Category: Resident care

Health-Related Language Cue Cards

Posted by Dr. El - December 4, 2009 - Communication, Customer service, Resident care, Tips for gifts, visits

In a staff meeting the other day, the social worker mentioned her new resident was having difficulty because he didn’t speak any English. It was arranged that the director of the Dietary Department would go up to act as translator.

“I know a website where you can get language cue cards with health-related words on them,” I told the team.
Following the meeting, the social worker and I went to the computer and pulled up the link from the “Products of Note” section of the sidebar in my blog: Eastern Health: Health-Related Language Cue Cards
“What language do you need?” I asked her, looking at a list of over 60 languages ranging from Italian, Spanish, and German to Ukranian, Farsi, Swahili, and Japanese.
“Punjabi.”
A few seconds later the pages printed out, and were at the 4th floor nursing station within the hour.
Each sheet contained pictures of important social and medical issues, with the English and Punjabi words for them below. The selection included “husband,” “wife,” “sit down,” “shower chair,” “diabetes,” “pain,” and “hospital.” Nestled between “audiologist” and “psychiatrist” was the Punjabi word for “psychologist.”

Something Good About Nursing Homes: A Nurse’s Story

Posted by Dr. El - November 23, 2009 - Resident care, Something Good About Nursing Homes
I’ve read Leslie Curtin’s story three times and it still makes me cry. Happy Thanksgiving everyone!
We had a man admitted status post CVA (after a stroke). He was never going to recover to the point where his wife could take him home since he was a 2 person assist to do anything and couldn’t really bear weight well. They were a lovely couple…had been married for 40 something years and clearly still adored each other. Every winter at this facility we had the Snowflake Ball. The residents would dress in gowns and suits…hair done, makeup on, be escorted to the ‘ball room’, listen to live music, have a special meal, and dance.
This man’s wife came in a beautiful gown. She watched some of the other residents dancing and said “I wish I could have just one more dance with my husband.” The social worker and I were standing there with her. We just looked at each other and without really discussing it, stood the man up so he could ‘dance’ with his wife. She was crying, he was crying, we were crying. It was such a little thing for us to do but it made such a huge difference for them.
I think things like this happen every day in facilities around the country but no one hears about them because they aren’t glamorous or exciting.
You can use my name or not as you see fit. As I tell my staff on a regular basis:
It’s not about you…it’s not about me. It’s about the people we take care of every day.

Creative Nursing Home Holidays

Posted by Dr. El - November 17, 2009 - Communication, Engaging with families, For Fun, Resident care, Uncategorized

The holidays can be a difficult time of year, especially for residents in nursing homes. Many residents once hosted family gatherings, or were regulars at a holiday event, but now their physical disability complicates their participation in familiar rituals. Last year I wrote a post on this topic from the residents’ point of view, ‘Twas the Week Before Christmas…. This year I’m hoping to gather creative ways family members have come together to celebrate the holidays with their loved ones, despite the challenges of physical limitations. Here I offer a few suggestions, and hope you’ll add your ideas and experiences to the Comments section below.
A few years ago, my Aunt Bevy wasn’t feeling well enough to join us for our annual family gathering, so my cousins and I stopped by with leftovers and a quiet chat after the festivities. I know she appreciated that visit, especially since it was the first time she’d ever missed our party.
Most residents would like to be at the home of a family member to celebrate the season, but once they’re in the nursing home, it’s not as simple as picking them up at the door. With some advance planning, the physicians can write out the home pass orders, and the nurses can gather the necessary medications and provide instructions so loved ones can spend a few hours with the family.
If the holidays will be spent in a home that’s not wheelchair accessible, the family could gather for a separate meal in an accessible restaurant, or some members could join the resident for dinner at the nursing home.
If a resident is on a special diet, such as puree, for example, a variety of pureed soups and puddings could be offered, as recommended by the dietary department.
I once knew a man who wasn’t able to eat and was on a tube feed. At Thanksgiving, he and his children gathered at the nursing home for a gratitude ceremony, sharing aloud the things they were grateful for that year, and the qualities they treasured in each other. It wasn’t the Thanksgiving everyone was used to, but they’d created a ritual that fit for their new circumstances.

Therapeutic Use of the Internet in Nursing Homes

Posted by Dr. El - October 20, 2009 - Boomers, Business Strategies, Communication, Customer service, Resident care, Resident education/Support groups, Technology

A recent study by the Phoenix Center looked at adults 55 and over, but not employed or in nursing homes, and found that Internet use decreased their level of depression by 20%. I’m not at all surprised by this, and I believe a similar decrease in depression levels would be observed in nursing home residents as well.

While residents are living together rather than isolated in their own homes, and therefore have more opportunities for socialization, there are still many people who don’t partake of the recreational activities offered for their enjoyment. Some residents never leave their rooms due to physical or psychological barriers, and some don’t like crowds. Other residents feel uncomfortable socializing because of the physical changes of illness, wish to pursue activities other than those available in the nursing home, or miss connecting with those outside the home. The Internet offers the opportunity for nursing home residents to transcend their physical illnesses, leave the boundaries of the facility, and connect with the world.
In an earlier post, I shared ways in which I use the Internet for therapeutic purposes, and I believe they’re worth repeating here:
1. Psychoeducation Regarding Illness:
Often residents are given diagnoses, but little information about them, leaving them confused or upset, which can result in noncompliance with medication and care. I search for a resident’s illness with them on the computer, and discuss the symptoms and treatment, which enhances cooperation with medical staff. Some residents are more receptive to information coming from a “neutral” source than from their own caregivers, and most residents appreciate a print-out of information they can refer to over time. Posting a list of illnesses and the Web addresses of important sites near the computer would facilitate this process (eg; The American Diabetes Association, the Amputee Coalition of America, etc).
2. Support Regarding Illness:
Most of the residents deal with their illnesses in isolation, when there are many avenues of support available to them on the Internet. Having the opportunity to “discuss” their concerns anonymously with peers can often be more effective than trying to generate a conversation between two or more residents at the nursing home, due to discomfort at revealing personal information. At strokenetwork.org, for example, stroke survivors can “meet” other survivors on-line and get information and emotional support, as can their caregivers. To find the appropriate support groups, enter the name of a particular illness and “support” into the browser window and look around from there. Another option: Look for a Yahoo group about the illness and sign up the resident after establishing a free email account through resources such as Yahoo or Google.
3. Connection with Family and Friends:
Why should residents have to limit themselves to family visits or phone calls when most of the rest of the country is communicating via email, Twitter, or a social networking site such as Facebook or MySpace? I’ve established email accounts for octogenarians to help them keep up with the grands, and a free Facebook page would accomplish the same thing with a bit more zing.
4. Reminiscence:
I once worked with a terminally ill 88-year old man who’d left Barbados in his thirties and had never realized his dream of seeing his country again. Imagine his expression as I entered “Barbados” into Google Images and up popped photos of the country he thought he’d never be able to see again. This intervention generated a flood of memories and a profound sense of relief and closure. Reminiscence could also be conducted in a group format, with connection to a large screen, so that residents should share with others information about their home countries or hometowns.
5. People Search:
One of my favorite things to do with residents on-line is to find their long-lost friends and relatives. For example, through the Internet white pages, I helped one extremely lonely and depressed resident find a friend with whom he lost touch sixty years ago. They are now enjoying an exchange of letters and photos, and my patient has something else upon which to focus besides his poor health and lack of visitors.
6. Fun & Miscellany:
Acting under the theory that doing something enjoyable will begin the upward spiral out of depression, I’ve occasionally brought a resident to the computer to listen to their kind of music (try shoutcast.com), to check out the latest fashions, or to see photos of famous movie stars (Google Images). Once a 97-year old Panamanian resident told me she’d felt unattractive all her life because she thought her lips were too big. “Oh, no,” I told her, “your lips are considered beautiful and the height of fashion.” She believed me after I clicked on Google Image photos of Angelina Jolie.
Do you have more therapeutic uses of the Internet? Please add them to the Comments section.

Pain Management for Nursing Home Residents

Posted by Dr. El - September 29, 2009 - Communication, Medication issues, Resident care

I read a post on McKnights.com last week that so distressed me I had to wait a week before I was ready to blog about it. The article, Nurses, Relatives Underestimate Pain in Nursing Home Residents, Study Finds, reports the results of a five-year study in the Netherlands that shows a tendency to underestimate pain, particularly in people with cognitive impairment. What got me as agitated as a dementia resident with undiagnosed pain is that I’ve been reading about these studies since I got into the field over a decade ago.

A quick Google search of “pain management” and “nursing homes” turns up page after page of information about the consistent lack of recognition and treatment of pain. On the first search results page is a 2001 Brown University study noting “woefully inadequate pain management.” Also on the first search results page are numerous studies suggesting ways to alleviate this problem (for example, tips from the End-of-Life Palliative Information Center and a 2002 National Institute of Health report).
On April 10, 2009, the Centers for Medicare and Medicaid Services (CMS) issued new quality of care guidelines for pain management. I’m hopeful this will help to change the culture of tolerating pain in the residents under our care.
The next headline I’d like to read is: Treatable Pain Virtually Eliminated Among Nursing Home Residents Worldwide

From McKnights: Communication problems stress caregivers of patients with Alzheimer’s

Posted by Dr. El - September 15, 2009 - Communication, Customer service, Dementia, Resident care
This article from McKnights.com suggests that a key factor in reducing staff stress and injuries during transfer is understanding each resident with dementia and tailoring your approach to the individual.

NY Times Article on a Brief Nursing Home Stay

Posted by Dr. El - August 24, 2009 - Anecdotes, Boomers, Customer service, Resident care

Here’s an interesting article on a brief nursing home stay by a medical student as part of her training.

Experiencing Life, Briefly, Inside a Nursing Home

By Katie Zezima

Published: August 23, 2009

MAMARONECK, N.Y. — For 10 days in June, Kristen Murphy chose to live somewhere she and many others fear: a nursing home.

Ms. Murphy, who is in perfect health, had to learn the best way to navigate a wheelchair around her small room, endure the humiliation that comes with being helped in the bathroom, try to sleep through night checks and become attuned to the emotions of her fellow residents.
And Ms. Murphy, 38, had to explain to friends, family and fellow patients why she was there.
Ms. Murphy, a medical student at the University of New England in Biddeford, Me., who is interested in geriatric medicine, came to New York for a novel program that allowed her to experience life as a nursing home patient.

To read the full article, click on the link below:

Interview with Father Bartolemeu Dias, CNA

Posted by Dr. El - July 28, 2009 - Inspiration, Resident care


Father Bart is a thoughtful, kind, and spiritual man who worked not only as a nursing home chaplain, but trained as a Certified Nursing Assistant prior to his four years in long term care. He graciously consented to be interviewed for my blog, despite having moved on to other pursuits. What follows is an intimate and touching discussion of his experience at the Cabrini Center for Nursing and Rehabilitation, a Christian facility in Manhattan, NY serving people of all faiths.


Why did you decide to work in a nursing home?

I decided to work in a Nursing Home rather than in a Hospital, because in the Nursing Home population both the patients as well as the Staff are more stable. I knew this factor would give time for people to come to know me as well as for me to come to know the people, and to have a better follow-up, day by day. By nature, I am a slow man. I would feel completely lost working with a constantly changing population.

What did you like about working in nursing homes?

I shall speak only of my experience at Cabrini Nursing Home, because that’s the only place where I have worked and that too only for four years. Therefore, with due respect given and allowance made to all kinds of human limitations, I must say that at Cabrini Nursing Home I came to appreciate the dedication of the CNAs as well as the rest of the Staff.

What didn’t you like?

With a distance of one year I would say that what I did not like there is part of my own inability and lack of skill to embrace the difference, that is, my inability to accept a way of thinking and doing things, which is different from mine. In fact, this is a constant challenge I carry within me.

Why did you decide to train as a CNA? How do you think your training affected your perspective?

I am a member of a Roman Catholic Religious Order, called “The Little Brothers”. We live mixed among common, ordinary people, earning our bread through manual work, sharing their daily life, their joys and sorrows, and participating in their festivals and celebrations, like Jesus in Nazareth. As a Little Brother I learned carpentry and worked as a carpenter in India for eighteen years.

Called by my Religious Order to New York, I was given the work to take care of the showers at the Holy Name Center for Homeless Men on the Bowery. So, for nine years, 5 days a week, every morning I welcomed Homeless Men at the Showers. In the afternoons, when all had left, I would clean the place, the Showers, etc, wash the towels and keep everything ready for the next morning.

After nine years, I felt it was time for a change. I had seen many of my Brothers in the Order working as Nursing Assistants and I had always wanted to learn that skill. Moreover, I had recently followed six months of psychotherapy as part of my personal human growth, mainly to learn how I could handle a deeply seated feeling of dissatisfaction and insecurity I carry within me. During those sessions I became aware that, as a grown up man, the path to manage those feelings, in short, to take care of myself, was to take of others. “To nurture” was the catch word my fellow worker at the Holy Name Center, David Batista, would use to describe this skill. David would say that anything you do with love is “nurturing,” whether it is washing the car or cleaning the windows. From him I learned that “nurturing yourself and nurturing others” is the same skill: It is to be a nurse to yourself as well as to others!

So, it was clear to me that I wanted to train as a CNA. The course itself lasted only a month. I was impressed to see how well done this course was, especially how it touched every aspect of human life, with great importance being given to the spiritual dimension.

During the gap of two months between the academic course and the State Exam we were to learn practice as a CNA. I was glad when Cabrini Nursing Home accepted me as an apprentice/volunteer CNA. I had chosen Cabrini because it was only five minutes walking distance from the place where I lived on the Lower East Side, NY.

After the Exam, when I got my Certificate as a Nursing Assistant, I approached Cabrini Nursing Home to ask to work there as a CNA. The Administrator said they needed me as a Chaplain/Priest. I said “yes” on condition that I may be allowed to use my skills as a CNA. I was thrilled when the Administrator replied: “so much the better.”

That is how I worked at Cabrini NH, without the people, I mean the visitors and the Staff, knowing or distinguishing in me, the Priest and the CNA, especially during the first two years. As to the Residents, I always introduced myself as a Chaplain/Priest. The fact that I combined my skills of a CNA to my work as Chaplain enriched immensely my relations both with the Residents and their families as well as the rest of the Staff. The fact that I was a CNA made me understand the Residents’ suffering better.

One of the things which has touched me the most, and which I would call “the spirituality of a Resident of a NH” is the following: One of the things which those of us who are not in a NH find very difficult to handle in daily life is to know to wait. We find it difficult to wait for the Bus, for the Train, for a Doctor’s appointment. We get upset when something unpleasant happens, when our Flight is cancelled, when we get stranded…, etc. Now, that is precisely what a Resident of a NH is going through all the time from morning to evening. He/she is dependent on others, family, Nurses, CNAs… He/she is waiting for the CNA to come to dress them up, to serve them the food, to help them with the toilet needs, to give them a bath, to take them to go to see the Doctor, etc. It is endless. I have tried to look at the Residents at Cabrini with deep respect and sympathy and I have tried to learn from them, and I’m still trying…

Is there anything you’d like people to know about the CNAs job?

CNA’s job is tough/stressful and a very sensitive one too. The CNAs are in fact the backbone of a Nursing Home. They are those who are the closest to the Residents, day in and day out, attending to their most basic human needs. The Nurses depend almost entirely on them. One of the teachers of the CNA course I took said: “It is the CNAs who make or break the Nurse.”

I would like the family members of the Residents to be more compassionate toward the CNAs. But more than that I hope the CNAs themselves learn to be compassionate toward themselves, by learning to do what they can, and to be happy to do what they can.

What changes would you like to see in the nursing home environment?

According to me, the Residents of a Nursing Home live a particular type of spiritual poverty, which touches their self-esteem and sense of human dignity. Almost all of them have had a professional life in which they were proficient. Being admitted into a Nursing Home it is like having lost almost everything: good health, their home, their family; and not being able to be in charge of their life and money, and the humility of becoming dependent on others. “No one is a happy camper in a Nursing Home” I would say, quoting once again my CNA course teacher.

On one hand one can ask what is the alternative to a Nursing Home. All things and aspects being taken into consideration one concludes that most of the time the family members do not have much choice. That is why all those who are involved in the care must do whatever they can not to make it more painful than it already is to their elderly/infirm family member.

During my four years at Cabrini N. H. I’ve observed that in general those Residents who are the happiest are those who receive frequent and regular family visits, especially from children. So, I’ve been asking myself how family members could become more involved in the care given to the Nursing Home Residents and at the same time how to avoid anything which would make the work of the CNAs and of the Nurses more stressful. I am very much aware that to strike the right balance is not always easy. But the goal would be “how to make a Nursing Home a real home away from home”. Our natural human tendency is to expect the “world and heaven” from others, that is, from those who take care of us. But no one is able to give the “world nor heaven” to oneself, let alone to others. Yet “to do what we can” is and remains the golden rule. Well, I think I’d better stop there, because I’m beginning to talk generalities…

Do you think a nursing home that isn’t run by a religious organization, but has a full-time (or even part-time) religious staff member can achieve some of the results of a religiously run organization?

Yes, I think so. All that is required is an integral human training of the Staff.

What do you mean by that?

Once again I’m going to be personal. It is just as you said of yourself: “I’m not religiously trained in any religion.” I believe we do not need to be trained in any particular religion. Because true religion is genuine love, which is solidarity with others for being human, nay for being part of the Creation. Love is not words, it is “caring,” “nurturing,” “being a nurse to yourself,” and “being a nurse to others,” without expecting anything in return. I think it requires tough discipline and a sustained practice in order to constantly battle with our natural narcissistic tendency which we take for granted as if it were a skill required for our survival. That is why I like your approach seeking to create “a nurturing and a psychologically healthy environment,” and I am entirely with you. I respect the “business aspect” of health care, just like in everything. As long as it is not a license to greed. Obviously we need to pay the rent, buy food, etc.

What I mean by an integral human training is: “a sound training appropriate to the respective task the Staff is required to perform; a sound training to being compassionate to one’s own self and to others; a basic knowledge of our human nature.” I suppose that a religious organization seeks to accomplish the above as part of their mission. But why wouldn’t every NH/Hospital/ School, etc want to conduct themselves in the same way? Since the goal is the same–the means should be similar too — whether such humanitarian institutions are run by a religious organization or not.

In conclusion, I would like to say how much I enjoyed my work at Cabrini Nursing Home. I have learned a lot of things and I’ve improved my skills as a “nurturer,” in everything I did, even when taking care of the plants in the Chapel. Because the goal of the nurturer is to handle all life with care from birth to its natural death. I’ve improved my skills, and acquired new ones, learning from fellow workers like you, Dr Eleanor. Your job was a very sensitive job, helping the Residents to handle their present situation with compassion. Also I remember the session you gave to the Staff in which you reminded each one of the very important task we have in life: “not to wait till we get old and infirm to sort out things we feel uncomfortable with in our life.” You see, I registered that very well.

May God fill you with great peace and joy for the work you are doing in every field.

Affectionately,
Father Bart

Helping Mentally Ill Nursing Home Residents

Posted by Dr. El - July 14, 2009 - Business Strategies, Common Nursing Home Problems and How Psychologists Can Solve Them, Communication, Depression/Mental illness/Substance Abuse, Resident care, Role of psychologists

The July 2009 report, Trends in Mental Health Admissions to Nursing Homes, 1999 – 2005 notes that “the proportion of nursing home residents with mental illness, in particular depression, has overtaken the proportion of those with dementia”. According to a July 1, 2009 article by Liza Berger in McKnights.com, “younger mentally ill people now account for nearly 10% of the nation’s nearly 1.4 million nursing home residents”. While there is discussion of more preferable housing options for these residents, here are some suggestions to help those currently in long term care. As always, if there’s something I’ve missed, please add it to the Comments section.

1. Collect as much information as possible prior to admission about the psychiatric history and the medications which stabilize the individual.

2. Upon admission, refer the resident to the psychiatrist to assess mental status, review medications, and to establish a relationship. Mentally ill residents need to feel there are people in the nursing home looking after their mental health care as well as their physical care.

3. Upon admission, refer the resident to the psychologist, who can offer additional mental health support and monitoring. It’s better to refer someone before problems arise than to wait until negative behaviors and conflicts have been established. For more on this, see my earlier post, The Critical Period in Nursing Home Placement.

4. The social worker, as the most consistently available member of the mental health part of the treatment team, can act as the liaison between the psychiatrist, psychologist, resident, family, and the rest of the nursing home team, helping to share information.

5. Train the staff, especially the CNAs and nurses, to be familiar with the signs and symptoms of mental health problems.

6. Add the element of “behavioral rounds” to the change of shift report, noting any changes in behavior. In the psychiatric hospital, we did it very quickly, running down the names of the patients on the unit, speaking up if any unusual behavior occurred. For example, when the CNA-equivalent on the psychiatric team reported she’d seen a man with Bipolar Disorder laughing by himself in the hallway, the psychiatrist immediately increased his meds, recognizing the early signs of a manic episode. Early detection is particularly important because the lag time between referral for and completion of a psychiatric consult can be substantial.

7. Refer unstable or aggressive residents out to the psychiatric hospital as soon as possible. Doing so sends the message to other residents, staff, and visitors that their emotional and physical health are important, and relieves them of the anxiety of living or working with a resident who might be dangerous to themselves or someone else. It also provides the limit-setting such a resident requires for their own well-being.

8. Establish a relationship with a psychiatric hospital that’s familiar with the needs of older adults and provides adequate stabilization. For example, one nursing home changed the psych hospital they used after a paranoid schizophrenic resident in her 80s returned from a hospitalization still actively psychotic, with a baby doll, reflecting the hospital’s view of the elderly.

9. If possible, use the resident and family as resources. Knowledgeable residents and family members will be able to tell the team what medications have been successful in the past, and what proved troublesome.

10. When the right combination of medications is found, post this prominently in the chart and educate the resident and family so they have the information for future use.

11. If there are a group of residents with a psychiatric history who are functioning relatively well physically, it can be beneficial to provide them with a well-monitored space for group activities such as dominoes and card games which they can initiate without staff intervention. Training the staff monitors to work with groups of mentally ill residents will make such programs more successful.

12. Consider providing access to support groups such as Alcoholics Anonymous, either on-campus or in the community. Many mentally ill residents have a comorbid substance abuse history due to attempts at self-medicating. Such groups will provide emotional support and skills for living.

13. The social worker and psychologist can prepare appropriate residents for living in the community in a less restrictive, but still supportive, environment such as an adult home.

Nursing Home Tips for Residents, by Residents

Posted by Dr. El - June 4, 2009 - Resident care, Resident education/Support groups

I asked some experienced nursing home residents if they had any advice they’d like to share with residents who were just arriving, in order to make their stay more pleasant. I was surprised by the diversity of their responses and the speed with which they gave them. Please add your suggestions to the comments section.

Find at least one person you trust to confide in

Attend recreational activities

Get a newspaper subscription and crossword puzzle books

Read the bible and pray a lot

Know your medication so you can double check what they’re giving you

Be friendly and polite

Make your room your own by decorating

Know that you’re not alone in thinking “I never thought I’d be in a place like this”

Read a lot of books

Accept where you are and remember, there are worse places you could be

Be as independent as possible

Don’t be afraid to try new recreational activities, because you might find something you really enjoy

Try to bring activities from your home life into your new life in the nursing home. For example, if you used to garden, bring plants into your room. If you used to do needlework, continue to do it.