Managing Resident Requests for Help, Nursing Homes Magazine, Oct 2003
Managing Resident Requests for Help
By Eleanor Feldman Barbera, PhD
The Shouters, the Constant Call Bell Ringers and the Complainers don’t have to be that way—you can reshape their behavior
Once, when I was new to a facility, I came up to the second floor to find a resident, named Paula, shouting “Nurse, nurse, nurse!” Helpfully, I went to the nursing station and passed along the resident’s call for assistance. They were very nice about it. The next day I came up to the floor again, and again there was Paula shouting “Nurse, nurse, nurse!” And the next day. And the day after that. Her calls had become the unit’s background noise.
Paula was a Shouter.
Anyone who has spent any time in a nursing home knows what I am talking about. Every nursing home has them. When my sister and I visited my grandmother in a home, we used to get very distressed about the lady down the hall. “Why don’t they help her?,” we wondered. We didn’t realize that that lady was calling constantly and often for no discernable reason, but because of fear and existential anxiety. Yet nursing homes are set up to respond to specific needs—there is little time to soothe existential anxiety or to grapple with longstanding psychiatric problems.
So, what can staff do about the Shouters? Fortunately, many things.
How do we determine which residents cross over the threshold of normality into the area of problem behavior? I don’t believe there is a specific “right answer.” Most of the time a resident’s “neediness” is subjective, and different staff members will have wildly different reactions to it. Some staff members take the needy under their wing; others resent the resident as a disruption. Defining genuine need is part of the problem.
Take use of the call bell, for example—in most cases, residents have no idea what constitutes a reasonable amount of call bell use. I have seen overusers and underusers. One underuser commented to me that he had waited in bed for 45 minutes after vomiting before anyone had come in to help him clean up. “Did you use your call bell?,” I asked. “No,” he said, “I didn’t think it was an emergency.”
That was when I began offering “Call Bell Education,” or “when and how to ask for help.” I found that educating residents empowers them, and that so much of their neediness and irritability comes from feeling out of control of their environment. Providing them with information gives them the ability to make choices about how to handle situations and makes them part of the treatment team. It sets up a collaborative approach to the challenge of getting one’s needs met despite a hectic environment. Once educable residents are educated, it allows the staff to observe when patient behavior is truly out of the normal range. If a patient knows that the average person rings the call bell 6 times a day, yet persists in ringing the call bell 15 times a day, this means the resident is either having physical problems that need a higher level of attention, or needs a referral to the psychologist and/or psychiatrist.
Call Bell Education should be done, ideally, as soon as the resident arrives at the facility, before negative patterns and expectations are set up. The approach should be one of impartially imparted information—“This is what is available to you, this is how it generally works, etc.” With modifications, the strategies outlined here will work for residents with mild-to-moderate dementia. For more severely demented patients, the focus will need to be on staff interventions that are outside the scope of this article.
I generally provide residents with information about their rights, saying, “You’re allowed to have access to your call bell all the time, you know.” Sometimes they don’t understand how to exercise their rights. In such cases, I consider it the resident’s job to find ways of working with the staff. “You may be retired,” I say, “but living in a nursing home is a full-time position, and you have to find ways of letting your new co-workers know what will get the job done.”
I remind residents that, if they are having a conflict with a particular aide, they need to use their best workplace skills to get it resolved. For example, they could make efforts to improve their working relationships, such as learning the names of their aides, or they can take their needs to an aide on another shift, or, if necessary, they can bring up their concerns with the nurse.
It’s important to help residents recognize the workflow of the unit. I often point out to them that the busiest times on the unit are at mealtimes and change of shift, and that they should, if possible, plan ahead to avoid these times for registering their needs. I remind people to ask for everything they need at once, rather than making numerous requests. Residents also need to be aware of how staff members work on their floor. For example, resident Sally was in tears one session after asking several aides to take her off the toilet, only to be met with humiliating refusals. She had been moved from a floor where the aides covered for each other regularly, to a floor where each aide took sole responsibility for the care of particular residents. Once Sally knew this, she stopped asking for things that wouldn’t be granted. She didn’t like the new system, but she learned to work within it.
Residents are often unclear about when it’s okay to ring their call bell or ask for help. Underusers need to be encouraged to speak up, otherwise problems won’t be identified until they have become difficult to treat (for example, skin sensitivity leading to bedsores). Call bell abusers, on the other hand, need to be told that it’s not okay to call the aide repeatedly to change the TV station, adjust room temperature or scratch the itch on their noses, but it is okay to ask for all of those things simultaneously, if the aide is there already helping a roommate.
For call bell overusing residents with some psychological sophistication, I ask them to look for other reasons why they might be continually asking for help. If they are lonely, for example, perhaps we can find other ways of addressing their loneliness.
Educating Aides and Nurses
It can be extremely frustrating to have a resident who is constantly requiring attention—interrupting work schedules and taking time away from other, equally deserving residents. Call Bell Education is just one step toward addressing this problem. Another important step is for staff to analyze why the patient is calling for help—to determine “the need behind the need.” Perhaps resident Lillian, who is occasionally anxious, really wants someone to reassure her that her son will come to visit; she just doesn’t know how to ask for that. She could interrupt the staff all morning with requests for water, a sweater, etc., but until someone addresses her underlying feelings, she will continue to seek attention. I have found that the best way to handle this is to meet the ostensible need, and while I am helping her put on her sweater, for example, might comment gently, “I wonder if you’re worried about your son coming to see you today?” Then, whether the answer is yes or no, I might add, “because sometimes when I am anxious about things like that, nothing else seems right.” And then I drop it, unless the resident acknowledges the worry and wants to talk about it.
Lillian would be an example of a resident who has an underlying need that is temporary—a single intervention acknowledging her feelings will suffice. Down the hall, though, you might be dealing with someone like Paula, The Shouter, whose underlying needs are ongoing. She is the type of resident who is likely to have had chronic mental health problems, although dementia patients can exhibit chronic neediness and anxiety as well. It is important to recognize that this behavior has been in place long before the resident arrived at the nursing home, and won’t disappear quickly.
Don’t despair—often a new environment with rewards and encouragement for different behaviors can lead to major changes.
One of the most effective techniques in dealing with The Shouter, for example, is to identify and work with his or her strengths. The idea is to help these residents to be their best selves. For example, Paula was a resident who had an extensive history of depression and disturbed relationships, but she was also a woman who prided herself on her intelligence. Interventions that showcased her intellect improved her self-esteem and gave her attention for possessing a positive quality. You can be very creative here. I might, for example, ask Paula what the “word of the day” was, since she had a good vocabulary, or talk to her about literature or movies. Similarly, if a troublesome resident knows how to crochet or has some type of special skill or knowledge, he or she might be asked to teach other residents or display some of their work at an art show.
Every resident has a “hook.” The fun part is figuring out what it is and how to use it. Hooks can be anything: the snappy way a resident dresses, an ability to speak a second language, or the resident’s role as a grandparent or family historian are examples. Try to get the resident known for this good quality; “brag” about it to other staff people, introduce the resident as “the person to come to with a question about gardening,” for example.
Another factor to consider with The Shouter is whether the environment might be contributing to the problem. Perhaps the resident is feeling isolated and lonely. It is tempting to put Shouters in the rooms farthest from the nurses’ station to minimize their disruptiveness. This makes it more likely, however, that The Shouter will feel obliged to shout many times before getting a response. If such a resident is placed near the nurses’ station, the staff can respond more quickly and break the repetitious pattern.
Other environmental factors might include living in a room located in a noisy and overstimulating area of the nursing home, or having ongoing roommate difficulties. It is important to individualize the analysis and solution of a problem to the resident.
Shouters and Call Bell Abusers should invariably have a psychiatric consult to assess any need for medication for underlying anxiety or other mental health problems. A psychological consultation will not only assist the resident, but help the caregiving team formulate and implement a plan to manage the problem behavior.
Once you have addressed the environment and any underlying pathology, and have started rewarding residents for their strengths, the team must work together to further reduce the resident’s negative attention-seeking. The resident should be seen as part of the team, and, as long as he or she is mentally aware, should be part of the planning process. Using our Shouter as an example, you might say something like: “Paula, when you shout like that, it disturbs the other residents and interrupts the staff. We want to take good care of you, but we have to work together on this. From now on, we will check in with you several times a day when you are quiet, so that you get what you need, and we will try to come as soon as you call for help. If you are able to get the help you need without shouting, we will put a star on your card toward a reward—but if you shout in order to get what you need, we won’t.” The resident should also have a say in choosing an appropriate reward.
This approach to reducing the shouting is classic behavior modification. Negative behaviors are to be discouraged, rather than rewarded. Positive behaviors are to be rewarded, rather than discouraged (all of which is, admittedly, easier said than done).
Now, let’s say that you’ve told Paula that you would be by in a minute, but she begins to shout. This is the time to say “Paula, if you wait patiently, I will come to your room and give you a star toward your reward, but if you shout you won’t get a star.” If you come to Paula’s room when she is shouting and you see that she is okay, you might try asking her to be quiet for five minutes so that she can work toward her reward. (Five minutes is just a guideline; it might have to be one minute for some people.) The important point is not to reward the shouting but to reward the silence.
Patience is key here. I find it helpful, when working on a behavioral modification program with a resident, to remember what happens when we push the button for an elevator and it doesn’t show up. If you are like most people, you push it over and over again because this behavior was previously rewarded with the elevator’s appearing. But if you push the button many times and the elevator still doesn’t arrive, you will eventually conclude that the elevator is broken and you take the stairs. When working with people like The Shouters, we have to realize that we won’t get to behavior change before going through the “button-pushing” phase. An increase in the problem behavior is usually an indication that behavior modification is working! This is the time to tough it out, rather than throw in the towel.
Behavior management should be a unified effort on the part of all staff, from the charge nurses to the activities department to the porters. It doesn’t work well if the day shift is doing it, but the night shift isn’t aware of the plan, or if all the nurses and aides are following the plan, but the well-meaning but uninformed cleaning lady is soothing our Shouter with candy. Everyone has to be part of the team.
It is also essential to work with the patient’s family. Let them know what you’re doing and why because, ideally, they should be part of the team as well.
Communication between shifts and disciplines is one of the more challenging aspects of working with psychological issues in a nursing home. In my “fantasy nursing home,” psychological issues are communicated along with physical problems at the change of shift. The nurse outlines the plan of action for a particular resident, and all staff members involved, regardless of department, would be asked to attend that part of the meeting. Staff members do not necessarily need to know details about why a particular patient is having problems, they just need to know their part in the plan of action.
Another possible communication method is to keep a log of plans, or “contracts,” in an accessible location. The contract consists of an outline of the resident’s problem behavior and the reactive or proactive steps the staff should take in dealing with it. Contracts are used with alert residents as part of an effort to encourage them to participate in their own treatment plan. For example, a Call Bell Abuser who uses the call bell 15 times a day might sign a contract that says that, if he drops the number to 10 (and then to 5 non-emergency uses, after the first contract is successful), he will be rewarded. A “call bell use” log could be kept next to the call bell, with a pen attached, for ease of tracking. The resident and team decide together on a reasonable reward, such as extra time with a favorite staff member, or a treat from the store.
Another option is to offer special inservice training by the psychologist to help staff members establish and implement the plan; this training could be videotaped and then shown to different shifts. Further, you might include in the care plan meeting the psychologist and staff members who are in closest contact with the resident. You might also consider posting the guidelines of the plan in the resident’s room for easy reference. It is likely that some combination or variation of these methods will work within your facility.
Unlike the Shouter or Call Bell Abuser, who disturb the staff with myriad problems, there are residents who continually ask for help with one particular issue that may or may not be legitimate. I have seen patients report a problem and then not have it addressed because it falls between the cracks, or is difficult to resolve and requires efforts by multiple departments, sometimes repeated efforts, to address it. Such a resident is often labeled as a Complainer, and his or her requests are no longer taken seriously. Remember, just because someone is a Complainer, it doesn’t mean they have nothing to complain about!
I often find that, if an ongoing complaint is taken very seriously, even if it is not resolved, the resident reaches a turning point and decreases the level of complaining. For example, Sylvia was upset that she wasn’t getting exercise in rehab like she used to. She raised the issue continually, and started to refuse other parts of her care, such as showering or even getting out of bed, because she felt that staff members weren’t taking her seriously. In fact, Sylvia had been scheduled for PT before but had refused to go, and the therapists were legitimately reluctant to bring her in again. It was also likely that she didn’t qualify for rehab any longer. None of these facts diminished her complaints. The intervention in this case was to have someone from physical therapy come up and “evaluate” her, and give her “dynaband” devices and exercises she could use on her own, if she were so motivated. As it happened, her motivation lasted only a couple of days, but she felt listened to and taken care of, and she started to get out of bed and to shower again.
As with many of these problems, the ostensible complaint was not really what was bothering Sylvia, it was that she was feeling neglected. The intervention worked because it met her underlying need for attention.
As the caregiver on the other side of these resident outbursts—never an enjoyable position—it helps to remember that: (a) this is not about you personally, and (b) if you allow the resident to vent her feelings without becoming defensive about it but instead try to respond to the underlying needs, you will go a long way toward assuaging her concerns regarding her safety and care and reduce the chances that a real call for help will go ignored.