Category: Communication
Posted by Dr. El - September 29, 2011 - Communication, Resident care
Me: Mrs. Jones, Where Is Your Hearing Aid?
Mrs. Jones: What?
Me: YOUR HEARING AID! WHERE IS IT?
Mrs. Jones: The nurse has it in her closet.
Me: I’LL BE RIGHT BACK!
Research shows that people with untreated hearing loss have a higher risk of depression than those wearing hearing aids. I believe it. Imagine sitting in the hallway and you can’t hear a thing your neighbor is telling you, while everyone around you is laughing at the joke. Imagine the aides and the doctors talking to you and you realize it’s important, but have no idea what they’re saying. So you ask again, still can’t hear, and then fake it, pretending to understand.
If our residents can’t hear, let’s put in an ENT consult and get the hearing aid process started. And if they’ve got hearing aids, let’s take them out of the closet.
The good news is that a recent study showed that within three months of hearing aid use, residents showed a significant improvement in cognitive and psychosocial functioning.
Posted by Dr. El - September 22, 2011 - Communication, Customer service, Resident care, Resident education/Support groups
“Tired CNA” posted a comment on my blog, saying she wished there were something that could be done about alert residents who ring their call bells 30 times a day. And there is. Here are some suggestions:
- Residents who ring their call bells frequently are often anxious, needing what seems like constant reassurance. Quell their anxiety by visiting with them at the beginning of each shift, telling them who you are and when you’ll be by again next. Check in on them when it’s relatively convenient for you so they don’t have to call and interrupt you when it isn’t.
- Answering the call bell right away reduces resident anxiety and decreases the frequency of calling. Ring, answer, ring, answer, even if it’s to say that help will be there in ten minutes. Then show up in ten minutes.
- I used to wait tables and there’d always be that group of diners who would wait until I’d returned from one request to give me a second, and then a third when I returned from the second. I learned to ask “Is there anything else you need right now?” Try this.
- I provide “Call Bell Education” on the theory that the residents, most of whom have never been in a nursing home before, have no idea how much bell-ringing is considered “too frequent” by the staff (and some of them don’t use it when they should). It’s better to do this in a calm, informative manner when the residents first arrive rather than waiting until everybody is aggravated. As a CNA you could give them a ballpark figure of what’s considered reasonable during a shift, while assuring them that you’re there to meet their need for care. Part of the education process is helping them to identify when it’s important to let the staff know they require assistance (for example, they need oxygen or to be changed) and when it might be better to “group” requests (for example, if they want the window closed and the TV station switched, and meds are coming in ten minutes, they might as well wait for the nurse).
- If a resident continues to need a lot of assistance, consider moving them to a room closer to the nursing station, where staff members are more likely to pass by easily rather than having to walk all the way down the hall.
- Consider a referral to the psychologist. My residents know they will see me each week and can ask me for assistance with a wide variety of matters. This significantly reduces their anxiety. This week someone said to me, “I don’t know what I’d do without you. I really feel like you’re listening to me, taking my concerns seriously, and getting things done to fix them.” And I am. Include the psychologist on your team, and any other staff and family members you can enlist to improve the situation.
Posted by Dr. El - September 13, 2011 - Communication, Customer service, Resident care, Transitions in care
“What the f***!” Ms. Webster was red in the face, shouting at the nurse who’d just arrived for the evening shift. “The day nurse told me I was moving to the third floor — now you tell me I’m not? You people better get your s*** together!” She began hurling onto the bed the belongings she’d gathered into a giant trash bag earlier in the day. She muttered profanity as she did so.
“I’ll make some phone calls and find out what’s happening,” the evening nurse said nervously and then rushed out of the room.
There’s been a lot of attention paid recently to transitions in nursing care: moves between the hospital and nursing home, and moves between home and the hospital or nursing facility. Another transition that deserves attention is room changes within the nursing home. The importance of this passage is often overlooked, resulting in confusion, anxiety, and distress. Properly handled, room changes are an opportunity to create a positive customer service experience within your facility. Here are some points to consider:
- Prepare the resident (and family) for the change by informing them as far in advance as possible.
- Attend to the emotional reaction to the move, especially if it signals a shift from being a short-term resident to becoming a long-term resident. Consider a psychology referral to facilitate adjustment to the new floor rather than waiting until problems become entrenched.
- Try to make room changes early in the day so that one shift handles the entire transition.
- Do an “idiot check” to make sure all property is transitioned to the new room.
- Label clothing quickly and make the resident aware of the reason the clothing is missing.
- Provide an introduction of staff and a pleasant welcome to the new unit to reduce anxiety.
- Introduce the transferred resident to another resident or two with whom they might get along.
- Ask a long-time resident on the floor to welcome the new resident.
- Create a policy that guides transitions so that “short-term” floors stay short-term, avoiding the resentments that crop up when one resident is reluctantly moved while another resident who has been there longer remains on a supposedly short-term floor.
Posted by Dr. El - August 17, 2011 - Communication, Customer service, Medication issues, Psychology Research Translated, Resident care
“Come on now, Vera, honey,” the nurse said in a high-pitched, sing-song voice, “be a good girl and take this nice candy.”
Vera swung her arm and knocked the tiny cups of pills to the floor.
In their 2009 study, Elderspeak Commnunication: Impact on Dementia Care, Kristine N. Williams, RN, PhD, and her colleagues report that resistiveness to care increases nursing home costs by 30%. They examined the way nursing staff speak to residents and its impact on the level of cooperation of residents with dementia. They found that residents became significantly more resistant to care when nursing staff used elements of elderspeak such as:
- simplistic vocabulary or grammar
- shortened sentences
- slowed speech
- elevated pitch or tone
- inappropriately intimate terms of endearment
- collective pronouns (“Are we ready for our bath?”)
- tag questions (“You want to get up now, don’t you?”)
They found that residents with dementia were more cooperative when spoken to in normal adult talk, and suggest the following research-based strategies in working with residents with dementia:
- normal talk
- reorientation
- distraction
- positive feedback
- memory aids
Posted by Dr. El - June 6, 2011 - Anecdotes, Communication, Customer service
I went for my annual mammogram last week, leaving work early to do so and throwing my schedule into chaos. When I arrived at the diagnostic center, the woman at the desk told me someone else would be out to talk to me. Never a good sign.
The second lady took an apologetic tone. “The doctor’s out today. I’m sorry. I thought I called everyone who was scheduled, but I must have missed you.”
“But I phoned this morning to confirm!” I replied with irritation.
After some negotiation and discussion with other people in the back room, they allowed me to have the procedure, with the understanding I’d have to come back again if more “views” were needed. It was a crapshoot, but better than wasting the whole trip.
I think of how often residents have told me, “They didn’t have the paperwork they needed, so we had to reschedule” or, “The ambulette driver couldn’t find the hospital and by the time we got there, the doctor had left for the day,” The residents were wrung out from the journey and from trying not to act irritated. Their anxiety about their next appointment would include the worry about whether or not it would transpire successfully.
Personal reminders like this increase my compassion for those living with illness, and my appreciation for the nurses, secretaries, and transport aides who check and double check that everything is in place so that residents only have to worry about their medical conditions and not whether or not they’ll make it to their appointments.
Posted by Dr. El - May 31, 2011 - Books/media of note, Communication
I just finished reading A Bittersweet Season: Caring for Our Aging Parents — and Ourselves, by Jane Gross, founder of the New York Times’ New Old Age blog. A chronicle of her mother’s last years, the book is part love story, part cautionary tale. Jane Gross bravely shares intimate details of her family’s journey down this path while providing essential information about the late life health care system and how to negotiate each step of the way.
Having worked for years in nursing homes, I thought I knew a lot about what lies ahead in later years. Upon reading this book, however, I realize I know a lot about nursing homes, and not so much about what life might be like before one gets there. As someone with seven close relatives between the ages of 74 and 92, I found the book a wake-up call. It provides a good jumping off point to start to one of those difficult, but necessary, conversations with elders who have read it too — and for elders to open the dialogue with reluctant adult children. Beautifully written, with wit and intelligence, it passes a New York City reader’s highest standard: I was so engrossed in the book, I missed my subway stop.
Posted by Dr. El - April 26, 2011 - Anecdotes, Communication, Resident care
It was around Easter time one year when the following exchange took place:
“Hand me my peeps,” Isabelle commanded from her geri-recliner. She pointed to something behind me.
I turned and saw a package of yellow baby-chick-shaped marshmallows on her tray table. The word “Peeps” was written on the front of the box. I handed them to her and watched as she stuffed one, and then another into her mouth. As she picked up the third, I pointed to her red wristband. “I guess you’re careful about the sugar with the diabetes.”
“I don’t have diabetes,” she stated flatly, munching the third peep.
This was only the second time I’d seen Isabelle, and I’d had to convince her to meet with me today. I didn’t know if she had diabetes and had forgotten, or was in denial about it. It was unlikely that her wristband was the wrong color, but she sounded so certain I had to consider the possibility. “Red wristbands are for people with diabetes.”
“Everyone’s been saying that since I got here two months ago, but I don’t have diabetes. Check my chart,” she directed me. “Check it now.”
I went to the nursing station and pulled out the thick binder, reading through the diagnoses on the Physician’s Order Sheet. No diabetes. I went to the nurse, who thumbed through her records. “No,” she said, “she’s right. She doesn’t have diabetes. I’ll change her wristband after I finish what I’m doing.”
I went back to Isabelle, who’d been referred for anxiety, and told her what happened.
“I wonder what other mistakes they’re making,” she said.
I had my work cut out for me, but, for now at least, Isabelle was letting me on her team.
Posted by Dr. El - January 31, 2011 - Anecdotes, Communication, Role of psychologists, Younger residents
“My aide treats me like I’m an idiot,” Katrina typed to me on her talking computer.
“What do you mean?”
“She thinks I don’t know what’s going on!” Her eyes radiated her emotional pain. “She’s a bitch!”
A series of strokes had stolen Katrina’s ability to speak, leaving her a silent observer of her surroundings and interactions. A former schoolteacher, she carefully typed her perspective on the world to me, hunt and peck with one good finger on each hand, then pushed a button that released them in a mechanical female voice. The computer saved her, but it was a slow process and the only way to prepare a sentence in advance was to store it in a memory key. We’d set it up so that Control-H was “Hello.”
“Does she know you can type on the computer?”
“That bitch won’t give me time to type!” Her brows were furrowed and she appeared ready to explode with anger. Her enforced silence was a frequent topic in our sessions.
“Let’s use psychology with her. We’ve got to show her how smart you are. And we need to make a personal connection to shift the dynamics. Is there anything you know about her we can use?”
Katrina thought a moment. “She used to work nights.”
“Perfect! What if we set up a macro that said, ‘How do you like the day shift?’ That way she’d know you knew her well enough to be aware of her schedule, and it would set up a friendly tone.”
Her eyes lit up and she nodded.
“What memory key do you want me to program? Hey, what about B for bitch?”
Katrina laughed.
I set up the macro and she pressed Control-B for practice. “How do you like the day shift,” the mechanical lady said. We discussed her plan: Control-H, Control-B the minute the aide came to her bedside.
———————-
The next week Katrina was beaming when I entered the room.
“Did it work?”
“Everything is different,” she typed. “She talked to me like I knew what was going on!”
“You pressed the key?”
“I didn’t have to! She just knew!” Katrina was smiling from ear to ear.
“Well, isn’t that interesting?” I said. “All we had to do was put it out into the world, and God took care of the rest!”
Posted by Dr. El - January 10, 2011 - Communication, Medication issues, Resident care
THE PROBLEM:
Because of their personality styles, some nursing home residents don’t ask for their PRN (as needed, or “per request of the nurse”) pain medication when they need it. The reasons for this vary:
Psychologist, finding the resident in pain: “Why didn’t you tell the nurse?”
Passive: “I didn’t want to bother her.”
Macho: (grimacing) “I can handle pain.”
Forgetful: “I can ask for pain medication?”
THE SOLUTION:
- Counseling the passive or macho types about appropriate use of their pain medication
The forgetful person and those who don’t respond to counseling would fare better with:
- a standing order (medications dispensed at a specific time)
OR
- by having the nurse ask the resident if they’re in pain every time they’re eligible to get pain medication
