The COVID-19 pandemic is a strange and difficult time for long-term care residents. There is a lot happening in their environment that is unfamiliar, and nurse leaders have the difficult job of ensuring residents’ physical safety while also addressing the importance of combating resident loneliness. Leaders have to adapt, be strategic, and find clever ways to engage residents. Joan Devine, RN, director of education for Pioneer Network, offers some insights, resources, and ideas that nurse leaders can utilize to improve person-centered care and resident well-being during this time.
The challenges isolation and Personal Protective Equipment (PPE) present
When asked how social distancing and isolation has impacted residents, Devine says, “It really depends on the individual, because we all have our preferences in terms of socialization and what our needs are, and what our comforts are. I think for the most part though, it has been pretty devastating. It can be lonely enough living in a traditional nursing home. That loneliness is absolutely exacerbated by the fact that physical contact is limited right now. Residents are stuck in their rooms. Imagine staying in a 300-400 square foot room, and that’s your world right now. You’re used to going out and playing bingo or having meals with your friends. Even if you are a mostly solitary person, just that contact, even a little bit, makes a big difference. And certainly, the families not being able to be there or to give their family member a hug is incredibly difficult.”
Having to stay in their room is not the only new situation residents have encountered. The staff they engage with are dressed in PPE, covering their faces and making communication a challenge. Devine notes that PPE can affect residents differently. For example, “To a person with dementia, when you enter their room all covered up, that can be scary to them. We look to people’s smiles. We look to their facial expressions. So much of communication is nonverbal, and yet our nonverbal cues are very much camouflaged in this type of a setting. They are hidden behind masks and gloves. Plus, you have the added dilemma of residents with hearing deficits who may find it hard to hear nurses through a mask. PPE might not directly cause loneliness, but it certainly can cause a feeling of isolation and an impersonal atmosphere.”
Devine believes that nursing homes and assisted living communities where residents and staff have a closer connection are going to fare better during this time, because when residents know the staff members who care for them and they have a more personal relationship, they adapt better to a changing environment, “If I know you and I have to see you with a mask on, it’s probably going to be less intimidating than if it’s a stranger behind the mask.”
Creative engagement ideas and bringing the community together to help
To overcome the isolation that residents are facing, many nursing homes and assisted living communities have implemented creative ideas for engagement. “We’ve seen window visits, a hug wall, hallway games, doorway bingo, and social distance singalongs—they are finding ways to bring residents together so that they can see each other, even if they can’t physically interact,” said Devine.
Another fun activity shared with Devine by the team from Longwood at Oakmont, a Presbyterian SeniorCare Network community, is a program they call “Adopt a Plant: Cultivating Happy Hearts.” Devine says, “An on-site therapist came up with the idea, because one of the other issues that is a side effect of isolation and is common in nursing homes is immobility. People don’t get up and walk around enough. So, their therapist came up with a planting program. They bring all of the items the resident needs to their room—a pot, dirt, a small shovel, a plant. Some of the tasks the resident does for the project require them to stand, so the therapist is looking to help maximize mobility while the resident is doing the activity. Then, they ask residents to put a word on the pot that has a special meaning to them, such as kindness or happiness. When they are finished, they are going to plant the residents’ finished projects outside and put stakes by each of the plants with the word the resident associated with their plant. They are building something that is helping with functional mobility, it’s creating some great opportunities for engagement, and it’s helping people carry on. There’s something enduring about it. It is a very simple, yet powerful idea. And it represents spring, which makes us think of a time of hope, and there’s something good in that message, too.”
Maximizing the quality of tasks and staff interactions
The planting idea is part of a larger concept of staff maximizing the quality of their interactions with residents. Devine says that nurse leaders should emphasize this idea with their staff and have them ask, “If my time is limited with a resident, which it is—I’ve had to put on all this PPE, and it takes more time to get from room to room—what am I doing while I’m there in the room with the resident to provide an enriching experience? Am I just taking the resident to the bathroom? Or am I spending just a little bit of time to have a conversation with the resident to help them socialize a bit?”
Devine notes that the nurse leader also plays a role in how staff approach residents, not only during the pandemic, but at all times. “If the nurse leader is focusing on just the task and the staff see that, then that’s the message they are sending to their team for how to approach residents. Instead, nurse leaders need to talk with staff about how to maximize engagement and not just focus on the task. They need to figure out how to make every experience staff have with residents a meaningful experience that achieves multiple goals, and they need to lead by example by showing them how it’s done.”
Pioneer Network’s Free Resource Library
Devine’s organization, Pioneer Network, developed a creative solution for nursing homes when COVID-19 was just beginning to spread. Devine explains, “One of the things we did with Pioneer Network when the pandemic started was we asked what we could do to support providers and decided to add a category to our Resource Library called “The ABCs of Combatting Social Isolation”. Providing opportunities for networking is one of the things we are most proud of as an organization. We bring people together to help each other.” The contributions to the ABCs of Combatting Social Isolation are all free resources, available to anyone, and have come from organizations and individual providers who share the common goal of supporting engagement through this period of isolation.
“In the ABCs of Combatting Social Isolation, we have links to several community connections, which have some wonderful resources from the arts,” says Devine. “For instance, there’s a group of professional performers who have put together special concerts, specifically for nursing homes, called ‘The Bridge Virtual Concert Series.’ These are all available for free under the subsection titled ‘Community, Connection and Creativity.’ There are creative arts projects that residents can do. Other resources address how to help people with dementia during this challenging time. The National Certification Council for Activity Professionals (NCCAP) has put together a number of helpful activity resources.” Nurse leaders can review the opportunities listed in the Resource Library and work with their staff, including the life enrichment teams, to identify safe, entertaining, and meaningful activities to offer their residents to help reduce isolation.
Nursing Homes and Assisted Living Communities are using technology as an isolation antidote
Technology has been a saving grace for many residents and families during the pandemic, and communities are embracing it. Being in a situation where technology is almost a necessity has challenged old views about technology and older adults, says Devine. “We’re finding that technology works for elders better than we thought it would. We wouldn’t even try it in the past. We had a pre-conceived notion that those who are older or are living with dementia don’t use technology and wouldn’t be able to figure it out. And yet we’re learning that’s not true.”
Devine mentions several technology resources to take advantage of and try out. “Some nursing home and assisted living communities are using platforms like Zoom meetings, Facebook Messenger, or Skype to help residents talk with their families. I think those who have an internal TV station are doing great things, too. There are also companies like TouchTown, Linked Senior, iN2L, and Eversound that have technology solutions. For example, Eversound has an incredible headset piece that allows residents to hear a specific staff member. Cedarhurst of Des Peres, an assisted living community in the St. Louis area, does social distance walks with their residents with the headsets on so they can stay far enough apart, and their team members can guide the walk, while having music playing to make it entertaining so the residents don’t feel as isolated.”
When asked how the residents do at incorporating new technology devices, Devine says, “I have seen residents use headset devices very well, even virtual reality and 3-D technology. Many individuals come alive with those types of interventions. I don’t think older adults are as afraid of technology as we think they are. I really don’t. You just have to give it a chance; you’ve got to try it.”
Virtual reality and other technology tools create a unique engagement idea that can help with memories, too. Devine adds an example, “Even having someone go to Google Earth and explore where a resident used to live can be an engaging activity.”
In Pioneer Network’s Resource Library, Devine says nurse leaders can also find helpful technology resources for their staff. “Lifespan of Greater Rochester and the team from the National Association of Activity Professionals (NAAP) have provided several resources such as Technology How-To Videos. This is all new, and we’re assuming that every activity professional knows how to teach others how to use social media, but first they have to figure it out themselves. These videos can help with that.”
If staff don’t have a lot of time to teach residents, there are also solutions such as those provided by TechPals, which is offering free over-the-phone training on activities such as accessing digital books online using a library card or how to use video chat to communicate with loved ones.
Taking care of isolated staff helps residents too
It’s a difficult time for staff, some of whom feel isolated as well, acknowledges Devine. “Our caregivers are incredible, and unfortunately are not getting the credit for all that they are doing in the midst of their own pain and their own challenges. A lot of them are suffering from loneliness too, because they are having to socially isolate from their families in order to be there for the residents.”
As a nurse leader, Devine says it’s important to talk about staff struggles, because how staff are feeling can affect the quality of resident care they provide. “Take time to listen. Do you sit down with your team and just ask ‘How are you doing? How are things at home? Have you been able to give your kids a hug?’ We need to take care of them, so they can take care of the residents.”
Devine offers another resource for nurse leaders to take into consideration to help them lead the way if their nursing home or assisted living community would like to commit to a culture of person-centeredness (with both staff and residents) during the pandemic. “In the Resource Library, under Culture Change Basics, there is a document called ‘Nurse Competencies for Nursing Home Culture Change,” that outlines competencies that nurse leaders can incorporate into their practice and which will help them as they implement change. Among the competencies are modeling, teaching, and utilizing effective communication and active listening. I think it’s more important than ever that leaders engage their team. People are afraid. They don’t know what to do. They are working with fewer staff in many cases because people are out sick. This is not a time to be heavy handed. This is a time to be understanding, to be a part of the team, and to show staff how to support each other. Practicing person-centered values and showing them in your interactions with your staff can help you start changing your culture and become more resilient.”
The pandemic as an opportunity to model leadership
Nurse leaders need to be a role model during this time, says Devine, “They need to be that voice to bring common sense and reason into daily communication. They need to listen to the caregivers and the CNAs who are going in and out of the residents’ rooms, even far more than the nurses sometimes, to understand what’s happening. It’s so critical right now to know how residents are doing.”
As the nurse leader, Devine says you have to engage the team and allow them to help you solve difficult problems. You might ask, “How do I share a difficult message with a family when that family member is just angry because they are hurting because they can’t come and visit their mom? Do I call them a complainer in front of my team, or do I sit down with my team and ask them to help me figure out how we can reach Mrs. Smith’s daughter? How can we help her see what we are doing for her? Should we send her a picture of the staff engaging with her mom so that she can see how we care and what we are doing?”
“Leaders sometimes don’t stop and think about how what they say and what they do affects outcomes.” Devine clarifies, “As a nurse leader, you’re being watched all of the time. If you’re angry and you’re being resentful, and all you can see is the list of things that need to be done, then that’s showing where your priorities are to your staff. Nurse leaders have incredible hearts, but sometimes, we can get caught up in the business and the stress of the day. Afterall, we’re all only human. As leaders, we have to make sure that the heart is shining through. This is the residents’ home, and it has become a challenging place to be for both residents and staff, but we’ve got to make it the best it can be.”
“It’s time to make sure you’re comfortable being that leader,” urges Devine. “This is an opportunity to make a difference, and I think that’s truly what most nurses really want: to make that difference and give the best they can. To prove that care is more than just passing a pill, it’s caring for human beings—for the whole person—and this situation is bringing that out.”
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