After reading a recent New York Times Opinion piece about the uses of lotteries to solve social problems, I began contemplating their potential application to long-term care.
According to “For Better Citizenship, Scratch and Win,” lotteries have been used to encourage voting, reduce speeding and even to attend to health needs such as getting tuberculosis screening, practicing safer sex and keeping medical appointments.
In one example, to combat tax evasion on small purchases, the Chinese government encouraged people to obtain receipts by turning them into scratch-off lottery tickets — leading to tax revenue amounting to 30 times the cost of the lottery prizes!
The theory is that lotteries are appealing because people want rewards and they enjoy playing games. As the CEO of a company that designs games for businesses put it, “They could… have everyone get an incentive for $15. But they’d get better results for the same average price by having variability — some get $10, some get $100.”
An element of fun might be a welcome addition to what’s typically the very serious business of long-term care. Presenting awards with humor and the thrill of winning a game could help offset the strain of coping with the ongoing losses inherent in direct care.
In addition, offering a lottery might appeal to a larger pool of workers. I often hear about the challenges of inducing less-engaged employees to improve their performance. Typical rewards, such as “employee of the month” programs, tend to honor those who are already committed and doing their best. Perhaps a lottery would engage disenfranchised workers in a way that other incentives have not.
Here are some playful ideas for applying lottery-style encouragement to long-term care:
1. The Show Up on Time Game: In the SHOUT Game, all employees who arrive to work on a timely basis for the week get entered into a lottery, which takes place at the end of the month. Each employee therefore has the opportunity to enter four or five times, depending on their timeliness and the number of weeks in the month. Winners of the drawing would get various prizes, which could be monetary, gift certificates to local enterprises or perks such as a good parking spot.
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!
I’ve learned a lot from listening to residents over the years, but it’s rare that I request specific advice. This month, I decided to change that.
In private conversations, I told residents that I was writing an article on advice from elders about how to live life and I asked them if they had any wisdom they wanted to share with young people.
Their responses were immediate and enthusiastic, as if they’d been waiting for someone to ask. They were so pleased with the question that I decided to ask my own elder relatives for their opinions as well. One family member, inspired by the inquiry, called to contribute further advice after her initial offering.
Many of the comments focused on wellbeing and taking risks in life:
• “If there’s something you want to do, go for it. Even if it doesn’t work out, at least you tried.”
• “Do what you can while you can do it. Take a chance!”
• “Do things you enjoy and keep as busy as your health will allow.”
• “Don’t overdo it.”
Others centered on maintaining independence:
• “Do the best you can and save a dime, because now when they jump me for money, I got a little something to pull out.”
• “Try to have something of your own, not your mother’s, not your father’s.”
Several people offered relationship advice:
• “Pay attention to your spouse but be an individual too.”
My mother has a knack for taking something awkward and, as she puts it, “turning it into a feature.”
For example, the previous owners of our family home placed the living room couch in front of a protruding radiator so that the sofa was oddly and obviously a foot away from the wall. By contrast, my mother had shelves installed above the radiator so that it became a pleasant focal point for books, photos and the stereo system.
I follow this line of thought with regard to the need for assistive devices such as canes, walkers, and eyeglasses. It’s possible to convert something unappealing yet necessary into an item that bestows confidence, evinces a sense of humor or becomes more useful.
Turning assistive devices into a feature creates a psychological shift for the wearer. It gives residents an element of control over mostly uncontrollable circumstances and allows them to retain their personal style in a situation that tends to strip them of their uniqueness despite our best efforts.
An organization providing the opportunity to purchase or design desirable devices can generate a change in their culture. Seeing residents sporting colorful walkers or personalized wheelchairs rather than standard equipment sends a message of individualized care and a zest for life despite disability.
In the spirit of giving your residents an emotional boost and taking the sting out of the need for assistive devices, your organization might try some of the following ideas (found through my handy search engine):
• Residents can purchase sophisticated walking canes featuring fancy handles or colorful shafts with a wide selection of items under $50. I know many residents who would find that an excellent use of their Personal Needs Allowance (PNA).
• Another company features a colorful range of walking canes for about $40 each. Choices include floral motifs, Irish themes, US military and biker inspired designs.
• With PNA funds being as limited as they are, a decorating event is a great addition to the recreation calendar. Help residents embellish canes or create personalized walker or wheelchair bags to carry their belongings using colorful duct tape, Velcro and other supplies, or sew a handy cup holder.
A few months ago, I was consulting at the Margaret Tietz Nursing and Rehabilitation Center in Jamaica, NY, when a remarkable woman named Trudy Schwarz walked down the hall. Her noteworthy qualities were obvious in several ways.
A diminutive woman, she nevertheless was pushing a sizable rolling metal cart filled with all manner of neatly arranged goods. This was despite being as old or older than many of the residents at the facility.
She exuded a calm, pleasant demeanor enhanced by her smile and her peach-colored lab coat as she purveyed merchandise from what I’ve previously termed an “independence cart,” an essential yet rare enterprise in long-term care.
“Trudy’s here!” exclaimed the resident I’d been speaking with, excusing herself for a moment to exchange a few dollars for a bottle of lotion. “She buys me the things I can’t get here. She’s a real lifesaver.”
It was a sentiment I heard echoed by many other residents over the next few months.
Overcoming systems failure
An “independence cart” is a small store on wheels that brings goods to residents. While many residents have personal needs allowances and therefore a small amount of money for purchases, it’s virtually impossible for many frail elderly to spend it due to a systems failure within long-term care communities.
Residents generally have no access to a store unless it’s one that visits their facility or they’re physically able to go off-campus with a family member or as part of a staffed excursion. Social workers are usually too inundated with other tasks to assist with online purchases and most residents don’t have access to a credit card, debit card or PayPal account necessary for web-based transactions anyway. Residents without family members to make purchases on their behalf are left to ask for help from staff members who sometimes assist them out of kindness — but against facility policy.
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.
It was the third week I was meeting with Mr. Schwartz, an 85-year old man with a thick mustache and a penchant for suspenders. I found him watching TV in the dayroom, surrounded by some of his peers. I crouched by his wheelchair so I could speak to him at eye level.
“Hi Mr. Schwartz, I came by to see how you were doing. Can we talk in your room for a while?”
“Sure, young lady!” he replied without hesitation, seeming eager to see me despite not being able to recollect my name.
“I can give you a push to your room,” I offered. “It might be easier since you’re holding that cup of tea.”
“Tea!” Mr. Schwartz exclaimed, with mock astonishment. “I thought it was beer!”
At a conference last week, I remarked to my audience of recreation therapists, “None of us went into this field for the money — we did it for the juice.” And by “the juice,” I mean the good feeling we get from helping seniors and the nice things they say to us in return.
This is why your employees stay, despite everything else.
To get us in the spirit of gratitude for Thanksgiving, I’ve included a sample of comments made by residents to their psychologists. (I solicited material from my colleagues in my favorite shrinky organization, Psychologists in Long-Term Care. I actually heard some of them at work myself, but I’m not gonna tell you which ones.)
• “Without you, I’m like a ship without a rudder.”
• “Girl, I am so happy to see you. I love your smiling face. You help me so much when you come. I don’t feel so crazy.”
• “Thank you for listening to me & not giving up on me.” (Written on a “Wow!” card.)
• “I know you understand. I’m not crazy, but sometimes I feel like I am. My family doesn’t get it and the girls here don’t have time to talk to me.” (LTC Alzheimer’s resident with pain issues.)
• “You help me to look at my life here in a way that my family, friends, and nursing staff can’t.”
• “You don’t know how much it helps to have someone come in and listen and talk to me! I’ve just felt lost. I know I forget things, but since you’ve been coming, it seems like I’m less befuddled!” (LTC resident with early onset Alzheimer’s disease.)
Last week, a New York Times article referred to the lack of training to prepare doctors to recognize the spiritual needs of their patients. Hospital physician Robert Klitzman, M.D., emphasized in the Well section article the value of meeting these needs.
Psychology graduate school also avoided focusing on clients’ spiritual needs, which were considered to be the province of those with formal religious training. Despite this, I’ve found that many of the conversations I have with residents can be considered spiritual work.
In the beginning of my LTC career, I quickly recognized that in order to be of service in this environment, I needed to come to a spiritual understanding of how such nice people could be dealing with such difficult illnesses. This led me to the book by Harold S. Kushner, “When Bad Things Happen to Good People.” The gist of the book, as I recall it, was that the question is not so much, “Why me, God?” but, “Why not me?”
That stance allows me to help people come to terms with their experiences and also to recognize very clearly that this could be me, or me down the road a few paces. I am merely assisting others as I hope someone will assist me when it’s my turn.
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.
It was the third week I was meeting with Mr. Schwartz, an 85-year old man with a thick mustache and a penchant for suspenders. I found him watching TV in the dayroom, surrounded by some of his peers. I crouched by his wheelchair so I could speak to him at eye level.
