Nursing Home Social Workers Share Their Stories
The practice of social work in skilled nursing homes involves multiple skills, a wide breadth of knowledge, and extensive problem-solving abilities. New ideas, sharing information, and practice wisdom can be important in maintaining and developing new ways to work with residents, families, and staff.Over 30 years ago, a small group of dedicated social workers began an educational opportunity for colleagues in the field through the NASW- MA Chapter at the Annual Nursing Home Social Work Conference. Each year, papers written by nursing home social workers have been presented to the conference audience. It is our intent to post these wonderful “voices from the field” on this website.
The most recently posted paper is below. Past papers can be found in Archives by clicking that tab at the bottom of this page.
Elise Beaulieu, PhD, LICSW, Nursing Home Committee Chair
Committee members: Frank Baskin, LICSW, Joel Langsam, LICSW, Julie Sahlins, LICSW, and
Toby Savitt, MSW.
Caring Hearts at Work
By Julie Sahlins, LICSW
I have worked in nursing homes for many years now and have always been comfortable in them in some way. I never chose this line of work but somehow I gravitated to it. I love the elderly, their gentleness, their wisdom, their humor, and their amazing stories they have to tell. And yet working in nursing homes has often been painful for many reasons. For one thing, I feel helpless at the sight of elderly residents parked haplessly around the nursing station, as if waiting for a bus. The residents are often trying loudly to gain some response from the harried staff, whose attention is being pulled in a multitude of directions at once, and eliciting mainly rebukes. Of course, the reality is that the busy staff would probably like to meet the residents’ emotional needs, but as any social worker who listens to their complaints and those of families can tell you, the nurses and CNAs can’t always even meet the residents’ physical care needs, in part due to large patient-staff ratios, and the nurses’ huge documentation requirements. All of this stress can lead to a dysfunctional working environment, or nursing home culture, where staff relations suffer, and conflict and discord abound.
I have worked in several homes where the dysfunction was so great that I as the social worker felt scapegoated and blamed whenever something went wrong. When I first started out, it was hard for me to figure out why this was so, but over the years of watching, listening, making mistakes and learning from them, I have begun to appreciate some of the universal dynamics of nursing homes, and how the various departments compete and conflict with each other, each one simply trying to get its tasks done. But all appear at the expense of the holistic needs of the residents.
My contention is that it IS possible for social workers to create a caring community in the nursing home that addresses both residents’ physical and psychosocial needs. In my current home, I have developed a program that, while not solving all the problems, has gone a long way towards changing the way nursing home staff interact with each other and with the residents. It is called “Caring Hearts at Work”. This is the story of the Caring Hearts program.
Basically, drawing on my skills and experience, I designed the Caring Hearts Program to do the following:
- To develop a caring community at Sunny Valley nursing Home that would better meet the holistic needs of the residents.
- To develop a way to integrate facility goals with the practice of social work.
- To meet the psychosocial needs of staff by increasing morale through job satisfaction.
This would include the beneficial effect of the development of an individual caring relationship with a resident. It would also involve the promotion of a well-functioning interdisciplinary team through mutual support and positive mutual reinforcement of caring behavior.
In order to understand more about how I formulated these needs, and how I chose this particular program to address them, I will describe a little bit of the history of the nursing home and its culture.
Sunny Valley is a medium-size (82-bed) facility. It is about 8 years old. The building is very solid and clean. What makes the facility special, and in my mind is its greatest asset is that it is family owned, and not part of a corporate chain, a condition that sometimes promotes an impersonal, institutional atmosphere. The owner is also the administrator, and she is personally involved and invested in the quality of care that the nursing home provides. Still, as good as the conditions were at Sunny Valley, I saw one area where they could substantially be improved.
As a social worker I perceived the need for individual time with the residents, something I could not provide alone. With discharge planning for an average of 30 short –term rehabilitation residents per month, I found very little time available to devote to meeting the psychosocial needs of the long-term residents.
One day last summer, as I walked the corridors looking at some of the residents’ sad and lonely faces as they watched their televisions in their darkened rooms, it struck me that there might be a way to help these residents get some of the care and attention they needed. I could not do it alone, but maybe other people could help me. I recalled Richard Pelland’s inspiring workshop at a conference on the use of creating Community. One program Mr. Pelland mentioned in his presentation was called “Partners in Time”. He noted that he had successfully petitioned the administrator to allow staff to spend a short time with one resident as part of their paid work-week. The relationships that developed from these resident-employee partnerships were extraordinary. He showed videotapes of the staff movingly discussing their relationships with the residents. It sounded terrific, but would the staff at Sunny Valley be motivated to try something like this? Without the commitment of the administrator and staff it would never work. I decided to strategize.
I employed the strategy of presenting the idea in a conventional forum, the Behavioral Committee, of which as the social worker, I am the chairperson. Here, staff felt comfortable discussing residents with behavioral problems (such as swearing, hitting, non-compliance with care, etc…). While this format was old and comfortable, there was a certain amount of frustration associated with it for the staff, mainly because it did not produce solutions.
Therefore, one month, instead of simply discussing a list of behavioral “issues”, I suggested to the Committee that we try to use an individual caring relationship with staff to reduce residents’ need to act out their frustrations and loneliness. By developing such relationships we might be able to increase the residents’ sense of being perceived as individuals and valued members of the nursing home community. The Behavior Committee was opened to this idea, which offered a possible solution to a longstanding problem. The discussion quickly moved to the identification of residents in need of this intervention, and to the development of a system for matching compatible staff with each resident.
In order to maintain the positive momentum that the Committee had shown on this project, we moved to bi-monthly meetings. Over the course of subsequent meetings, the committee voted on a name for the program (“Caring Hearts at Work”). I drafted a proposal for the program to present to the administrator, explaining the plan, and requesting that the staff be allowed to spend twenty minutes of their work-week (either in one session or divided over the course of the week) with one resident. We also requested that the administrator provide a monthly luncheon for Caring Heart Workers. These luncheons would serve to reward the staff for their extra commitment to their job as well as provide a forum for the committee to reinforce their caring behavior towards the residents. Before presenting the proposal to the administrator, I was careful to have each member of the committee review the proposal. It was submitted at a Department Head meeting, and it was approved.
Engaged in the task of program creation, the Committee proposed the development of a list of regulations governing the program’s operation. The Committee drew up guidelines defining the resident-worker relationship as a caring, professional one. Gift giving or receiving was discouraged, maintaining confidence was reinforced, and an emphasis was placed on validating residents’ past accomplishments. Thus the committee’s involvement helped to shape the form that the program took.
In addition to developing the guidelines, the Committee designed a “time-slip” for staff to fill out weekly to allow the Committee to track the results of the program. This slip consists of a brief, half-page check-off form that allows employees to give the committee feedback as to the residents’ mood and behavior during their visits. The Caring Hearts workers are expected to turn in the slip each week. The slips are not always filled out, but they are an important communication tool for all of us.
Once the structure was in place, the next step was implementing the program. It was immediately successful. To my surprise, about 12 staff members signed up at once, mostly from the Rehabilitation Department, as well as a few nurses, CNAs and a housekeeper. They immediately began to enjoy the benefits of being a friend to one particular resident. The housekeeper commented on her weekly Caring Heart check-off slip, “She knows I am something to her.” Families began to mention their gratitude to the caring hearts workers assigned to their loved ones.
In order to promote the program, I wrote a press release with pictures for the local newspaper. The published article was posted prominently in the facility. It made a statement about the nursing home as a part of the larger community. Many staff saw the article and eagerly signed up as caring hearts workers. Thirty staff are involved the program.
Now that the program has been established for several months, continuous energy is required to maintain it. In order to concretize and validate the commitment of the staff, I put together a photo-collage depicting many of the Caring Hearts Staff Members with their residents. This type of recognition has definitely encouraged new members to join.
At times, I turn to the Behavior Committee for ideas in keeping the program strong. For example, the Activities Director has proposed a summer barbeque with Caring Hearts Workers and their residents. The Behavior Committee had recommended exploring further how to develop the feelings of connection that the staff already have for their residents. The Activities Director again suggested holding a workshop for staff on Life-Review at a Caring Hearts Luncheon. This helped staff to better know and understand the person they work with as an individual with unique life experiences.
In short, the basic strategy of the Caring Hearts Intervention has been to involve each of the staff personally in a close relationship with one resident, while from the beginning engaging them collectively in the creation of a program to better the residents’ quality of life. Together, we have established a program that is at once special, and is incorporated into the structure of the organization. It is even part of some of the residents’ care plans.
Because of the program, and the monthly working luncheons that we hold for the Caring Hearts workers, things are a little different at the nursing home. Staff have shared that at least one resident’s life is a little better because of them. The focus is now more on the residents’ needs. An occupational therapist observed that “her” resident needed a splint to prevent hand contractures, and promptly obtained one. A physical therapist advocates for her resident to ambulate daily with nursing staff.
This new attachment puts the staff at risk of loss. As the social worker, I must attend to this matter. This happened, for example, when one resident, “Ellen” became so vociferous and combative in her increasing dementia that it was decided that she required a transfer to an Alzheimer’s unit at another facility. Sun Valley was ill equipped to care for extremely combative or disruptive residents. Her Caring Hearts worker, the occupational therapist, had developed such a close relationship with Ellen. She often brought her infant son to visit on weekends to visit this resident. The Caring Heart worker reported that when she heard the news of Ellen’s transfer, she cried all the way home. We discussed how difficult it is to get to know someone, only to lose her.
In the course of our talk, the Caring Heart worker mentioned that at a previous job, the activity director and the social worker held monthly memorial services to help the staff deal with the issue of death. I had wanted to do something like this for some time, but was waiting for an expression of the need to come from the staff, so that they would feel ownership of the process, and be more likely to participate.
At the next Caring Heart’s luncheon with the support of the group, the Care Heart worker, working with Ellen, shared her sadness around Ellen’s transfer. This topic provided a vehicle to present the worker’s idea of a Monthly Memorial Service to the staff, who received it well. The worker was validated for creating something positive out of a sad situation.
Perhaps in loss, it is easiest to see the greater sense of community that has developed at the nursing home. Recently Genevieve, a very long term resident who was failing, passed away. We were united in our grief. Some residents sank into depression. Family members remarked on their feelings of sadness. We held our first Memorial Tea, and residents, family and staff came together over tea and cookies to remember Genevieve and other residents who had died. All shared their memories of Genevieve: her love of Bingo and scratch tickets, her delight in children, and her indomitable spirit.
This event, I felt, was a measure of the nursing home’s growing identity as a community. In the past, the death would have passed almost unremarked upon, the bed filled, and the residents informed that the person had gone “to a better place”. The busy routine would have continued unchanged, the staff and residents more weary and irritable with the tension of all of the unshared loss. But now, the Caring Hearts Program and the Monthly Memorial Tea have changed this attitude and mood. This community, indeed the final community for many residents, has begun to become a place where their lives and personalities make an impact. They matter!
In summary, the social work intervention, I devised to meet my nursing home residents’ psychosocial needs through the inspiration of a workshop I attended and the help of the staff, was a program that enhanced residents’ sense of identity as individuals and as members of a caring community. This program also strengthened the staff morale and staff commitment to the holistic needs of the residents, one resident at a time. As the program grew, it took on a life of its own. Where it will go next depends on the needs of the residents, and ideas of the members of the community.