Category: McKnight’s Long-Term Care News

The tumult of turnover

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

The tumult of turnover

I once rode down a crowded afternoon elevator with the CEO of a managed care company. “It must be 5:01,” he commented wryly. I heard a measure of scorn for his employees’ lack of dedication to the job. What I saw was a group of people fleeing from utterly uninspiring and unappreciated work.

Similarly, in long-term care facilities with high staff turnover, some may see an absence of commitment on the part of workers, while others recognize that there’s something wrong with the job and the way employees are being treated. If workers are fleeing for the private sector, it’s not because they have an intense desire to work at Burger King.

Managers are no doubt familiar with many ramifications of turnover, such as the time and expense of finding and training new hires, the overtime costs for filling in shifts and the need to engage expensive agency workers. It’s also recognized that staff become demoralized in a high-turnover environment and that the quality of care can suffer — two points worth considering in more depth.

When key employees depart — such as nursing supervisors, department heads and nurses — direct care staff may be hesitant to bring problems to new workers just settling in to their jobs. Without the ease that develops between team members over time, important information may not be relayed, glitches in the system aren’t identified and resolved, and problems can fester and multiply.

When staff retention is low, workers become burned out on meeting new team members. They don’t want to put in energy toward welcoming newbies because they know the likelihood is that the individual isn’t going to stick around. This exacerbates the problem because a new worker who doesn’t feel welcomed is less likely to remain with the job.

The impact on residents is profound. Residents are in a vulnerable position, reliant on others for their most personal needs. It’s difficult for them to adjust to being assisted with toileting and bathing by a familiar person, but an unpredictable rotation of strangers who are new to the work adds another level of stress to their lives. For residents with dementia, expect an increase in distress — and the kinds of behaviors that make new hires less likely to remain on the job.

Turnover begets more turnover.

For the entire article, visit: The tumult of turnover

Dr. El’s Theory of Angry Activities

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

Dr. El’s Theory of Angry Activities

“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.

For the entire article, visit:

Dr. El’s Theory of Angry Activities

Vacation envy, or ‘How to get your groove back’

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

Vacation envy, or ‘How to get your groove back’

Perhaps, like me, you’ve recently had time off from work but the only break on the near horizon is a measly midweek Independence Day.

Or maybe, like a coworker of mine, you’ve scheduled your summer vacation for the last week of August and you’re holding down the fort for your coworkers in the middle of a heat wave, watching others return to work tan, energized and eager to show off their vacation photos.

Or possibly you’re just plain tired, exhibiting some of the symptoms below:

1.  Wondering if the work you do really makes a difference.

2.  Feeling overwhelmed by regulatory requirements.

3.  Noticing every unfilled sanitizer dispenser and every chip in the wood veneer furniture.

4.  Wanting to buy gifts for all the elders. (This is both a sign of and a contributor to fatigue)

5.  Considering lying down on one of the resident’s beds for an afternoon nap.

If you recognize any of these signs in yourself, it’s wise to take note and to take steps toward self-care. Our work is important and the attitude with which we complete our tasks matters. Especially in jobs where we care for others, we need to “fill the well,” as the saying goes, because it’s impossible to “pour from an empty cup.”

How to get your groove back

If your vacation break is behind you, or so far ahead that you wonder how you’re going to make it, try these ideas to re-energize and add zip to your workday.

1.  Complete your paperwork in a quiet corner of the nursing home patio.

2.  Take up a new hobby or rekindle an interest in an old one. Tennis, anyone?

3.  Take a mental health day, morning, or afternoon. For added mileage, don’t tell anyone at all.

For the entire article, visit:

Vacation envy, or ‘How to get your groove back’

Suicide prevention in the workplace: What employers need to know

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

Suicide prevention in the workplace: What employers need to know

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.

I’ve written about suicide prevention in older adults and protocols for managing suicidal residents before. This column focuses on what organizations can do to address employee suicide.

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.

For the entire article, visit:

Suicide prevention in the workplace: What employers need to know

Enhancing organizational communication improves outcomes, reduces adverse incidents

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

Enhancing organizational communication improves outcomes, reduces adverse incidents

McKnight’s Long-Term Care News frequently notes stories about rogue employees engaging in illegal and disturbing behavior and then trying to cover it up after the fact.

There are regular reports about intra-organizational systems that fail, leading to wrongful death lawsuits and other problems, such as this one about a resident who died from scabies.

Occasionally there’s an article about a whistleblower alerting the authorities about a questionable practice, resulting in repercussions for the company.

It’s very likely that there were employees who noticed that things were going awry before these stories became stories.

I know I’m not the only one who has observed that in some facilities, staff reports of potential problems are met with appreciation for the alert before rectifying the situation, while in other nursing homes, information is so often ignored that it is no longer reported. These vast differences in the culture and communication style of organizations directly impact health outcomes.

In a New York Times article last week, “A More Egalitarian Hospital Culture Is Better for Everyone,” author Pauline W. Chen, M.D. detailed efforts to alter interactions between hospital staff members, moving from an authoritarian style to a more egalitarian approach.

In authoritarian hospital cultures — those with a “do as I say” management strategy — nurses feel powerless to affect change. Patients fare worse in authoritarian environments than in egalitarian hospitals where nurses are regularly asked for input and senior management staff meet consistently with clinicians.

The article describes a program called Leadership Saves Lives, which created significant cultural changes in a relatively short time frame and improved clinical outcomes. The effort involved “guiding coalitions,” with the more successful coalitions having more diverse membership, including participants across departments as well as frontline, mid-level and top leadership and administrative staff.

Effective groups were able to elicit authentic contributions from members, who felt that their perspective was welcomed and valuable, and they found ways to handle conflict, fatigue and motivation over time.

While this particular study focused on hospitals, long-term care — with its similar interdisciplinary team approach and fragile population — might take note. Authoritarian, top-down communication makes it less likely that workers will notify supervisors about practices that could negatively affect the health of residents and could potentially lead to litigation and unfavorable press.

Teachable moments

While there’s a temptation to blame rogue workers for their mishandling of an event (and to feel relief that the situation happened elsewhere), we’d be better off viewing these events as teachable moments for any organization.

For the entire article, visit:

Enhancing organizational communication improves outcomes, reduces adverse incidents

Discussion forum of multicolored wooden toy figures on white background

To reduce burnout and turnover, improve family-staff relationships

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

To reduce burnout and turnover, improve family-staff relationships

Earlier this month, I took some much-needed time off to go on a cruise. I came home to a LinkedIn notification about “The big cost of not taking vacation,” reflecting on a CNN article regarding the vast number of vacation days forfeited by Americans. The author notes that people who travel tend to be happier with their jobs and companies than those who don’t.

It got me thinking (and researching) more about burnout and long-term care staffing problems. Certainly one piece of the puzzle is taking scheduled time off in order to refresh and gain perspective.

As I’ve noted in the past, there are many tactics employers can use to decrease burnout and turnover. In The keys to reducing turnover in LTC, I outlined the causes of the alarming rate of staff turnover in LTC, which can range from 55% to 75% for nurses and up to 100% for aides.

Preventing burnout in long-term care addressed training, staff scheduling and other adjustments that have been shown to reduce turnover. In another piece, I focused on ways to make long-term care jobs appealing enough to compete with less stressful jobs in the same salary range.

In my recent perusal of the research, I came upon a study that looked at factors contributing to the levels of anxiety experienced by staff members. The study suggested that the two biggest contributors to staff anxiety were “guilt about the care offered” because it wasn’t up to the standards of the individual workers and the “poor quality of the relationship with the residents’ family.”

Many of the suggestions I’ve offered in the articles noted above can improve the quality of care, but I was intrigued by the notion that improving relationships with residents’ families could have a significant impact on the anxiety levels of workers and thereby reduce burnout and turnover.

For the entire article, visit:

To reduce burnout and turnover, improve family-staff relationships

The ticklish balancing act: Resident rights vs. care quality

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

The ticklish balancing act: Resident rights vs. care quality

You know the scenario: A resident wants to eat donuts, but it will send her blood sugar skyrocketing. The staff members aren’t sure whether to let her indulge as part of person-centered care or to insist on a sugar-free alternative so that they’re not out of compliance with her care plan.

A recent study by Parker et. al examined the staff-perceived conflicts between providing services that are consonant with resident-centered care and those that are in compliance with regulations and the rights of other residents, referred to in their research as “care quality.” They made recommendations based on their findings to ease these conflicts.

The research

They interviewed nursing home staff at 12 different Veterans Administration facilities, including senior leaders, middle managers and direct care staff, asking them questions about care such as, “Is resident-centered care implementation competing with other facility goals?”

All of the nursing homes found some level of conflict between resident-centered care and quality.

The three main areas of divergence were in 1) resident preferences versus medical care, such as issues around dietary compliance, 2) resident preferences and the rights or safety of others, such as someone disrobing in common areas, and 3) “limits on staff ability to respond, related to either time or regulations.”

The first type of conflict was the most common by far, with issues not only around dietary compliance, but also around situations such as when the resident wants to go outside to smoke but weather extremes make it physically unsafe, or residents who are in danger of falling but want to assume the risk and walk unaided.

The second area of friction was related to social or emotional health, such as roommate conflicts. Others related to concerns about physical health, such as when a resident with an infection wants to engage in activities that could put the health of others at risk.

A complicating factor in these instances was the need to explain these situations to family members who might feel that the limits being put on a loved one are not consonant with resident-centered care.

In the third category of conflict, staff members found it difficult to accommodate resident preferences when they were short-staffed, especially at mealtimes when there were multiple demands on their time.

The recommendations

The authors of the study made several recommendations to help minimize these conflicts in the approach to care.

•  Determine how each resident feels about the balance of quality of life versus long-term survival. Assess and document the risks involved in their choices and the efforts of team members to mitigate the risks. Helpful tools and examples can be found in this Ideas Institute document, “A Process for Care Planning for Resident Choice.” McKnight’s blogger The Real Nurse Jackie wrote more about the document here.

For the entire article, visit:

The ticklish balancing act: Resident rights vs. care quality

Why it’s impossible to maintain prior levels of care quality, and what to do about it

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

Why it’s impossible to maintain prior levels of care quality,

and what to do about it

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.

For the entire article, visit:

Why it’s impossible to maintain prior levels of care quality,

and what to do about it

The importance of leadership in creating good deaths in LTC

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

The importance of leadership in creating good deaths in LTC

For the entire article, visit:

The importance of leadership in creating good deaths in LTC

Aging Insider Article

Using technology to improve care, reduce costs

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

Using technology to improve care, reduce costs

At Maimonides Medical Center, 24 frail older adults were taught to use laptops so that they could manage their health information from home. The technology facilitated communication between patients and providers and improved the quality of life of participants.

The program was a collaboration between the Department of Geriatrics at Maimonides and the Older Adults Technology Services (OATS), who trained the elders and installed the laptops in their homes. I met with OATS founder Tom Kamber, Ph.D., to follow up on our conversation earlier this year and to hear more about how technology can play a role in reducing costs and improving the quality of care for nursing home residents.

Kamber was enthusiastic about the Maimonides program, noting that the elders, with an average age of 85, were able to use the devices to manage information, communicate with the care team and explore areas of interest.

Fun, he emphasized, is crucial to success.

The desire to connect with the grands on Facebook is a more powerful motivator to learn new skills than is tracking blood sugar levels.

For facilities, particularly those working in healthcare systems focused on providing care at the lowest cost (i.e. in the community or in skilled nursing rather than in the hospital), the ability to remain virtually connected provides a host of benefits. Patients remain within the network, medical issues can be tracked and health crises can be averted before needing expensive hospitalizations. Tailored health information can be offered effortlessly, such as sending out post-surgery information videos at a scheduled time. Patient and family satisfaction increases, as does that of care providers who can quickly answer questions via email rather than return lengthy phone calls at the end of a long workday.

From a mental health standpoint, the program is a winner. Residents and their families are typically anxious about discharge and how to manage once they’re home. A virtual system reduces anxiety because it allows for easy access to medical professionals, offers continuity of care and averts costly, stressful and frequently debilitating hospitalizations.

For the entire article, visit:

Using technology to improve care, reduce costs

Tom Kamber,PhD
Executive Director, OATS
Older Adults Technology Services