One of the things that most brightens my workday is when I see long-term care residents hanging out together.
In particular, I’ve noticed two ladies who attend activities in tandem wearing dresses with hats and costume jewelry, a threesome of confused residents who sit near the nursing station laughing at jokes only they understand, and an African-American and a Caucasian octogenarian twosome who are amazed to be best friends since neither of them had a friend of the other race before.
Men gather for card games, guys group in the hallway offering wry observations on the behaviors of the staff and other residents, and rehab patients tell me how inspired they are by someone they meet lifting weights in physical therapy. Sometimes I’ll discover that the resident they mentioned is, in turn, inspired by them.
What long-term care offers, aside from medical help and safety, is the opportunity to connect with peers and to maintain a social life. One of our best selling points is the fact that folks can get to activities without needing a coat or umbrella. New residents are often surprised and reassured to learn that there are “transporters” who will bring them to and from daily recreation programs, all for free.
I waited outside the room until the rehab therapists finished talking to Jim, who’d been admitted to the nursing home the night before. I read over the basic info on his face sheet before my consult. Jim was an 87-year old widower with a long list of diagnoses, some very serious.
After a moment, the rehab people left and I sat across from him and introduced myself and explained my role as the psychologist.
“How are you handling all of this stress?” I asked.
“I’m dying,” he replied.
“You don’t think you’ve got much time left?”
“No.”
“Does that upset you?”
“No, not particularly.”
He seemed quite calm.
“Are you sleeping okay? Eating okay?” I proceeded to ask him all the questions I’m supposed to ask patients I meet for the first time. “What kind of work did you do?”
He quietly answered them all. After a while there was a knock on the door and his physician poked her head into the room. “Just give me a minute. I’ll finish up,” I assured her, and turned back to Jim.
“It’s one of us right after the other, isn’t it?” I commented. “Let’s stop here today and I’ll come back next week to see how you’re doing.”
He gave me a funny look and half-shrugged. The doctor knocked again and I rose to leave.
It wasn’t until I returned to work the following week, when I learned Jim had died, that I realized his look meant, “I told you. I’m dying. I won’t be here next week.”
In hindsight, I wished I’d asked Jim more specifically what he meant when he said he was dying. People sometimes make remarks like that to me in their first few days in the nursing home without meaning that they’re in the active dying process. If I’d realized I wouldn’t have more time with Jim, I would have abandoned my standard questions and focused more on being present with him.
I was even more distressed that Jim had spent his last day fielding interviews from well-meaning staff members determined to provide good care. He was patient and kind about it. I’m guessing he was a really pleasant man, maybe too nice for his own good. That might have been something we could have worked on in psychotherapy.
If I knew I was dying, I wouldn’t want to spend my last day answering the questions of strangers trying to provide services I knew I wouldn’t be around to receive. I hope I’d be more assertive than Jim about refusing care, but there must be a way to offer a better experience for a dying person than having to rely on their level of assertiveness when ill and faced with medical routines. Perhaps we could establish a “last day” protocol.
Last week a nurse, aide and police chief were killed at an Ohio nursing home, along with the gunman, who died of a self-inflicted gunshot wound. While it’s impossible to prevent all tragic events, especially those involving an armed assailant entering the building despite an order of protection against him, there are ways to reduce the likelihood of workplace violence.
According to a 2014 Scientific American article, “Health-care workers experience the most nonfatal workplace violence compared to other professions by a wide margin, with attacks on them accounting for almost 70 percent of all nonfatal workplace assaults causing days away from work in the U.S., according to data from the Bureau of Labor Statistics.”
The article goes on to discuss the institutional acceptance of violence against nurses, the lack of violence prevention training and the implication from management that the employees were responsible for the assaults against them.
While the Scientific American article focused on nurses in a hospital setting, a 2016 study of nursing staff in long-term care facilities finds that “65% of the participants had experienced workplace violence while 41% believed that management shows little or no concern for their safety.”
I’m reminded of the many times over the years that residents have hit, spit on and otherwise abused nursing staff, and a team meeting was convened or a resident transferred to the psych hospital only after assaulting the doctor. If we want to retain staff, we need to convey that the safety of each individual is important regardless of their stature within the organization.
We also might hypothesize that people who have grown up in homes without violence are unlikely to stay in positions where they feel endangered; similarly, the staff members who stay have some level of comfort with aggressive behavior, perhaps due to exposure to domestic violence as children. Research on the “cycle of violence” indicates that childhood exposure increases the likelihood of violent relationships as an adult.
If that hypothesis is true, it becomes even more crucial for the facility to set the standard that violence is not “normal” and that the safety of those in their community is paramount.
Last week during a talk at the Pennsylvania Department of Aging 2017 Ombudsman Conference, audience members told me that they’re having difficulty speaking to administrators and other senior staff when they visit the facilities. In fact, some people reported that the administrators close their office doors when they find out the ombudsman is in the building!
While I can imagine from an administrator’s point of view that an unexpected interruption from someone complaining about problems is not exactly a welcome visit, perhaps there’s a way to shift the relationship to mutual advantage.
In fact, ombudsmen may be able to use their resources to help you solve problems within your facility.
Their role
Long-term care ombudsmen act as advocates for residents to address problems and to facilitate quality care. According to The National Long-Term Care Ombudsman Resource Center, ombudsmen promote “the development of citizen organizations, family councils and resident councils.” Ombudsmen and the councils can identify areas of potential improvement and, if properly guided, can offer solutions and assistance.
Local ombudsman’s offices have, for example, sponsored training programs on culture change and invited facility staff free of charge. Ombudsmen have arranged trips for staff to visit nearby Green Houses and provided free staff training on various resident care matters.
Pennsylvania’s Ombudsman Program is very active in promoting resident participation. Their ombudsman-trained PEERs (Pennsylvania’s Empowered Expert Residents) focus on improving the quality of life for residents. PEER efforts include initiating activities in which elders have the opportunity to assist others, such as a program making blankets for the homeless. That would make a nice mention during the prospective resident tour, don’t you think?
Ombudsman contact tips
While it’s likely that your ombudsman will be sharing resident complaints with you, it’s better to hear about these problems from them than from a state surveyor. Consider the following methods to improve your working relationship and to enhance resident care:
Due to a series of unfortunate events, both of my previously independent parents were recently injured over the course of five weeks. In the past, I’d been the granddaughter, the niece and the daughter-in-law of someone in long-term care, but I’ve now taken on the very different role of daughter of a resident.
In between errands, trips to medical appointments and calls to the facility, I’ve been making mental notes of insights afforded me by my new perspective and that of my family members.
Here are some thoughts from someone who’s seen the long-term care world from both sides now:
• It’s worthwhile to have a pleasant and efficient receptionist. I don’t often call the facilities in which I work so it hasn’t affected me personally if the automated telephone system sends callers into a netherworld of options and hang-ups or if the receptionist is curt or bumbling.
As a family member, however, it’s tremendously reassuring to have a calm, competent individual answering questions and guiding me to the appropriate staff member.
• Visitor areas are scrutinized. While my general philosophy is that I’d much rather be in a place that focuses on emotional and physical comfort than on outward appearances, my visiting family members are definitely aware of disrepair, cleanliness levels and shabbiness.
Having enough of it at work, I tend to avoid drama in my entertainment choices unless it involves aliens or post-apocalyptic nonsense. My family and I are currently enjoying the creative spectacle of Project Runway “Teams” version from a few seasons ago. In it, the judges of the clothing design competition repeatedly make the point that “teams are only as strong as their weakest link.”
A significant part of the Project Runway teamwork challenges involve communication. Collaborators who take over the project and those don’t speak up can both get penalized by the judges. Similarly, teamwork within the long-term care setting heavily relies on communication. For the best healthcare outcomes, it’s essential for all team members to contribute their expertise.
An article in the American Psychological Association Monitor, however, suggests that people who feel powerful are more likely than those who don’t feel powerful to share “opinions that differed from the norm,” a important element of team interactions.
Further, the authors cite research that describes how “people who feel powerless are more likely to…behave in inhibited ways. People in positions of greater power, on the other hand, are more likely to…act in uninhibited ways.” A care team member who feels inhibited is less likely to speak up and contribute to a group discussion.
In the hierarchical world of LTC, administrators, nursing directors and medical directors have more perceived power than, say, charge nurses or recreation therapists, despite whatever layers of upper management and accountability exist.
In my conversations with aides and residents, there is consistent disagreement among them regarding who has the power. Aides will argue that the “Resident’s Bill of Rights” gives the residents control, while residents, waiting on aides for intimate care, feel that the aides are in charge. Both struggle to deal with the moods and behaviors of the other.
Family members can be considered a part of the team that wields power in the form of potential phone calls to senior staff, the ability to transfer their loved one to a different facility, a negative social media review or a lawsuit. At the same time, relatives are often overwhelmed by the new and unfamiliar situation and the shifting dynamics within their families and many feel powerless in relation to the staff members upon whom they depend for good care for their loved one.
The challenge for LTC is to empower all team members to overcome their “inhibitions,” so that they offer their expertise despite the imbalance of power and in perceptions of power.
Perhaps, like me, you’ve heard of Aging2.0 but hadn’t had the opportunity to attend one of their events. When I discovered that they were holding a pitch session a subway ride away from my home, I jumped at the chance to be there. I was curious to see if any of the startups were promoting products to benefit elders in long-term care.
Here’s what I learned:
What’s Aging2.0?
According to their website, “Aging2.0 is a global innovation network on a mission to accelerate innovation to improve the lives of older adults around the world.” Moving beyond the development of medical products for seniors, Aging2.0 seeks to facilitate collaborations between senior care providers and entrepreneurs to create products and services that can be integrated into their businesses.
The scene
The event was held at the modern, tech-oriented community space of SeniorPlanet.org in Manhattan. (The tagline for SeniorPlanet.org is “Aging with Attitude.” One of their recent articles is titled, “Is it time for #OscarsSoYoung?”)
The large, windowed, ground floor room on West 25th Street was filled with the animated clamor of innovators munching on crudité and discussing products to better the lives of elders. The youngest attendees appeared to be twenty-somethings and the oldest participant was octogenarian and aging activist Muriel Beach, Chief Elder Officer and a judge for the event.
The format
Each inventor had several minutes to pitch their product and take questions from the four judges, who also included the CEO of 1-800-Wheelchair Joseph Piekarski, HealthTech Angel Investor Sacha Levy, and AARP’s Director of Market Innovation Jeffrey Makowka.
Aging2.0’s host Crispin Baynes kept things moving along swiftly and explained that the winner of the event would receive cash, mentorship and an international spotlight, going on to pitch at Aging2.0’s inaugural Americas Summit in Toronto on June 21, 2017.
The inventions
Nine people pitched their products, which were designed to assist elders with a wide variety of challenges.
In “The LTC industry should be ashamed,” guest columnist Buffy Howard admonishes long-term care leadership because their treatment of nursing staff is leading caring professionals to leave the field.
Reduced funding, departing staff members, widespread uncertainty in the industry … even the most stalwart individuals might feel uneasy. I’ve postponed my earlier topic to consider what I could say as a psychologist to help.
Perhaps you’ve heard the tale about the boss who yells at the worker, who comes home and grouses at his wife, who is short-tempered with her child, who kicks the dog. Anxiety can spread like that too, from CEO to administrator to supervisor to charge nurse to aide to resident.
In order to better face whatever is ahead — and to avoid causing panic in those around us — we can make an effort to be serene and centered. Below are some tried and true calming techniques to help you remain levelheaded despite unnerving times.
Denise B. Scott, president of Drive Consulting, posted an intriguing story on LinkedIn the other day about a Scottish supermarket that partners with Alzheimer Scotland to help those with memory loss.
The workers are trained to understand how to help people with dementia, and the supermarket offers a “relaxed checkout lane” for seniors and others who might need a little extra time when paying for goods at the register.
On senior citizen discount day, the store posts a sign at the entry to the cashier’s line designating it as the “relaxed checkout lane,” allowing customers in a rush to go elsewhere. Those on the relaxed lane can check out slowly, without the pressure of worrying that someone behind them will get irritated.
The concept is so simple, easy and kind that I decided to ask my local supermarket if they’d join in.
Once again, McKnight’s will host its annual online expo, which is a chance to attend a conference without leaving your desk. Register for the conference in advance, and then log in to hear the talks, visit the vendors, and chat with the reps and attendees.
This year’s topics are:
PAYMENT: Medicare compliance update: Are you up to speed? March 14th, 10 a.m. ET
CAPITAL: Following the money in 2017 March 14th, 12 p.m. ET
QUALITY: Strategies for surviving the survey March 14th, 1:30 p.m. ET
WOUND CARE: Accident or Intentional? Assessing patient injuries in long-term care March 15th, 11:30 a.m. ET
TECHNOLOGY: Your data always tell you what to do…are you listening? March 15th, 1 p.m. ET
Once again, McKnight’s will host its annual online expo, which is a chance to attend a conference without leaving your desk. Register for the conference in advance, and then log in to hear the talks, visit the vendors, and chat with the reps and attendees.