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Nursing Home Social Workers Share Their Stories
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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:

  1. To develop a caring community at Sunny Valley nursing Home that would better meet the holistic needs of the residents.
  2. To develop a way to integrate facility goals with the practice of social work.
  3. 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.


Joel Langsam, LICSW

I have worked as a nursing home social worker for sixteen years and as a community-based clinician for the last three years. I believe that this paper could meet the needs of this audience comprised primarily of nursing home social workers despite the fact the paper is written from my work within the community.

Florida (a factitious name for the character at the basis of this paper) represents a growing number of younger elders in their mid-fifties, early sixties who require extensive mental health, physical and social supports to survive living in the community. These individuals exhibit long histories of both mental illness and chronic care needs along with impaired social networks. In the past, they would have resided in state institutions, which closed their doors to this population in the late nineteen-seventies.

To be eligible for enrollment in the Elder Service plan of the North Shore, a program serving elders living at home, Florida needed to meet the requirements for nursing home placement. But, as cited in the OBRA Regulations in 1987, Florida also has the right to choose whether she wants to reside in a nursing facility. I believe that this right does create ethical dilemmas for nursing home social workers to examine., Clearly every resident's right must occur with some sense of responsibility. Thus, in this paper, my peers and I confront Florida's decision to return to her apartment after signing herself out of two separate nursing homes.

Florida's ego functioning is so limited that, as a team we have had to fully invest ourselves in her care to assure her choice to be home. As long as our network can sustain her, she will staying in her apartment. Otherwise, she will become homeless and eventually admitted to a nursing home. Our team has helped her find comfort within conditions, which remain ghastly to each of us. Thus, nursing home social workers can in addition come to appreciate the role nursing homes play as the final solution to aid people like Florida

Florida and I met during my visit to her two-bedroom apartment in June 2004. Her apartment was in total disarray. As the social worker, I began my work by introducing her to a variety of in home services. I also tried to set up a calendar in her kitchenette to note providers' schedules. The list of services included: home making, home health aides, a companion to take her grocery shopping, a money manager, Life Line, and a discounted telephone service plan via Verizon.

Florida nodded and agreed with me. But, as care providers arrived, she refused their care; assuring them when she was ready she would clean her apartment or take a shower. I found the calendar lying underneath medical supplies and her uneaten food scraps. She even failed to pay her telephone bill, thus losing her Life Line. The plan only lasted two weeks.

Visiting nursing staff came to her apartment every morning to administer her insulin injection to manage her fragile diabetes. The nurses also monitored to make certain that she had an adequate breakfast. One Monday morning in June, the nursing staff reported finding Florida lying on her floor, barely breathing, pale with low vital signs. They called 911 and arranged for the EMS personnel to transport Florida to the local Emergency Room. This led to her first hospitalization and five months of subsequent nursing home placement until October 2004. The team assessed that nursing home placement would enhance Florida's quality of life. The team identified several concerns including her poor physical health, neglect, inadequate support, and a very limited capacity to maintain her apartment.

During this nursing home admission, Florida actually flourished but could only tolerate residing in the nursing home for five months before becoming too anxious, pacing between her room and the nurse's station, asking repetitively when she was going home. The team eventually agreed that she had progressed as far in her care as possible and felt it was time to honor her request.

Florida was aware of her rights and would readily warn the team that she would seek out legal aide if her right to live independently in her apartment was violated. When her level of competency was assessed, she would share the she understood the consequences of her behavior. She recognized that she would further compromise her breathing if she continued to smoke. She understood that she could lapse into a diabetic coma if she continued to purchase sweets or did not maintain healthy meals.

The Housing Authority and the VNA serving her in her apartment complex were unhappy to see her return. The Housing Authority had frequently shared it disgust with the apparent squalor in her apartment. The Housing Authority had attempted to exterminate fleas and cockroaches. But , no one had ever filed for an eviction.

The Housing Authority also pointed to the need to identify a cleaning service to do major chore service in the apartment. Florida's closets were filled with trash. She had not thrown out food in the kitchen cabinets and by this time the food had begun to rot. Half eaten food was often left on the kitchen table for days. Florida's two cats would climb up on the table to eat the remaining food. Florida would remain ambivalent.

The VNA staff were equally traumatized. They found it very frustrating to come into the apartment in the morning, discovering that Florida had slept in the same clothes, often soiled and reeking from urine. She would resist the suggestion that she either take a shower or have staff give her one. Several nurses complained about the heavy layer of cigarette smoke that encased the apartment finding it impossible to breathe as they tried to care for Florida.

In addition, staff continued to identify concerns around Florida's diabetic and respiratory care. As they arrived at her apartment, they often met her coming across the street from the local mini mart either with another pack of cigarettes or munching on a Hostess Twinkie. When her blood sugar was extra low, the staff could never find a carton of orange juice in the refrigerator to treat her diabetes.

Florida's self neglect led to a second hospitalization and subsequent placement in March 2005. Florida only tolerated residing one month in the nursing home. Smoking was forbidden at the home. The team hoped to better care for her respiratory condition by easing her access to cigarettes. But, she could not stop smoking after smoking two packs per day. She began to trade her daily snacks with the CNA staff for cigarettes. Our medical team agreed that it was futile to fight her urge to smoke and discharged her back to her apartment.

The heat and the humidity during the summer of 2005 reinforced the difficulties to keep Florida in her apartment following her second discharge. She needed to walk up a narrow winding staircase to get up to the bathroom. She found it difficult to manage the stairwell but would not utilize a commode. Instead, she became incontinent as she spent her days lying in her couch in the living room area. Her incontinence caused an infestation of fleas to the couch.

The Housing Authority did not want to re-spray her apartment. They saw spraying again as futile as long as the couch was present. But again, no one wanted to remove the couch since it had become Florida's only place to sleep at night. Florida did not have money to purchase a new couch and no one appeared willing to donate one. Thus, the infestation multiplied over the summer months. The nurses eventually refused to return to the apartment, fearing that they would carry the fleas in their hair and clothing to other clients' apartments or home to their families.

Florida's crisis at home created many accusations between agencies. Our ESP team was only supposed to serve as Florida's health insurance provider. The Housing Authority and the VNA began to turn to us to resolve Florida's crisis. The other agencies began to telephone my office almost daily. It became more difficult to set limits on my scope of involvement. It was also difficult to watch Florida decompensate. The situation became reminiscent of the struggles I faced to structure my role previously as a nursing home social worker. Although, I successfully managed to involve our PCA staff, they often questioned how much they should provide Florida since she was not willing to help herself.

I realized that I could not trust Florida alone to take ownership for her hygiene and the care of her apartment. She required a clinician to visit her regularly as the early pioneer friendly visitors did at the turn of the last century. I had to gradually develop Florida's trust in me so I in return could help her.

I hired a cleaning service to clean Florida's apartment. Personnel kept resigning due to the extent of the work. The staff would clean the surface areas without addressing the underlying clutter. Staff reported that Florida declared that it was not necessary to throw out the rubbish. They feared disturbing her privacy. One day, I did a thorough cleaning with a staff person. We found cans of food rusting in the kitchen cabinets. Some of the older cans had begun to explode. Their contents had begun to drip unto the shelving. I assured the person that we were not harming her by removing these cans. Florida remained on her couch through this exchange staring at her television set. She was ambivalent to our disposal of these cans.

I then became determined to locate a cot, in an attempt to persuade the Housing Authority to re-spray Florida's apartment. A PCA eventually donated a small cot. Our maintenance man and I carried the sofa out to the trash. I persuaded Florida to give me some money. I went out to Bed, Bath, and Beyond to purchase a set of sheets, pillows, pillow cases, and blankets.

My site supervisor and I were able to persuade Florida to attend our day program on Mondays Wednesdays, and Fridays to receive a shower. She also gave us cash to purchase new clothing for her to wear. Staff sometimes put rouge on her cheeks.

We wanted to help Florida use her cash to purchase food and other household supplies. I began to meet with Florida to provide me with money after she cashed her Social Security check. At first, she insisted that she handle her own shopping. She also stated that she required money to pay her rent and telephone bill. Although she did manage to pay her rent, her telephone service with Verizon remained disconnected for non -payment. She would often give her cash away. She eventually let me purchase groceries for her every week.

Together, we planned a grocery list. Each week, she requested a pre-cooked barbecue chicken, a box of instant potatoes, a gallon of milk, a loaf of bread, butter, a box of Cheerios, a gallon of orange juice, and a pound of bologna.

Unfortunately, nothing was sacred. Items we purchased disappeared or were misplaced. We still received complaints weekly from the VNA. The nurses still found it difficult to treat her diabetes without the right food. They worried that they would lose their licenses, Florida's incontinence continued to also frustrate the staff.

In March 2006, our team met with an ethicist to present Florida's case. The ethicist shared his respect for our work to give our participants the same values we wanted for our families and ourselves in our homes. But, he also recognized that Florida would never be happy living outside her apartment. I acknowledged a past experience of taking her to visit a group home. I was excited at the prospect of locating her to a better home. But, she remained completely indifferent to the experience. The ethicist remarked that Florida had found security in a setting which, based on our values, we found disgusting and inhumane. He felt that it was important for the team to aid Florida in maintaining her happiness and security in her residence. He encouraged ESP to continue to provide her with all the services we render her daily to ensure she will be able to live in her apartment as long as possible. The ethicist acknowledged the stress we were confronting as a team as outside providers.

One day, he said “the eleventh hour will come and she will need to be rescued”. She will no longer be able to live in her apartment. We will need to make a decision for her to move into a long term care facility. Something will happen to trigger the need for placement. She will suffer from an episode of respiratory distress or lapse into a diabetic coma. She will not be able to rebound. The Housing Authority for some reason might evict her, leaving her homeless. Until then, the ethicist saw Florida as being competent to make the decision to stay in her apartment.

I want to now conclude my paper. But, I cannot end without leaving you in a lurch. Florida's care remains a cliff hanger. We continue to operate in a crisis mode rather that find a way to dialogue to develop a long term service plan. Every agency remains satisfied as long as each problem is addressed and resolved. We proceeded through the month of April unscathed. But in early May, our PCA staff found her one morning lying in her cot, covered in feces. Despite our work to buy groceries for Florida every Friday afternoon, the VNA staff one Monday morning phoned to announce the refrigerator was bare once again. Florida's care continues to both tire and frustrate us.

I leave the audience with several questions to think about and discuss. (1) How many were satisfied with the ethicist's recommendation? (2) How many would favor strongly advocating for long term nursing home placement? (3) How many would have rather fought for Florida's individual rights verses advocating for placement? (4) How many would have well considered the importance as nursing home social workers of continuing to follow Florida in the community as part of discharge planning and the need to work in closer collaboration with community agencies serving elders with chronic mental health needs? We could offer a reward to the person or persons who could resolve this dilemma.

ADDENDUM: Florida maintained her daily routine for a few weeks. VNA staff found her deceased on the floor of her apartment one morning in June 2006 subsequent to a severe cardiac arrest. The staff presumed that she had just returned from her daily visit to the local store having purchased Hostess Twinkies for breakfast.

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