Category: McKnight’s Long-Term Care News

Preventing violence in long-term care

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

Preventing violence in long-term care

As I developed a training program on violence prevention, I reflected on a scenario I’ve witnessed many times in my career. A resident who had been physically aggressive toward aides and nurses got sent to the hospital only after he hit the attending physician.

Situations like this send the message to nursing department staff that they aren’t important, and that violence is just part of the job. That attitude explains why nurses are estimated to report violent behaviors just 30% of the time¹.

Instead of accepting aggressive behaviors as normal, facilities would be wise to approach then as anomalies that can and should be addressed. As research indicates,² aggression toward workers decreases staff satisfaction and increases burnout. Violence prevention efforts reduce turnover costs and improve morale, and result in fewer lawsuits and a reduction in worker’s compensation claims.

Violence prevention programs

According to the Occupational Safety and Health Administration, a violence prevention program has several key elements:

• Management commitment and employee involvement
• Worksite analysis
• Hazard prevention and control
• Training and education
• Record-keeping and evaluation of program

The thrust of such programs is to support and encourage staff to report events so that there can be an accurate evaluation of the circumstances contributing to violence. Using the information gleaned from this analysis, adjustments are made to the environment and workers are trained to handle aggressive behaviors. These steps are followed by reevaluation and readjustment as needed.

The efforts can be remarkably effective. In one hospital-based program,³ Operation Safe Workplace, the incidence of violent behaviors was reduced by 55%! While hospitals have different factors contributing to these problems, such as a younger, more physically able population, there are many aspects of a long-term care environment that could be adjusted to reduce the likelihood of aggressive behaviors.

For the entire article, visit:

Preventing violence in long-term care

The added value of social workers and psychosocial services

The top recommendation in the April 9 McKnight’s article “Researchers share 6 tips to improve nursing home care for blacks and Latinos” was to include a social worker on staff in the facility. “Great,” a reader commented, but “ask CMS … if they will pay for it.”

Perhaps, though better yet, social workers will pay for themselves.

A study published in March discussed the role and value of social work staff, with the surprising finding that deficiency scores are reduced twice as much when there’s an increase in social service staffing as compared to an increase in nursing staff. Lower deficiency scores can translate into better CMS star ratings and increased admissions, as well as reduced liability risk, creating a financial savings worth the price of a social worker salary.

The research brief goes on to report that while there’s been an increase in staffing in many other departments over time, the number of social workers remains low. The authors also note that there are no mandated qualifications for social work staff but that when social workers have higher qualifications such as a master’s degree, resident outcomes improve.

Interestingly, the other department that had almost as much effect on improving deficiency scores was the activities department, another psychosocially focused part of the team. (They didn’t study consulting psychologists, but I’d like to think we would have helped as well!)

For the entire article, visit:

The added value of social workers and psychosocial services

Benefits of acknowledging success

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

Benefits of acknowledging success

“My column won a bronze award for best blog in the 2019 American Society of Healthcare Publication Editors competition,” I informed a friend of mine, “but I feel funny telling people.”

“Women have such a hard time with this!” she said with some exasperation. “You HAVE to tell them, Eleanor. Who else is going to let them know but you?”

With her words in mind I posted about it on LinkedIn, Facebook, Twitter and my main psychology group, Psychologists in Long-Term Care. I received many wonderful, supportive, unexpected replies. I wasn’t going to write about it for this column (because, gosh, wasn’t that enough already?), but I decided to for several reasons.

I view part of my job as a psychologist as being a role model. On the units, I’m aware that the aides and my other co-workers are observing how I speak to them and to the residents and families. Similarly, in writing this column, I represent psychology to those who work in long-term care management. If people, particularly women, find it difficult to talk about their accomplishments, then perhaps I can model sharing an achievement in order to encourage more colleagues to do the same.

Dealing with extensive regulations, reimbursement challenges, elaborate documentation requirements and a punitive environment can erode the joy of helping elders. Acclamation for accomplishments, on the other hand, can bring joyfulness back to the job. I could have told just my mother and while that would have been nice, by sharing it with a larger group, the positive response is magnified, giving me added energy to continue my work. I’m sure there’s a scientific, dopamine thing happening, but the gist is that it feels good to be acknowledged. The reverse is true as well: Offering a genuine compliment can make the giver feel better too.

For the entire article, visit:

Benefits of acknowledging success

Why Five-Star ratings should measure staff retention, not staff ratios

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

Why Five-Star ratings should measure staff retention, not staff ratios

The Five-Star Quality Rating System reports the results of health inspections, staffing and quality measures. I suggest we replace the current staffing measure with one tracking staff retention.

Here’s my logic:

The existing staffing score is the ratio of nursing staff to residents, taking care needs into account. In allowing for self-reporting of the data, some nursing homes overstated their resident/staff ratio. It therefore hasn’t been a particularly accurate measure of staffing.

It also misses the fact that while some residents have low-acuity physical health needs, they — or their family members — may have high-acuity emotional or mental health needs that require a great deal of staff time and attention. In such situations there are enough workers for the facility to be compliant technically but understaffed in reality.

If we shift to a system that measures staff retention rather than staff ratio, however the whole picture changes.

Staff turnover is a strong signal that something is wrong with a nursing home.

As I noted in an earlier post here, “Reducing Turnover in LTC,” employees tend to leave facilities not just because the pay and benefits are low, but also because of a high workload, poor staffing, unsatisfactory work conditions and a lack of appreciation. Unless they’re older, invested in the facility and perhaps looking forward to retirement benefits, employees depart when a facility isn’t a good place to work.

If a nursing home isn’t a good place to work, it’s an even worse place to live.

Residents and their families want clean, safe environments with quality care and reasonable food — and they especially want workers who know and respect them. High turnover makes meeting these expectations virtually impossible.

For the entire article, visit:

Why Five-Star ratings should measure staff retention, not staff ratios

12 steps to starting a new job with serenity

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

12 steps to starting a new job with serenity

In my last column, “How to quit like a shrink,” I outlined ways to exit a nursing home that solidify the connections made there and offer the opportunity for healing. Assuming you’re not independently wealthy, what follows after leaving one position is beginning another.

The start of a new job, while exciting and hopeful, also can be very stressful. Perhaps it’s your first position, or maybe you’ve taken on a supervisory role or increased your responsibilities. Even if you’re performing the same types of tasks you’ve completed for years, you’re now in a new setting, adjusting to an unfamiliar work culture with different people and systems.

Here are 12 steps that may make the transition more manageable:

1. Give it time.I estimate that it takes six months before your new coworkers — who may have seen them come and go many times over — actually believe you’re there. It’s not until you go on vacation and they miss you that they realize you’re a solid part of the team.
2. Give it time. Relationships with coworkers won’t be established overnight. Be pleasant. Be professional. Be chill. It will happen and it will be better if you don’t try to force it. Join coworkers in the cafeteria if invited but bring a book to read just in case.
3. Don’t let ’em see you sweat. You’re not imagining it. Everyone IS checking you out to see what kind of person you are and whether or not you’ll be able to do your job. This is a good time to “act as if” you’re unperturbed even when you can’t locate the restroom or there’s a code for the copy machine no one told you about. Freak out at home or with your friends but maintain a calm façade while at the facility. If anyone asks, things are going great.
4. Ask questions. Even when you’re trying your best to showcase your competence, there will be times when you don’t know the answer. It’s better to ask how particular tasks are accomplished at the facility than to assume that they’re done the same way they were at your last nursing home or how you were taught in school. Reasonable questions showcase competence more than erroneous assumptions.
5. Be aware of dynamics. If you’re lucky, you’re following in the footsteps of someone truly awful at their work and everyone will be rejoicing at your arrival. More often than not, however, there are mixed feelings about your replacement of a former employee and unspoken interpersonal and departmental dynamics. Maintain the aforementioned calm façade while people adjust to your presence and if problems arise, consult with a wise friend, former colleague or current supervisor.
6. Get organized. One of the best ways to gain a sense of control over a new situation is to begin putting systems in place. After you’ve discovered what you need to do, taking the time to figure out how to do it most swiftly and successfully will pay off in the long run. Create paper or digital files, post telephone numbers by your desk and/or enter them into your phone and establish order to calm your mind and make your process easier.

For the entire article, visit:

12 steps to starting a new job with serenity

McKnight’s Online Expo, FREE, March 27th and 28th 2019

How to quit like a shrink

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

How to quit like a shrink

Employees leave their positions for many reasons — organizational restructuring, family needs, a better offer — and they exit their jobs in a variety of different ways. Some sneak out quietly so that their coworkers find out only after they’re already gone. Others have a swift, drama-filled exit, walking off after an argument, never to return.

While we as individuals may have no say over how our companies discharge workers, if we’re voluntarily leaving an organization, we’re likely to have a significant amount of control over how we depart. For professionals hoping to maintain connections with colleagues, leave-taking is an opportunity to create a positive last impression. While we’re making the effort to finish up our work and create a smooth handoff of responsibilities, we also can showcase our expertise in handling exits.

As I noted in a column about how to fire staff members, “The Good-bye Guide: Why and how to terminate tenderly in LTC,” endings of all kinds are especially important in this field. Beloved residents may die unexpectedly or be transferred to the hospital and vanish from our lives. With the departure of each resident, their families disappear as well, compounding the loss.

This steady but generally unacknowledged drumbeat of sadness has a strong impact on workers. (I believe it’s why many employees don’t complete their first year. For more on that topic, see “Absenteeism and turnover in LTC? Death anxiety could be the cause”.) In an environment where there are many sudden and sometimes disturbing endings, well-planned departures can be opportunities to heal some of this pain.

They also can help to solidify connections and offer an opening to obtain contact information for colleagues with whom you’d like to stay in touch after you’ve gone.

There are entire volumes devoted to the psychological process of termination, but I’ve created a quick guide below based on my experiences with leave-taking in LTC:

1. Give people time to emotionally and practically process your departure. Typically, this is two to four weeks, depending on the level of your interactions with them.

For the entire article, visit:

How to quit like a shrink

Sleep deprivation and pain

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

Sleep deprivation and pain

Despite the fact that my search for column inspiration took place at 3 a.m., I chose the topic of sleep deprivation because residents regularly tell me about their own sleep disturbances. They also discuss their pain.

Though their aches often keep them up at night, a January 2019 article in the New York Times, “Why It Hurts to Lose Sleep,” suggests that there’s a more complicated relationship between sleep and pain.

Author Benedict Carey described research finding “that a single night of sleep deprivation reduced a person’s pain threshold by more than 15 percent.” In addition, “small deviations in the average amount of sleep from one day to another predicted the level of overall pain felt the next day.” Staying up all night — which has been known to happen in the long-term care setting — increased pain sensitivity by 15% to 30%.

This interaction between sleep and physical discomfort is particularly relevant to those of us working in eldercare. Increased use of pain medications not only raises pharmacy costs, but can lead to a host of other problems, including constipation, daytime drowsiness, increased fall risk, the possibility of addiction, medication interactions, breathing problems and more. Each of these complications can, in turn, lead to further difficulties.

Perhaps the silver lining in these significant complications will be that more attention is paid to sleep disturbances in long-term care.

I suspect that the shift-based nature of nursing care makes it easier to discount this issue. If an elder with disrupted sleep were at home keeping their caregivers awake, it would be a major problem for the family. In the nursing home, the nighttime care providers are already up, the daytime workers arrive to work rested and the administrative staff members aren’t around to directly observe the effects of unsettled sleep. It’s the residents who must contend with the mid-night disruptions of their peers.

One loud, agitated resident can awaken most of his or her neighbors. If, as this research suggests, all of those people feel discomfort more intently the next day, this could increase their requests for pain medications. Their fatigue might reduce their progress in rehab and increase their likelihood of irritability. This outbreak of insomnia, pain and aggravation should be attended to as much as scabies or lice.

For the entire article, visit:

Sleep deprivation and pain

Self-care, team-care and an empty well

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

Self-care, team-care and an empty well

“How’s it going?” I asked Larry, one of the maintenance workers I chatted with from time to time. He didn’t have his usual smile and his wrist was in a brace from a repetitive stress injury.

“I’m tired,” he replied. “I’m real tired. I was supposed to be off today but Jules called in sick and we were already short one guy. Tomorrow will make seven days of work in a row.”

“You’ve got to take care of yourself,” I encouraged him.

“I know,” he said, “but they needed me.”

A few months after my encounter with Larry, I noticed that an excellent nurse had “lost her shine.” I stopped by her med cart to see why.

“My sister’s very sick,” Shirley told me, becoming tearful. “She lives in Haiti and I’m worried about her.”

“Oh no! Do you have any vacation time? Can you go see her?”

“I do, but I don’t know if the director of nursing will sign off on it. I guess I could try.”

I followed up with her the next week as if she’d been one of my patients.

“No,” Shirley said as I approached the nursing station, “I didn’t put in for the vacation time.”

She’d lost weight since the prior week and her expression had become grim. I regularly observed her completing paperwork and tending to the residents an hour after her shift was over.

“Let’s do it now,” I insisted. I stood at the desk while Shirley filled in the form requesting time off the following month. That weekend she had a heart attack.

I’ve met many Larrys and Shirleys over the years. If asked, they’ll work the extra shift because they’re the type of people who don’t like to say no. While it’s tempting for organizations to meet staffing needs with someone who always says yes, good managers recognize that such requests can push employees to the brink. Encouraging employees to engage in ongoing self-care and to recognize when they need to “refill the well” can reduce their chances of burnout and illness, leading to better workers, improved care and fewer missed shifts overall.

Self-care for healthcare workers is, according to one research paper, “a proactive and holistic approach to promoting personal health and well-being to support professional care of others.” Team-care — a concept I learned while researching this article — refers to coworkers supporting and encouraging the self-care efforts of their teammates.

When I asked after the well-being of Larry and Shirley, I was engaging in team-care. While I often informally check in with my coworkers, team-care is much more effective if it’s a consistent, leader-supported element of workplace culture.

There are many ways in which individuals can engage in self-care and be supported by facilities and coworkers in their efforts.

Self-care, team-care and an empty well

Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave

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

Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave

Long-term care facilities are admitting more residents with longstanding psychiatric illnesses. Such individuals enter the nursing home for physical rehabilitation but are difficult to discharge back to the community due to their mental health needs, weak or nonexistent support networks and unstable prior housing situations.

This column focuses on why the severely mentally ill (SMI) population is increasing, and the impacts of this change and on strategies to manage care.

A mounting possibility

I predict we’ll be seeing greater numbers of SMI residents due to the combination of factors outlined below.

The movement toward deinstitutionalization in the 1970s and 1980s closed many psychiatric facilities without increasing community assistance. Because of the lack of community resources, parents of children with severe mental illness frequently became their lifelong supports.

Many SMI people are now over 50 years old; their caregiver parents are in their seventies and eighties. Older parents are less able to provide financial, practical and emotional aid for their adult children due to their own aging and health problems.

In addition, as adults with SMI get older themselves, they’re increasingly likely to experience medical problems requiring hospitalization and rehab, which brings them to our doors.

To estimate the numbers of older SMI individuals, I looked at statistics on mental illness and aging. According to the National Institute of Mental Health (NIMH), 2.7% of US adults aged 50 and older were diagnosed with SMI in 2016. In 2014,  AARPnotes that there were 108.7 million people aged 50 and over in the US. Combining these statistics gives us a rough estimate of almost 3 million SMI adults over age 50 in the US, with the number increasing as the baby boomers age.

I looked at the statistics on LTCfocus.orgto ascertain whether this trend toward increasing numbers of people with SMI in LTC is beginning. The data show the numbers of residents diagnosed with schizophrenia and bipolar disorder between the years of 2000 and 2016. In my state, New York, 6.45% of residents had those diagnoses in 2000; in 2016 it was 11.8%. In Pennsylvania, the numbers increased during that time period from 4.45% to 9.3%. California: 8.87% to 15%. Texas: 4.91% to 13.4%.

The pattern is clear.

As a complicating factor, the US healthcare system has distinguished between treatment for physical health and mental health. There are very few institutional or community resources that are able to care for people with both physical and mental health impairments. There is virtually nowhere to discharge residents without family support who need assistance for comorbid medical disorders and severe mental illness.

Thus we have a perfect storm of treatment failures for our aging severely mental ill population and one that’s likely become more critical as the number of aging SMI individuals increases due to demographic shifts.

Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave