Empowering Long Term Care Facility Residents Using a Resident Staff Group Approach

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Empowering Long Term Care FacilityResidents Using a Resident Staff GroupApproachOluwafemi Agbayewa MB, FRCPC a , Amoy Ong MSW b & BevWilden MNS, RN ca Associate Professor, Department of Psychiatry, University ofBritish Columbiab Regional Coordinator of Elderly Services, Mental HealthServices, Northern British Columbiac Director, Geriatric Psychiatry Program, Deer Lodge Centre,Winnipeg, MBPublished online: 25 Oct 2008.

To cite this article: Oluwafemi Agbayewa MB, FRCPC , Amoy Ong MSW & Bev Wilden MNS, RN(1990) Empowering Long Term Care Facility Residents Using a Resident Staff Group Approach,Clinical Gerontologist, 9:3-4, 191-201, DOI: 10.1300/J018v09n03_11

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Chapter 11

Empowering Long Term Care Facility Residents Using

a Resident Staff Group Approach

M. Oluwafemi Agbayewa, MB, FRCPC Amoy Ong, MSW

Bev Wilden, MNS, RN

Edltor's lntroductlon

Agbayewa, Ong, and Wilden discuss the psychosocial challenges that institutionalization olaces on both LTC residents and staff. The authors recommend empowerment, debureaucratization and com- munication as solutions.

Previous issues of CG have discussed issues of patient autonomy

M. Oluwafemi Agbayewa is Associate Professor, University of British Colum- bia at Prince George Regional Hospital. Amoy Ong is Regional Coordinator of Elderly Services, Mental Health Services, Northern British Columbia. Bev Wilden is Director, Geriatric Psychiatry Program, Deer Lodge Centre, Winnipeg, Mani- toba.

Correspondence may be addressed to Dr. M.O. Agbayewa, Department of Psychiatry, Prince George Regional Hospital, 2000 15th Avenue, Prince George, British Columbia, Canada V2M 1S2.

The authors wish to thank the residents and staff of 5E at Deer Lodge Centre and especially Mrs. M. Benjaminson and Mr. Nick Assiz who ensured that residents and staff on their unit had "a say in things." The authors also wish to acknowledge the support of the Deer Lodge administration and the secretarial assistance of Dianne Wyatt.

Q 1990 by The Haworth Press, Inc. All rights reserved. 191

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192 MENTAL HEALTH IN THE NURSING HOME

and staff morale

SUMMARY. Beyond the stress of relocating into a long term care facility, the dependent elder1 is often forced to give up his or her autonomy because of entrenc K ed institutional practices. As a way of improving the quality of life in the residents of a long term care facility through increased autonomy we organized a program that empowers the residents and staff of a unit. It increases their participation in the management of their immediate environment. The program used regular staff-resident meetings as the instrument of chany., We d~scuss hen the characteristics of these meetings, our initia d~fflculties and preliminary observations. We conclude after a year of operation that empowerm residents of nursing homes can lmprove their life satisfaction an d sense of community within the unlt with better resident-staff relations.

INTRODUCTION

A nursing home is about the last place to which most older people would prefer to move.' It is however noted by Goldfarb (1977) that while old persons should be helped to remain in their own homes or in family homes for as long as their needs are met without senseless destruction of family and social patterns, this attempt can often be over enthusiastic and exceed what is physically, emotionally or fi- nancially practical for the patient, family and community.' A long term care facility then becomes a logical choice of residence with subsequent relocation. Relocations which occur for several reasons,'."ragment routines and disrupt spatio-temporal orientation, and result in a change of lifestyle. Some older people increase their independence, while others become more dependent. Factors which determine the direction of change are multiple and multidimen- sional.

Several reports attest to the many stressful and negative outcomes of involuntary relocation, such as lower morale, disorientation, dis-

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Group Therapy in the Nursing Home 193

rupted social relationship, and increased morbidity and mortality.'J There are, of course successful relocations into nursing homes.

The quality of the environment in an institution i ~ - ~ e r h a ~ s the most critical factor in a successful relocation. Environmental factors that encourage depersonalization, loss of identity and development of docile behaviour which characterize institutional setting^^.^ are detrimental to residents. In discussing the development of institutionalization, Linden (1967) for instance suggested that the initial loss of identity in residents may progressively deteriorate into com- plete psychosocial degradation.I0

Goffman (1962) blamed the detrimental effects of institutionalization on the process of interaction between residents and staff.B The milieu of the institution may encourage or prevent this process, i.e., restrictions foster psychosocial degradation in residents.

The findings of Wolk and Telleen (1976) suggest that higher levels of life satisfaction, alertness and adjustment are related to fewer institutional constraints." Life satisfaction and morale for residents in an institution depend on the residents' perception of control over daily activities or autonomy."." Meanwhile Bennett (1963) had ear- lier noted that staff saw themselves as caretakers for a group of powerless individuals who are in need of help, i.e., residents are passive recipients of care.'"n turn, the residents seem to comply with these expectations. While the surrender of autonomy may come from the residents, it is all too often initiated by the institution.

In their study of the quality of life of older persons in nursing homes, Wells, Singer and Polgar (1985) reported lower expectations for resident functioning among staff.ls Staff also placed physical comfort above psychosocial needs, whereas residents placed higher values on opportunities for self-expression, personal growth and resident influence. There is thus a discrepancy in the staff's and resident's expectations of their individual roles. This is detrimental not only to residents but also to the staff. For instance, nurses in custodial wards see their jobs as mechanical activities that provide little professional gratification.I6 This discrepancy is not limited to staff-resident relationships but also operates within the staff hierarchy. Gubrium (1975) noted that while the top staff expressed total needs and individualized care philosophy, the floor staff practiced

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194 MENTAL HG1LTH IN THE NURSING HOME

task-oriented bed-side care." This is the same mechanical activity that they find ungratifying, and this significantly affects the care provided.

Suggestions to improve the quality of life in nursing homes include the adoption of humanizing hospice principles that include a total needs emphasis, increased resident autonomy, a community ideology and a multi-disciplinary team orientation that cuts across levels of staff hierarchy.I8 As previously observed, these principles are already espoused by policy-makers but still remain to be practiced.

We observed some of the above issues in our long-term care facility and decided on an easily implementable, and inexpensive way of improving the quality of life of the residents. We realized that quality of life is multiply determined, i.e., biomedical, psychoso- cia1 and physical environmental factors contribute to the quality of life. We chose to focus on intervening at the psychosocial level because it is the most amenable to intervention and least expensive, i.e., no new monies needed.

We then set out to develop a program that utilizes group work as an interventive modality to improve; (1) quality of life of residents in nursing homes by fostering resident autonomy; (2) staff satisfaction through involvement in decision-making on issues affecting their own immediate work environment; (3) stafflresident relationship, i.e., a sense of community through improved understanding of each other and collaboration in managing certain aspects of the unit environment. This group interventive modality involved both staff and residents and was called resident-staff meeting.

SE'lTING AND SUBJECTS

The setting of our program is a 277 bed facility designated in 1983 as a geriatric centre. Prior to 1983, the centre had for more than 50 years been administered by the Department of Veterans Affairs. At the present time, the facility houses six personal care units, two extended treatment areas, one intermittent admission and rehabilitation unit, and a day hospital. One of the personal care units with a 30 resident capacity was selected for this program fol- lowing a series of consultations to that unit by the psychiatrist. All

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Croup Therapy in the Nursing Home 195

30 residents were male with varying levels of mental alertness and physical disability. The psychiatrist observed. a lack of formalized settings for residents to air grievances despite increasing levels of frustration. These frustrations were expressed through non-compli- ance with care, physical and verbal aggression and other disruptive behaviors for which he was being consulted.

Personal care units function like nursing homes, and residents are selected on the basis of disability which makes it difficult for the family to continue care even with support outside of an institution. Residents of the selected unit are all male, above 65 years of age and veterans. They have an heterogeneous group of diagnoses which include Parkinson's disease, chronic obstructive pulmonary disease, schizophrenia, stroke, Alzheimer's disease, bilateral above knee amputation of the lower limbs, various malignant conditions, ischemic and other cardiovascular diseases, etc. These'conditions occur multiply in most residents. Most of the residents have family members some of whom visit from homes within the city though some residents are from out of town.

FORMAT OF RESIDENT-STAFF MEETINGS

A five minute briefing session and an agenda planning session precede every meeting. Issues for discussion, as put down on the agenda list which is posted on the unit, are sorted out and grouped as to content. Any,potentially volatile situation or event on the uni t since last meeting is identified and strategy for defusing it and making the meeting functional and non-disruptive is planned. These briefing sessions are attended by the unit coordinator, the recording secretary, co-chairpersons and the facilitators (a social worker, a nursing care specialist and less often a psychiatrist).

The meetings were chaired by an elected resident and,co-chaired by an elected staff member for a four-six month period at a time. Co-chair position was given to staff so that resident and staff will consider the meetings a forum for discussing issues that affect their lives on the unit. Each meeting started with a welcome statement and the introduction of all newcomers (residents and staff) to the unit. Those who by virtue of disability are unable to. introduce themselves, i.e., dysphasics, are introduced by staff or resident vol-

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unteers. All newcomers to the unit are asked to give the details surrounding admission, feelings about it, whether or not they have a family, physical illness and expectations of the unit and other rele- vant personal history.

After the introduction, the minutes of the last meeting are read and discussed. Follow-up to suggestions from previous meetings are also discussed. Guests are introduced and reasons for visits are explained. Then the agenda-a sheet of paper left on the ward for staff and residents to write issues of concerns to be discussed, is read and as many items as possible considered. Any issue can be raised by staff or resident, e.g., staff can bring up for discussion certain behavioral or management problems on the unit while residents can choose for discussion the behavior of staff or other residents, need for modification in ward routines, etc. Attempts are made to resolve all issues discussed and resolutions for implerncnta- tion are passed. Implementation is often designated to a subcommit- tee (staff andlor residents) which reports back to the general meeting. The degree of structure within each mccting varies with the topic and chairperson. The minutes of each meeting is circulated to the facility and unit administration, admitting physicians and residents. At least one of the facilitators (a nursing care specialist, social worker and a psychiatrist) attends every meeting.

A debriefing session is also held right after the meetings to discuss the events and the dynamics of interactions within that mect- ing. Issues that seemed to be ignored and possible reasons for their being ignored are also discussed along with alternative approaches for handling similar issues in the future.

DISCUSSION

The program was started in response to perceived clinical and administrative needs which were identified during a series of consultations by the psychiatrist. Like any new program, i t had its teething problems such as finding a suitable time block that did not conflict with task-oriented care; residents were not dressed or other- wise prepared for the meetings; poor turn out by staff, domination of meetings by staff, or a particularly vocal resident. The early meetings were looked upon by residents and staff as unimportant

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and a waste of time. Some staff only attended to humour the orga- nizers of the meetings and because of administrations support. Resi- dents were often arbitrarily withdrawn from these meetings for tasks that could have waited. These created frequent distractions. With the support of the centre's administration, we were able to invite guests from various facility departments to discuss services provided by their departments and how these services affect residents. For example, after a complaint about having to wake up for breakfast at a particular time, the Director of Food Services was invited to attend the next meeting. He explained the reasons for the timing of breakfast. This and other issues were clarified in the ensu- ing discussion, and the time and style of serving breakfast was ad- justed to everyone's satisfaction.

Positive results from such efforts, along with overt administrative support gave the perception of these meetings as an instrument of change. Staff participation improved both in quantity and quality. Residents became emboldened, having realized the absence of any punishment consequent on their group comments. The next phase saw some residents becoming more complaintive, using the sessions to get back at the staff for real and/or imagined transgressions. We then had to work on residents' appropriate use of their new found power to avoid an inevitable backlash. Other problems included decreased participation by threatened staff; staff using the meetings to inappropriately carry out administrative functions; abuse of the process by a handful of residents and staff.

Because of this new resident power to influence their environment, staff response also improved. Gradually we evolved the idea of resident-staff co-chairing of meetings to give the perception of a community of staff and residents, and not residents only.

While a dynamic understanding of the processes operating within the meeting is essential, there is usually no dynamic interpretation provided within the sessions. Instead, issues are addressed in very concrete terms within the meeting. The concretisation of these meetings is essential for this population with varying degrees of mental alertness. The briefing and debriefing sessions also served as a teaching forum for the staff. Debriefing sessions provide the forum to explore dynamic issues within the meetings, and to explore alternative interpretations for resident behavior prior to and

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during meetings. We occasionally explored staff responses, mani- fest and latent, to specific events. This allowed staff to accept the normalcy of their feelings, e.g., not to be ashamed of feeling angry, abused or unappreciated by residents, while examining their behavioral response to these feelings. It is worth mentioning at this point that very few of the front-line staff of nursing homes and other long term care facilities had experience with group work or psychody- namic approaches to understanding behavior and interactions. In- sights gained into residents' behavior and staff response in these sessions provide new perspectives to interpreting resident behavior, and humanized residents and subsequent interactions with them. Minutes of meetings and agendas are regularly distributed to residents, staff and administration.

Observed changes as reported by unit staff and residents that are attributable to this program include:

a. Improved sense of community: staff-resident relationship improved; residents cooperated more with their care and staff were less rigid in enforcing routines.

b. Increased resident autonomy: they planned, initiated or co- planned some of their unit programs. They made suggestions for activity oriented programs that they felt would be benefi- cial.

c. Decreased need for psychiatric consultation: there were no re- quests for the last seven months in the first year of the program. This could be due to informal resolution or conflicts, i.e., a shift to liaison as opposed to consultation. Frequency of disruptive behavior in the residents had also decreased.

d. Subjective expression of pride and greater job satisfaction by staff: Staff expressed pride in being part of a unit that initiated a program with a different focus on the care of residents which is more than custodial and diversionary activity. The better satisfaction was attributable to greater resident participation and less staff frustration.

The program described above is common in psychiatric settings where they are referred to as community meetings, but almost non- existent in nursing homes and other long term care facilities that

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care for the dependent elderly. Reasons for this lacking include the physical and mental status of residents. We found that after a while, those who were more aware helped to verbalize the concerns of those who were less able to, perhaps because of a dysphasia or mental disability. The staff also helped out residents who could not make themselves comprehensible. The use of agenda circulated ahead of time reduced the limitations due to forgetfulness, since residents could write down issues of concern at the time of occur- rence and not have to wait till the next meeting;

A meeting like the one described above needs patience, experience of group process and more activity on the part of the group leader. Unlike other groups, this is not aimed at achieving a thera- peutic change such as relief or reduction of symptoms. In fact, it is expected that conditions of these residents would continue to deteriorate. Furthermore, majority of. group members were cognitively impaired which precludes the many other features of group process. Nevertheless, similarities to other groups include goal formation, universality and pairing. Common resistance issues included verbal attacks on staff by residents, passive-aggressive behavior in both staff and residents, e.g., staff walking in and out of groups presum- ably to help residents and residents complaints of pain or other symptoms which would focus attention on them or somewhat inter- rupt the flow of group discussions.

CONCLUSION

The impression of our program given above is descriptive. We are now embarking on a controlled study of this mode of intewen- tion to determine what specific components contribute to improved life satisfaction in the residents of long-term'care facilities.

The literature suggests that food, physical facility, staff-resident interaction, autonomy, etc. are associated with life satisfaction. ''3

These factors and issues have proved, so far, to be the initial complaints of most residents who participated in this program. Because life satisfaction is a subjective concept, we leave the issues to be discussed at each meeting to residents and staff, i.e., residents or staff bring up issues that they consider important. Further observations from this project suggest that elderly individuals in long term

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care facilities respond positively to less passive, more empowering environments. These seem to reduce frustrations, allow group resolution of conflicts with avoidance of potentially explosive situa- tions. It is suggested that programs borrowed from other health care settings can be useful in long term care settings for the elderly, provided these are suitably modified to accommodate the disabili- ties that are common in this population. We have embarked on a systematic evaluation of the impact of this program on staff and residents of the unit.

REFERENCES

1. Agbayewa MO, Michaelski B: Accommodation Preference in the Senior Years. Canadian Journal of Public Health 75: 176-180, 1984.

2. Goldfarb A: Institutional Care of the Aged, In Busse EW, Pfeiffer E, (eds): Behavior and Adaptation in Late Life. Boston, Little, Brown and Co. 264- 292, 1977.

3. Palmore EB, Mancon K Modernization and Status of the Aged: Interna- tional Correlations. Journal of Gerontology 29: 205-210, 1974.

4. Nelson LM. Winter M: Life Disruptions, Independence Satisfactions and the Consideration of Moving. Gerontologist 15: 160-164, 1975. . 5. Kral VA, Grad B, Berenson J: Stress Reactions Resulting from the Relo- cation of Aged Populations, Canadian Psychiatric Association Journal 13: 201- 209, 1968.

6. Liebeman MA, Tobin SS & Salver DL: Effects of Relocation on Long- Term Geriatric Patients. Unpubli$hed Project Report, University of Chicago, Committee on Human Development, June 1971. In B. Yawney and D. Slaver, Relocation of the Elderly. Social Work, 18; 86-95, 1973.

7. Kasl SV, Rosenfeld S: The Resid~nfial E~vironment and its Impact on the Mental Health of the Aged. In Birren JE, Sloane PB, (eds). Handbook of Mental Health and Aging. Englewood Cliffs: Prentjce-Hall inc., 468-498, 1980.

8. Goffman Irving: Asylums. Chicago, Aldjne Publishing Co., 1962. 9. Townsend Peter: The Last Refuge: hndpn: Routledge and Keegan, Paul,

1964. 10. Linden ME: "You Won't Believe It." Pgper presented at State of Dela-

ware Governors Conference on Aging, 1967. (Mimeographed copy available from New Jersey Department of Community Affairs, Division of Aging, Trenton, New Jersey).

11. Wolk S and Telleen S: Psychological and Social Correlates of Life Satis- faction as a Function of Resident Constraint, Journal of Gerontology 31: 89-98, 1976.

12. Blenkner M: Environmental Change and the Aging Individual. Gerontolo- gist 7: 101-105, 1967.

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13. Chang BL: Generalized Expectancy, Situational Perception and Morale Among institutionalized Aged. Nursing Research, 17: 316-324, 1978.

14. Bennett R: The Meaning of Institutional Life. The Gerontologist 3: 117- 125, 1963.

15. Wells LM, Singer S and Polgar A: Quality of Life: Adapting & Integrating a Demonstration-Research Model Within Long-Term Care Facilities. Paper presented at the Canadian Association on Gerontology, October 17-20. Hamilton, Ontario. 1985.

16. Coser RL: Alienation and Social Structure. Friedson E (eds). The Hospital in Modern Society. Free Press, Gilencoe Illinois: 231-265. 1963.

17. Gubrium JR: Living and Dying at Murray Manor. New York: St. Martin's Press, 1975.

18. Munley A, Powers C, Williamson JB: Humanizing Nursing Home Envi- ronments: The Relevance of Hospice Principles. International Journal of Aging and Human Development, 15: 263-284, 1982.

19. Palmore, E. and Luibart C: "Health and Social Factors Related to Life and Satisfaction." lournal of Health and Social Behavior 13: 68-80, 1972.

20. Miller P, Russell DA: Elements Promoting Life Satisfaction as Identified by Residents in the Nursing Home. Journal of Gerontological Nursing, 6: 122- 129. 1980.

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Empowering Long Term Care Facility Residents Using a Resident Staff Group Approach