“One-third of nursing homes cannot meet behavioral health needs” read the headline of a McKnight’s Long-Term Care News article this month. As someone who’s been providing mental health care for nursing home residents for over 20 years, I’m not surprised at this finding.
I’m heartened, though, that behavioral health concerns have been receiving more attention, from PHQ-9 questions about depression to the upcoming focus on trauma-informed care and the push for nonpharmacological approaches to managing dementia and other care needs. To me, it’s a welcome course correction.
The researchers in the above article state that there’s an urgent need for improvement in staff education. This is undoubtedly the case, but I’d argue that the first step in the process of addressing the behavioral health needs of residents is to improve staff retention.
I say this because all the staff instruction in the world will do no good if the employees who have just been trained walk out the door.
In addition, unstable staffing has a negative effect on quality of care.1 For example, rotating workers have no idea if there is a change in resident behavior from one day or week to the next, a key element in addressing both physical and emotional problems before they worsen.
New employees are unfamiliar with the routines that create a safe, comforting environment for residents, essential for all residents and particularly those with dementia.
Aides, who are tasked with providing the most intimate care imaginable, need time to establish reassuring relationships with their charges. The effect of a new aide can be observed when regular aides on long-term care units go on vacation and new substitutes arrive daily; residents often experience an increase in anxiety and depression. On short-term units — with newly admitted individuals who are in emotional and physical crisis — an experienced, trained aide can be an antidote to frayed nerves.
To explain the psychosocial impact of turnover on a long-term care facility, consider Maslow’s hierarchy of needs, which readers may recall from their Psych 101 class. The hierarchy can be represented as a triangle comprised of bands, with the widest band at the base representing physiological needs, topped with layers of increasingly small bands of needs and ending with self-actualization at the apex.
The traditional focus of nursing home care has been physiological needs — physical care, including food, warmth and rest. The next level, safety, could be interpreted as the type of risk-avoidant, litigation-minded safety concerns that lead to chair alarms and a cautious approach to resident independence.
Consider instead that safety refers to emotional safety. For residents, who are in physically vulnerable positions and relying on others for personal assistance, it’s emotionally unsafe to have a continual stream of new helpers. When the people the residents are counting on for care are swiftly disappearing, it leads to a feeling of instability and insecurity. Even the most well-adjusted individual would have a difficult time under such conditions.
The next level of Maslow’s hierarchy is a sense of love and belonging. This is clearly something more likely to develop in a stable staffing environment. A nursing home, at its best, is a supportive, loving community. In a stable setting, residents are more likely to feel like they belong and able to attain the following level in the hierarchy, that of esteem.
Esteem is, according to Maslow, a sense of prestige and accomplishment. Many residents, however, have a loss of self-esteem just because of the fact that they’ve “ended up” in the nursing home, as if it discounted all their achievements over the years. Being in a home with high turnover exacerbates this feeling because “even the staff don’t want to be here.”
Good mental health — the goal of behavioral health initiatives — is more likely when residents have their physical needs met in a secure, stable environment where they feel they belong and where their individual accomplishments are valued. This is almost impossible to achieve in a high turnover facility. In a nursing home with stable staffing, however, I believe that this is absolutely attainable with training, teamwork and a focus on the facility as a community.
Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her award-winning website at MyBetterNursingHome.com.