Training in Communication and Problem Solving (The 4Ps)

In the mid-1990s, trainers at Home Care Associates (HCA) in Philadelphia began to notice a deficiency in their worker training curriculum.

At the time, HCA’s training programs taught problem-solving skills to the organization’s home health aides — but the training fell short when it came to instructing workers on how to handle the internal frustrations that can easily arise during problematic interpersonal situations. “There was nothing [in the curriculum] about dealing with personal attitudes that came from within,” says Terrell Cannon, HCA’s director of nursing and an HCA employee since the organization was founded in 1993.

HCA administrators knew that its training needed to go deeper. To that end, HCA introduced the concept of “the 4Ps” into its four-week training curriculum for new workers. The 4Ps instill in workers the importance of thoughtfully communicating with consumers — displaying an active interest in what the consumer is saying, extracting and processing all the information necessary to doing one’s job successfully, and then taking appropriate actions based on what was learned in the conversation. The 4Ps rely heavily on the concept of active listening.

The 4Ps curriculum — which was developed originally by HCA’s former Director of Education and Workforce Development Sara Joffe (now PHI’s Organizational and Executive Coach) — has been revised constantly over the years by HCA trainers. After each training session, they meet to discuss which aspects worked and which ones did not, and revise the curriculum accordingly.

Specifically, the 4Ps are:

• Pulling Back: Clients may sometimes be difficult to work with; they may say hurtful things out of frustration or anger or simply because they aren’t very nice. Workers must learn to “pull back” when a client pushes their buttons, minimizing the conflict as much as possible so that they can continue to do their jobs. Workers are taught to pull back when having a difficult conversation with a client by identifying and acknowledging the emotions they feel and, then, figuratively “stepping away” from those emotions. Pulling back teaches workers “to have a response, as opposed to a reaction,” Cannon says. “It puts them in a calmer state.”
• Paraphrase: This step encourages workers to be persistent in their attempts to obtain all the information they need from their clients. There are many potential obstacles to clear worker-client communication: speech or hearing impairments, language barriers, cultural differences, and so on. If there is any confusion as to what a client is saying, HCA workers are taught to repeat what the client has just told them in their own words — to paraphrase their last statement. HCA trainers also instruct workers to ask open-ended questions in order to coax useful information from their clients.
• Present Options: When confronting a problem, HCA aides are trained first to obtain as much information as possible on the client’s perspective, and then to make several suggestions as to how to proceed. All of the options they present will be centered on the idea that a consumer’s dignity and independence must be maintained at all times. To that end, HCA workers are encouraged to brainstorm options with their client in order to reach a decision that satisfies him or her while balancing any safety and health issues.
• Pass It On: When workers reach this step in the 4P process, they must decide what to do with the information they have gleaned — specifically, whether they should pass along the information, and to whom (for example, the consumer’s physician or an HCA administrator). Workers learn to document this information in an objective fashion so as to communicate it as accurately as possible.

HCA trainers introduce the 4Ps during the first week of the entry-level training program; this allows them to refer to the 4Ps throughout the next few weeks, ensuring that these communication skills are fully integrated into the curriculum. By introducing the 4Ps early on, and consistently reinforcing the skills throughout the curriculum, they stay fresh in the minds of trainees for the entire training, says Karen Kulp, HCA’s president/CEO. Trainers use a variety of teaching methods, including games and role plays, to impart the lessons of the 4Ps. After each training session, trainers take time to evaluate exactly what worked and what didn’t work, then adjust the curriculum accordingly.

Outcomes

Quality Care. Kulp says that the 4Ps program has not been formally evaluated in recent years. Anecdotally, however, there are always numerous indications that the program has a positive impact on HCA workers and clients. Chief among those is the positive feedback that HCA consistently receives from consumers regarding the quality of care they receive. Worker retention rates at HCA are also consistently high.

Confidence. Kulp theorizes that these outcomes stem from the confidence that the 4Ps instill in HCA’s home health aides and personal care assistants. By giving HCA’s workers a clear guide to handling difficult interpersonal situations, the 4Ps foster a sense of pride in their jobs, which translates to professionalism. “When our aides feel better about their work, the clients are going to feel better too, because they’re going to do a better job,” Kulp said.

Communication and Collaboration. Another outcome of the 4Ps program is that it’s given HCA workers and trainers a common language to use when discussing the often-elusive subject of communication. Trainers have found it much easier to teach communication skills with 4Ps since it gives them a set of phrases and terms with which they can describe certain abstract concepts. For example, it can be hard for trainers to convey the importance of emotionally separating oneself from a difficult moment in order to objectively analyze the situation; using the term “pulling back” is much clearer.

Lessons Learned

Buy in. Kulp says that HCA has learned that trainers are successful in teaching the 4Ps only if they completely “buy into” the underlying philosophy. Trainers must show conviction; they can’t gloss over any part of the curriculum, even if an activity seems contrived or makes the class feel awkward. “Being specific and direct about it is really important, because you could just assume that people know how to [communicate effectively], and I would venture to say that it doesn’t come naturally to everybody,” Kulp says.

Real-World Usage. Over the years, HCA trainers have also noticed more and more trainees talking about how they incorporate the 4Ps into their everyday lives. The “pulling back” part of the 4Ps may have proven the most useful of all in a real-world sense, Kulp says. “I’ve heard people say, I went home and talked to my mother, and when she started to get on my case about X, Y, or Z, instead of reacting the way I usually do, I pulled back so I could react in a different way.”

Consequently, HCA trainers have learned to actively encourage more real-world usage of the 4Ps. The training has developed to include more 4Ps-based interactions and activities with all agency staff, as well as family, friends, and other acquaintances. For example, HCA has developed a take-home assignment in which trainees are instructed to have a conversation with someone in their personal lives who they don’t usually get along with. After the conversation, the trainees give their conversational partner a form asking them to evaluate their performance. Did the trainee appear to be interested? Did she make appropriate facial expressions and hand gestures? Did she paraphrase accurately, and ask pertinent follow-up questions?

The Importance of Communication. Ultimately, HCA trainers and administrators have learned that they cannot overlook the importance of communication skills training; it’s as critical to aspiring home health aides as any other task they will have to perform. “If you don’t know how to communicate and you don’t know how to express yourself and you don’t have some understanding of what people are trying to say to you, you’re not going to be successful,” Kulp says.

Sponsoring Organization: Home Care Associates (HCA) is a worker-owned home care agency modeled after Cooperative Home Care Associates (CHCA). Like CHCA, HCA is a PHI affiliate.

Best Practice: HCA trainers use the 4Ps — paraphrasing, pulling back, presenting options, and passing it on — to help workers better communicate with consumers and their supervisors.

Setting: HCA is based in Philadelphia, PA, and employs approximately 200 home health aides and personal care assistants.

Start Date: The 4Ps were introduced in 1997.

Costs & Funding: The curriculum is included in Home Care Associates’ entry-level training. The annual budget for training is roughly $875,000 a year, or about $7,500 per trainee. Foundation support and Temporary Assistance to Needy Families (TANF) reauthorization funds cover some training costs.

Contact Information:

Karen Kulp, President/CEO
1500 Walnut Street, Suite 1000
Philadelphia, PA 19102-3523
(267) 238-3231| www.homecareassociatespa.com