Category: Common Nursing Home Problems and How Psychologists Can Solve Them
Posted by Dr. El - December 5, 2009 - Common Nursing Home Problems and How Psychologists Can Solve Them, Communication, Customer service, Resident care
“You’re bleeding, Mr. Ramsey! Go upstairs with your aide!” The nurse’s well-meaning directive was falling upon deaf ears.
“I ain’t goin’ nowhere until I get my money!” Mr. Ramsey clutched a tissue to his bloody lip with one hand and waved his other hand around in a fist.
The aide took hold of the handle bars of his wheelchair. “Come on, Mr. Ramsey. Come with me.”
Mr. Ramsey swung his fist around in an attempt to hit the aide.
“Mr. Ramsey! Stop it! Calm down! You’ve got a bloody lip! You’ve got to get cleaned up!” The nurse turned to the aide. “I’m going to page Security.”
It was clear to me the staff had escalated the resident to the point of aggressive behavior. It was equally clear they had no idea they’d done so. I debated the pros and cons of intervening and perhaps undermining staff authority versus a showdown between Mr. Ramsey and the security guard.
“The social worker will be back in just a minute with your money, Mr. Ramsey. Just let him get his money and then he can go upstairs calmly.” They looked at me like I was speaking a foreign language.
Luckily, the social worker, who’d realized Mr. Ramsey was adamant in his position, rushed back from the business office with his funds. Immediately mollified, Mr. Ramsey went upstairs without further incident.
Psychologists spend years examining the nuances of human interactions and are trained to deescalate situations like this, which happen every day, in the nursing home and out. While many nursing homes have psychologist consultants who work with the residents and provide an occasional hour-long staff training on communication skills, very few have psychologists on staff. A psychologist on staff at least part-time could provide intensive interpersonal training to reduce resident/staff conflict, increase resident, family, and staff satisfaction with the nursing home, reduce time spent on incidents, and increase the quality of care.
Posted by Dr. El - September 11, 2009 - Anecdotes, Common Nursing Home Problems and How Psychologists Can Solve Them, Role of psychologists
Have you ever wondered what nursing home residents discuss with their shrinks behind closed doors? Here I solve the mystery, revealing the types of conversations I’ve had with residents over the years.
- Feelings about leaving home and being ill.
- Issues around loss of control and being dependent on other people, with a focus on gaining control over what they can.
- Ways to work with the staff to get their needs met.
- Roommates, and how to cope with them.
- The reaction of family members to their placement and illness, including ways to help adult children understand that Mom or Dad can’t be there for them in the same way because Mom or Dad is sick and needs help themselves, and ways to help adult children understand that just because Mom or Dad is sick, it doesn’t mean they can’t go off campus every once in a while.
- Issues around dying, including concerns about the afterlife and worries about how the family will get along without them.
- Ways of making the most of the time they have left, including getting more involved in nursing home activities and the life of the nursing home community.
- Their lives, choices, accomplishments, and regrets.
- Stuff that interests them that they don’t get to talk about with anyone else, just to be their regular selves again instead of being a patient.
Posted by Dr. El - September 1, 2009 - Business Strategies, Common Nursing Home Problems and How Psychologists Can Solve Them, Motivating staff
Taking a page from my industrial/organizational psychology colleagues, I’ve been thinking about easy, inexpensive ways to improve efficiency in nursing homes. I recently read an article about the Starbucks company asking managers to put together a Mr. Potato Head doll as quickly as possible and then apply the experience to their work behind the coffee counter. This resulted in moving the supplies around for ease and faster turnaround of customers. I think about this when it takes me 15 minutes to photocopy a face sheet from a chart because the copy machine is located five floors away. Then I multiply that by the number of staff members needing to make a copy or two, and the outcome is this blog post.
Here are some simple ideas for improving efficiency (and reducing staff frustration) in nursing homes. I’m sure there are many more; please add your suggestions to the Comments section.
- Have a fax machine at each nursing station for faxing and small copy jobs.
- Set up all the file drawers the same way on each floor so there is no guessing where one might find an interim order sheet and other important forms.
- Put frequently used forms in an easily accessible location. Move less frequently used forms to a secondary file drawer.
- Color code the doctor’s communication books so that if Dr. Lewis is Lemon Yellow on the first floor, she’s Lemon Yellow on all the floors.
- Color code the weight books, CNA logs, etc, or at least have them all be the same type of book on each floor.
- Post important telephone numbers and procedural information in the same places at each nursing station.
- Standardize the location of the charts, logbooks, etc.
- Standardize the organization for the medication rooms, supply rooms, and linen closets.
- Be sure to include the staff members in deciding how to organize each aspect of the facility. For example, the decisions about the linen closet should be made by a small committee including representatives of the CNAs, the people who deliver the linens, the Director of Housekeeping, any other departments involved with the linen room, and someone able to guide the discussion of the committee. It’s important for every department to be represented because moving certain items might make it easier for one group but harder for another. Having all the information will make for better organization, improved job satisfaction, and greater buy-in from the staff.
Posted by Dr. El - July 14, 2009 - Business Strategies, Common Nursing Home Problems and How Psychologists Can Solve Them, Communication, Depression/Mental illness/Substance Abuse, Resident care, Role of psychologists
The July 2009 report, Trends in Mental Health Admissions to Nursing Homes, 1999 – 2005 notes that “the proportion of nursing home residents with mental illness, in particular depression, has overtaken the proportion of those with dementia”. According to a July 1, 2009 article by Liza Berger in McKnights.com, “younger mentally ill people now account for nearly 10% of the nation’s nearly 1.4 million nursing home residents”. While there is discussion of more preferable housing options for these residents, here are some suggestions to help those currently in long term care. As always, if there’s something I’ve missed, please add it to the Comments section.
1. Collect as much information as possible prior to admission about the psychiatric history and the medications which stabilize the individual.
2. Upon admission, refer the resident to the psychiatrist to assess mental status, review medications, and to establish a relationship. Mentally ill residents need to feel there are people in the nursing home looking after their mental health care as well as their physical care.
3. Upon admission, refer the resident to the psychologist, who can offer additional mental health support and monitoring. It’s better to refer someone before problems arise than to wait until negative behaviors and conflicts have been established. For more on this, see my earlier post, The Critical Period in Nursing Home Placement.
4. The social worker, as the most consistently available member of the mental health part of the treatment team, can act as the liaison between the psychiatrist, psychologist, resident, family, and the rest of the nursing home team, helping to share information.
5. Train the staff, especially the CNAs and nurses, to be familiar with the signs and symptoms of mental health problems.
6. Add the element of “behavioral rounds” to the change of shift report, noting any changes in behavior. In the psychiatric hospital, we did it very quickly, running down the names of the patients on the unit, speaking up if any unusual behavior occurred. For example, when the CNA-equivalent on the psychiatric team reported she’d seen a man with Bipolar Disorder laughing by himself in the hallway, the psychiatrist immediately increased his meds, recognizing the early signs of a manic episode. Early detection is particularly important because the lag time between referral for and completion of a psychiatric consult can be substantial.
7. Refer unstable or aggressive residents out to the psychiatric hospital as soon as possible. Doing so sends the message to other residents, staff, and visitors that their emotional and physical health are important, and relieves them of the anxiety of living or working with a resident who might be dangerous to themselves or someone else. It also provides the limit-setting such a resident requires for their own well-being.
8. Establish a relationship with a psychiatric hospital that’s familiar with the needs of older adults and provides adequate stabilization. For example, one nursing home changed the psych hospital they used after a paranoid schizophrenic resident in her 80s returned from a hospitalization still actively psychotic, with a baby doll, reflecting the hospital’s view of the elderly.
9. If possible, use the resident and family as resources. Knowledgeable residents and family members will be able to tell the team what medications have been successful in the past, and what proved troublesome.
10. When the right combination of medications is found, post this prominently in the chart and educate the resident and family so they have the information for future use.
11. If there are a group of residents with a psychiatric history who are functioning relatively well physically, it can be beneficial to provide them with a well-monitored space for group activities such as dominoes and card games which they can initiate without staff intervention. Training the staff monitors to work with groups of mentally ill residents will make such programs more successful.
12. Consider providing access to support groups such as Alcoholics Anonymous, either on-campus or in the community. Many mentally ill residents have a comorbid substance abuse history due to attempts at self-medicating. Such groups will provide emotional support and skills for living.
13. The social worker and psychologist can prepare appropriate residents for living in the community in a less restrictive, but still supportive, environment such as an adult home.
Posted by Dr. El - January 23, 2009 - Business Strategies, Common Nursing Home Problems and How Psychologists Can Solve Them, Customer service, Depression/Mental illness/Substance Abuse, Resident care, Role of psychologists, Transitions in care
I couldn’t wait to go to college. I was ready to shake off the old me, and begin a brand new self. No one would know who I’d been, and I could therefore be whomever I wanted to be.
In my Psych 101 textbook, there was a picture of animal behaviorist Conrad Lorenz, followed by a row of baby geese. The goslings had found Dr. Lorenz during their critical period of imprinting, when they bonded to the first suitable stimulus they saw. Conrad Lorenz became the goslings’ mama.
When residents enter nursing homes, they have the opportunity to create new identities. They are surrounded by strangers and novel social situations, with as limited a pull from family and friends to be their old selves as they are likely to have experienced in decades. While most residents aren’t necessarily looking to become new people, their early nursing home contacts can affect how they settle into their environment.
Mrs. Leibowitz arrived at the nursing home depressed, but wasn’t referred for psychological services until months after her arrival. She’d already established the pattern of spending days alone in her room, watching television for hours at a time. She was irritable with staff members, often refusing care, or chasing them out of her room with her foul language. “There’s nobody to talk to here,” she told me. I had my work cut out for me. The critical period had been lost.
Mr. O’Conner, on the other, was lucky enough to be placed in a room with Mr. Chu, the President of the Resident Council. Mr. Chu took Mr. O’Conner under his wing (so to speak), and together they played cards with some of the other gentlemen, and attended activities which appealed to them both. Our new resident integrated nicely into the community and never needed psychological treatment.
I’d like to see every nursing home form a welcoming committee, by residents, for residents, to help aid the transition to the nursing home. And I’d like to get my referrals early, during the critical period, instead of after the conflicts, isolation, and other problems have become entrenched. That way I can more easily help people take advantage of the best that nursing homes have to offer.
