A salute to the stalwarts of long-term care

The idea behind this column is to recognize and celebrate the commitment of tireless caregivers in long-term care. Over the months we have profiled programs and people, who, with scarce resources, unflagging commitment and a fertile imagination, have invented simple solutions to stubborn challenges. Long-term care is replete with many such exemplars who, day in and day out, without fanfare, perform minor miracles in the service of our elders.

The on-site nursing home managers—the director of nursing and the administrator—serve as a deserving illustration of such unsung LTC stars.

A nursing home is a community unlike any other. It is an artificial creation held together by an uneasy coalition of interests and needs. A nursing home starts as an assortment of individuals whose most common denominator is old age, frailty and dependence. The elders, experiencing a loss of faculty, function and roles with the accompanying intimations of mortality, are now uprooted from family and friends; they are shaken by the thought that they will live their last years with strangers. Researchers have documented suicides precipitated by an impending move to the nursing home. Passive suicide may be common.

The staff that serves them complicates matters. To begin with, the staff often differs markedly from them in age, race, ethnic culture, social class and even in country of origin. Furthermore, they are assigned a task that is demanding, ill-paid and that pegs them at the bottom of the esteem ladder. 

A TALL ORDER

This complex situation notwithstanding, we still expect nursing homes to transcend these divisions and contradictions; we expect them to be reborn as person-centered communities.

Culture change is a tall order. That transformation has to begin with the precarious encounter between a CNA and the resident. Here are two parties with contrasting backgrounds, both socially the most powerless and the least esteemed, who spend significant hours each day in close and even intimate contact. It is from the chemistry of their odd interchange that we expect nursing home managers to generate the wondrous culture of person-focused quality.

Brave DONs and administrators—32,00 across the nation—have answered the call. Daily, in 15,600 nursing homes, they bear the awesome responsibility of mentoring 650,000 CNAs, 130,000 RNs, 185,000 LPNs and 400,000 other staff in the art of adding quality to the life of our elders. They build trust across the cultural and social gaps; they calm their anxious and reluctant new residents. They deal with agitated families. They create an inviting work environment that softens the hards demands of a CNA's personal life. They create policy, design protocol, invent ways and foster practices that make up the greenhouse that tends to and nurtures the nascent community of trust.

AN UNFOLDING MIRACLE

The experience is edifying. You witness a veritable miracle unfolding within the walls of many nursing homes. Caring managers guide a silent, unobtrusive transfiguration of an assorted collection of transient strangers into a community of residents and caregivers who become connected in warm friendship. This singular, everyday feat seeks no limelight, it makes  no headlines and its authors go unsung and unrecognized.

Teams of state inspectors who regularly conduct a quality audit have testified to this drama. In 2010, state surveyors— not reputed to be soft on nursing homes—cited an average of nine deficiencies per nursing home in the United States. That is, they found that a typical nursing home complies better than 96 percent with the standards they are required to live by. This is an enviable record when compared with any other service sector. Especially so, since nursing homes may be the most regulated sector besides nuclear power. Even the deficiencies cited aginst noncompliant nursing homes show a silver lining: 95 percent of all citations fall under the heading of "no actual harm done."

This positive official verdict runs congruent with the judgment of residents and of thousands of family members who witness caregiving firsthand—nearly two in three families visit their relative in the nursing home at least once a week. Eighty percent of more than 230,000 residents and their families who responded to the My InnerView survey in 2010 rated their satisfaction with their nursing home as good or excellent—more residents did so than their families. Around 40 percent in each group said they would recommend their home to others as excellent. Their assessment was validated by the staff. Sixty-five percent of caregivers rate their satisfaction as good or excellent, and more than 40 percent would recommend it as an excellent place both to get good care and to give care.

Without a doubt, nursing home excellence is the handiwork of their on-site managers. There is no documented evidence that a nursing home can deliver quality for long, guided only by a venerable tradition, institutional routines, systems or processes. Quality thrives when wise managers tend it with a caring touch and shrewd expertise. Many an exemplary home has flamed out when such a steward left and was replaced by mediocrity. In the absence of good managers, the best of best practices turn into empty rituals. Nursing home quality is a fragile blossom; it calls for eternal vigilance and care.

STALWARTS OF LTC

The most telling indicator of a manager’s success, research shows, is the friendly bond between caregiver and resident. You can sense it as soon as you step into such a home. You notice its wondrous effect—friendly bonds have transformed workers into devoted caregivers; what was seen as work is now a commitment; where there was a facility, now you experience a sense of community. Good managers, of course, also promote professionalism and set high standards. They create appropriate policy, establish protocols, set budgetary priorities and initiate systems to encourage, monitor and reward accountability.

How do you deliver satisfaction in a nursing home? Successful nursing homes generate happiness by creatively blending three ingredients: compassionate management, trusting relationships and a culture of professionalism and caring. All else is just fluff, fillers and flavorings.

In columns to follow we will touch upon ideas and initiatives—from the mundane to the wonderfully imaginative—that successful managers have adopted, experimented upon or fantasized about.

For now, join me in a salute to the DONs and nursing home administrators, the stalwarts of long-term care who strive with devotion and imagination to add quality to the life to our elders.

V. Tellis-Nayak, PhD, a medical sociologist, is a researcher at My InnerView. He has been a university professor, has conducted research in the United States and abroad, and has authored books and articles. He can be reached at vtellisn@gmail.com.