Promoting staff teamwork to improve quality of care: the regressed residents found so typically in nursing hones require more than "everyone doing her job."

The regressed residents found so typically in nursing homes require more than "everyone doing her job"

With the numerous changes in extended care now highlighted by the OBRA regulations, perhaps none is as significant as the current emphasis on the issue of quality of life.

For practitioners in the field of extended care, quality of life has always been an influence in all that we do for the resident. We pay close attention to the furnishings and atmosphere of our facility, accommodate dietary requests, and plan special activities toward this end.

Indeed all of these efforts do enhance the quality of life for the resident who is out of bed, has good cognitive skills and is able to attend special activities. There remains, however, another type of resident who does not receive full benefit, and requires additional measures. This is the regressed, or "frail," resident, an individual often excluded from the mainstream of facility life.

In her article "Psychological Adjustments Associated with the Aging Process," Cox describes a theory of isolation in the aged, aptly labeled "disengagement." In this theory, the aging individual begins to decrease social contact with others, usually following retirement. The individual may develop new interests during this period, but the interests are often of a personal rather than a social nature. In short, a certain degree of social isolation is often self-imposed by the older individual. Coupled with the effects of illness and debilitation, the result is often the socially and emotionally regressive behavior of residents our nursing home staffs witness so frequently.

In the past, lines of responsibility for the interdisciplinary care team members were clearly drawn. In a system of multidisciplinary care planning, nursing addresses issues of physical care of the resident, physical therapy addresses issues of ambulation, recreation focuses on issues of social and intellectual stimulation, etc. With OBRA regulations, however, a holistic approach is indicated in determining a plan of care.

Under these regulations, a strong emphasis has been placed on resident care conferences, the goal planning process and team approaches. All facets of the resident's life must be examined in arriving at a plan of care. In determining goals, the team must look at each segment of the resident's life and note where the deficits occur. Team members must then determine their involvement in achieving the goals.

For the regressed resident, confusion is often the source of many other problems. A resident who is confused can be at-risk as a result of wandering or can be combative. The confused resident may forget to eat, which can lead to such medical problems as malnutrition, dehydration and skin breakdown. Confused behavior can also manifest itself through episodes of crying, shouting and agitation.

Team goals must therefore be designed to alleviate confusion as much as possible. One team goal might read "Resident will show increased awareness of self and surroundings through participation in a weekly sensory stimulation program." If the goal is to decrease undesirable behavior, it could be written as "Resident will have fewer than three episodes of crying and agitation/week through participation in a weekly sensory stimulation program." Each goal specifically identifies a behavioral outcome that the team is seeking, while making the goal measurable to meet regulatory guidelines.

As a practical matter, however, while this goal may meet appropriate documentation criteria, it will become the sole responsibility of the recreation worker unless all members of the team reinforce it. For example, the social worker can reinforce a sensory stimulation goal during visits with the resident by utilizing tactile stimulation, reality orientation, or reminiscence as part of the visit. Similarly, the dietician can reinforce this goal through simple questions during meal rounds, such as "What are you eating?" "Have you ever eaten this before?" "Is it sweet or sour?" etc. The judicious use of questions during routine care by the nursing staff ("Is your bath water hot or cold?") can also reinforce a sensory stimulation goal.

Another problem common to regressed residents is that of poor dietary habits and low body weight. In the past, this was viewed as a dietary problem and was solved through a high-calorie diet. Through the new regulations, this becomes a team problem and requires team problem-solving. There arises a need to devise a team goal, such as "Resident will consume 75% or more of each meal and will gain 1 lb. per month for three months." A goal such as this again permits all disciplines to be involved in its realization. The recreation worker can assist by encouraging the resident to eat in a social setting (such as at a party). The social worker can be involved by using meal time as a time for one-to-one interaction with the resident. Nursing can be involved by cueing the resident during the meal and providing assistance as needed.

In sum, the extra attention provided by the staff as a whole can be the motivational tool needed for promoting better nutritional habits for the regressed resident.

Mutual Support

Often overlooked is the role of the nursing staff in assisting with goals established by other disciplines. As mentioned, nursing staff has the primary responsibility to provide physical care for each resident, but may often feel that there is little that they can do to carry out the goals of another department, such as recreation or social service. In the book Behavior Modification and the Nursing Process, Berni and Fordyce note that the nursing staff can become constructively involved in the work of other disciplines by "keeping the therapists informed regarding the patient's behavior during the time that the therapist is off-duty." Keeping a well-maintained line of communication between all three shifts of nursing staff and the other disciplines will further enhance the team goals and objectives of quality care.

But as the nursing staff is expected to reinforce the efforts of other disciplines, it follows that other disciplines must now reinforce the work of the nursing department in attaining patient goals. An example of this would be a goal for the resident who is incontinent. A suggested goal might read "Resident will experience no more than three episodes of daytime incontinence per week and will participate in a bowel and bladder training program." As with the previously stated dietary problem, it was easy in the past for adjunct disciplines to acknowledge this as a "nursing problem" and to remove themselves from its resolution. With the new OBRA regulations, this becomes everyone's problem and demands a team resolution.

Reinforcing the use of the call bell during one-to-one time can be an approach for the social worker. Reality orientation by the dietician during meal rounds can also be utilized as a means of reaching this goal. Similarly, physical therapy can schedule treatments around the training program sessions of a bowel and bladder regime and can take the resident to the bathroom when the resident asks. A recreation approach for this problem may include activities which provide intellectual stimulation and increase the resident's awareness of self and surroundings. Additionally all members of the health care team can use reality orientation technique as a part of their approaches for this patient.

Utilizing the Paraprofessional 

Staff

Another valuable resource that is often overlooked in carrying out team goals is the use of paraprofessional staff. Housekeepers, dietary workers and nurse aides often have strong ties to the residents, and yet are almost never informed of team goals due to a concern of violation of confidentiality. Housekeepers often have strong personal relationships with the residents whose rooms they clean. Similarly the nurse aide often knows the resident as no one else knows him or her because of the extremely personal tasks that the aide assists the resident in achieving e.g. dressing, bathing, feeding, etc.).

In her article "Who Provides for the Nursing Assistant?" LeSar notes that |nursing assistants deliver 90% of nursing home care and comprise 43% of the nursing home staff.' Yet frequently team goals are not shared with these vital team members.

Paraprofessional staff can and should be informed about some of the team goals - and this can be done without violating patient confidentiality. A housekeeper can be told that a patient needs to be encouraged to eat properly without being told of the nature of the resident's diagnosis or the source of the problem. Input from the aide in planning a bowel and bladder training program can lead the team to planning goals that are, in fact, achievable.

The team leader, whether it be a registered nurse or other designated team member, has the responsibility to inform the paraprofessional staff about goals when their input is needed. Not only does this extend the work of the professional staff but it assists in team building among all members of the staff.

The Family

Families who have provided loving care for years must not be excluded from the planning process now that their family member no longer lives at home. However, the staff frequently sees the family as intruding and staff members often feel that only they truly know what is "best" for the resident.

In his article "UPDATE: Family Involvement in Long-Term Care" Gross examines the ongoing conflict between staff and family. He notes:

When we as workers in long-term

care speak of family

involvement, is it our intention

to serve the families who need

our help with the care which

has always been their

responsibility ... Are we helping

the families or are they

helping us?

While new regulations can mandate that families be invited to patient care conferences, they do not specifically mandate, that the family has to have any involvement in the team goals. And yet, paradoxically, family involvement benefits the staff and the family as well as the resident. In the case of the regressed resident who is unable to express himself, the family can provide information that may be the key to goal resolution.

Therefore, in spite of staff feelings of territorialism, the family must also be viewed as part of the planning team. The family member who complains that nothing is being done to help her family member gain weight might benefit from a meal time training program. This would enable her to see what the staff actually does to alleviate the problem. Meanwhile, if the same family member is asked what she did when the resident was still at home, the staff may learn new techniques in dealing with this resident. Seeing day to day care and being involved in it when possible may not end all family complaints, but it often can lessen some of the guilt that is usually the source of many complaints.

When the staff learns to view family input as valuable, the resident can only benefit from the atmosphere of mutual cooperation. Gross further notes:

The goal is not to win the

exclusive privilege of determining

what is in the best interest of

our residents. The challenge,

rather, is to learn from families-the

socially evolved caregivers at

the aged-how we can assist one

another in fulfilling this role.

Such learning can only occur in

the act of sharing the care.

Using the family as an educational resource and a part of the planning team can only enhance our efforts.

Conclusion

Team care planning can be a source of enhancing the quality of resident life if all members of the team reinforce clearly defined goals. Professional staff as well as paraprofessional staff can work together to reinforce each other's efforts. Goals should be seen as no longer multidisciplinary, but rather interdisciplinary, if they are to be achieved, and thus promote the quality of life of the regressed resident.

Emma M. Forsythe is Director of Therapeutic Recreation at the Kane Regional Center, McKeesports, PA.