Getting staff on-board.

Do you ever feel that your staff does not comply with your instructions, nor carry out the carefully planned programs you have posted?

Try a few basic guidelines.

First, whenever possible, ask for suggestions from your staff - that is, inform them what your department needs to accomplish and ask for their help. (If they help to plan a program, they are more likely to be enthusiastic about the followthrough.) Also, you will be amazed at their wonderful ideas. You find that the people who actually do the task are the ones who can suggest the best ways to accomplish it.

Next comes delegation, one of your most importation jobs. One realizes at the very onset of becoming a DON that you cannot do everything yourself, nor even personally see that everything gets done - even though you are held personally responsible for this. To effectively delegate, always remember to explain why something must be done; do not just routinely tell people to do something because you told them to. Also, make sure they know how to do their assigned tasks. The fact is that most nursing assistants love to learn. Treat them with respect (as you would your whole staff), and they will do their best to earn that respect.

Be outcome-oriented. A good way to do this, oddly enough, is to look backward: Start where your patients are today and trace how they got there. I did this in a facility where I had just become the Director of Nursing. We chose a female resident who was incontinent of bowel and bladder, wheelchair-bound, with flexion contractures of the elbows and knees and adduction at the knees and feet, and disoriented. Working backward through her records, we found that less than a year earlier she had been ambulatory without assistance. One day, however, she had been incontinent of urine while standing and had slipped and fallen without injury. The staff was frightened and confined her to a wheelchair unless someone was available to help her ambulate. She was unable to understand that she was not to get up without help, so the staff applied a soft belt restraint. Within only a few weeks this mildly confused lady became totally disoriented, totally incontinent, and began to experience contractures of the limbs. Furthermore, because she sat with her head downward, she was beginning to experience a flexion contracture of the cervical vertebrae, which limited her socialization and increased her confusion. After spending too much time in a sitting position, her incontinence made her very prone to skin breakdown at the buttocks and coccyx, and her contractures made her prone to skin breakdown in her extremities, especially of the feet.

As a further potential complication, without weight-bearing exercise, calcium tends to "leak" out of the long bones into the bloodstream and is filtered by the kidneys, which could lead to weakened bones and renal calculi (kidney stones).

Because of the staff's well-intentioned but misguided attempts to protect this resident, her outcome was poor and worsening. No blame was assessed. Rather, sharing this with the people who cared for her was a lesson in itself, and boosted staff performance more than I could have imagined.

Staff's compliance with high-quality care is based on a special realization: Often they are the resident's only family. If you and your staff do not meet residents' needs - both physically and emotionally - they will not be met. If they do not hear laughter from you, they will never hear laughter. If they do not get affection from you, they will never get affection.

If your staff members grasp this and feel good about their jobs, hear compliments on work well done, and feel they are treated fairy and with respect, your residents will receive the best care possible. It will be their home, not an institution, and as a DON doing your job, you can take a good share of the credit.

Karen L. Bonn, RN, a former director of nursing, is founder and president of Restorative Medical, Inc., Brandenburg, KY.