Use ‘nudge principles’ in LTC to prompt staff in the right direction

Here’s my latest article on McKnight’s Long-Term Care News:

Use ‘nudge principles’ in LTC to prompt staff in the right direction

Standing by the salad bar in the newly opened restaurant, I recoiled at the sign that read, “Please don’t use your hands.” I suggested to the manager that the notice should instead advise diners to “Please use the serving spoons.” My recommendation for that short-lived establishment followed what’s known as “nudge principles.”

What are nudge principles?

Nudge principles use basic human tendencies to encourage people to engage in positive behavior. One aspect of nudge is to craft messages, like how to use the salad bar, in ways that are more likely to result in positive action.

Another aspect, according to Tori DeAngelis in Coaxing Better Behavior, is to harness “our less laudatory traits — short-sightedness, inertia, inflated optimism and our tendency to submit to peer pressure.”

Research shows people have a “default bias” which makes them more likely to choose the first option in front of them. Putting fresh fruit before the desserts in a cafeteria line would be one way of making positive use of this bias. Another is creating a default option that enrolls employees in a retirement account rather than requiring them to opt into the program.

Care must be taken to create good default options, though, or they can backfire. One poorly constructed automatic retirement account enrollment, for instance, resulted in more individuals contributing, but fewer dollars set aside overall. Why? The default choice set aside less money than what people might have chosen if they’d given it more thought.

Starting with the end result

Some “nudge” researchers identify the outcome they want to see and then look at what methods are most successful in achieving that outcome. In one study, the British government sent letters to delinquent taxpayers, saying, for example, “You are one of the few who have not paid us yet.” They altered the wording of the letters to see which phrasing would result in the greatest collection of outstanding funds — and retrieved an extra $15 million overall.

Applying nudge principles in LTC

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Use ‘nudge principles’ in LTC to prompt staff in the right direction

Establishing rapport (an anecdote)

“I’M THE NEW PSYCHOLOGIST,” I screamed. “DO YOU HAVE A HEARING AID?”

“What?” Ms. Oakes replied.

The rest of our first session went downhill from there. I stopped at the nursing station on the way off the unit. “She never wears her hearing aid,” the nurse reported. “I’ve got it right here but she refuses.”

The following Thursday I approached Ms. Oakes with the hearing aid box in my hand. “I’M GOING TO PUT THIS IN, OKAY?” I pointed to the box, to my ear and then hers.

“All right.” She allowed me to fumble with the device and stick it in her ear.

“Can You Hear Me?”

“You want to know if I can hear you? Yes.” She looked worried. “I can’t find my glasses.”

“When Was The Last Time You Had Them?” I asked.

“When the girl took me for a shower this morning.” A pair of unmarked glasses in the shower room could disappear forever.

“I’m Going To Look For Them. I’ll Be Right Back.”

I returned a couple of minutes later with the glasses in my hand.

Ms. Oakes looked at me with amazement. “Lord a mercy, I didn’t ever think I’d see them again!”

I cleaned them off and slid them into place. She beamed.

Reducing antipsych meds: 5 ways psychologists can help (McKnight’s LTC News)

Here’s my latest article on McKnight’s Long-Term Care News:

Reducing antipsych meds: 5 ways psychologists can help

With the mandate to reduce the use of antipsychotics, many facilities are looking for alternative methods to address the behaviors often associated with dementia. There are several good resources available for training staff (such as the Center for Medicare & Medicaid Services’ Hand in Hand toolkit and the Pioneer Network’s programs).

Within each facility is another good resource — your consulting psychologist. Here’s how psychologists can help:

1. Psychology is all about nonpharmocological alternatives. The most frequent question for any psychologist during their career is, “What’s the difference between a psychologist and a psychiatrist?”

The answer: “Psychiatrists go to med school and prescribe medications to help people feel better. Psychologists go to graduate school to study interpersonal interactions and talk with people to help them feel better.”

The cornerstone of what psychologists do is to look at behavior and find ways to treat people without medication. While psychologists might not be able to use the exact same techniques for those with memory loss, they can offer behavioral insights that aid the team.

2. Psychologists are trained to understand group dynamics. They can support ways in which your treatment teams are working well to help those with dementia and offer alternatives in areas where conflicts arise. For example, if psychologists have observed that mealtimes are stressful for staff and residents, they can offer suggestions that reduce triggers for behaviors on the part of persons with memory loss.

3. As part of their studies, psychologists collect and synthesize data. Combined with their group/team experience, this makes psychologists ideal sleuths to gather information from various team members about particular residents and identify the cause(s) of agitation.

The fact that they don’t necessarily leave at change of shift allows them the opportunity to discuss the cross-shift behaviors of the residents.

For the entire article, visit:

Reducing antipsych meds: 5 ways psychologists can help

What if psychologists ruled the (LTC) world… (McKnight’s LTC News)

Here’s my latest article on McKnight’s Long-Term Care News:

What if psychologists ruled the (LTC) world…

In the medically focused setting of long-term care, psychologists are mindful of the emotional environment. While most psychologists almost exclusively address the mental health of the residents due to the current reimbursement system, we’re also aware of the interactions between staff members, families, the physical setting and the organizational culture.

Here are some of the important things psychologists might do to address the emotional climate of long-term care:

1. Every resident would be evaluated by the psychologist upon admission (just like other disciplines), because entry into long-term care can be very stressful.
2. Every staff member would have access to the counseling services of an Employee Assistance Program, because working in LTC can be very stressful.
3. Family members would be able to join regular educational groups so that they better understand the illness(es) of their loved one, how the treatment team works, and how to best manage their important role on the team.
4. Administrators, department heads, charge nurses and others in managerial roles would be given management training so that they’d have the skills they need to lead those on their teams, because chances are they didn’t learn management strategies in school.
5. Treatment teams would learn communication skills that enhance collaboration between disciplines and improve interactions with residents and families.
6. All staff members would be trained in non-pharmacological approaches to dementia care, because the porter needs to know what to do too.

For the entire article, visit:

What if psychologists ruled the (LTC) world…

The Eldercare Method: Using psychology for positive outcomes (McKnight’s LTC News)

Here’s my latest article on McKnight’s Long-Term Care News:

 The Eldercare Method: Using psychology for positive outcomes

I watched with dismay as the nurse abruptly moved a table in front of a confused and agitated resident trying to leave the dining room. “Sit down!” she told him in a stern voice. “Dinner will be here in an hour!”

Those of us in long-term care have undoubtedly witnessed similar incidents where residents become agitated and staff members don’t have the tools to prevent or manage their distress. Psychologists — who could offer such tools — are largely limited in the current reimbursement model to providing individual services to cognitively intact residents.

Using mental health expertise

The Eldercare Method, developed by psychologist Kelly O’Shea Carney, PhD, CMC, executive director at the Phoebe Center for Excellence in Dementia Care in Pennsylvania, harnesses the training of mental health professionals to successfully address the gap between what’s known in the mental health world about how to handle challenging behaviors and how they’re often managed in long-term care.

The method uses interdisciplinary teams facilitated by mental health professionals (psychologists and licensed clinical social workers) to examine the causes of resident distress and to identify ways to prevent it. Team members include representatives from the nursing department and other direct care staff such as dietary, housekeeping, and aides.

Needs assessment

The first step in the Eldercare Method is to assess the overall behavioral health needs of the facility and to establish training programs and annual service goals. This dramatically increases the focus on behavioral health as compared to facilities that provide behavioral health training sporadically, often after an incident occurs, missing the opportunity to prevent problems on an ongoing basis.

For the entire article, visit:

 The Eldercare Method: Using psychology for positive outcomes

Kelly O’Shea Carney, PhD, CMC

Using psychology to reduce roommate conflicts: A handy guide (McKnight’s LTC News)

Here’s my latest article on McKnight’s Long-Term Care News:

Using psychology to reduce roommate conflicts: A handy guide

“My roommate is driving me crazy with his oxygen machine. I haven’t slept in days.”

“Her husband stays in the room all the time, even when she’s in rehab.”

“She always leaves the window open and I’m freezing!”

These are some of the many complaints about roommates I’ve heard from residents over the years. While some roommate difficulties need to be addressed on a situation-by-situation basis, most conflicts revolve around a few basic issues.

Here’s a handy guide to conflicts and potential resolutions to print out and give to staff members involved in making room assignments.

•       Temperature of the room: Have the person who likes it colder or hotter by the window/air conditioner/radiator so they are closest to the source. The temperature in the hallway will moderate the atmosphere around the bed near the door. Give extra blankets to those who like to be warm but have a roommate who likes it cool. Or change rooms so that people who like similar conditions room together.

•       Noisy medical equipment: Someone with such needs might do better living with a hearing impaired roommate or a sound sleeper or being moved to a private room if it’s a temporary condition.

•       Frequently visiting family members: While visiting hours have been expanded in many facilities, it doesn’t mean they need to take place in a resident’s room, especially if it’s disturbing to others. It may be necessary to distinguish between facility visiting hours and in-room visiting hours and to refer families to alternative locations for visits, such as a lounge. Family members can be directed to wait in common areas if their loved one is not in their room.

•       Loud televisions: Setting a time (such as 10 p.m.) to lower the volume on TVs and to turn out lights that aren’t in use will help with sleep hygiene on the floors in general and will reduce conflict between roommates (because it’s “policy” and not personal). Those who want a loud television can use a headset or be moved to a room with a hearing impaired roommate.

For the entire article, visit:

Using psychology to reduce roommate conflicts: A handy guide

Care model for more than just medical condition needed in long-term care (McKnight’s LTC News)

Here’s my latest article on McKnight’s Long-Term Care News:

Care model for more than just medical condition needed in long-term care

Of the most efficient countries for healthcare, the United States ranks second in healthcare costs per capita but 46th in efficiency (out of the 48 countries ranked!). The move from a biomedical to a biopsychosocial model of healthcare might be able to change that.

Consider the following scenario: Estelle’s fall at home sent her to the hospital. She was diagnosed with a hip fracture and diabetes and transferred to the nursing home for short-term rehab. A biomedical model would treat both conditions and send her home again. A biopsychosocial model would also address her need to make dietary changes, her fears of falling again, the alcoholism that contributed to both her diabetes and her fall, and her noncompliance with the rehab staff.

From biomedical to biopsychosocial

In her American Psychological Association presidential address, psychologist Suzanne Bennett Johnson discussed the change from a biomedical model of care to a biopsychosocial model of healthcare. The biomedical model of care that has “dominated Western medicine … for over 100 years” focuses solely on biologic factors to understand illness. It’s resulted in cures for infectious illnesses such as tuberculosis, pneumonia, and influenza, and increased life expectancy from 49 years in 1901 to 77 years in 2001. The biomedical model has been a great success in many respects.

As Johnson points out, however, “while infectious disease was the leading cause of death in 1900, today most Americans die of chronic disease: heart disease, cancer, chronic lower respiratory diseases, and stroke.”

Underlying these diseases are behaviors such as smoking, poor dietary habits, sedentary behavior, and substance abuse. In addition, she notes, “as many as 40% of medical patients are co-morbid for a mental health disorder and as many as 75% of seriously mentally ill patients are co-morbid for a physical health disorder.”

Implications for LTC

Clearly, in order to reduce chronic disease in this country (and to decrease medical costs), we need to address the behaviors – the psychological and social factors — underlying the diseases. But we work with elders, you might say, the damage caused by years of poor self-care has already been done! Perhaps.

But as a psychologist talking with seniors over the years, I’ve found that many of my lovely old dogs were ready for new tricks. We need to intervene, however, in certain key ways:

For the entire article, visit:

Care model for more than just medical condition needed in long-term care

6 common problems a shrink on staff can solve (and your consultant can’t): McKnight’s LTC News

Here’s my latest article at McKnight’s Long-Term Care News:

6 common problems a shrink on staff can solve (and your consultant can’t)

As a psychologist consulting in long-term care facilities, I was paid through Medicare, Medicaid, and/or private insurance for only one task: direct contact with residents. That’s it. I provided a lot more because it was needed, but that’s all I was paid for.

There was much more help that I didn’t offer, not only because I wasn’t paid for it, but also because the organization wasn’t structured to accept this type of assistance. The facilities’ needs were the kinds of things that made me sigh and shake my shrinky head in frustration. Oh, what we psychologists could do for you if we were on staff!

Here are some examples:

Problem #1: Admissions decisions

As your admissions department scrambles to fill beds and wonders whether the facility can manage a new resident with a psych history and a recent diagnosis of cancer, imagine if they could ask the opinion of the psychologist likely to be treating the resident. Now imagine if they could do this for every questionable admission. Psychologists could set up mental health services upon the new resident’s arrival and you would have the support necessary to meet the mental health needs of the residents under your care.

As the number of residents with behavioral issues increases, this psychological screening becomes an increasingly important element of providing good care and preventing time-consuming problems on your units after admission.

Problem #2: Team Communication

Watching two aides argue about giving care to a resident over said resident’s head or observing an essential piece of information get lost between shifts, I’ve fantasized about offering in-service training to eliminate these destructive behaviors. Not half-hour meetings sandwiched in between resident care, but real training that allows time for examples and practice as well as observation and feedback on the floors.

Real training provides the opportunity for staff to turn to the psychologist for guidance in handling the sticky interpersonal dynamics that are inevitable as people work in groups.  It also offers assistance in designing and implementing procedures that facilitate written and oral communication.

Problem #3:  Interacting with residents

Improperly trained staff members frequently escalate tense situations, cause unintended distress in residents, or miss cognitive changes that signal physical illness. They aren’t doing this on purpose — they just haven’t been taught how to handle such situations.

For the entire article, visit:

6 common problems a shrink on staff can solve (and your consultant can’t)

Suicide risk in LTC: Effective protocols may not be what you think (McKnight’s LTC News)

Here’s my latest article at McKnight’s Long-Term Care News:

Suicide risk in LTC: Effective protocols may not be what you think

According to researchers, 11% to 43% of LTC residents have thoughts of suicide^1-3, with higher rates in larger facilities and in those with more staff turnover⁴. Other stressors include medical illness, the presence of a mood disorder such as depression, social isolation, and recent life stressors⁵ – factors that frequently affect our residents.

The MDS 3.0 requires that facilities ask residents questions regarding their risk of suicide. If a risk is identified, then effective protocols should be employed. In a June 2013 Annals of Long-Term Care review article, Challenges Associated with Managing Suicide Risk in Long-Term Care Facilities⁶, authors O’Riley, Nadorff, Conwell, and Edelstein offer alternatives to the procedures frequently in place in LTC settings – close observation or transfer to a psychiatric facility. These methods are often used unnecessarily, the authors note, due to staff fear of legal liability, concerns regarding their perceived competence in handling suicide risk, and the personal fear of losing a resident to suicide.

Essential for immediate risk

The authors argue that while close observation and hospitalization are essential when residents have the means, intent, and ability to end their lives at any moment (high risk situation), they’re ineffective in situations where there is a minimal or low risk of imminent death by suicide. For example, a resident may express thoughts of suicide but have no access to a means to do so or no ability to make use of an available means, making suicide very unlikely or virtually impossible. Other times a resident may have thoughts of suicide but no plans to do it any time soon. “If things get worse down the road,” they’ll sometimes say, “then I’m going to end it all.”

Ineffective for minimal risk

While a low or minimal risk should still be taken seriously, there is no evidence that it’s effective to put a resident on 15-minute checks or to send him or her to the psychiatric hospital.

For the entire article, visit:

Suicide risk in LTC: Effective protocols may not be what you think

1.Haight B K. Suicide risk in frail elderly people relocated to nursing homes. Geriatr Nurs.1995;16(3):104-107. 
2. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry. 2009;25(8):843-849.
3. Ron P. Depression, hopelessness, and suicidal ideation among the elderly: a comparison between men and women living in nursing homes and in the community. J Gerontol Soc Work. 2004;43(2-3):97-116.
4. Osgood NJ. Environmental factors in suicide in long-term care facilities. Suicide Life Threat Behav. 1992;22(1):98-106.
5. Conwell Y, Van Orden K, Caine ED. Suicide in older adults. Psychiatr Clin North Am. 2011;34(2):451-468.
6. O’Riley A, Nadorff MR, Conwell Y, Edelstein B. Challenges associated with managing suicide risk in long-term care facilities. Annals of Long-Term Care. 2013;21(6):28-34.

Reducing Learned Helplessness in LTC (McKnight’s LTC News)

Here’s my latest article at McKnight’s Long-Term Care News:

Reducing learned helplessness in LTC

Despite this, O’Connor points out, psychological services in LTC are often underutilized.  As I noted in my 2010 article, Improving the treatment of mental health issues in nursing homes, we can do more to identify residents who may benefit from psychological services and systematically refer them for treatment before problems become entrenched.

Learned helplessness

The University of Pittsburgh study reported that one of the helpful aspects of psychotherapy is the reduction of the learned helplessness often seen in depression. Learned helplessness comes about when a person believes that they have no control in a situation, even when they do….

Learned helplessness in LTC residents

There are many situations in long-term care that can lead to learned helplessness among our residents. Every time a call bell goes unanswered for too long, it leads residents to conclude that there’s no point in asking for help. When a staff member tells a resident she’ll follow through on a task and then doesn’t, that experience is reinforced.

For the entire article, visit:

Reducing learned helplessness in LTC

My book, The Savvy Resident’s Guide, is a great tool for reducing learned helplessness.  Please consider giving it to your residents or loved ones.