Category: Communication
Posted by Dr. El - June 15, 2012 - Communication, Medication issues, Resident education/Support groups
Early in my blogging, I wrote a post for residents about how to speak to doctors, outlining what I call the Newspaper Headline Approach. It’s designed for residents to make the most of their interactions with their physicians. I was reminded of the Newspaper Headline approach when I read a recent Mind the Gap post by Stephen Wilkins, MPH titled Why It’s So Important For Physicians To Listen – The Patient’s Perspective. How to talk and why to listen — a great combo.
Dr. El’s Newspaper Headline Approach
Talking to a medical doctor is not like talking to a normal person. In a regular conversation, one person says, “Hi. How are you?” The other says, “Fine. And yourself?” And they go from there. If busy Dr. Shah stops by Mrs. Crenshaw’s room, inquires how she is, and hears that she’s “Fine,” he’s likely to be on to the next room before Mrs. Crenshaw can utter another word. Instead, I suggest the Newspaper Headline Approach.
Newspapers grab the attention of readers by revealing the most important and tantalizing details first, so we’re compelled to read on. The same approach, applied to a visit from a physician, would sound like this:
Dr. Shah: ”Hi. How are you, Mrs. Crenshaw?”
Mrs. Crenshaw’s headline: ”I Have Pain.”
Now she has Dr. Shah’s attention and he will almost certainly ask her where she has pain and other follow-up questions.
Another possible headline: ”I Have Two Things I Want to Discuss with You.”
This indicates to Dr. Shah that he’s going to need to stick around after the first issue is complete, and it helps him estimate how much time he can spend on each matter. With the Newspaper Headline Approach, the most important problem is revealed first. This way, if Dr. Shah has to leave, at least Mrs. Crenshaw had her most pressing concern addressed, and her doctor is aware there is more to be discussed.
Perhaps this sounds simple, but it’s surprisingly difficult not to answer the question, “How are you?” with the response, “Fine,” even when we’re not. It takes practice to resist the temptation and to tell the physician from the start what’s really going on.
Why It’s So Important For Physicians To Listen – The Patient’s Perspective
by Stephen Wilkins, MPH at Mind the Gap
A recent qualitative study (structured interviews) of patients conducted at McGill University School of Medicine underscores the importance of listening in physician-patient interactions. In this study, patients were asked to identify the qualities of a good physician. The following is a typical patient response:
“A good physician is somebody who will listen to what the problem is and explain to you what it is and what is being done.’’
When people were asked why listening by the physician was so important, researchers discovered three important themes that have apply to every provider today.
Theme #1 – Respondents (people/patients) believed that listening was essential if the physician was to arrive at the right (and credible) diagnosis.
Representative Comments:
- ‘Physicians “should trust the person in front of them and hear what they’re saying. . .because I know my body better than anybody else.“
- ‘‘Listen to what they [patients] have to say; not just what other people wrote about them in the doctor’s notes.
- ‘‘[If] I feel that I haven’t had enough time with you to tell you exactly what my story is, even when you give me a prescription I’m going to say, ‘Really? Is this prescription right for me and for my illness? Or [is it] going to give me more complications?’. . .and I think sometimes that’s why you find patients will take it for 1–2 days and after that they forget about it, because they say, ‘He didn’t hear what I had to say about this pain.
Visit Mind the Gap to read the whole post, which discusses all three important themes and the take-aways from the research.
Posted by Dr. El - May 23, 2012 - Anecdotes, Common Nursing Home Problems and How Psychologists Can Solve Them, Communication, Role of psychologists
“I had a couple of relapses this week,” Betty told me, looking ashamed.
We’d been working in psychotherapy on her efforts not to snap at the aides and nurses who came to care for her.
“I try not use to my call bell,” she went on. “Sometimes I sit here for two hours thinking about it before I press it.”
“Maybe that’s part of the problem,” I suggested. “If you’re waiting for two hours before you let them know you need help and then it takes them a little while to get here, by the time they arrive you’re ready to explode.”
She nodded. “That’s true.”
Betty was more psychologically-minded than many residents, so I took things a step further. “It’s also not taking very good care of yourself to wait two hours to ask for help. If you had a child who needed help, would you make them wait two hours?”
“No!” Betty’s bulletin board was filled with the Mother’s Day, birthday, and Christmas cards her only child sent instead of visiting.
“Now you have a chance to give yourself the care you didn’t get as a child.”
“What do you mean?” she asked sharply, “My parents took care of me!”
“From the things you told me about what went on in that house, you children were not getting enough supervision.”
Betty, an incest survivor, stared at me. “I never thought of it that way.”
“This may sound corny, but now Grown-up Betty has the chance to take care of Little Betty, and ask for what she needs when she needs it.'”
Betty burst into tears. “Wow…wow…I never thought of it like that.” She pulled a tissue out from the box on her tray table and blew her nose. “I could do that. I could take care of myself.” She gave me a piercing look. “Wow…thank you!”
Posted by Dr. El - April 27, 2012 - Business Strategies, Communication, Motivating staff
Here’s my latest article in Long-Term Living magazine online, 5 Secrets Your Line Staff Wishes You Knew:
Click-clack. Click-Clack. The hard-bottomed shoes of the administrator echoed through the halls once again, this time accompanied by the high heels of the director of nursing. The crepe-soled nursing staff moved about the floor, silently hoping the bigwigs would notice and address the problems that frustrate them on a daily basis.
Do you ever wonder what your staff isn’t telling you? Are you puzzled why, despite all your efforts, the organization isn’t functioning as efficiently as you’d hoped? In January, I revealed the secrets your line staff doesn’t want you to know. Now, here are the secrets the staff won’t say, but wants to—secrets that will transform your facility.
1. The staff members who are doing their jobs properly wish you’d be on the floors more often.
They’d never “rat out” their coworkers, but they’d like you to catch how often their colleagues disappear for unscheduled breaks, or the way they talk to some of the residents. Your frequent and unexpected presence raises the level of professionalism of your staff and keeps you in touch with the realities of day-to-day care. By taking some time to sit at the nursing station, for example, workers can observe and emulate your style of interacting with the residents and their families. Participating during the change of shift report can offer the opportunity to influence the type of information offered during this important transition. You become more familiar and approachable, rather than a “bigwig” in an office, and find out more of the information you need to know to make your nursing home proactive and productive.
2. All this disorganization is driving them crazy.
It’s not in the nursing job description to reorganize the file drawer—but isn’t it in somebody’s job description? Please, send someone over to put the forms in place, because if it takes each staff member 10 minutes to locate the MD order form, that is way too much time wasted. While you’re at it, organize the linen, pantry and supply closets—and make them the same on every floor, so floaters can quickly find the things they need. The time it takes to do this properly—with some forethought and planning about what goes where—will quickly pay off as multiple staff members on multiple floors can easily locate the tools essential for their jobs.
Posted by Dr. El - March 29, 2012 - Business Strategies, Communication, Long-Term Living Magazine, Motivating staff
Here’s my latest article, on The Silo Effect, at Long-Term Living magazine’s online site:
The employees listened carefully to their boss as he outlined a new procedure.
“Any questions?”
None were raised, and the boss, pleased at the consensus, adjourned the meeting. But outside the conference room, the murmurs started.
How do they expect us to do that? Don’t they know that’s going to lead to this other problem? If they want that to happen, why didn’t they just do it this way? You and I both know that’ll never work, but I’m not going to be the one to say anything.
Me neither.
What is the Silo Effect?
The Silo Effect refers to a lack of information flowing between groups or parts of an organization. On a farm, silos prevent different grains from mixing. In an organization, the Silo Effect limits the interactions between members of different branches of the company, thus leading to reduced productivity.
Long-term care silos
Silos operate at various levels of long-term care. They can be found in the silent acquiescence of department head meetings, hospital transfers without complete documentation, care plan meetings where key players are missing, and nursing home admissions that neglect to provide residents and families with the information they need to become proactive members of the team.
In fact, our current healthcare system is one of silos: private insurers, Medicare, Medicaid, hospitals, nursing homes, home healthcare, regulators—all working independently, but connected, to haphazardly manage the nation’s healthcare.
For more, visit LTL mag: How to eliminate the silo effect in LTC organizations
Posted by Dr. El - February 1, 2012 - Communication, Resident care
According to their website, The National Consumer Voice for Quality Long-Term Care is “the leading national voice representing consumers in issues related to long-term care, helping to ensure that consumers are empowered to advocate for themselves.”
This Friday, February 3rd from 9am-3pm ET, The Consumer Voice is taking to Facebook to discuss mental health issues in long-term care. Be there to be part of the discussion.
How it works: Simply click on The Consumer Voice Facebook page any time between 9am and 3pm to find questions posed by The Consumer Voice and to leave your comments about issues related to meeting the mental health needs of those in LTC.
I’ll be dropping by periodically throughout the day. Hope to “see” you there!
Posted by Dr. El - January 11, 2012 - Anecdotes, Communication, End of life, Resident care, Transitions in care
I hadn’t been on the North wing of the nursing home in a while, and when I saw Juanita Johnson sleeping in a geri-recliner, I turned to the nurse, aghast. “I barely recognized her! She’s lost so much weight!”
“I know. It’s terrible,” the nurse replied. “We’re having her evaluated by hospice today.”
Ms. Johnson was accepted into the hospice program, and died two days later.
I’ve seen many late referrals to hospice in my years as a nursing home psychologist. It’s the rare older resident who wants every treatment possible late in life. Most of the time, the resident is going along with the program, waiting for the doctor to say that it’s time to rethink how we’re handling things. The resident is waiting for “the conversation,” but all too often the conversation doesn’t happen until it’s too late. The resident’s last days and months are ones of unpleasant medical interventions rather than a time of comfort and emotional support. This affects their family as well, with the emotional ripples of a “bad” death living on for years.
It’s not so easy to determine when someone is dying, but this week’s article by Paula Span in the New York Times, Interactive Tools to Assess the Likelihood of Death, discusses the use of interactive tools and how they can help us make better end-of-life medical decisions. The tools are posted at ePrognosis.org.
Coping with Grief, for Staff Members: Conversation with grief expert Courtney Armstrong, LPC
Beloved residents decline and then die, their families stop visiting the nursing home — coming to terms with these losses is an unacknowledged challenge of our work. Especially helpful for training directors, new employees, or those struggling with a current loss either on or off the job, this 20-minute audio will help staff members:
- Understand their feelings
- Recognize symptoms of grief
- Identify coping skills
- Assist each other in creating a supportive community
Includes FREE:
- Signs of Grief checklist
- LovingKindness Meditation Sign suitable for posting at the nursing station
Instant Download: Only $7.99
Posted by Dr. El - January 4, 2012 - Communication, For Fun, Resident care
A 2011 study by Australian researchers focused on the use of humor to reduce agitation in nursing home residents with dementia. The Sydney Multisite Intervention of SmileBosses and ElderClowns (SMILE) study investigated the effect of providing humorous interactions with residents through the use of a character dressed like a bellhop, who kindly jokes with participants. Residents who were initially silent and withdrawn became animated and engaged.
The researchers found a 20% reduction in agitation during the 12-week program, as compared to a control group. Once the humor therapy concluded, happiness and positive behaviors returned to previous levels, but agitation levels were lower at the 26-week follow-up point. The Arts Health Institute is training nursing home staff members in Australia to act as humor practitioners to continue this work.
For a more detailed article on the “humor doctors,” click here: The Arts Health Institute makes people with dementia SMILE. To see a short trailer of the movie, click here: The Smile Within.
For Dr. El’s suggestions on reducing resident agitation, download my free report, “Stop Agitating the Residents! 17 Secrets from Psych That Will Transform Care on EVERY Shift.”
Posted by Dr. El - November 15, 2011 - Business Strategies, Communication, Motivating staff
“I asked the nurse for a psychology consult for Gloria Teller on the third floor,” the dietician told me. “She’s not eating well, and when I went to talk to her, all she could do was cry.”
“Thanks,” I replied. “I’ll keep an eye out for it.” I jotted the name down in my book so I could follow up. Consults had a way of going missing.
Sure enough, after a week had passed and no consult appeared in my mailbox, I began to track it down. Putting on my Sherlock Holmes cap and taking out my pipe, I considered the possibilities: the nurse could have forgotten to write the consult, the order could have been written but no corresponding consultation form was generated, or the consult form could have been misplaced on the way to the mailboxes.
I wonder how many other consults go missing?
I wonder if a clinic appointment gets cancelled, how often it’s rescheduled?
I wonder if a family member tells the aide that her father does better on Medication B than on Medication A, if that information ever gets to the attending physician?
I wonder if I leave a note for the doctor on the floor where he has only one resident, will he see it in a timely fashion or at all?
I wonder if we’ve run out of MD order forms, how many orders go unwritten?
I wonder who’s in charge of the FLOW of communication, because it seems to me that while we’ve got department heads, we don’t have an INTERDepartment head, and we could use one.
Back to my consult: I started with the most likely scenario and asked the nurse, who replied, “Oh my gosh, I completely forgot!” She pulled out some papers, scribbled furiously while telling me about the emergencies she’d been fielding the day the dietician spoke to her, and thrust the yellow consult form into my hand. “Ms. Teller really needs you. She’s a mess.”
Posted by Dr. El - November 7, 2011 - Communication, Psychology Research Translated, Resident care
I read some helpful ideas on working with residents with dementia in the most recent Psychologists in Long-Term Care newsletter (Vol. 25, Issue 2-3). Psychologist Nancy Hoffman, PsyD, discusses research findings and her interview with Lucy Andrews, RN, MS, owner of At Your Service Homecare in Santa Rosa, California. The main points to consider:
- Agitation often reflects underlying physical needs such as thirst, hunger, or pain, or an undiagnosed infection such as a Urinary Tract Infection (UTI)
- Many LTC residents suffer from sensory deprivation, boredom, and loneliness
- Behavior interventions aim to treat to underlying needs that are causing inappropriate behavior
- We should provide positive attention when residents are calm so they don’t need to become agitated in order to gain attention
- It works better to distract agitated residents rather than to reason with them
- Soothing music, toys, gentle touch, or favorite personal items can be helpful coping tools for residents with dementia
- Asking closed questions is more effective than open-ended questions that can leave the resident struggling for an answer
- Reminiscence therapy focused on pleasant and meaningful experiences can address underlying emotional needs, as can therapeutic activities such as art, exercise, and music
What are you doing in your nursing home to help residents with dementia have a meaningful, agitation-free day?
Posted by Dr. El - November 4, 2011 - Common Nursing Home Problems and How Psychologists Can Solve Them, Communication, Engaging with families, Tips for gifts, visits
With Thanksgiving upon us in less than three weeks, it’s time for this perennial post from Dr. El at mybetternursinghome.com:
‘Twas the Week Before Christmas…
And 83-year old Albertha assured me her family was planning to take her home for the holidays.
“Have you talked to them about it? Have they called the social worker to arrange a pass, and meds, and transportation?”
“No,” she replied, “but they’re coming to get me.”
‘Twas the week after Christmas, and Albertha was glum.
“They didn’t show up. I waited all day, but they didn’t come.”
Albertha spent Christmas day watching other people go out on pass and return, and seeing families arriving with food and gifts and smiles.
Now my patients and I start discussing the holidays a few weeks in advance, addressing wishes and practicalities, phoning families if needed, and getting the social worker involved. We set up a hierarchy of plans.
Plan A: Go home for the day.
Plan B: Go out to a wheelchair accessible restaurant with family.
Plan C: Have visitors come with food and go around the corner for coffee, if possible, just to get out.
Plan D: Stay in with visitors and food.
Plan E: Talk to family members on the telephone, discussing plans for a future visit, while sitting in a room festooned with cards and holiday decorations. Attend the nursing home holiday party.
Plan F: Have a small holiday gathering in the room with nursing home friends after the facility party.
Since then, my people know what to expect from the holidays, even if the expectation is that their family might not arrive as hoped.
