The previous two sections provided information regarding how to overcome culture change implementation and team building obstacles related to:
1. Your possible lack of clarity
2. Your possible lack of courage
3. Your possible faulty thinking
This section will deal with the last two of the five obstacles. We will discuss obstacles to implementing Culture Change regarding confusion over responsibility and rationalizing.

The preceding section outlined the obstacle of irrational thinking as it related to Culture Change. These were catastrophizing, always never thinking, and must have thinking. In addition to these three, two other areas of faulty thinking are confusion over responsibility and rationalizing.

Confusion over your responsibility and rights regarding implementation of Culture Change may be a major obstacle to your taking action. You may have confusion regarding your own responsibility and rights and those of other staff members. When you inappropriately take on responsibility or fail to take responsibility for a situation you may end up with an obstacle to implementation of culture change.

What is appropriate? If you are confused about your rights and responsibilities you will probably not act appropriately. However if you are clear on these you decide what is appropriate and act accordingly. An example of inappropriately taking responsibility regarding Culture Change would be reprimanding Wendy, the CNA, for not giving yarn winding to Effie. To avoid this obstacle of inappropriately taking on responsibility, complete the following exercise.

Organizational Structure in my Facility.

For example, let’s assume you have
1. Given a few Inservices on transporting and Activities to staff
2. You have established a personal relationship with the CNA.
3. In informal conversations with the CNA, he or she understands what they are supposed to do.

However, if a CNA does not transport a resident, provide activities, or a charge nurse does not change a shower or med schedule to accommodate participation in activities, what is the next appropriate level above that staff member to talk to? (Charge nurse? Shift supervisor? Inservice nurse? MDS nurse? DON/DNS? Corporate consultant? Administrator?)

Name of non-compliant staff member:

What is the next appropriate level above this staff member?

What is the next appropriate level above that staff member?

What is the next appropriate level above that staff member, etc?

In addition to inappropriately taking responsibility, responsibility can become an obstacle if you “fail to take responsibility.” Obviously, “failing to take responsibility” means you ignore the areas in which your facility lacks compliance with Culture Change and you do not take action. In short, you do nothing, and hope that when Surveyors come into your facility they have decided to focus on other areas, like bedsores, restraints, and Dietary compliance.

If you’ve been through a CMS Survey, you know that Surveyors are usually nurses. The reality is, if a Survey team comes in to your facility and finds your number of bedsores, falls, and resident deaths above the statistical norm, Culture Change compliance might end up being low on their list, due to time limitations. So you may realize after the survey report is received, that this time your failure to take responsibility for implementing Culture Change went unnoticed. Yes, it went unnoticed that transporting, Activities by all staff, and schedule changes were either not implemented at all, or not implemented to their fullest extent. Yes, Culture Change implementation may have received little attention and you slipped by deficiency free. However, for this reason, it is my greatest hope that you implement Culture Change not out of CMS Survey fear, but out of a sense that IT IS THE RIGHT THING TO DO.

In what areas am I failing to take responsibility for implementing Culture Change, hoping these deficiencies will go unnoticed at Survey time?
1.

However, in order to overcome the payoffs or benefits of not taking action, you need to be aware of what these payoffs or benefits are. The main benefit, I feel, to not implementing Culture Change is safety. It seems safer to do nothing. Right? You avoid the risk of hurting or upsetting other staff members. When you keep the status quo and do not request Culture Change implementations, you continue to be perceived as polite and easy going and a “good guy or gal.” So you may decide to give in and do nothing and perhaps for reasons you feel are good ones. But when you make it a habit to ignore Culture Change implementation, at some level you have the nagging feeling that you really aren’t doing the job you were hired to do to its fullest extent. In short, the core issue becomes a conflict between safety and your conscience.

Another area of faulty thinking which goes hand in hand with failure to take responsibility is rationalizing.
Some examples of rationalizing are:
1. Making excuses to yourself with the goal of self deception. For example stating, “What can I do? Carol, the speech therapist, would not change Helen’s schedule to allow her to attend Crafts.”
2. Talking yourself out of taking action or responsibility. For example, stating “Carol is employed by an outside contractor. I don’t have the right to tell her what Helen’s schedule should be.”

Listen to your own inner dialogue before, during and after difficult encounters.
1. Discriminate between what is true and what is irrational. For example, it is true Carol is employed by an outside contractor. However, what is irrational is that in a Resident Centered facility, you have every right to request a schedule change providing you take the time to figure out what is the most tactful way to do this.

Situation in which I am using rationalizing:

What is true or factual in this situation?

What is irrational or illogical or not true or factual?

2. Sort out unrealistic assumptions. For example, it is unrealistic for me to assume my facility will have 100% compliance with 100% if the Culture Change guidelines 100% of the time. The use of absolutes and extremes become a convenient excuse-making escape hatch to rationalize not taking action. You will always be able to point to the staff member or the situation where perfection is not being accomplished. Be self-honest enough not to use areas of non-compliance to give you an out for implementing the changes that need to take place.

Instead, look for the half-full, not half-empty glass of water. In a few words, describe a specific situation in which Culture Change was implemented. For example, Suzy the CNA transported Harold to Men’s Discussion Group today.

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