Health is a large word. It embraces not the body only, but the mind and spirit as well… and not today's pain or pleasure alone, but the whole being and outlook of a man. ~ James H. West
Care facilities are not all the same and looks can be deceptive. As the old cliché goes, "you can't judge a book by its cover." In practice, some facilities that feel institutional and sterile are actually happy, healthy places to live. Other facilities may appear warm and inviting, welcoming people with art-lined walls and fresh flowers, but measure sub standard in quality of life for tenants.
In assessing a facility, quality of care and organization are as important as the environment. To evaluate a care facility requires a deep look. You need to look at the environment, the staff and administrator’s attitudes, resident expressions, meal and activity schedules. You need to see the full picture. You don't want be fooled by beautiful surroundings that only distract from the lack of quality care being provided.
Some of the questions to ask are straightforward: is good cognitive care implemented? Is there a positive, structured and organic flow of the organization? Is effective, top leadership setting examples that trickle down to all employees? Is there flexibility among staff and administration to be creative in approaches that encourage growth? And if not, why not?
One of the key elements to clinical care is providing good cognitive care. Research studies have shown time and again how good cognitive care lessens depression, anxiety, increases patient safety measures i.e. falls, improves care for those with delirium, stimulates neural development and improves overall health. To assess what kind of care is available, you can look for signs of depression or evaluate communication patterns. You can ask: Is staff effectively communicating and engaging with patients and residents? (That includes custodial, maintenance and kitchen staff).
Neuropsychiatrist, Frederick Schaerf, M.D., Ph.D., at the Neuropsychiatric Research Center of Southwest Florida states, “A good hospital system will not only focus on the physical ailments, but will include cognitive care to gain a broader scope of how a patient is really doing. For example: if a patient is given a tray of food and the plate isn’t touched, instead of the nurse coming in and taking the tray away, believing the patient isn’t hungry, there needs to be standards set in place. Most of the time, it’s not that the patient isn’t hungry, it’s that he lacks the motivation or cognitive ability to eat and needs assistance. Dementia, delirium, and/or depression may be the underlying factors needing to be addressed. It’s a safety concern that patients are not discharged too soon. Hospitals can not afford to keep having repeat patients.” Schaerf further explains, “Hospitals should start cognitive assessments at the time of admittance and reassess at discharge to assure a successful and safe transition to home. This would avoid the potential readmission caused by, for example, a delirious condition that interferes of a medical compliance.”
Another area to monitor is activities. Are therapeutic activity directors offering dignifying, meaningful activities that support quality of life and encourage mind growth? Is each day full of fluff, where every day is the same activity only disguised with different terminology? Are there an array of activities that match cognitive levels? Are they creative in their approaches? Do they offer art therapy or other expressive and recreational therapies? Are programs run by qualified professionals? Is the television constantly on, and what kind of programming is being displayed? What genre of music is playing overhead? Is there too much or not enough stimulation happening in the environment? How are staff interacting with patients, and in what tone of voice are they speaking to them in?
If I were a choosing a place, I'd look for something like a facility I recently encountered. A woman, 'Annette', with a background in spiritual and recreational therapy was interviewing for the role of Activity Director at a care facility. In the interview, the Director of Nurses (DON) asked Annette, "Why should I hire you?" Annette replied without hesitation, "Because next to you, the Activity Director is the most important person in this facility. I have the skills to ensure good care." Annette was offered the position.
The importance of good care can't be understated. Care facilities across the continuum have a responsibility to ensure residents are well taken care of in mind as well as body.
With good cognitive care, depression rates lower, chronic pain symptoms may ease; reliance on PRN’s (as needed medication) lower, and patients may develop a sense of identifying healthy leisure activities through dignified interactions, including the types of the activities being offered.
Another area of assessment is housekeeping. But a clean environment or a pretty one isn't enough of a test. What kind of people are the housekeepers? How broad is their role in the facility?
In my experience, one of the most underappreciated and underutilized staff are housekeepers. In good care environments their efforts can be seen, and are understood that housekeepers not only clean patient rooms, they interact with patients; become their friends. Because they are not a nurse trying to give medications or a physician prodding, residents will often be more trusting and open. Housekeepers can become allies and confidants. I've seen it firsthand.
An elderly woman was in a skilled nursing facility (SNF) in Texas. Despite the need, she began to refuse to go to physical therapy; saying they hurt her too much. She felt they pushed her harder than her limits would allow. Then the housekeeper came to clean up and she blew kisses at the woman who smiled and returned the gesture. "You’re my best friend,” said the woman, “you talk to me, take care of me, and you listen to me."
The nurse came in abruptly and quipped, “You need to get out of bed and go to your therapy. Are you going or not?” she asked impatiently. The woman wouldn’t look at her, nor would she answer her. In a huff the nurse saw me and said, “I tried,” and walked out. The housekeeper was picking up the bathroom trash and she said to the woman, "Mrs. You should go to therapy, it will help you get stronger. I care about you." The woman deeply sighed and miraculously got out of bed, "because you want me to go," she said, "and I know you care about me."
This woman’s story is just one of many examples of positive interactions that happen when care is good. In another SNF located in Monroeville, Alabama, they encourage housekeeping staff to attend the activity groups and work with residents.
It's successful on all accounts. Staff feel like they are a part of the team and residents benefit. There is no divide among staff and administration roles as all are accounted for in supporting patient health.
The same kind of positive attitude is important with nursing staff too. In the woman’s case, she didn't like many of the nurses because they didn't talk to her, they talked at her, or worse, talked among themselves as if she wasn't there. She would hear the CNA's (Certified Nursing Assistant) complaining about how much they got paid, or lamenting about a particular patient and his family member who'd been difficult to deal with.
The problem wasn't that the CNA's were upset, it was the venue they vented it in. Unfortunately, venting staff inappropriately clearing their frustrations is a common phenomenon. CNA's are grossly underpaid. They tend to provide the most care, work two and three other full-time jobs and sometimes lack adequate dementia training in their education. They're human and entitled to their frustrations but it is not acceptable to discuss such topics in front of patients. Good cognitive care, on both accounts, requires knowing (and observing) the right time and place for different discussions.
Having positive interaction, meaning and purpose is a part of maintaining an enriched life. Providing dignified substance in activities, and merely communicating by asking patients how they're feeling, what are they thinking about, where they're from, what they like to do, what positive attributes do they carry, a world of life begins to thrive that may be equally shared as patients may be interested in talking and learning about those taking care of them. A deeper appreciation for patients is often seen when staff are connected. When administrators build upon empathy and utilize all their resources, it's amazing what staff, family members and interns will do to step in and go above and beyond helping out.
When a patient's physical health is talked about, but the mental health is avoided, what happens to that person who is depressed, anxious or scared? They may relapse and find themselves back in the facility, dive deeper into despair, or worse, give up.
I recall when my grandmother was in a hospital and the nurse came in and said to her in a rushed, matter-of-fact tone, “Mrs. Duncan, lay down, I need to change your diaper.” She left the door wide open exposing my grandmother as people walked by, and were coming in and out of her room. My grandmother’s response broke my heart, “Go ahead, I have no dignity left.” As a professional working in geriatric mental health and Alzheimer’s research I tried to be understanding and sympathetic that the nurses were working challenging eight to ten hour shifts, sleep deprived and had twenty other patients to see in one day. As a granddaughter watching her grandmother be treated so poorly, I was furious. I spoke to the medical director and he said he would talk to his staff, but we both knew that wouldn’t be enough. I recommended they all get educated in communication strategies and how to best assess a patient’s mental health. I offered to provide such training. He did not take my offer, but assured me they would have an in-service. I advocated for on-going in-services with a qualified, compassionate professional.
My friends asked me if I was nervous for speaking up and wondered if the nurses would retaliate and treat my grandmother worse because they got into trouble. Unfortunately, many loved ones face this dilemma and usually keep quiet in fear of the same thoughts. But change will never happen if we do not advocate for our loved ones, ensuring that care is of quality, not only for them, but for ourselves in our time of need. Who to call upon: the Ombudsman, the facility’s patient rights advocate, the Coalition for Patients Rights or the National Patients Rights Association (NPRA), and in dementia cases, the Alzheimer’s Association, the Dementia Society of America or a community’s local Alzheimer’s organization, the media, and your local government. There is help to address the issues at hand, but for ourselves, we must take action if positive change is to be implemented.
Implementing effective communication may provide important clues into a patient’s cognition, and perhaps save a life in more ways than one. Without providing good cognitive care between physicians, staff and administrators, a care facility is not providing best clinical practices. It is very costly to run a facility, with expenses typically exceeding thousands of dollars a month just to maintain its overhead. When cognitive care is excluded, the costs escalate and a facility merely survives; no one is thriving.
The difference between mediocrity and excellence is often a matter of effort ~Diana Waring