Category: Communication
Posted by Dr. El - October 20, 2009 - Boomers, Business Strategies, Communication, Customer service, Resident care, Resident education/Support groups, Technology
A recent study by the Phoenix Center looked at adults 55 and over, but not employed or in nursing homes, and found that Internet use decreased their level of depression by 20%. I’m not at all surprised by this, and I believe a similar decrease in depression levels would be observed in nursing home residents as well.
While residents are living together rather than isolated in their own homes, and therefore have more opportunities for socialization, there are still many people who don’t partake of the recreational activities offered for their enjoyment. Some residents never leave their rooms due to physical or psychological barriers, and some don’t like crowds. Other residents feel uncomfortable socializing because of the physical changes of illness, wish to pursue activities other than those available in the nursing home, or miss connecting with those outside the home. The Internet offers the opportunity for nursing home residents to transcend their physical illnesses, leave the boundaries of the facility, and connect with the world.
In an earlier post, I shared ways in which I use the Internet for therapeutic purposes, and I believe they’re worth repeating here:
1. Psychoeducation Regarding Illness:
Often residents are given diagnoses, but little information about them, leaving them confused or upset, which can result in noncompliance with medication and care. I search for a resident’s illness with them on the computer, and discuss the symptoms and treatment, which enhances cooperation with medical staff. Some residents are more receptive to information coming from a “neutral” source than from their own caregivers, and most residents appreciate a print-out of information they can refer to over time. Posting a list of illnesses and the Web addresses of important sites near the computer would facilitate this process (eg; The American Diabetes Association, the Amputee Coalition of America, etc).
2. Support Regarding Illness:
Most of the residents deal with their illnesses in isolation, when there are many avenues of support available to them on the Internet. Having the opportunity to “discuss” their concerns anonymously with peers can often be more effective than trying to generate a conversation between two or more residents at the nursing home, due to discomfort at revealing personal information. At strokenetwork.org, for example, stroke survivors can “meet” other survivors on-line and get information and emotional support, as can their caregivers. To find the appropriate support groups, enter the name of a particular illness and “support” into the browser window and look around from there. Another option: Look for a Yahoo group about the illness and sign up the resident after establishing a free email account through resources such as Yahoo or Google.
3. Connection with Family and Friends:
Why should residents have to limit themselves to family visits or phone calls when most of the rest of the country is communicating via email, Twitter, or a social networking site such as Facebook or MySpace? I’ve established email accounts for octogenarians to help them keep up with the grands, and a free Facebook page would accomplish the same thing with a bit more zing.
4. Reminiscence:
I once worked with a terminally ill 88-year old man who’d left Barbados in his thirties and had never realized his dream of seeing his country again. Imagine his expression as I entered “Barbados” into Google Images and up popped photos of the country he thought he’d never be able to see again. This intervention generated a flood of memories and a profound sense of relief and closure. Reminiscence could also be conducted in a group format, with connection to a large screen, so that residents should share with others information about their home countries or hometowns.
5. People Search:
One of my favorite things to do with residents on-line is to find their long-lost friends and relatives. For example, through the Internet white pages, I helped one extremely lonely and depressed resident find a friend with whom he lost touch sixty years ago. They are now enjoying an exchange of letters and photos, and my patient has something else upon which to focus besides his poor health and lack of visitors.
6. Fun & Miscellany:
Acting under the theory that doing something enjoyable will begin the upward spiral out of depression, I’ve occasionally brought a resident to the computer to listen to their kind of music (try shoutcast.com), to check out the latest fashions, or to see photos of famous movie stars (Google Images). Once a 97-year old Panamanian resident told me she’d felt unattractive all her life because she thought her lips were too big. “Oh, no,” I told her, “your lips are considered beautiful and the height of fashion.” She believed me after I clicked on Google Image photos of Angelina Jolie.
Do you have more therapeutic uses of the Internet? Please add them to the Comments section.
Posted by Dr. El - September 29, 2009 - Communication, Medication issues, Resident care
I read a post on McKnights.com last week that so distressed me I had to wait a week before I was ready to blog about it. The article, Nurses, Relatives Underestimate Pain in Nursing Home Residents, Study Finds, reports the results of a five-year study in the Netherlands that shows a tendency to underestimate pain, particularly in people with cognitive impairment. What got me as agitated as a dementia resident with undiagnosed pain is that I’ve been reading about these studies since I got into the field over a decade ago.
A quick Google search of “pain management” and “nursing homes” turns up page after page of information about the consistent lack of recognition and treatment of pain. On the first search results page is a 2001
Brown University study noting “woefully inadequate pain management.” Also on the first search results page are numerous studies suggesting ways to alleviate this problem (for example,
tips from the End-of-Life Palliative Information Center and a 2002 National Institute of Health
report).
On April 10, 2009, the Centers for Medicare and Medicaid Services (CMS) issued new quality of care guidelines for pain management. I’m hopeful this will help to change the culture of tolerating pain in the residents under our care.
The next headline I’d like to read is: Treatable Pain Virtually Eliminated Among Nursing Home Residents Worldwide
Posted by Dr. El - September 15, 2009 - Communication, Customer service, Dementia, Resident care
This article from McKnights.com suggests that a key factor in reducing staff stress and injuries during transfer is understanding each resident with dementia and tailoring your approach to the individual.
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 - June 24, 2009 - Communication, Resident/Family councils
Part Two of a Three-Part Series
(Part Three: For Residents: Reclaiming the Resident Council)
Resident Council Meetings, as I discussed in my previous post, Why Most Resident Council Meetings in Nursing Homes Are a Sham, often can be improved to become a powerful tool for change in nursing homes. Giving residents a true voice within their nursing home community creates meaning and purpose in their lives, and reduces depression and acting out behavior.
In the one nursing home I’ve observed with effective Resident Council Meetings, residents actively campaigned for positions on the Resident Council and were voted into office. Meetings were conducted by a charismatic and enthusiastic staff leader, and concerns were seriously considered and acted upon by the administration. The residents felt they had a place they could bring their ideas, and the entire nursing home was a dynamic, thriving environment.
For Resident Council Meetings like that, try these steps:
Step One: As part of the administration, decide how open you’ll be to suggestions for change from the residents. Is the nursing home willing to consider, for example, how to offer computer access to residents, if they request it, or to bring 12-Step meetings such as Alcoholics Anonymous into the facility? Or is the home more comfortable with smaller changes such as adding a week to the food rotation schedule to increase the variety of meals served? The group leader should be aware of how willing the administration is to work with the group in order to guide the meetings more effectively.
Step Two: Evaluate which person on staff would make the best group leader. A successful leader will be someone who is a strong resident advocate, has good rapport with both residents and other staff members, and either has the skill to run meetings or is willing to learn and practice.
Step Three: Recruit new group members. The staff leader and current resident attendees can, with the support of the facility, begin a community-wide campaign to “rehabilitate” the Resident Council Meetings. Speak privately with those residents who might be willing to attend improved meetings and get a commitment from them to give it a try. Ask them to talk to their friends in the home and then follow up with the friends. This process may take some time, so plan for the kick-off meeting to be a few months down the road, rather than the following month. Bring in many new, alert people at the same time, so the group is strong enough to encompass confused, off-topic, or quirky members.
Step Four: Educate the group members about how the meetings work, what types of issues can be addressed, and where other concerns can be brought. Spending group time discussing the process of the group is a worthwhile investment. For practical, rather than clinical, information on running groups, check out Robert’s Rules of Order.
Step Five: As group leader, utilize group therapy techniques, such as creating an emotionally safe environment for discussion and ensuring that as many members as possible get a chance to express their opinions. Care should be taken to avoid a few members dominating the group. Leaders might consider reading about group process if they don’t feel comfortable with their skills. My group therapy “bible” is The Theory and Practice of Group Psychotherapy, by Irvin D. Yalom, which, while geared toward psychotherapy, offers many techniques which would enhance Resident Council Meetings and many other group activities. If anyone reading this has other resources, please add them in the comments section.
Step Six: Like all well-run meetings, issues raised by the group members should be addressed and followed up either within the current meeting or in subsequent gatherings, with a recording secretary so that items aren’t lost.* If suggestions made by the group aren’t able to be realized, give reasonable explanations so members understand their requests were seriously considered. Use the wisdom of the group to find ways to make things happen while working within the constraints and realities of the nursing home system.
Effective Resident Council Meetings are within the grasp of all nursing homes. I welcome further suggestions about how to make the meetings work, and I’d especially like to hear from those who currently participate in successful meetings. What makes them successful? How did you go about the process of transformation? What types of issues are you now addressing in your groups?
*Here’s a question for readers: If surveyors read the meeting minutes, then nursing homes will be reluctant to list all the issues raised by the residents out of concern they will be pointing surveyors to potential deficiencies. Is it enough for facilities to show they’re in the process of addressing concerns, or that they have good reasons for not fulfilling certain resident requests? For those with effective Resident Council Meetings, how do you handle this? Are there any surveyors out there who can shed some light on this?
Part Three: For Residents: Reclaiming the Resident Council
Posted by Dr. El - March 17, 2009 - Anecdotes, Communication, Engaging with families, Resident care, Tips for gifts, visits, Transitions in care
Please:
- Hang my psychology diplomas on my wall, so I’m reminded of my accomplishments.
- Display family photos, so I feel surrounded by my loved ones.
- If I have Dementia, label my photos so the staff can talk to me about my family and help me to remember.
- Put a quilt or bedspread on my bed from home so my room won’t look so institutional.
- Over my bed, put up the Halloween photo of me dressed as Wonder Woman, to remind everyone of my hip and glamorous past.
- Make sure I have some nice clothes in my closet (and some lipstick on my lips), so I can continue my hip and glamorous life.
Posted by Dr. El - March 7, 2009 - Anecdotes, Communication, Resident care
Occasionally I pull up a chair to sit with the residents in the hallway, chatting and watching the passersby. One thing I’ve noticed is the vast difference in perspective between eye level and viewing from above. This difference becomes most shockingly clear when the aides wheel the shower chair, with their naked charges covered only by a sheet, to and from the shower room. What may appear to be a completely concealed individual from the perspective of the aide, is often all-too-revealing for those seated in the halls. Similarly, an unwanted light left on by a staff member is no trouble for someone able to walk around the bed to pull the light cord, but can be a difficult and frequently impossible task for a person in a wheelchair. If we take the time to put ourselves in a resident’s position, either literally or figuratively, we often find situations look entirely different, and we can act accordingly.
I recently heard from another blogger, Steve Gurney, who’s made a career of referring older adults to assisted living residences. He decided to take some time to live in a few of these places himself, to see what things might be like from the perspective of a resident. You can follow his journey at
www.everyoneisaging.com. While you’re there, check out the link in the right column, under New and Interesting Sites, called Ben Cornwaite Nursing Home Immersion. It details the experience of a nursing home administrator who briefly lived in his nursing home, and the changes he implemented as a result of his experiment.
Posted by Dr. El - February 8, 2009 - Anecdotes, Communication, Customer service, Dementia, Resident education/Support groups
97-year old Rosebud, whom I mentioned in my 11/15/08 post, was a social worker, raised two children, and now lives in a nursing home. She would like to share with you the following thoughts about recreational activities:
“Old folks know a lot and need to have their minds stimulated. We residents can’t speak back and forth, so there’s a lot of lonely time. We’ve lived different lives and we need to find out what we have in common so we can be drawn together. The recreation staff can help us talk to each other about our lives.
I have the will to have a purpose, but now I need assistance grabbing onto it. Just as we residents need help with cooking and serving our meals, but have the will to eat, we need help in putting our thoughts together to work on a project with a purpose. Growing older, I would like to use my wisdom to help someone else. I want to contribute to a larger cause.”
Posted by Dr. El - January 19, 2009 - Anecdotes, Business Strategies, Communication, Customer service
I once dated a man who didn’t speak nicely to me. I don’t know when his endearments changed into negative comments, because, frankly, I didn’t notice them until I returned from a solo weekend vacation. “Hmmn,” I thought to myself after he threw a verbal barb at me upon my return, “they didn’t talk that way to me at the spa!” I recalled the pleasant demeanor of the staff and their courteous anticipation of my needs. We ended our relationship shortly after that.
I thought about this as I watched the scene unfold in front of the Nursing Station the other day.
“Did you hear what Carlos just said to me?!” his aide asked the staff members standing near the desk. The residents sitting in a row nearby looked up with curiosity. “He said he wanted to marry me and move to my house!”
The staff members laughed. “Carlos,” the nurse behind the desk called out, “I thought you were going to marry me?!”
Carlos glanced up at her, knowing he was being discussed, but not quite comprehending the subject. Smiling, the workers went back to their tasks.
I studied the faces of the residents across from the nursing station. None of them were smiling. What could be seen as good-natured teasing by the staff might easily be perceived as disrespect and mockery by the residents. No one would talk to them like that at a spa!
If we could marry the skills and expertise of the hospital model with the respect and philosophy of the hospitality industry, then maybe a nursing home might be a place I’d want to live.
Posted by Dr. El - January 8, 2009 - Communication, Engaging with families, Tips for gifts, visits, Transitions in care
I recently met a new resident who demanded almost constant attention from her loved ones. Her family visited daily for hours at a time, and she’d call them soon after they’d left and tell them she was lonely. Trying to please her, they were exhausted, frustrated, irritable, and terribly sad. I reminded her tearful daughter about the recommendation of flight attendants for those traveling with people in need of care — put on your own oxygen mask first. For many families, the road to the nursing home has been long and difficult, and it’s okay to take a breath now that your loved one is here.
It reminded me of my work with a wonderful 50-something man with Multiple Sclerosis, who spend most of his time in his room, hanging out with Jaime, the private aide his wife had taken a second job to afford. He was very depressed about his situation. Moving to the nursing home, he felt his life was basically over. “George,” I tried to persuade him, “come out of your room and join the activities. There are some really nice people here and fun things going on.” But no, he was fine talking with Jaime. Until his frantic wife, collapsing under the stress of her work schedule, finally dropped the second job, and Jaime. George emerged from his room and tentatively attended the trivia group I thought he might enjoy. He went back again the next week, and then added word games to his recreation schedule. He started meeting people, making friends, and cracking jokes. And his wife, who had recuperated from her burnout, was able to visit more frequently now that she wasn’t pulling double shifts at work.
The first weeks and months at a facility are hard on everyone, no matter what the particulars of the situation. Residents are often frightened and can feel abandoned despite regular family contact. Families frequently feel guilty about the move, as necessary as it might be. One of the benefits of a nursing home for the residents is the social environment — meeting new people, attending recreational activities, and making connections with others in similar situations. I often suggest that family members accompany their loved one to activities they might like, to help break the ice. Another benefit of a nursing home is that, to a large extent, it gives the resident back their independence from relying heavily on their family as caretakers. It creates more opportunity for family members to enjoy each others company without the tensions of day-to-day caregiving.
