Individual Committment to a Group Effort...That Is What Makes a Team Work

As we continue to explore the expanded role of the registered nurse ("RN") under the new Hospice Conditions of Participation ("CoPs"), brings to mind a quote from the legendary Green Bay Packers football coach Vince Lombardi, who said, "Individual commitment to a group effort — that is what makes a team work..." (www.vincelombardi.com/quotes.htm). ESPN called Lombardi the "Coach of the Century" and for good reason, with five NFL championships and Super Bowls I and II to his team’s credit.

It is with this same spirit that the RN’s commitment to the Hospice Interdisciplinary Team will promote the improvements and stability needed within the hospice organization to move toward excellence in performance and quality of care for each hospice patient.

In the last issue of Hospice EndNotes, we focused on the expanded role of the RN as related to the Hospice Plan of Care. In this issue, we want to address the RN’s role as it relates to hospice aide supervision.

The North Carolina Nurse Practice Act, at N.C.G.S. § 90-171.20(7), spells out the supervision responsibilities of the RN as teaching, assigning, delegating to or supervising other personnel in implementing the treatment regimen; supervising, teaching, and evaluating those who perform or are preparing to perform nursing functions and administering nursing programs and nursing services; and providing for the maintenance of safe and effective nursing care, whether rendered directly or indirectly.

The CoPs provide the supervision framework for the hospice RN in 418.76 (h):

• L629 - A registered nurse must make an on-site visit to the ..patient’s home: No less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary  group meet the patient’s needs. The hospice aide does not have to be present during this visit.
• L630 - If an area of concern is noted by the supervising nurse, ..then the hospice must make an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he or she is performing care.
• L631 - If an area of concern is verified by the hospice during the ..on-site visit, then the hospice must conduct, and the hospice aide must complete, a competency evaluation in accordance with 418.76 (c).
• L632 - A registered nurse must make an annual on-site visit to ..the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care.

The Centers for Medicare and Medicaid Services ("CMS") desires to ensure that aide skills are continuously re-examined, competency is maintained and the services being provided for hospice patients are appropriate and adequate. To this end, hospice aide supervision is an important part of a hospice’s Quality Assessment and Performance Improvement ("QAPI") program. "Outcome measures and supervision can and should work together, rather than replace each other, in order to enhance the quality of the service, patient outcomes, and patient satisfaction." 73 Federal Register, pg. 32131 (June 5, 2008).

If problems are noted during the aide supervision visit, the RN may choose to coach the aide on how to improve care. Acoaching approach can promote problem-solving skills, professional growth, personal development, job satisfaction, job performance, and improved quality of care.

It is interesting to compare the traditional model of supervision (which we all have used for years) with a coaching model of supervision.

Traditional Supervision

• Identify issues to be addressed
• Explain the rules clearly
• Explain the consequences of breaking the rules
• Offer possible solutions to the problem
• Request or direct the worker to comply with work rules

Coaching Supervision

• Create a relationship
• Clearly state the problem
• Gather information about the worker’s perspective
• Engage in problem-solving with the worker
• Help the worker commit to action steps

RNs who employ the coaching model of supervision use different skills, including active listening, self-management and self-awareness of their own feelings, responses and actions, and possess the ability to clearly present the problem and seek assistance with prob lem solving. The coaching model balances support and accountability; provides direction and limits without criticism; establishes acceptable behaviors; provides a guide for problem solving; builds on intrinsic motivation; and greatly helps to diffuse stress. (Coaching information used with permission of PHI, a national non-profit organization that promotes the link between quality jobs and quality care: www.PHInational.org.)

When the New York Giants won the 2008 Super Bowl and received the Vince Lombardi Trophy, this was noted by the Associated Press regarding Coach Tom Coughlin: "An interesting subplot all week was his change in attitude - less yelling, more listening - helped turn this team around - the plan worked." (www.foxnews.com/story/0,2933,327971,00.html)

As Coach Lombardi so succinctly said, the individual commitment of each person makes the team successful. As important as Lombardi’s words of wisdom are, so are the testimonies of those he coached. Fuzzy Thurston, who played offensive line during the Packers glory days, had this to say about his famous leader, "He prepared us so well, and he motivated us so well, I felt he was a part of me on the field." (www.vincelombardi.com/quotes.htm).

Perhaps through the RN’s coaching approach to supervision, our hospice aides will carry the best part of us into the "field." And wouldn’t that be a great testimony to our commitment to the hospice team and quality patient outcomes – maybe even better than winning a Super Bowl!  

For more information about this article, please contact Cindy Morgan at 919.971.8731 or cindymorgan@homeandhospicecare.org.