“Scream as loud as you can,” I encouraged my companions before we plunged down the waterslide in our rubber raft at the water park on Independence Day. “There aren’t enough opportunities for yelling in everyday life. Let’s make the most of it while it’s socially acceptable.” The shouts of our foursome pierced the air as we flew down the steep slopes and then dissolved into laughter as we splashed to a halt at the bottom of the ride. “That was great!” we all agreed.
Our residents tend to be stressed out. At a minimum, they’ve suffered debilitating and often sudden physical losses, they’re living 24/7 in a communal environment and they have to rely for assistance on helpers they’re sharing with other people. Add to this unfamiliar food, financial stressors, physical separation from their homes and family and worries about the future.
Is there any one of us who wouldn’t be angry about something in that situation? Yet we as organizations strive to have units filled with residents without “behaviors.”
I’m not suggesting nightly “primal scream” sessions, but we could add into the rotation some activities where residents get to be “bad,” or at least aren’t expected to be so darn good all the time.
For example, I used to counsel a 100-year old woman, Claire, whose active life had slowed to a crawl due to age, arthritis and other maladies. She often let out her frustrations by making sarcastic comments to her aides and other residents, which led to conflicts.
To help her blow off steam, as we talked, we slowly set up dominoes in a circuitous row on a table. When the domino chain was completed, I’d give her the signal and she’d gently push the first domino over with one arthritic finger and watch with glee as the whole chain loudly self-destructed. On some days, Claire was particularly “bad” and didn’t wait for the signal. This activity allowed her to be “good” bad and her sarcasm diminished.
With the high-profile deaths this month of designer Kate Spade and chef Anthony Bourdain, the crisis of suicide has been thrust into the spotlight. Suicide deaths in the United States have increased 25% between 1999 and 2016, with an estimated 45,000 occurring per year.
As I prepared for this article, I realized that we don’t hear much in the industry news outlets about suicide among our staff members. But that doesn’t mean it isn’t happening.
Research has shown that physicians are twice as likely to commit suicide as the general population, and while there is a notable lack of information about the suicide rates for nurses in the US, a report from the UK finds that “for females, the risk of suicide among health professionals was 24% higher than the female national average; this is largely explained by high suicide risk among female nurses.”
A suicide death in the small-town atmosphere of a nursing home can have a devastating ripple effect, deeply affecting other staff members, as well as residents and their families. It can be particularly difficult to absorb a suicide death in an environment where others are struggling to live, despite age and disability and where the job of workers is to keep people alive.
A death by suicide leaves those around the deceased wondering how they might have failed their coworkers and teammates. This feeling can be particularly acute among individuals who pride themselves as excellent caregivers — the kind of people who work in long-term care.
How employers can help
The Suicide Prevention Resource Center (SPRC) points out that it is not only more humane to create an organizational culture of physical and mental health, but it also leads to more productive employees. They suggest a comprehensive approach based on the following three elements to make workplaces more supportive to those who are struggling with depression.
In Editorial Director John O’Connor’s April 16th column, he reported on a study from the Kaiser Family Foundation indicating that increasing numbers of new residents have dementia, are more physically ill and are more likely to be on psychoactive medications.
The study showed that there has been a shift away from long-term services and toward short-term rehab treatment. O’Connor noted the pressure that this puts upon facilities to provide high-quality care in the midst of the churn of residents.
There are many difficulties that can arise from this shift in pace and population, but I’ll focus here on the mental health aspects and their effects on nursing facilities.
One problem that occurs when the length of stay decreases is that the team has a shorter period in which to get to know their residents. They are less likely to notice subtle changes in behavior and mood and they have less time to make the type of personal connection that reassures residents.
Adding to this, the fact that many facilities are operating short of staff in an environment of high employee turnover creates a “perfect storm” of emotional neglect.
Residents enter long-term care facilities in distress. When I adapted the classic Holmes-Rahe Stress Inventory to the circumstances of nursing home admission, I found that residents are experiencing a level of stress considered to be a “life crisis” that puts them at a high risk for further health breakdown. Their families also tend to be in crisis.
Residents and their family members are likely to expect that when they enter long-term care, staff members will provide compassionate medical treatment. Instead, what they frequently find are stressed out nurses and overworked aides who have just enough time to dispense medications or to make up a bed, but none to sit and talk with an understandably anxious resident and their family members about what they can expect regarding their stay and their future.
Social workers — most of whom got into the field in order to provide such counsel — are now buried under a flood of admissions and discharges. They cannot offer emotional sustenance when they need to complete the paperwork on three new admissions and order a walker for the lady whose family wants to take her home tomorrow because her insurance coverage ran out.
It is impossible for direct care staff to provide the same level of service that they did prior to this change in acuity and length of stay. In turn, distress over providing suboptimal care contributes to staff turnover, exacerbating the problem.
Cold weather. An uncertain world. Rogue shrinks making the rest of us caring, diligent professionals look bad. I don’t know about you, but I need a mood lifter.
I came across an article that suggests that exercise of all kinds, even small movements, can make us feel less depressed. In “Get up and move. It may make you happier,” New York Times health writer Gretchen Reynolds notes that people in a University at Cambridge study “turned out to feel happier when they had been moving in the past quarter-hour than when they had been sitting or lying down, even though most of the time they were not engaged in rigorous activity.”
How can we incorporate more movement into our days across the spectrum of long-term care?
Personally, I purposely forego my car so I can walk to and from the subway and I take the stairs instead of the elevator whenever possible. I encounter surprisingly few coworkers doing the same, so perhaps that can be number one on this list of get-moving ideas:
1. Take the stairs.
2. Use public transportation. Sign up for or offer workers a transit tax exemption if a program, such as TransitChek in New York City, is available in your area.
3. Kill two birds with one stone by walking around the facility on rounds and checking in with staff members and residents.
4. Join or begin a lunchtime walking program. Find a buddy to add fun and accountability.
In preparing for a webinar on suicide prevention, I came across startling statistics about suicide rates among older adults. Despite the concern we often hear about teen suicide, the rate for elders is even higher.
While older adults make up 12% of the U.S. population, they account for 18% of all suicide deaths. In 2014, the highest suicide rate in the U.S. population (19.3 per 100,000 people) was among people 85 years or older.
In addition, elder suicide may be under reported by 40% or more. Not counted are “silent suicides,” like deaths from overdoses, self-starvation or dehydration, and “accidents.”
Training staff to assess suicide
Given its prevalence, it’s important for long-term care staff members to know how to recognize and address suicidal thinking and behaviors.
As a psychologist who’s been assessing suicidality since my teen years as a peer counselor in college, I feel comfortable with the process. Most facility staff members, however, haven’t had extensive training and are understandably anxious about an issue that’s likely to be out of their area of expertise. This can lead to over-caution, such as unnecessary one-to-one observation, or to missing signs of distress.
Staff training programs should educate team members about factors increasing the likelihood of depression and thoughts of suicide. Many of these influences are prevalent in our elderly population, such as physical illness, pain, functional impairment, losses and social disconnectedness.
Make use of consulting psychologists by referring residents for evaluation after losses and a decline in condition such as a downgrade in diet from chopped to pureed food, a limb loss, a move from a wheelchair to a reclining chair or a death in the family.
Team communication and support
Virtually all workers know it’s necessary to inform the charge nurse and other personnel about direct statements such as “I want to kill myself,” but staff members should be trained to look for other warning signs of potential suicide, which include changes in grooming, loss of interest in previously appealing activities, giving away possessions and making statements like, “I won’t be needing any more appointments.”
Mabel was in her late 80s, had lost a leg to diabetes and didn’t hear well. She’d been suicidal upon her admission to the nursing home, but the team had worked hard to stabilize her mood. Months later, she wasn’t exactly happy, but she and Liza, her young private aide, attended activities together and she no longer thought she’d be better off dead.
I focused on her strengths when I was with her, appealing to her best self and trying to coax her out of her negativity. I frequently updated her on the news, giving her a report tailored to her interests.
“What do you think of this, Mabel?” I asked, sharing the latest events on the presidential election.
“I think it’s disgusting,” she replied.
“So are you ready to vote when they come around with the absentee ballot?”
“I’m not going to vote.”
“What?! Why not?” I asked, genuinely shocked.
“I’m not going to be alive to see it. Why should I care?”
“What about me?! What about Liza? She’s been awfully nice to you. Surely you can vote for Liza.”
Mabel paused and considered. “Yes. I can vote for Liza.”
A few days later I saw Liza and Mabel out of her bedroom talking to some other residents. Mabel was animated and actually smiling, a rare occurrence since I’d known her.
I’m sure a number of things contributed to Mabel’s shift in mood, but I have no doubt that recognizing her continued value as a citizen and having the opportunity to help Liza were among them.
Adaptive tandem bicycles allow residents the pleasure of riding a bike and feeling the breeze through their hair. As John Brunow of All Ability Cycles puts it in the video below, an adaptive bicycle event triggers reminiscence, stimulates appetites, and reduces depression. Sounds like a win, win, win to me!
When psychologists provide direct care services to long-term care residents, a note is required for every session, documenting symptoms, therapeutic interventions and other information proving that each and every session is medically necessary. The goals and progress of treatment are reviewed every three months. Audits and case reviews by insurers are not uncommon. Other disciplines in the organization read the notes and can incorporate the work into their efforts or, occasionally, question why the resident is being seen.
Sometimes, particularly when I haven’t had a vacation for a while, I wonder if I’m being truly helpful. I don’t want to discontinue treatment too soon because often mine is the only consistent, deep contact a resident has in life, but the steady drumbeat of needing to prove it’s worth it can lead to doubts at times.
Luckily, my residents have a way of letting me know that my services make a difference to them.
I was considering discontinuing treatment with a somewhat confused woman. When I woke her from a nap the other day, she smiled broadly, pointed to my business card which she keeps by her nightstand and almost leaped out of bed to talk to me. She spent the session following up on topics we’d been addressing in previous sessions and proudly showing me her progress on activities in which I’d encouraged her to engage.
I’ll keep going with her a while longer.
Another resident approached me in the hall recently, saying he’d been waiting for me and telling me, “You give me a reason to live.”
I’d consider that medically necessary, wouldn’t you?
We often think of culture change as a formal process initiated by company leaders that involves setting organizational goals and moving employees in big and small ways toward those goals.
But culture change also can be a grassroots effort that shifts the dynamics between residents, staff and community, one unit at a time.
Altering expectations
As a psychologist, I’ve been trained to observe the interactions of groups of people. The current dynamics of many long-term care settings involve residents who are in the passive role of “recipients of care” while the staff members are in the active role of “providers of care.” The residents are frequently isolated from each other and from the community outside the facility. They feel bored and useless, leading to depression.
Leaders in the culture change movement, the Eden Alternative calls loneliness, helplessness and boredom the “three plagues” of long-term care. Its aim is to eliminate these plagues through transforming the culture of the facility. Another culture change resource, the Pioneer Network, refers to the need for elders to have, among other things, “purposeful living.”
These organizations and others offer tried-and-true paths to alter the dynamics of your facility, but not every setting is ready for them yet. If you’re working in a culture-change-resistant organization and find yourself yearning for a way to make a difference — today — consider the possibilities here.
Grassroots culture change ideas
• Purposeful pursuits such as knitting and crocheting
As part of a therapeutic recreation program, these crafts can dramatically shift the dynamics noted above, especially when the needlework has a point. (Sorry, I couldn’t resist!) Residents who are working together to make lap blankets for new residents or hats for premature infants change from being passive recipients of care to active providers of care for others within the facility and in the larger community. Industrious and engaged residents show workers that elders can contribute to the world despite their age and physical or mental limitations. (For more on this, see the Recreation audios on my website. For more on therapeutic knitting, visit stitchlinks.com.)
• An active welcoming committee
Entering long-term care is very stressful for newcomers and an effective welcoming committee is an excellent way for long-time residents to recognize their own value and share their expertise.
Though it was close to 20 years ago, I’ll never forget the reaction of one of my patients to losing both of her legs to diabetes.
“I’m 81 years old and I’ve traveled and danced as much as I could. I wasn’t sick a day in my life until this happened. I’m satisfied,” Lila told me earnestly.
I was astonished by her acceptance of such a difficult situation. If it had been me, I was sure I would have railed at the injustice of the world.
Residents like her, however, make it quite clear that it is possible to be grateful and to live fully, despite disability.
Lila came to mind recently when I asked a resident, Daisy, how she was doing three years after a debilitating stroke. Her curt reply: “The same old damn thing — I still can’t walk.”
Creating better mood
A 2015 study in Spirituality in Clinical Practice suggests it might be possible to use the tool of gratitude in order to help residents like Daisy.
The study looked at the impact of gratitude and spiritual well-being on a group of asymptomatic heart failure patients with an average age of 66.
The researchers found that “gratitude and spiritual well-being are related to better mood and sleep, less fatigue, and more self-efficacy.” Those positive effects can reduce the chances that an individual will move from being asymptomatic to symptomatic heart failure, which is “associated with a five-fold increase in mortality risk.”
The researchers point to studies that tried to enhance participants’ sense of gratitude. Gratitude is considered part of “positive psychology,” which focuses on the strengths that allow individuals and communities to thrive.
Mabel was in her late 80s, had lost a leg to diabetes and didn’t hear well. She’d been suicidal upon her admission to the nursing home, but the team had worked hard to stabilize her mood. Months later, she wasn’t exactly happy, but she and Liza, her young private aide, attended activities together and she no longer thought she’d be better off dead.
