Eleanor Feldman Barbera, Ph.D.

Editor’s Note: These are the initial posts of the popular new McKnights.com blog “The World According to Dr. El.” See more from her at McKnights.com.

I sat in morning report as the nursing supervisor announced the arrival of a new resident. An 80-year-old woman was taken to the hospital after a fall at home, where she received a below-knee amputation and contracted C. diff. before being transferred to our facility.

I looked around the room and speculated about what each of my team members were thinking:

• The wound care nurse was wondering how the leg was healing.

• The rehab director was considering the chances an 80-year-old woman might be able to manage on a prosthetic leg. 

• The infection control specialist was mentally reviewing a checklist of infection control procedures that needed to be put in place.

• The social worker was hoping the woman lived in a ground-floor apartment.

What was I thinking about this new admission? I was worried she might be suffering from symptoms of Post-Traumatic Stress Disorder if she had been alone on the floor for any length of time. I wondered about the quality of her family support and whether she’d consider attending the choir performance in which one of the soloists was a glamorous amputee from the third floor. 

I hoped she had the grit and determination for rehab with a prosthesis or the spiritual strength to handle life with one leg, and that she would be willing to talk with me.

Fortunately for the newly admitted lady, most of my colleagues have the concerns of their disciplines represented at care plan meetings and other formal discussions. The voice of mental health is a louder one now that MDS 3.0 requires asking residents themselves about their mood symptoms, but psychologists and psychiatrists are still most often consultants rather than formally on staff, and still most often consulted in reaction to an obvious problem rather than proactively to prevent problems. Their contributions are made through chart notes and conversations with staff members at the nursing stations, rather than at team meetings where decisions are being made.  

Online option

And, fortunately for those of you who recognize the impact of mental health upon, well, everything, McKnight’s has decided to run a regular blog on mental health needs in long-term care. 

I will tackle the concerns not just of the residents, but also of the staff members who balance job and family to work in an emotionally challenging environment.  

I’ll be looking at ways to adjust programming to create mentally healthy facilities, offering suggestions to shift the role of family members from adversary to ally, and weighing in on the issues of the day. Feel free to write with questions about how to handle sticky situations or improve any aspect of mental health care in long-term care.

The doctor of psychology is in.

POST 2: Emotional healing

Back when I worked in psych, one of our most effective tools to improve mental health was maintaining a healing emotional environment. That’s why I was shocked when I first entered long-term care.  

I couldn’t believe the din that faced me on the floors or the way some people spoke to the residents or the lack of coordination of care. In some ways, the settings are so similar —inpatient care, short- and long-term stays, family involvement, treatment teams, etc. — but the focus on physical versus mental health creates completely different atmospheres.

The reality is that even though our residents are entering LTC due to physical problems, their medical troubles impact their mental health and vice versa. 

When I read a chart filled with medical diagnoses, I know it’s likely my prospective patient will spend much of our initial interview discussing the barrage of procedures he or she has undergone. A session or two later, the discussion will be about how the staff treats patients or about a difficult roommate situation. 

My long-term residents will be frustrated by the lack of follow-through on medical tests or by the interpersonal dynamics on the floor.

The good news is that it really isn’t that difficult to create an emotionally healing environment. It doesn’t have to cost a lot of money or take all that much time. What it does take is recognizing there’s a problem and then dealing with it.

The first step is to walk onto your unit and listen. If you were in long-term care, would what you hear make you feel better or worse? Is the atmosphere soothing or disturbing?

If you’ve identified any problems, then take the second step of reading about the therapeutic milieu. The article “The Nurses’ Role in Milieu Therapy” gives a good overview of the elements used in psychiatric settings, most of which can be easily adapted.  

Third, outline a plan of change and begin. Start training your staff to make each interaction therapeutic, to adjust the physical setting so that it’s more pleasant and less jarring. Have them set up policies for challenging behavior so that staff are proactive rather than reactive, and involve the entire facility in recreational activities. 

Then watch your community flourish.