Behavioral approaches to improving wound care.

Editor's Note: As any staffer knows who has spent more than a few moments in clinical care of residents, therapy involves more than using good technique and effective products. It requires a positive attitude among all participants - staff, residents and families. And that means behavioral management. In fact, in these OBRA-enforced days, behavioral management is (or should be) given primary consideration over other therapeutic modalities. That is true even of therapy as technique- and product-intense as wound care. No matter what tools you use, wound care works best in an "environment of healing."

Productive                     What Supervisors can do to encourage
Staff Behaviors                and reinforce these behaviors

Express belief that wounds     Set attainable treatment goals.
will heal. Show confidence     Provide training that demonstrates
and enthusiasm. Accept and     effective wound care attitudes and
express responsibility for     procedures and how they can achieve
patient outcomes.              desired outcomes. Use success to
                               stimulate confidence which, in turn,
                               stimulates further success.

Talk with and listen to each   Emphasize the importance of attitude
patient. Get to know likes     in wound care. Coach staff to focus
and dislikes. Include          on the whole person. Empathize with
patients in their own care     staff. Listen to staff whenever
planning. Ask patients         possible, help solve treatment and
questions to better            behavior problems. Support and
reward
understand how they feel       staff for good work. Promote
feelings
about the wounds and the       of self-respect. The better staff
care goals.                    understand the importance of real
                               teamwork - with patient, family and
                               staff all working together to reach
a
                               goal - the more likely appropriate
                               information will be shared.

Give positive reinforcement    Provide training in behavior
(attention, recognition and    management that helps staff first
reward) to patient for         look for reasons for a behavior -
behaviors that are product-     training that stimulates creative
ive in regard to reaching      behavioral approaches or situational
wound care goals.              changes that foster more productive
                               behavior.

Set goals as a team. Work in   Supervisors continue to treat wounds
concert with other team         - to model caregiving techniques
for
members, including doctors,    staff and assist with work load.
therapists and other staff.    Assure a well-formulated care plan
Respect the expertise of       that can be monitored and provide
colleagues. Keep up-to-date    regular feedback to team members
about
with new ideas and             their performance. Listen to and
treatments.                    respect the experiences, ideas and
                               insights of team members. Be alert
                               for ways to reward desired staff
                               behaviors. Correct counterproductive
                               behaviors quickly, without
undermining
                               self-respect. Utilize learning
                               opportunities in everyday
supervision
                               and in scheduled inservice sessions.

Ask questions when they        Respond to treatment questions as
don't know how to care for     opportunities for learning. You can
a wound.                       have high standards without
expecting
                               perfection. Give effective staff an
                               opportunity to do some of the
                               training - reinforcing their
                               performance and helping provide a
                               role model for other staff.

That is the concept behind a guidebook released earlier this year by the Beverly Foundation, an independent, non-profit educational organization based in Pasadena, CA. One of its new "behavior management educational products" is entitled Healing People: Using Behavioral Approaches to Improve Wound Care Effectiveness. The booklet focuses on common behaviors - by staff, by residents, by families - that can either promote or delay wound healing. Succinct guidelines are presented describing how each group can learn to encourage positive behaviors and counteract negative ones. As a sampling, Nursing Homes has been permitted to reproduce the booklet's guidelines for staff. All three sets of guidelines, however, can be useful to nursing home management in understanding how behavioral factors can promote a healing environment.

Counterproductive Staff        What Supervisors can do to
discourage
Behaviors                      counterproductive staff behaviors

Don't like wounds and wish     Help staff look beyond unpleasant
to be off the service.         aspects of wound care and appreciate
                               and be proud of their healing role.
                               If aversion cannot be mitigated,
                               reassign as soon as possible.

Don't understand rationale     Assure that inservice training fully
of treatment. Don't report     addresses treatment rationale. Check
changes in wound status or     and recheck to ensure that staff
breaks in skin integrity.      understand the purpose and
importance
Don't document treatments.     of the treatment plan and are
Dressings don't get changed.   convinced that treatment goals are
                               realistic.

Treat the wound with little    Coach staff in talking to the
patient
regard to the whole person.    as care is given or services
                               provided, focusing on the responses,
                               concerns and feelings of the
patient.

Convey negative thoughts       Help staff recognize the importance
to patients. Criticize         of attitude in wound care, that
patients for lack of           healing is a mental as well as a
progress.                      physical process. Assure that care
                               plan expectations and goals are
                               realistic.

Are self-centered and          Supervisors encourage and reward
territorial in care            teamwork and cooperative behaviors.
planning. Don't communicate    It is easy to inadvertently
with team members.             reward competitive performers who
                               erode team effectiveness,
                               particularly if they personally
                               excel. Perhaps giving the star
                               performer the opportunity to help
                               train other staff might serve
                               everyone's needs. Hold them
                               responsible for sharing expertise
and
                               being a sounding board for questions
                               on wound care.

                               Reward team performance. Recognize
                               and reward contributions to
improving
                               wound care services.

Don't like a specific          Encourage and reward behaviors that
patient.                       convey understanding and compassion.
                               This is the essence of providing
                               care. In extreme cases, transfer the
                               staff person.

(Copies available at $13.50 per copy from the Beverly Foundation, 70 South Lake Avenue, Suite 750, Pasadena, CA 91101-2601; phone [phone].)