PAYING ATTENTION: A Leap Toward Quality Care

The difference between highly effective organizations and others “is the sensitivity or mindfulness with which people [in all positions (e.g., nurse aides to DONs)] react to even very weak signs that some kind of change or danger is approaching” (Coutu 2003, p.86). Paying attention to others, our surroundings, and ourselves is a powerful component of “mindful practice” (Epstein 2003a) and requires an internal discipline that means that nothing is accepted as routine. Using all of our sensory and cognitive resources, paying attention occurs by listening, noticing details, and taking actions that change the course of events. Similar to vigilance, it encompasses staying alert and on guard for the unexpected or unpredictable in order to take necessary and quick action. When all staff are paying attention to early or weak signs of potential resident care or staff management issues, information relevant to decision-making can be shared and used before such issues escalate into larger problems. Because early warning signs of change or danger (whether it is something as simple as recognizing that a resident is chilled and needs a sweater, or as complex as impending stroke), are by definition unexpected, staying “tuned in” and expecting the unexpected is key to fostering resilient and reliable organizational environments (Coutu 2003). Not paying attention, or non-vigilance, has been associated with concerns over patient safety, particularly medication errors and infection control (Burke, 2003). In a study of nursing homes, we found that paying attention is critical in providing good resident care and facilitating effective peer and supervisory relationships. In this article, we describe paying attention as used by administrators, supervisors, charge nurses, and CNAs with the aim to challenge nursing home leaders to: 1) hone their awareness for paying attention; 2) understand the impact that paying attention has on residents and staff, and 3) encourage an environment where all staff members pay better attention.

Introduction to the Research study the data presented below are from in-depth case studies about relations patterns and nursing management practices in four nursing homes one state. Over six months, two field researchers directly observed staff working and in meetings and conducted in-depth interviews. Case summaries and a description of participants may be found in the February 2006 issue of The Director (Corazzini et al., 2006). The authors read and coded the 500-plus field notes and interview transcripts comprising the data. For more details of the case study research design, see Anderson, Crabtree, Steele and McDaniel (2005).

Findings

During the case studies, we observed what staff members termed “paying attention” (and not paying attention), across all levels of staff and departments. The staff described paying attention as needed both in providing direct care and managing staff

Paying attention in direct care: Several direct care staff said that “paying attention” allowed them to identify and address resident care issues integral to good resident care. ~ It was essential to “knowing the resident” and enabled staff to register subtle resident signals before these could become serious issues. For instance a Nurse Supervisor (RN) described her reliance on nursing assistants (CNAs) to pay attention to the details of a resident’s condition:

I always go to the CNA … They are the ones that know the resident … They may not know the scientific names but they know what is going on … They see [the resident] every day from top to bottom.

By paying close attention to a resident’s repetitive behavior while restrained in a wheelchair, a CNA recognized the unspoken desire of the resident to be free from the chair restraint. This is how she explained the situation;

[CNA]: I noticed that he is always trying to get up … he’ll lean up and try to get out of the wheelchair, but he can’t get up.

By paying attention, the CNA understood what the resident was trying to express and she subsequently intervened by periodically taking him for walks. This action, allowing the resident periods to stretch and move freely, facilitated tolerance of the chair restraint and averted potential harmful outcomes such as venous stasis or blood clots. Further, this example suggests that paying attention can be especially important in caring for residents who cannot communicate their needs or discomforts. In contrast to the example above, we found evidence that ignoring or missing resident cues can result in poor care and potentially harm residents, for example in this observation:

[Field Observer]: I watch the CNA give the resident steaming grits that look really hot. He jerks his head from side to side and tries to spit them out, but she keeps on giving them to him. Finally she says, “Are the too hot for you?”

Here, the CNA was not paying attention to the temperature of the food and risked burning the resident’s mouth by the delay in recognizing the resident’s cues that the food was too hot. We observed that across departments and disciplines, openness and attention to diverse information allowed staff to identify care issues that may otherwise have gone undetected. In the following quote, a Social Worker noted a particular odor that prompted her to action

[SW]: I walk into a room and there is an odor that I’m not used to smelling, and I’m wondering if this person is getting a urinary tract infection and if [staff have] addressed it. Rather than ignoring a “weak signal” that she hypothesized might be a possible urinary tract infection, the Social Worker simultaneously shared this information with the nursing staff and tried to make sense of her observation.

Staff from other disciplines expressed frustration when they felt nurses did not act when told about observations of possible resident care issues. For example, the Maintenance Director described how he persisted to get a nurse to pay attention to his observation of a resident: [Maintenance Director]: One resident wasn’t feeling well … I went to the nurse and she said, “he’s always that way.” You know it’s not acceptable. [I told her] you need to look at him now. And I was told it wasn’t none of my business. I went and got someone else, and sure enough, the guy [resident] had a legitimate complaint.

Along the same lines, a CNA returned to work after being off and observed that a resident had lost function of his arm; she used persistence to get the nurse to pay attention:

[CNA]: I told the nurse, something is wrong with him [resident]. She said, “Oh, he’s okay.” And I said, no, something is wrong with him because he usually helps be bathe him. You need to do something about it. Finally [the nurse] starting looking at him and she said, “something is wrong with him.”

Besides frustration, these quotes indicate that staff members feel helpless and not respected when others refuse to pay attention to a situation to which they have “tuned in”. Also, apparent is that other disciplines, such as social work and maintenance, can contribute meaningful resident information that if attended to will avert potential problems. The Maintenance Director and the CNA felt that nurses ignored their observations. Had they not persisted, a critical component of paying attention, issues may have gone unaddressed with direct implications for resident care.

Many staff described paying attention to the “little things” as important contributor to quality of care. For instance paying attention to smells within the building, unfilled water pitchers, delayed responses to call bells, and getting medications were some of the little things that can mean a great deal to residents’ comfort. As the Admissions Director stated: It’s the little, everyday livin’ things that we automatically take for granted … It’s their independence that they’ve had to give up, so we’re got to fill in the gap. All the little things contribute to the quality of care as much as meeting their medical needs.

Paying attention in management: Some managers in the study used paying attention as a management strategy. Just as “knowing the resident” and paying attention to changes in resident status were important, many managers acknowledged a critical need to “know the staff’ and pay attention to their needs. These managers recognized that providing care is hard work and described that when managers pay attention to the moods, feelings and morale of staff members, they are better able to provide quality care. These managers believed staff would put forth better effort in resident care if managers were sensitive to staff members’ individuality and feelings about the work. This included paying attention to nonverbal staff cues:

[DON 1] If I see somebody frown or whatever, I know that is my key. “Hey what is going on. What is up today?”

[DON 2] How can I say it? You know, you can walk, into a room and you can feel the air. You can get a feel of people’s emotions or if somebody’s angry, or what’s goin’ on in a situation.

One Administrator described how paying attention to staff as unique individuals can be very meaningful. He stated:

I try to stop by a couple times a day and just ask ‘em how it’s goin’ … I need to know a little bit because that shows we care about each other, you exist. You know. You had a touch time getting’ to work today, whatever… I try … to show that … I remember what we talked about yesterday.

Managers also described the importance of paying attention to the operational details that facilitate staff members’ ability to carry out their job duties. An Assistant Administrator noted, [O]n a daily basis you need to be very … vigilant and very proactive with [staff] in makin’ sure they have the materials they need to do the job, they have the manpower to do the job … I wanna make sure I give them the time that they need.

In the following quote, during a daily “stand-up” meeting, an Administrator admonished her managers for not attending to staff in the moment:

“Some of you are not taking care of your staff.” … “When they feel that you’re not gonna help them out and they come to me first … with something that should have been handled.” [T]hey were there - right then and there - and they were wanting help right then and there.

Managers also described that sometimes, not paying attention to what staff members are telling you can have negative consequences, including the loss of key direct care staff. A Rehabilitation Manager described a situation involving a new staff member who was being ignored and treated disrespectfully by a member of another department:

So I approached [the Administrator] regarding this issue. [The Administrator said], “Ok, I’ve heard you.” And … again, I bring it up. And nothing. Until finally, one day…I hear that she [staff member] is in tears…I march her right down to Administrator’s office and I sit her down and I say, “… You listen to her. I want you to hear this.” It was at that point that he … finally [acted to] head off the … problem … If … there was … an earlier response time -I think she wouldn’t have put in her notice.

Managers in our study also recognized that paying attention to families and the issues they raise can make a significant difference in resident outcomes. One DON told her staff: Family members are part of the solution … Talk with them while you are folding clothes … When you see them come into the facility, go up to them first. … We need them just as much as they need us.

Developing a capacity to notice what otherwise might be considered background noise while taking care of routine job tasks can be very helpful. A Business Manager described how she pays attention to what family members say as she is taking care of business matters with them and also suggested that others may not be paying attention: [A resident’s family member] will be sitting here talkin’ about their account, but then they’s mention, “Oh, Mom fell,” or “Mom bumped her arm; I’m kinda concerned about it.” [I ask them] ‘Have you talked to the nurse about it?’ [They respond] “No, I don’t wanna bother the nurse.” I let [the social worker] know …

On a practical level, managers described that paying attention to family concerns can also help them deal with the demanding regulatory environment and “head off’ unnecessary and unpleasant visits by the State. In this regard, one Social Worker was very blunt:

Well, yes, families are at the center of things …. Here, everyone is scratching their heads, and, the Sergeant Shultz [Hogan’s Heroes] approach to family complaints, “I know nothing”, and so the staff ask, why is DFS [Department of Facility Services] coming all the time, and with all these complaints? It’s because they’re not paying attention to families.

In summary, we observed many situations of not paying attention. In some cases, staff members were moving at such a fast pace that they did not stop to ask the questions or gather the information required to take mindful action. However, we encountered many direct care and management staff who had learned (sometimes the hard way) the importance of, as our DON above put it, “feeling the air,” and paying attention to the details of individual feelings, behavior and circumstances.

Discussion

Beset by financial and regulatory pressures, sicker residents, staff shortages and families who appropriately demand high quality care for loved ones, it is easy for staff to lose that fundamental ability to “tune in” to our shared human experience and be mindful of residents’ lives, right there, in the moment (Hunt 2004). Several factors influence what we pay attention to, including our training, educational level and socio-cultural background, as well as our understanding of our roles and those of others staff members. An attitude of “that’s not my (your) job” can narrow perceptions, reducing sensitivity to important stimuli. Futher, time constraints, competing demands and feeling overwhelmed can narrow our attention and we may not “see” what is before us, weakening the flow of quality of information necessary to mindful resident care and staff management.

Strategies for Improving your Ability to “Pay Attention”: In this study, staff at all levels recognized the value of paying attention as a strategy enabling them to provide better care. The following strategies may help to improve outcomes with the use of paying attention.

Actively monitor with a fresh look. What are your senses telling you? What do you smell? What do you hear? What do you see?

Ask questions that force you to pay attention to areas you may be normally unaware.

Be persistent. Step back and take stock of your own reactions when you perceive others are not listening to you or acting on your observations. If you feel that your concern has patient care implications and needs follow-up, speak up until you are heard.

Learn to pay attention to others when they come to you with concerns.

Break the mold of “group think.” People who work in teams sometimes do not want to go against the prevailing understanding of a problem and may fail to speak up. Encourage others to argue a different point of view.

Be open to differences in opinion. Actively seek information from others who you expect to have a different point of view.

Share information with others. Work with others to develop new, perhaps less obvious, understandings of the situation and react as a team. Having one or two people as the repository of information leaves staff in the dark about why actions were taken.

Use information you have that is readily available, relevant, and that you have on hand. The “devil is in the details” is a common phrase that suggests that (in)attention to small but significant factors can lead to a good or poor outcome.

Expect the unexpected. When you see something you did not expect, ask questions.

Cue in to others. During interactions with staff members, tune in to body language and voice tone as well as to what they are saying. Not paying attention to others may inadvertently communicate disrespect. Are you “listening deeply” (Epstein 2003b) by conveying to staff that you “hear” them and value their input?

Strategies for Guiding Staff to Pay Attention: Managers in effective organizations learn to “keep their attention focused on the front line where the work really gets done” (Coutu 2003, p. 86). The following strategies facilitate staff to cultivate paying attention behaviors.

Use formal and impromptu staff meetings as opportunities for brief discussions about paying attention. Point out occasions when you have observed a staff member paying attention with positive outcomes. Explore barriers to being open to all kinds of information, asking questions, getting at the details of a situation, and using sensitivity during interactions.

Model “paying attention” for staff. When you are with staff members, describe your own paying attention behaviors. Tell them what you are “tuning in” to right then and there.

Encourage your staff development coordinator to incorporate paying attention (e.g., to unspoken resident signals and sensory cues) into in-service training sessions.

Give feedback to staff when seemingly minor or small observations add meaningful information for solving a problem.

Create “buzz” about how different staff contributed information that, when pieced together, helped solve a vexing or clinically important problem.

Encourage charge nurses to give praise and recognition to CNAs who provide information based on closely paying attention in resident encounters.

Conclusion

Paying attention is a powerful strategy that facilitates optimal resident care and fosters effective peer and supervisory relationships. Enhanced skill by nurse leaders in paying attention provides a level of vigilance that promotes safety and best care practices. Nursing leaders in long-term care are challenged to address ways to facilitate the mindful use of paying attention to maximize quality of care and optimize supervisory relationships.