Category: McKnight’s Long-Term Care News

The high cost of rudeness

Here’s my latest article on McKnight’s Long-Term Care News:

The high cost of rudeness

A study about rudeness in the medical journal Pediatrics got me thinking about the possible effects of rudeness in long-term care.

In “The Impact of Rudeness on Medical Team Performance: A Randomized Trial,” teams were subjected to rude comments by a supposed visiting medical colleague. For example, he suggested that the team members in the neonatal intensive care unit (NICU) “wouldn’t last a week” in his country.

Compared to the control group, teams that had been exposed to the rude comments had lower diagnostic and procedural performance scores.

Naturally, I wondered how this research might translate to senior living.

I’m sure I’m not the only person who has observed rudeness occurring in eldercare settings, whether it’s an administrator being curt with staff, nasty remarks between staff members, a discourteous statement to or from a resident, or a sharp comment by a family member.

To complicate matters, LTC teams are often multi-cultural. What’s considered reasonable for one culture may be deemed rude by another culture.

In addition, a comment can be interpreted differently depending on the ages and genders of the people involved. If an older female staff member compliments a young woman on her outfit, it can come across differently than if an older male staff member similarly compliments his young female colleague.

Long-term care is also very hierarchical. Doctors often “get away with” rude comments to nurses, as do administrators with underlings.

The research, however, suggests that nobody is getting away with anything. Rude statements negatively affect team performance in the NICU and, I suspect, in teams everywhere.

The good news is that the study found two behaviors reduced the impact of rudeness: information sharing lessened the negative impact of rudeness on diagnostic scores and help-seeking reduced the adverse impact of rudeness on procedural performance scores.

Here are some ways to address rudeness in LTC:

For the entire article, visit:

The high cost of rudeness

Spirituality in Long-Term Care

Here’s my latest article on McKnight’s Long-Term Care News:

Spirituality in Long-Term Care

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.

For the entire article, visit:

Spirituality in Long-Term Care

Dr. El’s Shrinky LTC Fantasy

Here’s my latest article on McKnight’s Long-Term Care News:

Dr. El’s Shrinky LTC Fantasy

I hung up the phone with the managed care case reviewer. The patient in question was in her late 50s, with multiple sclerosis and other physical problems that had unexpectedly interfered with her ability to return home or even to sit comfortably in a wheelchair. Bed-bound, she was irritable with the staff and distressed about the changes in her life, and in financial circumstances that had resulted in this new insurance coverage.

“You can see her for another 30 days,” the case reviewer told me. “After that, I’ll have to send it to a second level review.”

I sat at the desk in the administration office, hyperventilating. What else would need to happen to this resident in order to get more than a month of treatment? An amputation? The death of her only child?

I took my mind to a better place:

I was in my office at the rehabilitation and care center reviewing the psychology calendar for the month:

• This week I’d shadow the east wing staff and focus on team building.

• My weekly open office hours with the staff had several appointments already filled to discuss conflicts with coworkers, finding better ways to interact with a difficult resident, and how an otherwise excellent worker could get to work on time.

• The topic for the August family group meeting was set: How to partner with the staff.

• The monthly staff training topic was planned to coordinate: How to work with families. Other trainings I had in mind were on facing challenges such as aggressive residents, understanding mental illness, dementia without medication and team management of end-of-life care, in addition to handling work/life balance, reducing stress, time management, and coping with loss.

• The data collection for my research project was progressing nicely. Copies of my book, “The Savvy Resident’s Guide,” had been distributed to the recreation therapists, who were using them to run discussion groups with the residents based on chapter topics such as “Working with the staff” and “Making the most of rehabilitation.” Residents were being measured on acquired knowledge, level of anxiety, conflicts with staff and participation in rehab.

For the entire article, visit:

Dr. El’s Shrinky LTC Fantasy

Diabetes care: Take two betta fish and call me in a week

Here’s my latest article on McKnight’s Long-Term Care News:

Diabetes care: Take two betta fish and call me in a week

More than 25% of the US population over the age of 65 years has diabetes¹ and the numbers are far higher for those in long-term care. (Approximately one third of nursing home residents have diabetes.²)
Diabetics often need to track their blood sugar level multiple times daily and administer medication. Uncontrolled diabetes can lead to a host of medical problems, including heart disease, neuropathy, and impaired vision and falls, and can result in hospitalizations and rehospitalizations.

While guidelines suggest that elders with comorbid health problems need less intensive glucose control than younger healthier people (who are more likely to benefit from years of strict control), many residents in our communities still need to keep track of their blood sugar daily.

We can borrow an idea from a recent study of children with diabetes to help empower our elders toward better self-care in our senior communities and more successful transitions home from skilled nursing care.

In an effort to test pairing twice daily glucose checks with pet care, researcher Olga T. Gupta, MD gave betta fish and tanks to children ages 10 to 17 years. The children were asked to feed their fish and check their blood sugar at the same time, and to review their glucose logs with their parents when they cleaned the fish tank each week. The results of this pilot study showed a small but significant improvement in glucose control.

We can adapt this study to seniors and simultaneously take advantage of the health benefits of pet ownership. Caring for a pet has been linked to fewer doctor visits, improvement in activities of daily living, reduced depression and better heart health, among other rewards. ³

For the entire article, visit:

Diabetes care: Take two betta fish and call me in a week

Creating Better Deaths in Long-Term Care

Here’s my latest article on McKnight’s Long-Term Care News:

Creating Better Deaths in Long-Term Care

I walked into Mr. Hobart’s room, ready for my initial evaluation. He was a thin, graying man whose loose clothes hung in folds around him. He’d spent every day last week in chemo.

He spoke quietly, discussing his estrangement from his family and the good old days hanging out at the bar. None of his drinking buddies were around. He had no visitors.

Following our talk, I stopped at the nursing station. “What’s his prognosis?” I asked the nurse. “Not good,” she said. I paid a visit to the social worker and asked softly but very bluntly, “Is there a reason we’re medically torturing this man?” “We wanted to put him on hospice, but his brother won’t return my calls,” she told me. She promised to try again. By the next week, hospice services had been arranged. Mr. Hobart died five weeks later.

Unfortunately, this scenario is a fairly typical approach to end-of-life procedures in long-term care. The case highlights common end-of-life challenges in LTC facilities:

• No clear leadership within the treatment team regarding end-of-life care — Often team members, regarding this as a medical situation, expect that the physician will be addressing these issues with the resident and their family. The physician, on the other hand, may view dying as an emotional issue and expect that the social worker and other team members will be handling it.

• Lack of communication with the resident regarding end-of-life wishes — With no designated team member to broach the topic, residents often follow along with the care plan assuming they’re going to get better and that someone will tell them when they’ve reached the point where medical interventions are unlikely to help.

• Lack of communication with family members regarding prognosis and care decisions — Addressing treatment decisions and whether or not to consider hospice or palliative care is often a time-consuming series of discussions with family members and it needs to be handled with sensitivity. This can be difficult to manage in what’s become an ever fast-paced care environment.

• Aggressive medical treatments with very low likelihood of success — There are increasing numbers of medical treatments that can be performed, but questions arise about whether they should be: Is the treatment likely to help? Has the resident been properly informed of the risks and side effects of the treatment? Does the resident understand how it will affect his or her quality of life? Atul Gawande, MD addresses these questions eloquently and in detail in his book, “Being Mortal,” which I highly recommend.

• Late referral to hospice — Hospice is an excellent support for residents and their families. (Unlike in LTC facilities, the entire family –— not just the resident — is seen for treatment.) Most often, however, the referral for hospice services is made when the resident has days or weeks rather than months to live and much of the benefit of hospice services is lost.

As organizations that serve people who are ill and in the last years of their lives, we can create better deaths by improving end-of-life care.

• Establish an end-of-life care committee — Select and train members from various disciplines to be part of the committee. This specialized group can work with the resident’s ongoing treatment team to speak with the resident and their family members about end-of-life care and decision-making.

• Use available tools to discuss care decisions with residents and their families — Here are two resources to be aware of:

For the entire article, visit:

Creating Better Deaths in Long-Term Care

Portrait of multi generations Indian family at home. Asian people living lifestyle.

The Goodbye Guide: Why and how to terminate tenderly in LTC

Here’s my latest article on McKnight’s Long-Term Care News:

The Goodbye Guide: Why and how to terminate tenderly in LTC

An experienced colleague was recently let go from her job to which she’d been dedicated for 10 years. “We want to take things in a different direction,” she was told by the administrator. “Pack up your office and go.”

An hour later, she was in the parking lot holding a box containing a photo of her kids and mementoes of a decade as head of the social service department. Her replacement started two days later.

There are, of course, occasions when people who are fired or otherwise are terminating employment and need to be escorted from the building. But many workers are career professionals who wouldn’t consider burning bridges with bad behavior. Despite this, I’ve witnessed hasty dismissals and hushed resignations on multiple occasions throughout my career.

Sometimes, departing coworkers will tell me they didn’t want to let anyone know they were leaving because they didn’t want to deal with the residents’ being upset.

In my training to become a psychologist, we spent a great deal of time discussing endings and termination of treatment. While work in long-term care isn’t necessarily a psychotherapeutic relationship, I believe leave-takings in LTC are more important than in other settings and that the style of departure should be given more consideration.

Here are some aspects to consider:

• Due to the nature of the work, staff members form deep relationships over time with the residents and their families. When we depart, it matters to them.

• Because we work with elders and those who are ill, people are constantly leaving — through death, discharges, and hospital transfers — often suddenly and without the chance to say goodbye. This can create small traumas. In compassionately addressing our departures, we have the opportunity to reduce the amount of trauma in the lives of our residents rather than contribute to it.

For the entire article, visit:

The Goodbye Guide: Why and how to terminate tenderly in LTC

Harnessing gratitude

Here’s my latest article on McKnight’s Long-Term Care News:

Harnessing Gratitude

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.

For the entire article, visit:

Harnessing Gratitude

Psychologists open up about LTC sex and dementia

Here’s my latest article on McKnight’s Long-Term Care News:

Psychologists open up about LTC sex and dementia

A recent Iowa court case acquitted Henry Rayhons of sexually abusing his wife, who had Alzheimer’s dementia and lived in a nursing home. The case not only prompted national debate, it led those in long-term care to consider how to handle sexual activity within the bounds of their facility, particularly in cases when one or both of the parties have a diagnosis of dementia.

Psychologists are frequently asked to determine whether or not a patient has the capacity to understand or authorize various aspects of care, including their ability to consent to sexual behavior.

Eric Redlener, PhD, president of The PsychAssociates Group, a company that provides psychological services to long-term care facilities, held a meeting for its supervisors to discuss the challenges that arise when considering capacity, sexual activity and the senior living environment.

I was on the conference call since I work for them regularly. Here is a fly-on-the-wall account of the concerns raised during the meeting.

Staff issues

Some of the challenges to handling sexual behavior in the long-term care environment involve the reactions of staff members to the situation.

· Some staff members show squeamishness about “Grandma and Grandpa” having sex.

· Staff members may be concerned, rightly or wrongly, that residents will be taken advantage of.

· Staff members project their notion of sex onto elders. Elders may be content with holding hands or heavy petting, but staff might be anticipating people “swinging from the rafters.”

· Sometimes an administrator or director of nursing bans sexual activity among the residents, considering it “bad behavior,” despite the fact that it’s a legal right in many states for residents to be able to engage in sexual relations within a long-term care facility.

Family concerns

The reaction of family members to the romantic/sexual involvement of their elders can vary greatly.

· Some family members are able to accept their loved one’s need for intimacy, despite its sometimes unexpected expression, such as when an elderly heterosexual mother spends time cuddling with another woman on the floor, or a husband with dementia becomes involved with a woman who is not his wife.

For the entire article, visit:

Psychologists open up about LTC sex and dementia

The Many Riches of Senior Living Conferences

Here’s my latest article on McKnight’s Long-Term Care News:

The Many Riches of Senior Living Conferences

I’ve been fortunate enough to attend several senior living conventions recently and my enthusiasm for the experience has yet to diminish. If you haven’t yet had the opportunity to be present for a conference (or if it’s been a while since your last one), consider these reasons for attending:

• There are interesting discussions that directly relate to day-to-day work. Hearing different ideas and perspectives can offer a new way to handle problems and can help you get out of a work rut.

• The conference discourse provides a great opportunity to brainstorm, on your own or with colleagues and coworkers.

• Attendees are often equally enthusiastic about LTC and the connections made with others there can help implement changes within your organization.

• The new products offered in the expo hall can improve operations and the lives of residents and staff.

• Sharing the lessons learned with coworkers can expand the value of the conference.

If an onsite convention isn’t possible for now, consider attending a virtual event, such as the annual McKnight’s Online Expo, which not only offers educational sessions but also has chat rooms and a virtual expo hall.

My experience at ALFA

My most recent conference was the Assisted Living Federation of America convention last week in Tampa, where I spoke at the session “The Importance of Environmental Factors in Senior Living.” During my whirlwind visit to ALFA, I was also able to take in two presentations and spend time in the expo hall.

One of the sessions was on using recreational activities as a way to improve morale among residents and staff and to promote your organization in the community. I’ve spoken about these goals in my audio, “10 Steps to Making Recreation the Most Valuable Department in the Nursing Home,” and I was encouraged to hear of unique ways senior organizations have been serving these dual objectives, such as knitting caps for premature babies.

The conversation among participants helped me think about the impact that the pro-social engagement of residents has on reducing the problem of senior bullying. If seniors are busy doing good in the world, not only are they less likely to be engaging in negative behavior such as bullying, but the organization has helped to create a culture of caring.

The second talk was a roundtable on engaging staff in order to reduce turnover. The suggestions focused on hiring for attitude and training for skills, being clear about the mission of the organization, and implementing programs that reward employees for their good work.

Expo hall jewels

As usual, I searched the expo hall to find products I knew my residents would appreciate.

Having heard far too many elders complain bitterly about pureed food, I was delighted to find a company that offered puree solidified into colorful, shaped molds that were far more appetizing than typical puree. The saleslady looked askance at my glee about getting to sample her wares — but regular readers know I like to experience things from the residents’ perspective whenever possible.

For the entire article, visit:

The Many Riches of Senior Living Conferences

‘Okie El’ rocks out, and then veges out

Here’s my latest article on McKnight’s Long-Term Care News:

‘Okie El’ rocks out, and then veges out

Given that the bulk of my prior knowledge of Oklahoma came from a 72-year-old musical performed by my class during grade school, I wasn’t quite sure what to expect when I arrived in Norman for the 2015 Oklahoma Association of Health Care Providers/Oklahoma Assisted Living Association conference.

The upshot (based on the journey between the airport and the hotel): No fringed surries. Plenty of flat, open, grassy expanses. Chain stores. A bustling well-run conference. Animated conversations with attendees invested in providing enhanced care for their residents. Life-altering products in the Expo Hall.

Younger adults in senior living

I was invited for two talks, the first of which was on younger adults in senior care. The group focused on ideas for handling the challenges of younger residents, from those with illnesses such as ALS or spina bifida to people who led rough lifestyles prior to the disabling injuries (e.g. gunshot wounds) that led to placement in long-term care.

The talk addressed the emotional reactions caregivers have toward younger residents that can make it more difficult to work with them than with the typical older population. It also got into ways of unifying the team through training and policies, and strategies to engage younger residents in positive activities.

As I wrote in this 2008 article, meeting the needs of our younger residents now will help prepare our facilities for the differing expectations of the coming Baby Boom generation.

Addressing mental health in LTC

My second presentation focused on the need to address mental health problems in long-term care. Not a week goes by without a news story about a behavioral health problem in one of our facilities, such as an assault by a resident on a peer or staff member.

I offered a three-tiered model for addressing mental health care as part of our general healthcare. None of the three tiers — engaging mental health professionals, creating a healing emotional environment, and improving customer service — cost anything more than staff training and increasing the priority paid to behavioral health issues. Well worth it to avoid being the next facility with a negative news headline.

Rocking the expo hall

Between talks, I visited the expo hall in search of exhibits that offered solutions for my residents.

The first thing that caught my eye was the mod-looking geri-recliner.

For the entire article, visit:

‘Okie El’ rocks out, and then veges out