Stop Agitating the Residents & Start Engaging Your Staff (Episode 8)

January 17, 2018

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Darcy Grabenstein: Hello from SmartLinx Solutions! In today’s podcast, we’ll talk about how long-term care facilities can implement proven techniques used successfully for decades by mental health facilities. My guest today is Eleanor Feldman Barbera, Ph.D., a psychologist better known as Dr. El. She has worked in long-term care for over 20 years. Dr. El writes a regular column on McKnight’s Long-Term Care News, “The World According To Dr. El,” and is the author of The Savvy Resident’s Guide. She frequently lectures on subjects related to psychology, aging, and nursing homes. Dr. El also helps others use psychological insights to build teams and create relationships that lead to thriving people and facilities. We are so excited to announce that Dr. El will co-present a webinar with us on February 2nd, titled “How to Dramatically Boost Staff Performance Using Proven Psychology.” More on that later. Welcome, Dr. El.

Dr. Eleanor Barbera: Glad to be here.

DG: Before we jump into today’s topics, could you tell our listeners a little bit more about your work with the long-term care industry?

Dr. El: Sure. As you mentioned, I train staff and corporate audiences on insights that I’ve gained from, I guess I would call it, a fly-on-the-wall perspective of clinical work with elders and caregivers, and I’ve traveled around the country doing that. I’m very interested in transient aging healthcare and tech and how organizations can put those changes into place into ways that result in more effective teams and better care.

DG: Great. It’s obvious you’re definitely entrenched in long-term care. Using proven techniques to avoid agitating residents, it sounds like a great idea, but are they costly or time-consuming for facilities to actually implement?

Dr. El: I wouldn’t say that they are costly at all, but it certainly takes time and money to properly train the staff, but once you invest in your staff, that makes a huge dividend in staff retention and resident and family satisfaction, so it’s really the kind of training that makes it fun to work in long-term care, which is part of why people come to that kind of environment. They’re not doing it for the money. They’re doing it for the enjoyment, and if we can make it fun, it is well worthwhile.

DG: Sure. I’m going to jump the gun a little here and ask you about one of the actual techniques that you recommend, answering the call bell immediately. To me, it makes sense, but is it really doable, given the current staffing shortage? What’s your advice on how facilities can accomplish that?

Dr. El: Answering the call bell immediately is — throughout my years, it’s been one of the things that the residents have mentioned to me the most often. It’s a number one complaint, and it’s a number one complaint for good reason, because when residents come into the long-term care environment, they’re very anxious. They’re worried that they’re going to be taken care of, and it’s one of those things that, if you can answer the call bell right away, it can reduce their anxiety tremendously. A lot of time, residents will say to me, ‘I could have died waiting for that call bell,’ and sure, they might be calling because they want somebody to change the channel on the television, but they know that they could have also been calling because they were having trouble breathing, so it becomes a very important thing for them.

It’s also something that anybody who comes onto your units will notice right away. A family member’s going to notice right away if the call bell light is on, and nobody’s answering it, so it’s a very visible way to make a difference. Certainly, the other residents know if the lights are on, and it just really is a core issue that, if it’s properly addressed, can really make a difference in the tone of the whole unit and in the whole facility, so you can tell staff that they can answer the call bell, but they have competing responsibilities, so you need to help them accomplish them. Maybe you want a little more detail on how to do that.

DG: Sure.

Dr. El: Okay, well, for example, I worked in a place where there was one unit that was very chaotic. Its team members weren’t getting along so well. The aides were having arguments about who’s supposed to take care of which resident, and there was a nurse that they moved to that unit. Let’s call her Ms. Wilson, and she was a very calm person. She didn’t get into any kind of drama with the other team members, and she just used her call bell as changing the entire environment. What she would do is, if a resident pressed the call bell, she would use the overhead page. This is the way they had a system. She could sit at her desk, and she could answer the call bell from her desk and say, what do you need, right away to the residents. Then, she could either answer it, or she could direct a staff member to go and take care of the resident, and so she handled it in a very calm way and completely changed the tenor. If listeners can give the team members the tools to do this, maybe an over-the-bed communication system or a walkie-talkie. Whatever is getting in the way of your staff members doing this, that’s the time to have a conversation with them, not in a punitive way, but what’s going on? How can we help you get this to happen?

DG: That’s a great idea, and I have to tell you, my mother was in a long-term care facility, and I think that was one of the most disturbing things is when, not her, per se, but another resident would be screaming because no one was answering the call bell, so yes, it does agitate the residents.

Dr. El: Definitely.

DG: Another question I have is, do techniques vary by shift? What I mean is, are there different techniques used for day and night shifts, and how do they differ? I just read an article from the National Institute on Aging, talking about sundowning, and I’m sure you know, but I’ll just give our readers a quick definition. Restlessness, agitation, irritability, or confusion that can begin or worsen as daylight begins to fade, and of course, that’s just when the tired caregivers need a break, so could you talk a little bit about the different techniques for shifts?

Dr. El: Sure, absolutely. There’s different goals for different shifts. That’s one piece of it, and also the study that they were doing about the sundowning and the caregivers getting tired along with residents or the elders ― luckily, in most facilities, the tired caregivers go home in the afternoon, and then new, refreshed caregivers come in, and they’re there to help with the sundowning, but because there’s different shifts, there can be issues around communication, and there’s often a lack of training to help the staff reach the goals of the shift, so let me explain that a little bit more.

The goal of the day shift is really to get people up and dressed, to have them engage in meaningful activities, whether that’s recreation or getting to rehab, but the early shift, which is usually, say, 7-3, that’s what they’re trying to do. The evening shift that comes in the 3-11, the goal is really to help them wind down, to get them ready for sound sleep, and there’s ― I mean, I would say almost universally there’s a lack of training on sleep hygiene, which is something that, in the mental health world, we talk about a lot but not so much in the long-term care setting. There’s communication challenges that can worsen sundowning so, for example, someone who’s 89 could be woken up by the morning shift at 7:15. They could be out of bed. They could be sitting out in a wheelchair all day long, and then the evening shift doesn’t realize they’ve been up so long, and they don’t put them to bed until 9 p.m., so you can imagine the kind of distress anybody would have, let alone someone who has dementia or is prone to sundowning.

If you’d like, I can get into a little bit of some of the behavior management techniques, about how they might deal with that.

DG: Yeah, I think that’d be very valuable. Thanks.

Dr. El: OK, well, I think it’s important for all the shifts to address any kind of distress immediately rather than waiting until things escalate and also to pay attention to the triggers of the distress and find ways to eliminate them, or if you can’t eliminate them, at least reduce their impact. For example, sometimes the staff members are really busy, and they have a million things to do, and then some of the residents are maybe starting to get a little distressed, or you can tell that there’s an argument that’s beginning to develop between a couple of residents, so sometimes this staff won’t address it right away, because they’re trying to get other things done. It’s about training them for an ounce of prevention to recognize when two people are starting to get into it and to separate them or change the vibe on the unit, so that’s one thing in terms of training.

Then, we need to notice the triggers. For example, I was once working on a floor, and sometimes I would stay late to write some notes. I noticed that one lady was sundowning, and it was time for her shower. She would always get really upset and start literally just screaming so loud. Everybody on the whole floor was distressed, all the residents, all the staff. It was quite terrible, and what they wound up doing was, there was an intervention among the staff. Instead of trying to keep giving her a shower when she was distressed, they started to give her bed baths, and that eliminated the problem, but it’s those kinds of things, figuring out what’s going on and what can we do differently as a team to make things better.

DG: That makes sense. Thanks. Are there a few other easy to implement techniques that you could suggest, not necessarily related to day or night shift but just in general?

Dr. El: Sure. I think that, in terms of communication, we can make better use of the change of shift report so that, instead of just focusing on the medical things that are going on, we might be able to communicate if somebody’s distressed. Maybe something happened in the family. Maybe a family member’s away on vacation or something like that. Communicate that kind of information, or we might want to notice if somebody was up all night, they may be sleeping all day, and kind of address those kinds of things. Certainly, we can look at pain, because a lot of pain, when people are distressed, it’s because they’re in pain. Physical pain is notoriously under-treated in long-term care, so that might be something that we can do, and we could also do really, really easy things, like train the evening staff to talk quietly when they come in at night and help people sleep or turn out the lights after someone, help them get them and their roommate back to sleep more easily. If people are interested in other techniques, there’s ― this talk is based largely on a free download on my website, so they could go to My Better Nursing Home. There’s a whole bunch of different techniques, very easy to put into place.

DG: Great. Thank you. Dr. El, now I’d like to switch gears and focus not on the residents but on the staff, since that’s our focus at SmartLinx Solutions. Of course, any staff improvement is directly tied to quality care and positive outcomes, but, that said, it’s no secret that turnover is high in the long-term care industry, so how do you apply psychological principles to increase employee satisfaction and loyalty? I would assume it’s more than just a bigger paycheck, and what role does company culture play in all that?

Dr. El: It is certainly more than just a bigger paycheck, because I think we can all agree that nobody goes into this direct-care business to make money. It’s certainly not about that. I mean, people want a living wage, but they’re not doing it because they’re trying to get rich. They want to help people. They want to feel like they’re making a difference, and so certainly the kinds of things that I was talking about, investing in staff training so that they have the tools that they need to do a good job, is well worth it. If you don’t invest in your staff, because you don’t think they’re going to stick around, then you’re not giving them the tools to manage the job, and they’re not going to stick around, so you really need to put something out in the beginning to help bring people along.

I would say, psychologically, people want to feel like they belong, that they’re part of a mission and part of a team, and their opinion counts, so if you can engage people immediately and help them to feel like they’re welcome into your organization, that can make a really big difference. You might implement something like a mentorship program, where new employees work with more experienced staff, and that can really be on-the-job training. It can help the experienced staff show how much they’ve accomplished, so that can be great for them. Maybe they can get some additional perks for doing that, whether it’s an increase in income or special pizza lunches for mentors or a little supervising aide kind of badge. Those kinds of things can make a difference to people, and it can help the new employees stick around longer and know what to do and have somebody they can turn to for help, so that’s one way. Certainly, working on a mission that makes the people feel like they have a goal more than we’re trying to stay in business and make money. That’s not motivating. It might be motivating for the people in the administration, but it’s not necessarily motivating for the people who do direct care.

The other piece about their opinion counts, I would say the more that the corporate culture involves including the team in making decisions, the more people are going to feel like they’re part of the organization, so I can give you an example about that. Let’s say the company wants to start using ― moving from paper notes, and they want to use a computer to enter data, so they could just put the computer terminals in the halls and say, OK, this is how we’re doing it now, or they could have a little group of aides who work together to determine where’s the best place to put these terminals so that it fits with our workflow, and how are you going to set this up so it’s ergonomically correct, and it’s manageable? And that kind of information, first of all, it makes for better decisions, and also it helps for buy-in, so any kind of decision the organization can make that includes the staff can really make a big difference in how they feel about working there.

DG: All good points. Thank you, Dr. El, so much for sharing your insights with us today. To all our listeners, thank you for tuning in. For more information on Dr. El and her consulting services, as she mentioned before, visit If you’d like to learn about SmartLinx Solutions and our fully integrated suite of workforce management solutions, visit us online at As I mentioned, to register for a free webinar February 2nd with Dr. El, visit the Resources section of our website, and if you’re listening to a recording of this podcast after February 2nd, you also can access a recording of the webinar on on our Resources Hub. Thanks again, and have a great day.

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