’ll be coming to him every day that I’m here - sitting down and talking with him and, you know, I’m going to help him, you know, try to resolve anything that I can. And he was very responsive to it.”

Quality improvement

Resident quality of life

• Suggest alternatives-- Give different options for others to consider before taking action

A Nurse stated, “I looked in on a patient, but, she’s been in the bed for the last few days…So, I asked [the charge nurse], ‘Why is she in the bed?’ And they said, ‘Oh she just hasn’t been feeling well.’ So, I tell the charge nurse, ‘You might want to look for a UTI, because she has a history of having UTIs.”

Earlier detection of problems

Better care outcomes.

• Sensemaking-- Talk with other people to ask, “what does this mean?” Together make sense of confusing information or situations

An Activities Director said, “There was an issue with [a resident] trying to sneak food. And he, at the time, couldn’t take anything by mouth. We had a lot of conversations…everyone could come with their ideas and really try to think about how to make it work for the resident and the family…It was great. It was a lot of conversation and really coming together for the resident’s best interest.”

Better care planning and decision-making

Better care outcomes