Gerotalk

Increasing the Social Emphasis to Override Mechanistic Clinical Standards

2008-07-10T14:22:00Z

To be old is to be demented, and this statement especially sounds in clarion fashion when dealing with older adults in long-term care settings. Yet, although many take this statement at face value, in reality one must pause with concern due to the widespread acceptance of such stereotypes.

Regardless of how many professionals who deal with the elderly in all phases of health care, including long-term care, consider themselves enlightened and immune toward stereotypic misconceptions, clinical thinking about old age is still filled with misconceptions that often lead to faulty diagnoses. Since the predominant features of long-term care continue to be strongly entrenched in dealing with pathology, often at the exclusion of the social individual, those who are responsible for addressing the social needs of older adults, those involved in "social" work and "social" services need to become vanguards toward making sure misconceptions do not come to minimize the quality of existence of the elderly in long-term care.

Human beings are social individuals, yet as we age or as people enter institutional settings they often are treated quite mechanically, similar to machines that wear down. In fact, at one time this analogy on the pathophysiological level, called the wear and tear theory of aging, was given strong credence toward explaining older adults (Christiansen & Grzybowski, 1999) However, although more recent scientific discoveries have failed to lend credence to this theory, it still comes to hold intuitive appeal toward dealing with aging and issues found in older adults. One can see how misconceptions and variable levels of dehumanization can emanate from viewing older adults and their bodies quite mechanically in the clinical realm.

Furthermore, long-term care environments such as nursing facilities continue to remain quite institutional. Even with the Edenization movement led by William Thomas, most nursing care facilities continue to be institutional environments that do little to nurture the important social qualities that create the social individual and separate the social person from being a mere biological entity (Thomas, 1996). Nursing care facilities continue to be "total institutions," which subordinate the older adult's social existence to the clinical mechanics of palpation and auscultation and allow very little room for older adults to grow and express their unique human qualities as individuals (Goffman, 1961). Moreover, often the paternalistic attitudes found by staff in these institutions further enhance the disempowering self-esteem that older adults come to feel about themselves.

In the first paragraph I mentioned that one of the egregious misconceptions about aging is that dementia is inevitable. Although many people, including medical and long-term care professionals embrace this simplistic and stereotypic thought pattern, it leads to problems that are compounded beyond the mere stereotype. Most individuals who are older adults as a whole do not encounter dementia and only approximately 25 percent of memory issues can be attributed to aging itself (Garavaglia, 2007).

Furthermore, even though individuals in long-term care environments face a greater probability of having an organic brain pathology such as various forms of dementia, patients who are part of long-term care environments are often "assumed" to have various levels of cognitive impairment. Therefore a norm of cognitive impairment comes to dominate the staff's perception of how they come to view older adults. In reality, this view is just an extension of the norms in general society that have typically assumed older adults as slower in their thinking abilities and are likely in the throes of senility. Most of this is based on a poor understanding of the aging process and an inability to distinguish between what I term the senescence versus senility error, with the former indicating normal aging versus pathology indicated by the later.

If we put together the probability of dementia increasing with age, and add to that most people in nursing care facilities usually have considerable levels of chronic medical conditions, compounded further with stereotypes that assume inevitable and pathological cognitive decline, we now have a labeled population situated in an institutional environment with its own labels that envision any kind of forgetting as a sign of brain pathology. However, although many manifestations of dementia are indeed truly biological pathologies, some are not, and this is where the labels and stereotypes can lead to self-fulfilling prophecies that may influence faulty diagnoses.

It must be remembered that boredom, lack of sensory and mental stimulation, depression, metabolic instabilities, the increasing number of medications used among this group, as well as a host of other conditions can lead to memory disturbances and other cognitive symptoms. When these symptoms are found in younger populations they often lead medical staff to assume some underlying pathology causing the cognitive changes. However, with older adults, it is often assumed that this senile or disease based symptom is part of normal aging or senescence, or again the senile versus senescence error. When an elderly person experiences these cognitive changes in long-term care facilities the likelihood of stereotypes and the self-fulfilling prophecy that they carry frequently lead to labels of dementia with very little further investigation into whether it is truly an organic cognitive pathology.

Where does this lead us to this point in this analysis? For one it is evident that older adults still face a considerable level of discrimination and subsequent stereotypes and labels or what Butler (1969) came to refer as "ageism" that creates a false understanding of this population. Furthermore it has been explained how these stereotypes are accentuated in long-term care facilities, which further can lead to faulty clinical diagnoses and cognitive profiles. Finally, when individuals are placed in a mechanistically clinical environment that fails to nurture their social needs, regression of their holistic existence, including their cognitive abilities, can decline quite precipitously.

Therefore it is at this point evident that there needs to be individuals in a long-term care environment that can understand the implications for nurturing the social and not just the physical being. It is here that the "social" worker (I use this term loosely, meaning that it can be not just a degreed social worker, but all clinicians that focus their needs to the social aspects of the individual) needs to be more than a clinician involved in taking psychosocial histories.

Those involved in the social services and social work area of long-term care have to understand the problems that are faced by older adults in these types of environments. They need to play a key role in making sure that older adults are not pigeonholed into neat and convenient diagnostic classifications without assisting and advocating for a greater holistic understanding and investigation into the older adult's condition. It is at this point that social services personnel responsible for social intervention, which does not necessarily have to be relegated to just the social worker, becomes the priest of the social soul of the older adult. With so much emphasis on the mechanistically and often depersonalizing elements of clinical medicine, there has to be individuals that remain focused on nurturing, maintaining and enhancing the social being. Again, ultimately there needs to be an understanding of the importance for all individuals in long-term care to nurture the social being of older adults, including those who are clinically involved with their biological functioning. They should not see themselves as any less absolved or responsible for nurturing the social self.

Therefore now is the time for the social paradigm with its "social practitioners" in the long-term care settings to become increasingly involved in the medical environment as social medicine specialists. Paying attention to the social and emotional development of the person, being sensitive to areas of social regression, and understanding how to enhance the lives of older adults in an often sterile, physical environment can only lead to greater pleasure for the elderly that they service and help enhance their very important niche in this important area of healthcare.

References

Butler, R (1969). Ageism: Another form of Bigotry. The Gerontologist, 9, pp. 243-246.

Christiansen, J. L & Grzybowski, J. M (1999). Biology of Aging, McGraw-Hill, New York.

Garavaglia, B. (2007). The Pitfalls of Diagnosing Dementia: Looking beyond Patient Age. Long-term Care Interface, July/August, 2007, Vol 8, No 4, pp.46-48.

Goffman, E. (1961). Asylums: Essays on the Social situation of Mental Patients and Other Inmates. Doubleday Anchor, New York.

Can Apples & Oranges Be Compared?

2008-06-30T14:20:00Z

The Bush administration advocated the need to rate nursing homes on a similar ranking system to that found in the hotel and restaurant industry. At first blush this seems an intuitively simple and consumer friendly system. Why not have consumers that are looking to place their loved ones in nursing homes have a simple system of one through five stars to help with their search. It appears to be a completely simple and adequate system that can be put in place quickly to assist the public with nursing home quality. However, remember when your algebra teacher said you cannot add apples and oranges? Can the rules be overlooked here? Can nursing homes be ranked similarly to hotels and restaurants? I think this question begs further consideration.

Currently there are a number of tools that are used to rank nursing homes. Probably the best known is the Medicare site that compares nursing homes on the basis of their number and type of citations. The information for this site is compiled from surveys of nursing homes conducted by surveyors. Yet, what is known about the system as it exists is it is far from perfect. In fact, there is a considerable level of subjectivity that is found in the survey process. Surveyors often make judgments about facilities prior to entering the facility. Furthermore, there is considerable variation from one surveyor to another as well as from one survey team as compared to another. In addition, states demonstrate a considerable level of variation among their surveyors. Surveys and the level of stringency found to exist in the survey process from one state to another differ considerably. Therefore, the system as a whole is filled with considerable variability that often is difficult to account for and would dramatically influence a supposed standardized rating system.

Another problem that exists is that hotels and restaurants do not have to rely on Medicare and Medicaid funding, or other third party funding, as do most nursing care facilities. Consumers in these other industries often pay up front with a fee set by the establishments. This allows hotels and restaurants to know their revenues and cash flows up front. However, in the nursing home industry, state and federal entities and third party insurance regulations place great restrictions on what earnings are actually realized. Most nursing homes operate on very small margins and therefore, many fail to have the funds to engage in extensive renovations as well as have the comfort to pay out large amounts of money for extensive and specialized staffing. In fact, there is also considerable statistical variability between nursing homes and the companies that own them, with larger companies often able to incur much greater capital expenditures to achieve the homelike environment that many seek.

So you may ask, what does all of this have to do with ranking nursing homes? As I hope has been illustrated so far, the complexity for a simple rating system is simply, not that simple. Even with hotels and restaurants, this simple five star system is not so simple. First, how many of us have been in supposed five star restaurants and hotels, only to come away quite disappointed in the food or service we encountered. Also, how many of us have come away saying that I wish I would have went instead to the smaller community restaurant or hotel where I get better quality and more food to eat for the money or better and higher quality customer service.

Yet, these hotels and restaurants, which are smaller and less spacious, are often viewed as the red-headed stepchild of the hotel and restaurant industry, especially when compared with their four and five star competitors. The same holds true for the nursing home industry, where the commodious environment of new, modernized, and large-scale facilities hold a primacy effect on those that rate these facilities.

For a true nursing home rating system to work, the rating system must be multifaceted and use many different indices for measurement. If the rating system is only going to be based on facility survey results, a less than true picture of the facilities that are being rated will result. This is not to say survey results should not be used. For sure survey results are an important indicator of the health of a nursing home facility. However, as was mentioned above, it does have its flaws and our current survey system, which has improved over the pre-OBRA years, is still predominately a subjective system. So with the subjective nature of the survey process, coupled with considerable differences found among state survey agencies as it relates to the level of nursing home survey stringency, other factors have to be considered in ranking nursing homes.

One important consideration is the type of people working in the facility and not just the number. Often, facilities are examined for having an adequate number of staff to residents. However, the quality of the staff is also important. What is the level of training, years experience, education, and level of specialization found among nursing home staff. Just as hospitals are viewed as progressive environments, predicated on the quality of their staff, so to should nursing care facilities be examined in the same manner.

In addition, how does acuity play a role in rating nursing homes? For instance, a facility that provides more extensive and intensive services such as bariatric care, dialysis, or ventilator care often have more critical residents with concerns that are more easily targeted during the survey process. However, they also typically have a clinical skill base that is higher as well. This also needs to be factored into the rating system of any nursing facility.

Moreover, is the nursing care facility a learning, teaching and training environment? Is it a place for training physicians, nurses or other long-term care professionals? Is research conducted among individuals within the long-term care environment? Is it a progressive environment that explores new strategies and techniques, especially toward advancing the care of long-term care residents? Many at this point may be saying you have to be kidding; these are nursing homes and not hospitals. However, many long-term care environments are now involved in many of these areas as well.

There can be more that can be targeted in creating a nursing home rating system with greater levels of legitimacy to help assist consumer knowledge in this area. However, just using survey results is not enough and I hope I was able to emphasize the importance in creating a multifaceted rating scale for nursing homes. Furthermore, I hope I was able to demonstrate that creating a rating system for nursing homes, based on and similar to the one used in the hotel and restaurant industry, would be very difficult. These industries are apples and oranges, and as your elementary algebra teacher explained to you early on, apples and oranges cannot be added together.

That being said, a system of rating nursing homes can be created, however in doing so one cannot create a valid system that is overly simplistic and based on a one-dimensional scale of measurement. It must be a system that adequately captures and reflects the complexity of the long-term care environment. Because of the complexity of the systemic nature of long-term care environments, capturing the complexity in creating a valid rating instrument for measuring nursing homes will be more difficult than for rating hotels and restaurants.

For more information: New Rating System in the Works for Nursing Homes

Recognize Alzheimer’s as a Social Disease

2008-06-19T14:52:00Z

Alzheimer's Disease is a progressive and debilitating disease that often leads to a person's inability to understand and be aware of their conscious existence. As a disease it is incurable and due to its inevitable progression, leads to one of the most frightening human conditions that exists. However, Alzheimer's disease and many associated dementias is more than just a progressive neurological disorder. Too often long-term care professionals come to view this as a physical disease, a disease that disassembles that normal neurological structure of the cerebral cortex. However, in addition to the physical manifestations that are part of its pathology, it is a disease that leads to the destruction of the social soul, which behavioral scientists have often referred to as the self.

The "self" is a unique component of human beings. We are not born with a sense of self (Handel, Cahill & Elkin). Our sense of self emerges with our overall development. Individuals are born as biological entities with some primitive biological reflexes, but at birth we have no understanding of what we are and how we are separate and unique entities from our environment (Handel, Cahill & Elkin; Santrock). Therefore, at birth we are living and breathing biological entities but with no self we fail to hold many of the qualities that we come to equate with being "human." This is especially evident from many studies, both in humans and other primates that have unfortunately been victims of severe abuse, neglect, and isolation.

As individuals develop our sense of self through social interaction, we come to develop into social beings, or as Elliot Aronson has come to refer to humans as a "social animal."(Aronson) It shapes our consciousness, how we come to view the world and ourselves, how we come to think and feel about ourselves, and most importantly, how we come to obtain those traits that we come to view as making us "human." However, possibly the most important part of our sense of self is the concept of "reflexivity." This shapes our mind to come and view ourselves as an "object" to itself. As conscious human beings our ability to see ourselves as others would see themselves is critical.

For instance, we develop important emotions such as pride, envy, and embarrassment because we are able to see ourselves as an object, viewing ourselves as others come to see us. However, as those long-term care personnel who have worked with individuals that suffer from this disease know, as the disease progresses, many of the person's social skills rapidly deteriorate. Patients suffering from this disease fail to be able to view themselves as an object, and this is often found in many forms of social behavior becoming compromised, such as undressing in public or taking their teeth out and placing them on the dining room table while others are eating.

What is happening in these instances is they lose their ability for shame and embarrassment, higher level social emotions that requires the reflexivity of the self. These emotions develop when we are able to see ourselves as others do, and they allow most people to understand what is appropriate or inappropriate behavior in any given situation. With a sense of self, it allows us to understand what others expect of us and how others will view us if we fail to live up to the social norms of particular situations. The person with Alzheimer's disease, whose self is slowly dying, is unable to understand these implications.

Furthermore, it is also very frustrating for many caregivers and family members to watch, since most cannot comprehend why their resident, or why a son or daughter's mother or father, is unable to understand may of these simple social graces that most of us take for granted. They fail to realize that the disease is more than just biological, but with the slow death of self, the important social nature of the person, that which makes are truly human, is slowly degenerating as well.

Long-term care staff often face continued needs to address older adults with this disease and the antisocial behavior that is often found among these elderly as the regressive spiral leads to a infantile level of self-consciousness, which further leads to behaviors such as disrobing, wandering without any concern for themselves, or urinating in public places. What is happening here? Again, the self, which allows us to control our behavior by seeing ourselves as others do; the part of ourselves that is important for higher level emotions such as pride, envy, embarrassment, shame, empathy, and even love; the part of ourselves that is important for understanding social situations and expectations that others hold; is dying along with the neurological tissue.

This is often noticed by many who care for residents that suffer from this disease when they attempt to explain to those who suffer from the disease their socially compromised behavior and its antisocial manifestations. In the earlier stages of the disease the explanation does revive some remnants of the self, as is evidenced by the resident demonstrating some awareness of their social transgressions when they are made aware of them by the long-term care worker. However, in the later stages, as workers attempt to explain their behavior to the resident, the resident often will stare blankly at the worker, similar to very young children being reprimanded for inappropriate behavior, both of whom are not able to understand the consequences of their actions due to not having the appropriate requirements for a truly social self.

In the child's case, their self will continue to develop and they will eventually be able to understand the social significance of their behavior. However, the person with Alzheimer's will never be able to understand the ramifications of their behavior and will only continue to spiral downward. For the child the self will mature and grow; for the person will Alzheimer's, the self will continue to regress and die. Therefore, Alzheimer's disease is more than a physical disease, but also a social disease, robbing the person of the essence of their humanity.

In summary, many individuals have come to view Alzheimer's disease as an exclusively biological condition. However, probably it most egregious impact is on the social nature of the human individual. With Alzheimer's disease comes the demise of what makes us human, our social self, and with it the ability to reflexively see ourselves as an object to ourselves. This becomes such an essentially important fact to understand about our human nature, and how Alzheimer's disease obliterates our human nature through its assault and eventual destruction of the self, that to not understand it leads clinicians and practitioners that deal with this population empty in their own right.

The implication to understand the social aspects of dementia, and the obliteration of the self, makes this disease as mentioned previously not just a neurocognitive disease but a social disease as well. The implications for treatment also should follow as well toward viewing it as a social disease with needed social intervention by long-term care professionals. Although biological treatments are still essential, by themselves they do very little to humanize individuals with these diseases that are ultimately so dehumanizing. Therefore, long-term care facilities must also invest more time in keeping those with this disease engaged in their social surroundings to slow and minimize the demise of the social self, the most egregious and frightening condition that is found in humans.

References

Aronson, E. (1980). The social animal. New York, Freeman Press.

Handel, G., Cahill, S., & Elkin. F. (2007). Children and society. Los Angeles, Roxbury

Publishing.

Santrock, J. W. (2006). Life-span development, 10^th ed. Boston, McGraw-Hill

The Psychology of Personal Orientation

2008-06-03T14:28:00Z

Health care administrators have to understand the psychology of the people that they interface with daily. A cooperative management environment is essential for the continuity of sound health care. However, to do so, administrators must understand something about the personnel psychology that exists among their managers and other workers. This is no easy task, since administrators are always dealing with individuals with unique personalities. Therefore it becomes necessary to understand the strengths and weaknesses of their personalities and tap the critical strengths found among these personalities to enhance the cooperative managerial climate within the organization.

Behavioral scientists have delineated four major types of personal orientations that exist and can have an influence on the work environment. The four types of personal orientations-competitors, individualists, cooperators, and equalizers-all hold significance in understanding the managerial science of cooperation in long-term health care. Competitors have an inherent disposition to compete and look to win at the expense of another's loss. Individualists are those that are concerned with enhancing their own self-interest, often at the expense of others. Cooperators are those that have a proclivity to maximize the outcomes of the group or team. Finally, equalizers are those that attempt to reduce differences found among the group (Greenberg & Baron, 2008).

A dilemma frequently exists for many administrators. The dilemma of "How does as an administrator bring the myriad of personal orientations together to establish a cooperative work environment" is one that can be bedeviling and quite frustrating. Since many personal orientations are well-entrenched into an individual's personality, leaving them with a predisposition to act in a certain manner, attempting to change a person and their inherent predispositions may be an impossible task. Yet many administrators nevertheless attempt to shape a person's behavior to their own ideals. To some extent there is nothing wrong with that since it is important for administrators to be able to get their managers and workers to believe in their vision. However, attempting to change them in totality can be an important error.

It is amazing the great deal of effort that administrators and upper level managers invest in attempting to change the personal orientation that others hold toward one that is more consonant with their own view. What usually results are administrators and managers becoming frustrated and brooding about why they cannot get others to be carbon copies of themselves. Some even become antagonistic and contentious toward those that fail to change their personal orientations. Therefore, many administrators attempt to manage different personal orientations by taking on an approach of "most resistance" rather than "least resistance." This is not often a sound investment of their management time and one that typically ends in fruitless efforts on behalf of the administrator to establish cooperative teamwork and work environments. Therefore the question that follows is how can one manage the diverse personal orientations that exist and do so in a manner that can bring reduced levels of frustration and enhanced productivity?

One important element in this question that needs to be understood is that attempting to completely change individuals to a personal orientation that you feel is consonant with what you believe to be correct is typically not going to happen. However, the administrator has to understand that given this different array of personal orientations, there will always be periods where tension may exist, and that aligning individuals that hold certain personal orientations with particular tasks may augment the productivity of your long-term care environment.

Therefore it is important to understand your people and know what types of personal orientations they hold that may potentially cause difficulties for you and your team, as well as if used judiciously to assist with certain tasks, may fit well with their personal orientation. For instance, competitors may not work well in the human resources role. In this role you often need a person that can help address conflict in a productive manner.

Competitors who are looking for wins at the expense of another person's loss, may be quite unproductive in this role for your organization. In fact, since this person often is needed to quell many types of labor issues, a person who takes on a highly competitive personal orientation may actually lead to heightened problems in this area. However, a business or marketing person who holds this same personal orientation may work quite well in their positions, especially since they are placed in a very competitive environment where complacency cannot exist.

What about the individualist? Individuals who have very high ratings in this area may be counterproductive for a team environment in totality. However, even within a long-term care organizational framework these individuals, if placed appropriately, can have a strongly productive impact on the overall framework of the organization. Since these individuals often like to work alone and have a strong concern about maximizing their own productivity, they often work well as schedulers and supply clerks. Their assiduous nature toward enhancing their own individual productivity works well in these areas.

Understanding personal orientations that people hold is crucial for creating a productive organizational environment. Understanding an individual's personal orientation and fitting them into the proper role is critical, and often this is a major role for administrators who are the leaders of the health care environment. Although, as previously mentioned, attempting to change personal orientations can be a fruitless endeavor, realizing and placing individuals in positions in which you are able to exploit their personal orientations is often much more productive and realistic in the long run. Although personal orientations are quite enduring, behavior itself is always a function of the person times their environment (B = P x E). Although most administrators or managers are not specialists in human behavior, you do not have to be to understand this simple principle.

So, one of the important questions that all administrators and managers should be asking themselves is, "Do I want to take on the path of most resistance or least resistance"? After answering this question the next question is "which path is often the most productive in dealing with personal orientations within a long-term health care environment"?

Again, attempting to shape and modify certain organizationally unproductive behaviors is needed. However, attempting to shape and modify enduring and intractable personal orientations is something different. The administrator or health care manager has to make this critical distinction. Moreover, learning to find ways that one can put these personal orientations to work for the good of the organization is critical. Good leaders either explicitly or implicitly understand this and they are able to complement the organizational environment by placing the right person with the complementary personal orientation in the correct position.

Therefore, well-oiled long-term care organizations have more than just people who are intelligent and skilled carrying out their tasks. These long-term care environments understand the importance of taking an inventory of personal orientations and matching their orientations to the correct position and tasks. This ultimately leads to an organization that can address issues by placing workers that have the correct dispositional strengths in the correct positions to deal with issues as they arise.

References

Greenberg, J. & Baron, R. A. (2008). Behavior in Organizations. Upper Saddle River, Prentice-Hall.

Trust Starts at the Company Level

2008-05-27T14:31:00Z

Team building is an important facet for an organizational environment. In a previous article I mentioned the importance of trust for team development. It was also mentioned that the facility administrator has to lead this effort toward establishing a sense of trust within an organizational environment. When trust fails to exist, workers look for other alternatives to assist with their perceived lack of trust in an organization, and one of these consequences may be worker unionization to compensate for a perceived lack of trust.

However, trust must not only be fostered within a particular organization, but it must also come for outside of that organization's environment as well. In today's world, many long-term care facilities are part of larger health care organizations or companies, which own and run dozens to hundreds of facilities in our country. For sound organizational development to exist, organizational trust must not only exist at the facility level, but also on the company level as well.

Frequently, I have noticed that many companies feel that they need to manage all facets of existence. In a previous post, Empowering Nursing Home Staff is the Key to Success, I mentioned that micromanaging leads to the disempowerment of workers. However, it also foments an organizational lack of trust. When the larger company acts as "Big Brother" to constantly oversee every facet of the health care environment, it instills in workers a level of uncertainty and apprehension.

Workers need to feel that they have the ability to be trusted in their duties. When companies lead by micromanagement, it is actually stating that workers cannot be trusted and a paternalistic influence at the company level needs to exist. This is very similar to what Douglas McGregor referred to as his theory X and Y workers. Although under theory Y the company often viewed workers more positively, those that adopted the theory X view of workers felt that they needed constant oversight because they were lazy and irresponsible. Micromanaging views the need for constant oversight of all its workers since it takes on a theory X view of workers. This inevitably instills a compromised level of trust built into the organizational environment.

So the problem that exists for many administrators is that at a time when they need to build trust within their management team and let that trust foster within the facility that they oversee, the larger mindset of the company itself may actually impede the development of trust. The organizational culture has to encourage trust, starting with those at the top, which in turn leads to a distillation of trust to the facility level, flowing subsequently downward to all the facilities and all their workers. However, if the facility attempts to develop a trusting culture and is impeded by the larger company's micromanagement landscape, a true development of cultural trust cannot and will not happen.

What comes to exist and what is created through micromanagement is what I termed the paternalistic organization. The facility actually becomes dependent upon leadership external to its boundaries. However, in doing this one must ask the question, "Who is the leader of the facility"? Paternalistic organizations, which many long-term care facilities exist as, frequently are pervaded with a lack of trust. And in asking why is this the case, the answer that comes forth is that without establishing trusting and accountable leadership within the facility itself, many individuals working in the facility come to wonder who is in charge and who will determine what direction that facility should move toward in achieving their goals.

Since the invisible hand of the company is guiding their many facilities, often in a generic manner, the administration in the facility itself often becomes a titular feature, disempowered with an inability to establish a trusting network among its workers. The workers look at the work environment in askance, viewing it as questionable territory if the leader is disempowered and controlled by forces outside of their control

The trouble that comes to exist is that trust needs to be established in an accountable source, which is typically the administrator. If administrators hold themselves to a standard of accountability, others come to view the organizational environment with greater stability. Enhanced organizational stability due to understanding that there is an individual that is leading with a solid standard of accountability helps to create a culture of trust within a long-term care facility. However, in paternalistic organizations the question of who is truly accountable is found outside the facility walls.

In addition to the problems mentioned above, paternalistic organizations are often immature organizations. Similar to individuals, organizational environments have a developmental or maturational level. When organizational environments are continuously dependent on others making decisions for them, organizational growth is thwarted and the autonomous nature of the facility fails to flourish, which in turn creates an environment that fails to have confidence or trust in their staff to make important health care related decisions.

Just as children have to eventually emancipate themselves and gradually move forth and establish a level of autonomy for healthy psychological development, organizations have to follow the same path for healthy organizational maturation. Yet, stifling organizational development through paternalistic oversight and micromanagement creates and infantilized organizational environment that is not conducive toward healthy work patterns.

If this type of dysfunction exists in paternalistic organizations, why do companies continue to create this type of organizational climate? Often it is due to their attempts to standardize the organizational climate. One can see that standardization is often an honorable attempt by many companies to provide the necessary structure and control over daily operations. However, this one size fits all strategy, along with the often anonymous outside control, breeds mistrust. If the foci of power and control fail to exist within the confines of the facility, workers will often question the legitimacy of the facility's administration.

It becomes obvious that an important element for a cohesive organizational structure comes from the establishment of a trusting work environment. Trusting work environments aid in organizational productivity in long-term care environments. Therefore it becomes imperative to establish a culture of trust, which helps to nurture a cohesion that is important for successful team building. However, trust needs to be established not just within the facility, but outside of the facility as well. With so many facilities being part of larger companies, the distillation of trust starting at the company level and moving downward has to be established.

I hope it has become evident that a company's cultural mentality to control all their facilities through paternalistic oversight in the long run actually creates an environment that is dysfunctional. As Gordon Allport has stated, trust is an important element of a mature and stable personality.

Organizationally speaking, the same holds true. Thwarting long-term care environments by establishing a micromanaged cultural climate in the organization actually creates a neurotic organizational climate in which trust is muffled and workers interact with anxiety and suspicion of the true motives of the organization. Since growth and empowerment fail to develop, both on an individual and organizational level trust will also fail to develop, perpetuating paternalism and reducing productivity.

Reference

Allport, G. W. (1961). Pattern and growth in personality. New York, Holt, Rinehart & Winston.

McGregor, D. (1960). The human side of enterprise. New York, McGraw-Hill.

Dealing with Problem Work Behaviors in Long-Term Care

2008-05-13T16:17:00Z

In the previous article, Problem Personalities can Lead to Workplace Turmoil, a few major personalities and their resultant issues were examined. This paper looks at personality problems, their behaviors, and how to address these issues in long-term care environments. However, before moving forth with this discussion, it must be stated that there are no full-proof ways that always work in addressing individuals with these problems. Yet, there are some major approaches or rules of thumb that can be used to deal with individuals that present these problems in the workplace environment.

In the previous article the passive-aggressive personality was mentioned as individuals that often engage in passive activities such as tardiness, lateness, procrastination, and obstructive efforts that are very disruptive to the workplace. What is interesting is that these individuals often enjoy the frustrating reactions that they provoke in others. These individuals will frequently manifest these types of negative and obstructive aggressive activities very early after being hired. However, because of the insidious nature of their aggressive behavior, failing to demonstrate the overt features of many forms of aggression, many individuals fail to pick up on the destructive nature of this type of behavior until it is too late.

Essentially, being aware of how aggression can manifest itself on a passive-aggressive level can be instrumental in ridding the workplace of individuals with these types of traits before they become part of the entrenched working environment. Since many long-term care environments are unionized and membership often is solidified after 90 days, picking up on these individuals early and weeding them out of the environment is imperative.

Furthermore, as was stated, these individuals often thrive on the response that they provoke in others. The reactivity from others that they achieve from their passive and obstructive aggressive activities feeds their personality needs. Although it is easier said then done, failing to be reactive, and failing to be taken into their manipulative web of passive aggressive tendencies often thwarts what they lust for most, the frustrating and over-reactive response from those that they aggress towards in a passive manner. Therefore, being firm yet non-reactive, will often help to address the concerns that this type of personality poses.

The narcissistic personality, often coming off with an over-inflated sense of self-importance, has a very fragile ego that often attempts to avoid any type of issue or event that may challenge their sense of self-worth. Their grandiose sense of self and exalted since of entitlement makes them an utterly individualized entity of pomposity. Here again, they are destructive to the larger team environment. They need to be reigned in quickly and their behavior addressed.

However, in addressing these individuals, it becomes imperative to not become overly confrontational. When this happens their delicate sense of self becomes insulted to the point that they lead a counter-attack against the person that is confronting them. They fail to listen to anything that is constructive and react to the apparent threat that is posed to their fragile sense of self. Therefore, addressing their behavior aggressively and confrontationally will only lead to a lose-lose conflict, leading to nothing productive for either party.

The paranoid personality is the third personality type that was mentioned in the previous paper and will again be addressed here. Their widespread suspicion of others, and their lack of trust make them a formidable challenge. Their maladaptive suspicious nature makes them feel that they are always needing to be on the defensive for fear that someone may unduly threaten them in a myriad of ways. Their lack of trust in their environment makes them react with accusations against others that may range from racism or sexism, to harassment or imputed violent accusations. Please do not mistake or misconstrue these statements.

I am not saying that all individuals that make these accusations as such have a paranoid personality. However, those with a paranoid personality will often assert these accusations when no firm reality basis for their existence. They engage in an autoplastic adaptation, which means that to deal with these perceived psychical threats they alter their perceptions to fit their ill-conceived mental constructs.

In dealing with the paranoid personality, one has to avoid engaging in a confrontational battle of trust. Since lack of trust and suspicion are the catalyst for their worldview, it becomes difficult, if not impossible, to make them the trusting team player that you need for success in your long-term care environment. It is often a terrible reality, but these individuals are often a highly litigious threat. They are just a slight push or pull away from filing suit over some issue. They need to be closely monitored and all your "i"s need to be dotted and your "t"s crossed in dealing with them. This is not to say that all individuals that present themselves in your organization with this type of personality will inevitably lead your facility to court. However, depending upon the level of their personality issues, the probability for such behavior does deserve watching and may even entail the need for frequent legal counsel to help address many situations that they will bring to your attention.

It becomes apparent that there are some very interesting, yet challenging, personalities that can wreak havoc on the long-term care environment. This paper reexamined three personalities from the pervious paper, but it looked at some further consequences as well as brief strategies of intervention that can be used to address these personality issues. However, this brief article far and away fails to provide a voluminous array of interventions that can be used. The topic and its complexity fails to lend itself to a complete discussion in the limited space available for this article. That being said, the reader should still be able to come away with a general knowledge and some rudimentary skills that can better enhance their ability to deal with these problem individuals as they arise in their long-term care environments. It is my hope that the reader will come away with a better understanding of individuals with passive-aggressive, narcissistic, and paranoid personality traits, as well as how to address these individuals and the many challenges they may present in long-term care settings.

Problem Personalities can Lead to Workplace Turmoil

2008-04-29T16:58:00Z

We are all quite different, and all of us come to the workplace setting with different personalities. Long-term care is no different. It brings individuals of different skills, education levels, temperaments, and in particular personality types to the organizational setting. Some individuals come in with a more introverted, placid personality, while others come to the milieu with a more extroverted, gregarious personality.

Furthermore, the adjustment level of certain individuals also demonstrates great levels of variability. Some individuals come to the workplace with a very stable personality while others have highly volatile, unstable personalities. It is addressing this latter element that will briefly be focused on in this paper. Whether we have come to be aware of it or not, many of the issues that are found in long-term care deal with addressing different personalities with varying levels of stability. So it becomes important to understand how certain personality characteristics can lead to problems that are found in the long-term care environment.

One personality type that often is found in organizational settings that leads to many problems are individuals that have a passive-aggressive personality type. In reality, this is not a current diagnostic classification in the Diagnostic and Statistical Manual of Mental Disorders. However, behavioral scientists are well aware of this personality and administrators and other long-term care professionals, some of whom may also harbor this personality, have witnessed the impact of this type of personality.

In fact, this is actually a type of aggression that is one of the most dangerous forms of aggression. This person is often the individual that is often agreeing with you while circumventing the organizational climate any time they get the opportunity. They will demonstrate a façade of feigned compliance when in reality they are contravening the organizational climate in their own manipulative ways. They are destructive to the team structure that is needed in a health care setting by superficially stating they are team players while they are at the same time attempting to split staff and drive a wedge in the team environment. The underlying aggressive nature of their personality is so insidiously subtle that is destroys the morale of others, fostering a consecution of destructive emotions in others in their immediate environment.

With the passive-aggressive personality instead of expressively asserting their aggression, they do their destruction by failing to do many things instead of actively or directly engaging in aggressive behavior. In long-term care environments these individuals assert their aggressive nature through being tardy or showing up late for work and their assignments, procrastinating on particular projects and tasks that need to be completed, or engaging in intentional forms of inefficacy. Since their passive-aggressive tendencies inflict pain to others that have to cover for them in their work, do the work that they continue to put off, or enhance their performance to make up for the reduced efficiency of the passive-aggressive person, it quickly leads to an epidemic dissatisfaction found among other workers.

The narcissistic personality is another personality that can wreak havoc among a long-term care team. Generally speaking, successful work teams in long-term care settings have to subordinate their own needs and interests to the interest of the larger team environment. This is very difficult, if not impossible, for the person who has highly narcissistic personality traits. The major reasons relate to the fact that the very traits that make up this personality type run counter to successful team building. These individuals often hold a grandiose view of their own self-importance. They are very individually centered, consumed and preoccupied with attaining their own success. They often hold strong feelings of entitlement, and furthermore they have an insatiable need to be admired. Moreover, their tendencies to exploit others to advance their own self-interests, express themselves in an arrogant manner, as well as being deficient in their ability to empathize with others, make them the ideal "anti-team" member.

As many of those who have worked in long-term care have witnessed, these individuals are also quite destructive toward enhancing a stable organizational environment. In any health care environments, where the emphasis has to be on the patients or residents, these individuals are so involved in their own self-aggrandizement that they lose sight of those who they are serving, as well as those that they have to work collaboratively with to achieve the results of the organization. Many of us have met physicians, nurses, administrators, therapists, as well as nurse assistants that have held this false sense of self-importance. Furthermore, many of us have witnessed the difficulty in working with individuals that exude such an exaggerated sense of self-worth.

Finally, many of those in long-term care have been on the receiving end of the narcissist's wrath when they have criticized these individuals. Because of the importance they place on their grandiose view of self-importance, they are very sensitive toward criticism that is directed toward them.

The last personality that will be discussed here is the paranoid personality. As is evident by its name this person has a widespread suspicion of others and their behaviors. They have great difficulty feeling secure and building a sense of trust with others due to their suspicions. They feel that others may be belittling them or engaging in unwanted attacks against their character. Often normal behavioral interactions that others place very little emphasis on will spur ruminations among the paranoid personality that individuals are targeting them in some manner. Their pervasive suspicion leads to feelings of resentment, ill-will, and a general unease with others, who are often viewed as a threat to them in some manner.

Here again, one can see that these individuals can be quite destructive to a long-term care environment predicated on cooperative team efforts and trust. These individuals are often unable to invest the significant level of trust needed in cooperative team efforts and this in turn leads toward the paranoid personality frequently isolating themselves from the larger social environment. In an environment predicated on social interaction with workers, residents, and family members, these individuals stick out like a sore thumb. Their destructive nature rests on the inability to trust others and react against those that they perceive are attempting to attack their character.

Although only three personality types were examined here, there are others that can be instrumental in destroying staff morale and inhibiting team development. However, this paper only focused on these three types of personality. It should also be mentioned that these are not the norm and most individuals, even those that are frequently labeled as "trouble-makers" hold more stable personality traits. Nevertheless, it is important to take note of those individuals that may hold passive-aggressive, narcissistic, and paranoid personality traits. I

ndividuals that have these types of personality traits can be quite damaging to the organizational environment. In addition, because these features are enduring by the very nature of personality, they are often not just your ordinary trouble-makers or discontented worker. They hold a persistence toward disruption that continues to interfere with the functional nature of the long-term care environment.

Therefore, although this paper did not speak about intervention, which is a much more sophisticated issue, it is important for long-term care professionals to understand the personality makeup of certain individuals, and in particular, those individuals that may hold a persistent disregard for the workplace and team environment and lead to a contagious turmoil that contaminates the morale of the long-term care environment. Although these individuals are more the exception than the norm, when they do make their appearance, they often hold a detrimental and destructive impact on the organizational behavior of the long-term care environment.

Team Building in the Long-Term Care Environment

2008-04-14T17:03:00Z

The importance of the team in long-term care cannot be overstated. No single individual has all the answers. For efficient management to exist, the importance of a functional team is needed. However, all too often, team building is viewed as something that just happens or that in some way mystically develops without any work needed by the participants. In reality, building a successful team is hard work. Furthermore, the hard work invested in team building often pays dividends. Finally, the work that is invested into building a successful team must happen every day and not just periodically.

In team building, especially in the long-term care environment, the administrator is very important toward leading this effort. Their leadership is important toward sensitizing other team members to the importance of teamwork and successful team building. Furthermore, by taking the lead and demonstrating the importance of team building they lead by example, so that others are able to see how seriously building a successful team is to the facility. With the administrator being the vanguard in this effort, the importance of the team is established.

Given that the team is an important entity for administrative success, what are important characteristics for team success? In this article only a couple will be examined. However, from the perspective of this writer, the ones that will be mentioned are viewed as invaluable for a successful managerial climate.

Probably the most important element for a team to achieve is trust. Without trust all further team-building elements are lost (Lencioni, 2002). Trust is a driving force for everything else that follows. Therefore, trust becomes the base or substructure for everything else to be built on. Just as a house needs a solid foundation for the walls, the floor and the roof to remain firm and to maintain a safe and secure environment, the team also needs the same type of solid foundation. Without it, everything else that may go into the team building enterprise will eventually fail.

Why is trust important for work team in a long-term care environment, or for that matter, any work environment? Quite simply, the team members have to feel a sense of unity and understanding among all its members. When individuals have trust in each other, they also develop a knowledge and understanding of the individuals that are part of the team. They learn to anticipate other team member's thoughts; they learn to feel a sense of camaraderie; they come to understand the strengths and weaknesses of each of their members; and furthermore, they learn to adopt an inextricable sense of unity.

When trust is established individuals come to feel a sense of security that team members are all on the same page, feeling a sense of openness with each team member, as well as working in an interdependent fashion. When trust is established on this level it results in the quarterback knowing where to throw the pass, knowing their receiver will catch the pass, even though they may not be able to see their receiver. Although the team in the long-term care environment is not a football team, the same basic principles of trust apply.

However, for a team to build trust, they also have to subordinate some level of individuality. This is difficult, especially in our culture, which places a premium on individuality. Being raised in a culture that has fostered individuality and independence, many individuals in our society have scorned the team, which often undermine these very important tenets that have been engrained in us from a very early age. The very nature of the team, its interdependence, often vies with the independence and individuality that is so dominant in our culture.

Another difficult problem that is often faced in building trust is that it exposes the individual to a sense of vulnerability (Lencioni, 2002). Trust in predicated on individuals having more intimate knowledge of their team members. However, when others have more knowledge about you, it can also make individuals feel more vulnerable. Individuals often avoid vulnerability by not investing in highly trusting relationships on a team level. This façade of invulnerability is a critical element that has to be addressed when building trust in the team-building approach.

After trust in the team has been established, other levels of team building can follow. One important element that needs to be addressed at this point is conflict. Many individuals come to view conflict as always being negative. However, quite to the contrary, conflict can be positive. Conflict is often feared and avoided within teams (Lencioni, 2002). However, rather than fearing conflict, it should be embraced by the group.

However, conflict can only lead to positive results after trust among group members has been established. If a group fails to have some level of open conflict among its members, the group can become static, apathetic and non-responsive (Robbins & Judge, 2007). At this point it should be mentioned that conflict does not mean involving oneself in contentious interactions and damaging arguments. This is exactly when conflict becomes unproductive. Productive conflict acknowledges differences as well as acknowledges an openness to address these issues in an open forum.

Conflict can also help to illuminate the differences found in the team and help to also shape and define many issues that are often ignored by a false sense of harmony in the group. Too often this false sense of harmony leaves many individuals feeling they are on the same page, when in reality nothing could be farther from the truth. Conflict helps to interject a level of intellectual stimulation toward important problem solving that often fails to exist when individuals accept a false sense of harmony on the team level.

Hopefully I successfully demonstrated the importance of team building in this paper. The team is so very important for the success of any organization, and the long-term care environment is no exception. However, team development is hard work. Although two basic principles were introduced in this paper, trust and conflict, which appear quite simple, the development of these team principles is more difficult than it appears.

For successful teams to exist both principles have to be present. Moreover, both principles have to be inculcated into the team mindset, which can only be completed through daily reinforcement. For this to be successfully completed it is dependent upon a leader to be mindful of its importance and to sensitize other team members of its importance as well as to make team building and development part of the daily agenda. It is important to remember that in almost every phase of life, constructive and functional teamwork brings about superior results. Therefore, recognize the importance of the team not just passively, but actively, and act on its daily development.

References

Lencioni, P. (2002). The five dysfunctions of a team: A leadership fable. San Francisco, Jossey-Bass.

Robbins, S.P., Judge, T.A (2007). Organizational behavior. Upper Saddle River, NJ, Prentice-Hall.

Challenging the Citation and not the Citer

2008-04-03T14:44:00Z

Nursing home surveys are frequently anxiety provoking for the staff. Not many individuals welcome others coming into their facility with the intent to play close scrutiny to the environment. This is quite similar to individuals experiencing someone who comes into their home and walks around, looking for things to find, such as a real estate agent, a perspective home buyer, or a nosy neighbor. In both cases it infringes upon our normal comfort zone that leads to a level of anxiety that is not normally found in the daily milieu.

However, this type of oversight, regardless of it being anxiety-provoking, it is a natural part of nursing home administration and the regulatory environment that exists in long-term care. Furthermore, all administrators will eventually encounter a situation, where they feel that certain citations are not justified. In this case what should the administrator and their staff do?

The survey environment can be a very emotional situation. Staff or often at ease, on edge and frequently feel like they are walking on glass. In other words, it leads to a tension-filled environment during the survey. This tension is accentuated when citations are given and magnified even further when certain citations are provided, which are felt to be unjustified. Moreover, often administrators feel that there are only two alternatives to deal with this situation: swallow your pride, take the citation or in other words, do nothing, or get into a contentious challenge with the surveyor(s).

The former is chosen due to the mindset of thinking that if a challenge is mounted, the surveyor will cite even more and with a greater vengeance. The latter is chosen on the basis of frustration, pride and provincialism, with the attitude of “who are these people to come into my building, take it over, and tell me what to do and what is wrong.” This is no new revelation and all administrators and administrative staff have felt both of these feelings at one time or another.

However, in reality, most citations that are given out are justified. Additionally, most good administrators know this and if they have been doing their job well, have been closely in touch with their facility and their quality indicator reports, and understand the survey process, will not be surprised by the citations that are received by the facility. Furthermore, most surveyors are not vindictive, but are usually doing their job in an appropriate manner. This being stated as human beings, mistakes can be made, by administrators, staff, as well as surveyors. Therefore there are times when citations are given out that may not be appropriate and need to be addressed.

In the first scenario above, it was stated that many administrators would just let the citation go unchallenged, no matter how inappropriate they may view it as being. A major problem with this “let sleeping dogs lie” approach is that if the administrator feels that a particular citation is unjustified, most of the other administrative staff will also view it as unjustified. If the administrator fails to challenge an unjustified citation, the staff will view the administrator, who is the leader of the facility, as a person who feels helpless, powerless, as well as being a person who is unable or unwilling to address an issue that they feel strongly about and that needs to be remedied. This does not fit well with the leadership role.

Conversely, in the second situation, when and administrator addresses the situation due to their pride, frustration, and provincialism, they will often come to lose sight of the problem. Their anger and frustration with the citation escalates into a contentious interaction with a surveyor(s), leading to a situation that will accentuate ill will and bad feelings between the administrator, their staff, and the survey team. The hubris of the administrator now leads them to feel that they are being a true leader by getting into the face of the surveyor and confronting them on the perceived inappropriate citation. The “I am not going to let them push me around” thinking is self-serving, failing to take the good of the facility into consideration, and fails to target the problem at hand.

So where does this leave us? The administrator as the leader has to avoid moving to either extreme. First, it is appropriate for an administrator to address issues that they feel are not valid. Second, to address the issue they have to do it factually. Finally, the demeanor of the administrator should address the issue cogently and in a professional manner. No person likes to admit to errors in judgment. Keeping this in mind, addressing the perceived error has to be done in a manner that will avoid what is psychologically called “reactance,” where individuals attempt to protect their sense of self from threats against it, and therefore react outwardly toward individuals that threaten their sense of self. Therefore, when a perceived inappropriate citation is challenged, it should be done so between the team leader and administrator, in private, to protect the threats against a person’s self that can be augmented when challenges are done in public.

When a survey is done, after the exit is completed, there is usually a period of time in which the administrator can challenge an inappropriate citation in what is often referred to as a level one informal dispute resolution. Although surveyors will frequently want to leave the facility and get back to the office, it is quite appropriate to advance your level one informal dispute resolution privilege and speak to the team leader in private about any concerns you may have regarding a citation. Doing so in private, in a respectful and professional manner, will usually quell the likelihood for reactance.

There is a school of thought that one should never speak to surveyors by themselves and they should always have someone else present. However, in this situation, it is probably best for the administrator and the team leader to meet in a dyadic, one-to-one private meeting. Again, this helps to protect each person’s sense of self, and it limits the probability for reactance to happen. Furthermore, phrasing the problem in a language that does not attribute blame or incompetence, placing the surveyor on the defensive, is very important to eliminate reactance. This is very important for establishing a rapport in which further evidence could be provided to the survey team to assist in addressing perceived inappropriate citations. In most cases the survey team will allow you to submit information the following day to demonstrate compliance.

However, if you have failed to build rapport, develop a level of professional trust, as well as nurture their need for respect rather than vilification, you have lost your case before you could even provide substantive supporting material.

It is important to recognize that surveyors can and do make mistakes. Even though most citations are justified, there are situations when particular citations should be challenged. The administrator as the leader of the facility needs to understand the need to challenge a citation that they may view as an egregious error in judgment. If such a citation does exist, it is quite appropriate to mount a challenge. However, as this article has discussed, there is a way to do this and the means for challenging a citation is often more important than the end that one seeks. If the correct means is not implemented, the end that one seeks will never come to fruition. Please feel free to comment on this subject matter.

Do Politicians Understand That Long-Term Care is Part of the Health Care System?

2008-03-13T19:17:00Z

During this year, a year in which our country will elect a new President, health care has become an important part of the agenda. Liz Rosto in her post entitled Decision 08, writes about the issue of heath care and the apparent lack of emphasis given to long-term care, especially through many of the major candidate’s policy advocacies. This appears to be an interesting phenomenon, which has not just appeared during this current election season, but has existed in past elections as well.

Although the amount of our Gross Domestic Product spent on health care is approaching 15 percent, with an expectation for it to climb to 17 percent by 2012, most individuals fail to apparently want to acknowledge the important contributions of long-term care to the GDP. With the burgeoning older adult population being a very important part of the electorate, an electorate that votes at higher levels than any other part of the population, you would think that politicians would not only focus on acute care, but long-term care as an important issue that needs to be addressed. Although the focus on changing the health care system is definitely important, to fix many of the deficiencies that currently exist in the system itself, it is important to recognize that these problems also extend to long-term care. However, it appears that many of the health policies that are frequently spoken about politically fail to address long-term care issues.

What appears to be an inherent contradiction here is this: Although politicians are aware of the importance of courting the older adult vote since they currently make up 13 percent of the population and have the most solid voting records of any age group, most fail to acknowledge a very important health care concern found in many families and among many elderly as it relates to funding and the provision of health care found in long-term care. Although the stereotypes of the elderly being a predominately nursing home bound population are false (in reality, only 5 percent of the elderly population is in nursing homes at any given period of time), long-term care will continue to have an important place in the American health care system.

It is estimated that there is a 70 percent likelihood that individuals in society will spend some time within a long-term care environment at some point in their lives, which includes home bound care (Gleckman, 2007). Furthermore, as many more long-term care facilities are becoming extensions of the acute care environment, especially for rehabilitation purposes, it becomes almost unfathomable to understand why the political environment often gives minimal to no attention to this area.

Total Medicaid costs for long-term care as a percentage of the GDP has increased from 0.7 percent in 1975 to 2.1 percent in 2003 (Gleckman, 2007). Furthermore, in 2000, the amount of long-term care expenditures that were part of the approximately 14 percent that made up the GDP was equal to 1.3 percent and it has been increasing. In fact, Medicaid and Medicare expenditures that are part of the GDP have been increasing. Moreover, public payment sources such as Medicaid and Medicare make up 60 percent of long-term care payment with another 23 percent of the payment coming from out of pocket expenses (Walker, 2002). When you couple this with budget constraints being placed on many long-term care programs and anxiety over the drying up of the coffers that support many long-term care programs, both on the state and federal level, one has to wonder why advocates for the elderly have failed to make this a more prominent concern to be addressed by politicians on both sides of the aisles in the 2008 political races.

So where does that leave us in the 2008 political race not only for the Presidency, but also for many other congressional offices that will be up for grabs. Unfortunately, it appears that long-term care will continue to be treated as the redheaded stepchild of health care policy. Possibly the most vociferous advocate of health care in the current presidential contest is Hillary Clinton and even Mrs. Clinton fails to address long-term care on a substantive level. It is without doubt that escalating costs, physicians forced to practice defensive medicine, escalating third party insurance costs, as well as too many individuals failing to get preventative care, or failing to be insured or underinsured is a national crisis. However, one needs to add to this the problems found in long-term care as part of the national health care system crisis as well.

Long-term care has to be recognized as part of the larger system of health care that exists in the United States. Yet, as has been evident, most politicians know very little if anything about the concerns faced by older adults, and in particular, the concerns that are faced by this population in long-term care. Therefore, not only is the national crisis in health care problematic since it often fails to address the long-term care part of our health care system, but it is exacerbated by the lack of knowledge by those who hold the most advantageous positions in our society to address this issue. With congressional subcommittees on aging having existed for some time, one has to wonder whether these committees have helped to educate the political faction on these very important issues?

With a plethora of elderly age groups in existence to address the concerns of the elderly, one has to wonder why they have not placed greater political pressure on our country’s politicians? And with the increasing level of the population that is currently over 65 years of age, a part of the population that is increasing quickly and have concerns about long-term care issues, one has to wonder why they as a group have not continued to place increasing pressure on the politically powerful to address many of their concerns in this area?

The above are all important questions that need to be addressed and addressed quickly. With each election that goes by, and with each year of failed response, the elderly population continues to grow. Along with this will be long-term care needs that will continue to increase. As our country continues to sit on the issue with little or no response, and as the older adult population continues to increase concomitantly with their growing long-term care needs, a growing lag between these two areas also will continue to increase. As the lag continues to increase between elderly needs and political response, our country sits on a powder keg that can and will explode. Prior to getting to this point, where our country has to mobilize into an emergency mode and reactive response, the American people and their political representatives need to forestall this growing crisis by acting proactively and with prudent foresight.

References

Gleckman, H. (2007/April). Medicaid and long-term care: How will rising costs

affect services for an aging population, An Issue in Brief: Center for Retirement Research, Boston University: April, no 7-4,

Gleckman, H (2007/June) Financing long-term care: Lessons from abroad. An

Issue in Brief: Center for Retirement Research, Boston University: June, no 7-8

Walker, D.M (2002/March 21). Long-term care aging baby boom generation will

increase demand and burden on federal and state budgets. Testimony made by Comptroller General of the United States General Accounting Office Before the Special Committee on Aging, U.S. Senate.

GroupThink as an Impediment Toward Team Decision Making

2008-03-06T19:40:00Z

Health care administration is not an easy job. Decisions have to be made and often these decisions rely on more than just one person. In the long-term care environment many decisions are made within a team framework. The administrator, along with the director of nursing, rehabilitation director, dietary and activities directors, maintenance supervisor as well as many other important administrative team players hold important positions in the decision making process.

However, there are times when decisions become compromised within group situations. Teams can be an incredible asset to assist in making important decisions, but also the important significance of bringing people together into a team situation can also lead to problems. One of the major issues that can compromise decision making in teams within the long-term care health setting in what is referred to as Groupthink.

Groupthink, a concept that was developing by Irving Janis (1982), is the propensity for group decision making to become hindered within decision making groups, regardless of whether they are in health care settings, large fortune 500 corporations, or even in Presidential cabinets. It does not just happen to people that are of modest intellect, but also among the brightest individuals as well.

For instance, groupthink has been implicated in such large-scale events as the Bay of Pigs invasion, the entry and escalation into Vietnam, as well as even our decisions to enter into our country’s current Iraq war. In all these cases there were reservations about the final decisions that were made that were never raised, acknowledged and properly evaluated. If decisions of such magnitude, affecting our nation on such a large scale, made by individuals who are intelligent and knowledgeable in their respective areas can become compromised, one can only guess how often it happens daily in more common situations. Although no exact number can be given, it can be stated that groupthink is quite pervasive, happening in most, if not all, organizations daily.

What are the symptoms of groupthink? Two key symptoms are an assumed consensus and a feeling of group unanimity. What this means is that often many individuals will not say anything or express their opinion because they feel that everyone else is in consensus with the group. Since they feel that everyone else is on the same page and share a consensual opinion, many will fear speaking about any reservations they may have with a particular idea or plan. If team members feel that they should express themselves on a particular issue, but feel that there is a unanimous opinion and shared consensus among the other group members, that is often enough to inhibit them from getting involved in expressing important opinions.

To prevent this it is important for the administrative staff to know about these endemic group forces that can lead to an inhibition toward full-team participation. Furthermore, the administrator should often encourage other group members to express their opinions, reservations and even possible dissenting opinions. Once the administrator becomes aware that individuals within the team meetings appear to be “shutting down,” it is at this point that the administrator should ask for opinions and even dissenting opinions. This may sound problematic since most administrators do not what to hear dissenting opinions. This does not mean they should encourage contention, but healthy disquisition on what other views may exist and what weaknesses may appear in the existing plans and ideas that have been presented to the team.

There are other important characteristics of groupthink. For instance, placing pressure on team dissenters is often a problem that is faced with groupthink. Since dissenters may be viewed as problem individuals that are failing to be cooperative team members, individuals will often not want to raise a dissenting opinion. There is often a misconception about the group or team. Many individuals feel that if dissenters exist they are not good team players and anything they say should not be given any weight and disregarded. Unfortunately, this often leads to the glossing over of many important opinions and views that are raised. Moreover, if individuals feel that they will be looked at in a negative light and that their opinions will not be given any credence, this will lead to pressure for them to not raise any dissenting opinions.

What is also important to mention is that many team members often fear dissent due to group norms that develop dealing with not questioning the leaders or by leaders, such as the administrator or director of nursing shutting down any conversation or differences in opinion. It is not uncommon for leaders to nurture a view of themselves as an omniscient individual that is the prevailing expert in what they do. Soliciting opinion is often viewed as a weakness due to a perceived lack of knowledge. With this comes the intolerance toward opinions that differ from their own.

Therefore leaders, especially those that are easily threatened due to feeling insecure in their position or with their knowledge, attempt to minimize dissent. In so doing they delude themselves toward thinking they have enhanced the solidarity of the group as well as protected their status as the undeniable expert for the facility. Ultimately, attempting to enhance their power and control by shutting down or disregarding opinions from other team members enhances the likelihood for groupthink to insulate itself into the team decision-making process.

What is interesting about groupthink is that it is a ubiquitous component of groups and teams at all levels. Unfortunately many individuals think that they would never act or behave in such a manner and that they are too much of an individual to be influenced by such group forces. Only individuals that are easily led can fall prey to such a problem. However, as has already been stated, no one is necessarily immune to groupthink and the problems that it brings. It has been shown that even bright individuals, involved in extremely important decisions that involve the national welfare of our country can fall prey to groupthink.

However, possibly the greater sin in not necessarily falling prey to groupthink, but denying its existence or its ability to effect you and your decisions. In fact, groupthink often breeds feelings of invulnerability by the group members and it is often these same feelings of invulnerability that lead individuals to be quite insidiously influenced by this prominent group force that can lead to potentially destructive team decisions (DeLamater & Meyers, 2007).

Although team decisions are important within any organization, and long-term care team decisions are no different, one has to recognize that team decisions can also go awry. In long-term care groups or teams, decisions are often part of the daily culture of the organization. Although many individuals have increasingly encouraged teams and team building as an important and effective part of long-term care management, one has to also realize that the team in itself does not work automatically. Team administrative management is an important factor for good long-term care administration.

However, teams have to be used effectively to maximize the decision-making process. As is evident, being aware how the decision making process can be thwarted through groupthink will become an important administrative skill toward preventing this type of process from leading to potentially destructive team decisions. Realizing that no individual or team is absolved from groupthink’s influence will help administrators make better use of the team and the potential that teams hold for making very sound and informative decisions.

References

DeLamater, J.D., & Myers, D.J. (2007). Social psychology. Belmont, Wadsworth.

Janis, I.L.(1982) Groupthink. Boston, Houghton Mifflin.