Category: Resident care

I took the Holmes and Rahe Stress Scale and modified it based on working with nursing home residents. For example, the Social Readjustment Rating Scale (SRRS)  allots 65 points for a marital separation, but since moving away from one’s spouse to enter a facility isn’t a typical marital separation, I gave it 50 points. Nursing home residents aren’t technically imprisoned (63 points), but it is extremely confining, so I reduced that item to 50 points.

In my view, residents are not retired, but have started their jobs of working with the staff 24/7 in order to attend to the business of taking care of themselves, so I included many work-related items not usually considered the province of residents. This left me with the following items on the 43-item scale:

Marital Separation  (50)

Imprisonment  (50)

Personal Injury or Illness  (53)

Business Readjustment  (39)

Change in Financial State  (38)

Change to a Different Line of Work  (36)

Change in Responsibilities at Work  (29)

Change in Living Conditions  (25)

Revision of Personal Habits  (24)

Change in Working Hours or Conditions  (20)

Change in Residence  (20)

Change in Recreation  (19)

Change in Church Activities  (19)

Change in Social Activities  (18)

Change in Sleeping Habits  (16)

Change in Eating Habits  (15)

Grand Total: 471 points

471 points, on a scale that finds a high risk of illness at stress levels over 300 points.  On the updated SRRS, the total comes out much higher, with the person considered in a life crisis.

Upon admission to the nursing home, residents are required to see the dietician, dentist, social worker, and recreation therapist. A life crisis, and we have yet to require a psychological evaluation of the residents.  Referrals are currently haphazard, and based on the psychological-mindedness of the nursing home staff.

Readers who feel they, their residents, or their loved ones might benefit from the assistance of a psychologist in coping with the magnitude of these life changes can suggest a referral for evaluation for a particular individual (until regulations catch up with the need).

Complaint #3: The Patient Lift

I’ve worked on units where the moment the call bell goes off, the charge nurse immediately and calmly asks an aide to check on the room. The bell goes off, someone arrives. Simple customer service. This leads to a unit full of residents who feel confident their needs will be addressed in a timely fashion, and are therefore far less anxious. Staff training is a good way to change the nursing home culture on this issue, but each worker can take it upon themselves to make it their own personal policy even if the nursing home as a whole isn’t making it a priority.

• Therapeutic recreation reverses the downward spiral of depression. There’s a theory that when we’re depressed, we stop doing the things we enjoy, thus leading to more depression. In order to become less depressed, we need to engage in activities we used to find pleasurable, even if we don’t feel like it. Once we do something fun, it energizes us enough to take the next pleasant action, thus leading to an upward spiral out of depression.
• Structured days are happier days. I suppose there are people who flourish with nothing much to do, but in my experience, most people feel better when they have plans. Residents who sit in their rooms all day tend to ruminate on the negative. As the saying goes, “When I’m in my head, I’m in a bad neighborhood.” I encourage residents to find at least two activities each week to attend on a regular basis.
• Activities are more vital when all time is leisure time. Nursing home residents don’t have to go to work. They don’t have to cook, clean, pay bills, or take care of other chores. When life tasks no longer take up the bulk of the day, it’s essential to fill the time with something else constructive.
• Therapeutic recreation allows residents to continue or create new identities. Our identities as individuals tend to be based on the things we do or have accomplished. Who are we when we are no longer able to accomplish what we used to? Therapeutic recreation provides the opportunity for new experiences and helps residents find creative ways to continue old interests that might be challenging due to disabilities.
• Activities foster socialization with peers. Residents often believe there’s no one in the nursing home they can talk to. This myth is dispelled through recreational activities, especially those that encourage the residents to speak up, such as trivia or group reminiscence.
• Life needs purpose. Activities that allow residents the opportunity to contribute to society give purpose to life. Residents can raise money for a world-wide cause, join the resident council to improve their nursing home, or create a gift for a family member in their art class. Purpose can also be found in personal satisfaction such as besting a Wii bowling record or appreciating a musical performance.
• Apart from medical care, therapeutic recreation is the best reason to be in a nursing home. Residents receive essential healthcare in nursing homes, but it’s the recreation department that gives them the opportunity to create a new life.

She reached out with an unsteady arm. The phone wobbled in her grasp as she held it up to her ear.

“Hello?” She was silent for a moment, then scowled and slammed the phone onto the receiver.

“Who was that?” I asked, surprised by her sudden anger.

“I don’t know! It’s some machine! They keep bothering me. Want me to buy car insurance or some such nonsense. I haven’t owned a car in years!”

“You’re getting phone solicitations. That used to happen to me until I registered my phone with the National Do Not Call Registry. If you give me your phone number, I can sign you up too.”

“But I don’t know my phone number. I think I wrote it down somewhere.” She looked toward the stack of papers piled on her tray table.

“That’s okay,” I reassured her. “I’ll get it.” I called my mobile from her landline, capturing her number in my display, then dialed the toll-free registration number. One minute later, the process was complete. “There! We’re done. It’ll take about four weeks, but those calls will stop.”

Velma looked at me like I’d just worked a miracle.

“Really, it was nothing,” I told her, but one less annoyance for Velma meant a great deal.

National Do Not Call Registry: 1-888-382-1222

Recent psychology research* showed reduced levels of agitation in nursing home residents with dementia, some to the point of not being considered agitated at all.

This promising study used a structured yes/no list to find the types of activities the residents found pleasurable either now or in the past, such as listening to jazz music or spending time with family members. The researchers presented participants with paired choices of desirable objects, such as different colored balloons or fabric. They also examined the times and reasons the residents appeared to be agitated, such as an apparent need to “escape” during the busy change of shift.

One resident wandered and jiggled the doorknobs of the rooms of other residents when he was left alone. Giving him his preferred objects (jazz music on a CD walkman, purple fabric, etc) significantly reduced his agitation. The resident who became agitated during busy times needed to be presented with her preferred objects (a family photo album, a felt flower, etc) before she became agitated and difficult to engage, but she also showed a dramatic improvement in behavior.

While readers might not use all the elements of this study simultaneously, there are many aspects that can be incorporated into our daily routines.

For further information:

*Based on the research study, Applications of Preference Assessment Procedures in Depression and Agitation Management in Elders with Dementia, by Leilani Feliciano, PhD, Mary E. Steers, MA, Alexandra Elite-Marcandonatou, LCSW, Maura McLane, MA, and Patricia A. Areán, PhD, Clinical Gerontologist, 32:239-259, 2009.

As my in-laws know, meals are one of the most enjoyable aspects of life for many people, nursing home residents included, and it’s important not to neglect the social dimension even when the focus is on dietary needs.

Here are some things I’ve noticed make for a pleasant nursing home dining experience, plus others I hope to see:

An iatrogenic illness is one which results from health care treatment, and iatrogenic depression is typically a side effect of medication. I take a broader view of “treatment” and think of iatrogenic depression as a customer service failure. I see nursing home residents who have become depressed as a result of interactions with staff that left them feeling unimportant, and with nursing home systems that resulted in feelings of powerlessness. The good news is that this type of iatrogenic depression can be cured by training staff and adjusting systems to be accountable to the residents.

Without Accountability

Staff: “I’ll be right back.” (Never returns.)

Resident: feels neglected, invisible, possibly paranoid (why are they doing this to me?), angry, anger turns inward to depression

With Accountability

Staff: “I’ll be back in about ten minutes, after I finish up with someone down the hall.” Returns in about ten minutes.

Resident: knows how much of a wait to expect, which reduces anxiety; feels cared for and respected

Or, Staff: “I’m sorry about yesterday. I meant to come right back to you, but I had an emergency and didn’t remember until I was halfway home. Please accept my apology.”

Resident: will probably take some time to forgive and begin to trust again, but feels better having the situation acknowledged

Without Accountability

Resident Council Staff Representative/Leader: “Great suggestion. I’ll bring it up with the administration.” (The last the group hears about it.)

Residents: feel bringing up concerns is pointless, the resident council meaningless, and that their experiences aren’t valued

With Accountability

Resident Council Staff Representative/Leader: “The administration and I discussed the suggestion raised by the group at the last meeting, and we’re going to begin the project by taking this first small action.”

Residents: feel their recommendations and experiences are valued and that they’ll get their needs/wants met by a responsive organization; feel energized as a group

Or, Staff Rep: “The administration and I discussed last month’s suggestion, but there were some obstacles in the way. Let’s work as a group to think of ways in which we might overcome them and move forward with the project.”

Residents: feel respected and included in decision-making even though they might be disappointed their suggestion wasn’t immediately implemented.

Psychologists spend years examining the nuances of human interactions and are trained to deescalate situations like this, which happen every day, in the nursing home and out. While many nursing homes have psychologist consultants who work with the residents and provide an occasional hour-long staff training on communication skills, very few have psychologists on staff. A psychologist on staff at least part-time could provide intensive interpersonal training to reduce resident/staff conflict, increase resident, family, and staff satisfaction with the nursing home, reduce time spent on incidents, and increase the quality of care.