Healthcare workers often face considerable levels of stress. In particular, nursing home workers often mention how stressful their jobs are and how difficult it is to deal with the daily stressors found in their work. When stress is mentioned, most individuals often refer to negative forms of stress. However, not all stress is negative. Furthermore, optimal levels of stress can actually be productive for nursing home workers and even residents. Moreover, optimal levels of stress can lead to healthy and productive interactions that invigorate the nursing home environment. The attachment below shows a diagram of how stress can be productive and unproductive. Notice the area of optimal stress and what happens when you move outside of those parameters.     

In the diagram it becomes obvious that moving too far to the left or to the right of the optimal level of stress problems come to exist. If you move too far to the left boredom exits. Boredom is a stressor that can have a stultifying affect on the productivity of work as well as the general wellbeing for those living and working within such an environment. Conversely, moving too far to the right of the optimal level of stress leads to anxiety, which also impedes the satisfaction of work and life in the nursing home environment. The administrator and management staff have to be aware of this to help enhance their own productivity as well as suffuse an appropriate level of stress into the environment that will ward off these two extremes. 

Excessive boredom in a long-term care environment leads to monotony. Workers do not feel challenged and the residents do not feel invigorated. An environment that has excessive levels of boredom slows an individual's cognitive ability due to the lack of appropriate stimulation. Workers often become less than productive and will often engage in careless mistakes that can become critical errors in the nursing home setting. For residents, excessive boredom can lead to regression and many older adults actually go through a period of desocialization, in which many well-learned social skills are lost. 

Excessive stress that leads to anxiety is also counter-productive. Workers in anxiety provoking environments become overwhelmed. Many administrators often face this problem with the countless numbers of duties that they have to accomplish in a given day. However, when anxiety becomes excessive, is clouds one's mental abilities, it leads to reduced performance, and rather than enhancing fluidity, it locks up the person's creative ability. For residents as well excessive stimulation can produce anxiety and apprehension that impedes the quality of their lives.

One of the greatest misconceptions I often hear is people saying they would like to have a workplace free of stress. In reality stress is a natural part of life and for one to live stress must exist. However, the trick is to develop an environment that minimizes the extremes and establishes an optimal level of stress for proper stimulation. Both too little and too much stress can be unhealthy and unproductive for workers and residents alike. The consequences of extreme levels of stress are multifaceted. Excessive stressors can lead to biological issues for workers and residents, leading to unhealthy increases in cortisol levels in the body, hypertension, increased susceptibility to infections, fatigue, muscle tension and headaches just to name a few. 

However, the psychological and behavioral toll also cannot be minimized. These problems included depressed and apathetic workers and residents, high worker turnover, low levels of worker satisfaction as well as low levels of satisfaction found among residents and family members, more worker sick days used, and more worker, resident and family complaints made. There are many more that can be mentioned but this helps to summarize some of the most common problems that are found. It becomes evident that unhealthy environments that fail to foster the optimal level of stress can become an endemic issue.  Unfortunately, in too many nursing care facilities, this problem is all too common. The problem of failing to achieve less than optimal levels of stress among facility workers and residents to enhance performance and health is an endemic issue that is found among many of our nursing care facilities within the United States.

Therefore the question that needs to be posed is how does one achieve optimal levels of stress that can be beneficial for worker and resident health? This is obviously no easy task. Furthermore, there is no measuring tool that can be used to tell you when your facility has reached the optimal level to enhance performance and health. However, for workers, optimal stress is achieved when the stimulation that they encounter leads to an environment that overrides monotony and challenges the worker, providing a stimulating environment that does not overload the worker. For residents, the environment should also provide an optimal level of stimulation that challenges their existing abilities without providing overload or underutilization of their abilities. As one can see there is a considerable level of variability that exists since all workers and residents have different skills and abilities. Therefore, the administrator, the management and the work staff have to be aware of this and attempt to sensitize themselves toward meeting this challenge.

Once a nursing care facility can meet this challenge, it not only goes a long way toward enhancing the psychological, emotional and physical health of the residents and staff, but also the facility as well. As human beings we are vessels that hold an incredible potential that can only be achieved under the right circumstances. It therefore becomes imperative that we understand the important impact, both positive and negative, which stress has for us and for those that we serve. Creating an environment that fosters optimal levels of stress, while preventing excesses in both directions, can be a formidable task for the administrator and staff of a nursing care facility. However, once successfully achieved, it can go a long way toward enhancing the health and productivity of a nursing care facility. 

Nursing home administrators face an important dilemma: They need to lead and at times be firm, yet they need to remain connected to their workers. 

Many administrators and managers think they cannot be leaders and be connected to their workers. A frequent management ideology is that one must remain distant from their staff to produce the most objective form of management. In other words, remaining distant, aloof and uninvolved is frequently viewed as the necessary means for managing people in long-term care facilities. However, quite to the contrary, this can be a very hazardous management style to employ. It may not only lead to a more contentious work environment, but it may also lead to lower levels of productivity among the staff.   

Connectivity does not necessarily mean that the administrator has to establish a buddy system. Connectivity means that there is a feeling by the workers that they are attached to the larger environment. Individuals with a sense of connectivity feel that they are productive members of the larger nursing home environment.

Feeling connected to something is very important. Studies have found that those that feel connected to their school excel at greater levels. Those connected to their community demonstrate lower levels of deviance and crime. And those connected to their workplace have lower levels of turnover and higher levels of job satisfaction. An important element of leadership is nurturing the connection of the workers to their work environment. However, administrators that are dictatorial, aloof and disconnected themselves create a fragmented environment.

Empathy and Connectivity

Empathy is an important emotion that helps to build feelings of connectivity. Empathy, contrary to sympathy, is an emotion that helps you feel what another person is feeling.  Empathy is so fundamental that without it individuals can commit unthinkable behaviors. 

However, it is also sometimes felt that empathy can be detrimental for sound administration. I have frequently heard many individuals say that in a higher management or administrative position you have to leave your empathy at the doorstep. The thinking here is that empathy will prevent an administrator or manager from successfully disciplining workers and making them work in a productive manner. 

However, in reality, nothing could be further from the truth. Workers often want to feel that they are being understood. In a nursing facility, an administrator is often faced with many workers that will frequently want to have the administrator's ear. Coming off distant, aloof, uncaring and unfeeling can make workers feel that their concerns and feelings are not important. Empathy is an important emotion that helps administrators and managers connect with their workers, helping them understand what their employees are feeling. 

Being an empathic administrator does not mean you will become "soft," unable to lead firmly and without conviction. However, it does mean that your leadership will be predicated upon a greater knowledge of your workers, and with it, a greater intersubjective understanding of your interaction as an administrator with those that you lead.           

The Importance of Listening

Listening is a very important part of communication. All too often when communication is discussed the transmission of the message, especially verbally, is emphasized. Being a good listener helps to establish a connection with your workers. One of the most common complaints that workers in nursing care facilities have is that they are not being listened to by management. 

When workers feel that they are being listened to, they feel a sense of connectivity. It should also be mentioned that productive listening skills are based on "active" listening, which is different than "passive" listening. Active listening leads to feedback and questions that are used. When an administrator, manager or regional director is listening to their workers and providing feedback as well as asking questions, workers feel a sense of connectivity. They are aware that the person they are interacting with is not only hearing them, but listening to them as well. They feel that the person who is actively listening to them is taking their entire "self" into consideration. This is quite different than the passive listener, who may just stare and hear what a person is saying, but is really not listening intently to the worker. Workers often are quite aware of these types of listeners and come away feeling disconnected and unappreciated, not only as workers, but as a person. 

The Secure Base

Psychologists, especially those that study attachment, have known for some time that establishing a "secure base" is very important to feel a level of connectivity. Psychologists have studied the importance of creating a secure base in childhood, as well as in adulthood.  This also applies to the workplace and in particular, the nursing home environment. Those that have a secure base feel a sense of security and trust. 

This is very important, especially during these volatile economic times. However, workers that feel that their environment is fraught with insecurity will fear speaking or interacting with the administrator or other managers for fear of what it may lead to. The nursing home environment becomes one that individuals feel they need to tread very gingerly in due to the perception that management is disconnected and not caring about their workers.   

Contrary to what most individuals have come to assume, nursing home management is predicated upon maintaining a strong level of connectivity. This attachment or connection to workers in the nursing home environment is critical. Workers that feel disconnected also will typically have lower levels of productivity, feel lower levels of job satisfaction, and experience higher turnover rates. 

Workers need to feel that their concerns and feelings are being taken seriously, that they are being listened to, and that their environment is one that builds on feelings of trust and security. An uncaring and disconnected administrator or manager can lead to an environment that leaves the workers disconnected and subsequently uninvolved. When this happens it further spirals into a work environment that not only leads to worker dissatisfaction, but it also compromises the care that is so paramount to the nursing care facility.       

One of the most important features for organizational success is making sure that the lines of authority are well delineated.  Organizational charts within nursing facilities should be quite explicit and larger companies should also make sure that this is clearly understood by those working under the larger organizational umbrella.  Unfortunately, all too often, we see that there fails to be a clear delineation in the levels of authority and who answers to whom.  For any organization, including long-term care organizations, their success depends on a clear understanding of the authority structure within these organizations. 

Understanding the importance of line and staff authority functions is critical for  the success of long-term care facilities.  Line personnel are those that are directly involved in the daily operations of the nursing care facility.  Starting with the administrator, the director of nursing, to the management nurses, down to the certified nurse assistants, these individuals all hold important line functions for the daily operations of the nursing care facility.  Furthermore, this creates a hierarchy of authority that needs to be explicitly understood for proper daily operational functioning within the nursing care facility.  Staff authority provides advice and assistance for the facility or organization.  Staff members do not have authority over line personnel.  However, this is where many organizational problems often start. 

A major problem that I have witnessed in many nursing homes is when many staff workers attempt to get involved in the decisions related to the line staff.  Decision-making and levels of control have to be clear and unambiguous.  Each person plays a particular role and each individual has to understand who they answer to in the organizational landscape.  As companies grow larger, there becomes a tendency for many of these lines to become blurred.  This is especially problematic since many companies have many consultants within their company holding many staff functions on an advisory level.  As the company grows, and the number of staff personnel increases, delineating clearly a line of authority that needs to be followed, with a clear demarcation between those that hold line versus staff functions is imperative.  

One of the critical problems that results from this nebulous distinction between individuals that hold line and staff functions is that role ambiguity results.  Roles have to be clear to not only aid those that hold these two different types of functions, but also to enhance their roles in the respective areas that they are involved in to conduct their jobs effectively and efficiently.  For instance, a nurse or human resources consultant, if they hold a consultant role, would typically be placed under a staff function.  However, if these individuals do hold some level of line function, it needs to be clearly established in the organization chart.

So one can see the need to clearly distinguish between those that hold line and staff functions in nursing care facilities. Although this may seem to be quite trivial, in reality making this distinction is very important for a proper functioning organizational environment. One of the biggest issues that often happens in nursing care settings is worker confusion on what roles certain individuals play and who they should answer to as it relates to their position.  As most individuals, especially those who have been in management within a long-term care  facility can attest to, having workers being confused on the roles of others is very common.  Furthermore, the administrator has to further establish the clarity that needs to exist and reinforce proper line and staff distinctions when ambiguity is found to exist and be a problem. 

The organizational environment works best when authority functions are well known. This helps to foster a clear understanding of the responsibility and expectations for individuals that hold particular positions.  Not only is this important to the non-management personnel, but management personnel also have to understand clearly the responsibilities and expectations that are held for each individual in the organizational environment. Is this a simple problem to rectify? It appears that it would be, but in reality it continues to exist as a major problem in most organizations. 

Moreover, as long-term care organizations grow and get larger, the organizational complexity often leads to this problem being endemic in most long-term care environments.  Therefore, in reality, the organizational complexity that develops from the growth of the organization itself not only makes this problem common, but more difficult to eradicate then it may appear. With that said, the managerial environment within a nursing care facility needs to continue to make sure that clear delineations between levels of authority as well as between line and staff functions exist. The managerial optimization of organizational resources strongly depends on this clarity.         

In my June 30, 2008 blog post "Can Apples and Oranges be Compared?" I wrote about the anticipated implementation of the nursing home rating system that the federal government was going to introduce. Since that time the Centers for Medicare and Medicaid (CMS) have introduced this system, leading to a system of ranking that has produced controversy and outrage among many long-term care professionals. Nursing homes are rated on three major measures: health inspections, nursing home staffing and quality measures. Out of these data CMS produces a ranking system based on stars with a one star ranking being the lowest and a five star ranking being the highest. Each of the three categories is ranked on one to five stars and each nursing home obtains an overall ranking of one to five stars based on these three criteria.

In my previous article I mentioned that you cannot compare apples and oranges and yet, this is apparently what the federal government has attempted to do in their ranking system. When you look at this system I am very puzzled on how many of the overall ranks are finally attained. I see many facilities that appear to average three or four stars yet receive an overall ranking of two or three stars. Conversely, I also see many that appear to average three or four stars in the areas that are examined, yet they come away with an overall ranking of two or three stars. 

This is interesting. I then wonder how they weigh the respective areas. Is one of the three areas weighted differently, or are they all weighted the same, which in turn in some way should lead to the overall rankings that are found. However, I am not sure how they come away with these rankings. Looking at this system reminds me of going into a college course with the professor not providing any information on how grading takes place.  Intuitively the system looks quite appealing. We like simplistic systems that do not require much thought.  When we hear that a hotel or restaurant is five stars, we automatically assume that it is a quality hotel or restaurant.  We often fail to question how the rankings were put together. With the nursing home ranking system it appears to be another consumer friendly ranking system, but what does it really mean, and how are the overall star rankings attained. 

A major question that I have to raise is how do individuals at the federal level put together an overall ranking of every nursing facility in the United States by looking at 1) health inspection surveys; 2) nursing home staffing; and 3) quality indicator measures. Of the three variables that are examined, nursing home staffing is the only highly objective and highly empirical variable that can be found. You can count and average out this variable with high levels of objectivity. However, the other two variables, health inspection surveys and quality indicator measures have tremendous variability. Health survey inspection teams have great variability. Some teams provide more citations than others. 

In addition, states vary considerably in the survey team's provision of health citations, with some states differing quite dramatically in the average number of citations given. Furthermore, the quality indicator reports provide information on how nursing homes rate in certain areas as compared to other nursing homes, but it fails to take acuity into consideration. For instance, a nursing home can rank very high in pressures sores but it may also have a terribly high acuity of clientele as compared to another nursing home that does not admit residents that are as severely ill or infirm. These are just a few of the major problems that can be found in comparing data of this nature. 

So how do those that conduct the analysis to provide these rankings create a common benchmark to compare all nursing care facilities equally? With all these confounding factors that can work to influence the results what type of statistical control exists, if any. It would be naïve to assume that the data that is being used is not compromised in any way. However, it appears that those at the government level that are conducting this rating are assuming that no variability or biases in the data exist and take the data at full face validity. This assumption is an important methodological flaw. Furthermore, how do they measure the data? When things are examined in the scientific community the methodology is always made public to assure that others can examine it as well. However, in this case, what types of measuring tools where used and how the measurements lead to this ranking system that in turn achieved the results are for the most part a mystery.

So where does that leave us. It leaves us with an apparent system that is suppose to rank nursing homes objectively. However, what type of objectivity really exists in this measure? Do nursing homes that take a higher level of severe residents get penalized unfairly in this ranking system? Do nursing homes within lower socioeconomic regions that fail to obtain the funding that other nursing care facilities obtain get penalized by this system unfairly? Can those who do the rating, not knowing if the data that they are using is compromised in some way, say that they are doing a totally objective analysis? These are important questions that this new rating system brings up and needs to answer. 

Unfortunately, when people here that a rating system has been done, they often view it as a totally reliable system that one must take unquestionable heed of as if it is the final word. But as I have mentioned, this supposed ranking system poses too many questions. It is interesting to note that as I have mentioned in my previous article, it is very difficult, if not impossible, to say that hotels, restaurants, and nursing care facilities can be ranked on the basis of stars. In an industry that deals with people's lives, with a byzantine complexity, it is interesting that we now feel that we can rank this complexity on a system of stars.        

Are you paying enough attention to your residents' cognitive wellness? Read my latest column on the ADVANCE Web site.

None of use like to loss on something. Having a financial, psychological or emotional investment in something makes it that much more difficult to walk away from. This is a common occurrence in the daily lives of many individuals. In health care the same issues are found. We make business investments and sometimes we get the business. 

In long-term care this is often found. We make a decision, an investment ensues, and on many occasions the correct decision has been made. However, what happens when the decision is made, an investment ensues, and then it does not work out. How long do you stick with a decision and continue to add more costs to an already unsuccessful project?

First, we have to understand the concept of sunk costs. This is a cost that has already been incurred. Money has been invested in a project and this money cannot be brought back. So the cost is sunk. Therefore, with the cost being sunk your decision to continue a project needs to be based on what can be anticipated in the future. With a sunk cost, determining whether a decision needs to be made for a project to continue needs to be held in abeyance. Past costs or costs that have already been spent now become irrelevant to any future decision. 

The decision now must be based on what costs will be incurred in the future versus what positive results from the project you anticipate receiving. The sunk cost becomes irrelevant for determining whether you want to continue with the project since what has been lost is no longer retrievable and your decision currently has to be focused on whether it is viable from this point on to continue with a project that will be viable. 

It is always difficult to make a decision about whether a project should be discontinued when it is not currently doing well. However, many individuals muddle the decision by bringing sunk costs into play, which makes it even more difficult to determine what decision to make. When costs are sunk, for all intent and purposes they become irrelevant to your decision for the future. 

However, this type of rational thought is easier said then done. One of the reasons is that we often have psychological and emotional costs tied to our financial costs.  Therefore, even when we attempt to disengage from the material financial loss, it becomes quite difficult to also disengage from our psychological and emotional commitments that are associated with our sunk financial costs. As many who work in long-term care administration read this they can probably appreciate this predicament.   

Because decisions in which financial investments have been made are also fueled by psychological and emotional investments, it becomes difficult to disengage from a failing proposition when the emotions of the person and the psychological needs of the person are involved with the decision. Long-term care administrators, wanting to justify their position and definitely not wanting to say they made an investment for naught will at times engage in the escalation of commitment phenomenon. 

This leads many to continue to commit to a course of action, even when it is not successful, due to the sunk costs that have already been incurred. As we mentioned above, the determination of whether a course of action should be continued cannot take sunk costs into account since they already are spent and are no longer retrievable. Yet, with the escalation of commitment, individuals fail to look at the course of action based on future benefits minus costs, but on what has retroactively been already sunk into the project. 

The psychological and emotional factors that are driving this phenomenon are great. Psychologically, not wanting to see oneself as leading a failed project and emotionally being closely tied to the project, as well as engaging in self-justification, where they are attempting to convince themselves that they made the correct decision are primary forces motivating many administrators to continue with the wrong course of action. All of us like to save face and in an attempt to not loss face, we escalate our commitments in the hope that they will finally pay off and achieve the goal that we set out to accomplish. However, we can see how this can be a pernicious thought pattern. Yet, how many of us have been caught in its grasp, where we attempted to save face and continue to escalate our commitment. Being wrong is hard to swallow and even more difficult to admit to others. 

I hope that the person reading this has gained a better understanding of sunk cost and escalation of commitment. Both work hand-in-hand, and they can impact on the decisions that many long-term care administrators make. Financially, sunk costs are all too often factored into decisions regarding future investments. This can become imprudent for decision-making. 

However, even more problematic is extricating the emotional and psychological investments that we incur in many courses of actions that we hold firm to in a stubborn, pertinacious manner. If we were robots, devoid of these processes, we could understand how we could extricate ourselves from sunk costs. However, because we are human beings, vested with these important processes, those who work with important business decisions, including those found in long-term care administration, have to be particularly sensitive to how these factors can lead to improperly engaging in an escalation of commitment. 

In long-term care rehabilitation is a very important part of treatment for many residents. Rehabilitation is a very important part of the interdisciplinary team process that focuses on helping those with physical impediments regain much, it not all, of their physical ability that is often lost through a myriad of physical problems.  However, a great deal of rehabilitation focuses on regaining the physical problems that were lost, such as fine motor movement and gross motor movement. 

Even when individuals have cerebral infarcts (strokes), the emphasis is often on gaining, to some level, the lost physical function that often accompanies this problem. Many rehabilitation programs will often emphasize that they do provide some level of neurological rehabilitation, but this is often based on the neuromuscular innervations that take place during physical movement exercises.

What is often missing in many rehabilitation programs for residents is a true neurocognitive rehabilitation program that focuses on enhancing the brain and overall nervous system. With this type of program the focus in not just on enhancing the physical mobility that is often lost through illness and disease, but also the neurological and cognitive loss that is often part of disease, illness, and even inactivity. 

Neurocognitive rehabilitation is a multidisciplinary approach, which is not just dependent on any one area of specialty. Unfortunately, most individuals in long-term care environments are not informed about the need for neurocognitive rehabilitation and furthermore, most fail to have any training in this area. This is quite perplexing, especially since our brain is the essence of who we are. With damage to our neurocognitive resources, we can strengthen the limbs through rehabilitation yet fail to improve the individual as a human entity. 

We are seriously behind in the area of neurocognitive rehabilitation. This is unfortunate since there have been tremendous advancements made in the neurosciences. We now know the brain is not a post-mitotic organ, fixed with all the brain cells and connections one needs for the rest of their lives. Research has demonstrated that active neurocognitive activity can lead to growth of brain cells in certain areas of the brain as well as changing the cerebral landscape of the brain by making new connections to enhance our ability to cognitively engage in many tasks with greater proficiency. Therefore the brain is not a fixed organ and can change.  However, when it is negatively changed through disease, we often feel that we cannot reverse these changes, or that if a neurocognitive reversal does happen, it will be predicated on the person's own healing mechanisms.

Given our knowledge of the regenerative potential of the human brain and its ability to adapt and change through developing alternative pathways even when the previous ones can no longer function, it becomes incumbent on long-term care professionals to become more involved in the neurocognitive rehabilitation potential that remains untapped in this area. However, inserting this new type of paradigm to deal with enhancing a person's life will not be an easy task. Since most individuals are not familiar with this area, and are even less familiar with the brain and its hidden capacity for change, it will take a considerable amount of training and education to foster the growth of this area.  

Brain science has come too far to not employ much of the knowledge that we have gained to assist in rehabilitating long-term care residents' brains. We now know that many pathways and alternative pathways can help with many of the neurocognitive deficits that exist among many individuals. Like an open patch of ground surrounded by a weeded area, the open area will be taken over by weeds if the patch of ground is not cared for. 

This is somewhat similar in the brain. An insult to a particular area of the brain will be grown over with other areas that are adjacent to it. However, if we target the neurological areas that need to be addressed a territorial invasion will not happen and the landscape that was faced with a physical insult will start to respond.  Moreover, in some cases if the area cannot respond new pathways are created. 

So it only makes sense to start addressing many of the important brain rehabilitation needs that exist among this population. However, to do so it requires a great deal of teamwork, starting with the rehabilitation therapists, to activities, social services and nursing. Furthermore, this type of intervention is not only for those that need rehabilitation services. It is a type of intervention that should at some level exist for all residents.  Because of the special needs that many older adults face on this level, one has to wonder how many more residents would lead more alert lives and possibly forestall the impacts of dementia for a few more years if they were provided with this service. All staff needs to be involved in producing a paradigm shift that starts to focus in greater detail on the resident's neurocognitive needs. This will be a daunting task to implement but the benefits will surely outweigh any costs.      

With all the changes that nursing homes have undergone during the last 20 years, we still have a considerable way to go.  Even with nursing home reform that started slightly over 20 years ago, especially the movement to make the nursing home environment more homelike, the changes that have been introduced still have not eliminated the institutional setting that exists in nursing homes in the United States. 

As I enter many nursing homes I have noticed different levels of accommodations. I have noticed nursing homes in communities that have higher socioeconomic levels having more resources and coming closer to many of the goals that the industry has set for the nursing home industry. However, at the other extreme, as I have toured nursing homes in lower socioeconomic level communities, and I have witnessed not only deprivation within the community but also within the nursing homes that are found in these communities. During our election year it sometimes makes me wonder that although we espouse democracy and equality, we still face considerable obstacles in perfecting these major concepts found outside as well as inside long-term care environments. 

As I walk through many of these nursing care facilities I often wonder why there is so much inequality in resources and care found in these health care facilities. Sociologically, I have to say it intrigues me that the provision of care that exists in many long-term care facilities is predicated upon the deferential level of resources that is found from one long-term care facility to another. This interests me because it reflects many of the same inequalities that are found in our larger society. However, at the same time that it interests me as a researcher, it also saddens me to think that this type of inequality continues to exist at a time when it should not. 

An interesting sidebar that exists is that we attempt to monitor and engage in regulatory oversight using the same standards for all nursing homes. However, how can we apply a universal regulatory standard to all nursing homes when there is such disparate features found among nursing care facilities in the United States. How can we apply the same standards to a long-term care facility that may have abundant levels of financial resources and say that the same standards should be applied and exist among nursing care facilities that have very few resources.   

Often we attempt to delude ourselves so we fail to realize the harsh realities that continue to exist in our world. We do so at times to distance ourselves from the true reality and pain that we would come to feel if we were to let ourselves comprehend the complexity and less than humane circumstances we face in daily life. As we continue to deal with the harsh inequalities that are found in society, we have to come to realize that health care facilities, as institutions of society, face the same endemic problem.

Therefore, it should not come to surprise me, or anyone else for that matter, that the disparity that is found in long-term care facilities continue to exist. It should not surprise us that the ideals for a homelike environment are more closely found among certain facilities and far from it in others. Moreover, it should not surprise us that there is differentials in the type of care that is provided among nursing care facilities based on a large differential in the resources that they have available. 

What should come to surprise, if not astonish us however, is that we continue to delude ourselves by thinking that many of these differences fail to exist. Furthermore, what should surprise us is that we as a society can employ the same standards for all nursing facilities, deluding ourselves into believing that they are all playing on a level playing field. 

Not only do we have to recognize that the inequality of long-term care facilities mimics that found in larger society in general, but we also have to recognize that we cannot continue to employ universal regulatory standards to all nursing care facilities as if they were all equal. If we fail to recognize the great disparity in resources that is found in long-term care, or bury our heads in the sand and say that it is not financial resources that matter, but the personnel that exist in the facility, or say that oversight needs to be equal when that entities that are being overseen are not, we will fail to be able to further enhance our industry.  As one can see we still have a long way to go.                  

True teamwork in a work environment is difficult to achieve. However, when it is achieved the dividends that it reaps leads to a phenomenal achievement that cannot be viewed lightly. Working together as a team means that each individual is intricately related to the whole. True teamwork is not just a collection of people in close proximity apparently working together in some desultory manner. Yet, many individuals, including those in long-term health care, have heard about the benefits of teamwork and think that putting a collection of individuals together creates a team. 

Furthermore, another common error that many make is assuming that 75% or 80 or even 95% of the team members can work together, creating a true teamwork experience. However, this is false. The true team fires like neurons in the brain: on an all or nothing principle. All individuals need to fire in harmony for true teamwork to exist and a productive solidarity to be achieved. This paper will explain the need to view teamwork on the basis of the "all or nothing principle," and how accepting anything less will only lead to the illusion of true teamwork.

A Few Examples    

A good way to start this paper out would be to provide a few examples. I am a football coach and my football team has 10 of 11 players on the offense that work quite well together. That is 91% of my offensive team members working well together! However, my quarterback, a very athletically talented individual really does not want to be on my team and really does not care about working together with the other team members. 

He is only concerned about his self-performance. He throws, runs, and carries out plays that only lead to attention given to him. The other players, although thinking and feeling in harmony, never know what to expect with their quarterback. Do you think this is a problem? It differently is and although the team is very talented and 10 of the 11 players are in sync, they continue to only have marginal success because of this one player being a team outsider.  

Moving away from the sport example, let us say I have put together a group of the brightest scientists to help me in my research endeavor toward finding an important drug that will cure a particular form of cancer. I have a collection of 20 of the brightest minds in oncology that our country has to offer. However, there is one individual, quite an individualist, who does not like to take direction and often likes to only do something that will bring light onto them. 

They will report to the lab in an untimely manner, often not finish their analyses, and when they do, frequently not contribute their findings in a timely manner to assist the other team members. Moreover, they are also working on a number of research papers in which they are the lead author and have given this work priority. Does a problem exist here? Yes it does and although we can say that 95% of the team works well together, this individual is very important for doing the statistical analysis and without their diligence in this area, this one person is always causing stress for the other 19 team members, never being able as a team to fully realize their goals.        

The All-or-Nothing Principle

This is the essence of the all-or-nothing principle. Like a group of individual spark plugs, any bad plug (or individual) will lead to problems in the car (or team) running appropriately. Yet, many long-term care settings think that their team can work to its optimal efficiency with one bad plug. True teamwork does not work this way. When individuals are firing in unison they come to think, feel and understand each other. They can anticipate other team individuals and their behavior. They can further augment other areas where other team members may not be as strong because they know in advance, through an anticipatory understanding, what they need to do for the team's success.  

True teamwork does not mean that the team is absent of any conflict. Productive conflict is often beneficial to the group. It helps to generate a level of tension that can often heighten an understanding of the team members, clarify viewpoints, as well as also lead to an environment that does not become complacent. This is important for working well together and generating ideas. However, true teamwork often understands how to accentuate productive conflict and reduce or eliminate destructive conflict that leads to team division.   

True teamwork also does not mean that team members should always acquiesce or engage in a level of groupthink because they feel intimated to state their opinion or feel that the other team members will not consider their opinion important. In true teamwork, the members feel comfortable expressing their opinion. They may not always agree with each other, but that is not the definition of solid teamwork. Yet team members who engage in true teamwork feel comfortable to express their dissenting opinions and also, even during times of disagreement, subordinate their own individual interests at the expense of placing the team and its goals first. 

This is what strong teams that have a sense of true teamwork do; they move outside of their own individuality and conflate toward the common goal of the team. Individuals in this type of team situation are able to view the team as a common point of extension of themselves. They can finish the sentence that is started by other team members by knowing their team members and being able to anticipate their behaviors and thoughts. They can throw the football in an area where they cannot even see their receiver, because they know and trust their team member. They can also anticipate the feelings, beliefs, and values of other team members because they are intimately linked to each other.

Excising a Problem

Just as in other industries that rely on teams, long-term care facilities have to guard themselves against the all-to-common divisive team members. This should start at the time of hire, to make sure you are hiring a person that appears to be a good fit. However, if a divisive team member does exist, there really is no place for this person on the team. In this case a divisive team member is only a "team member" by the chair he takes up in the meeting room. They are not a true contributor to the overall team effort. 

When a person(s) on this level exists, a decision has to be made quickly on how this individual should be addressed. The longer a divisive individual continues to exist on the team, the greater will be the disruption to the other team members and the larger overall goal that they look to achieve. Furthermore, the greater time a divisive person exists on the team, the more time that person has to further divide and fragment the team process. 

This will ultimately lead to many good team members leaving your team. When a problem such as this exists, it can act like a malignancy for solid and productive teamwork.  Therefore, if the individual fails to be able to integrate themselves into the team and provide a level of stability and productivity, removing the problem individual needs to be considered. If a divisive individual is allowed to continue their malignant efforts and behavior, the malignancy, similar to a cancer in a living organism that is not addressed, will metastize. In this case the organic team environment dies due to the inability to isolate and excise the problem. 

Conclusion                  

Long-term care situations need true teams to achieve the ultimate goal of providing the best care that is possible in serving their clientele. Long-term care is not short on teams for quality assurance, wounds, infection control, or safety, but how true is the teamwork that goes on in these "teams."

True teamwork is composed of a number of players sharing a similar mindset and goals. They subordinate their own self-interests and place the goals and needs of the team above their own individual wants and needs. Furthermore, true teams cannot tolerate individuals that attempt to circumvent the efforts of the larger totality-the team. It is imperative that long-term care professionals understand the importance of what a "team" is versus a "true team." 

Furthermore, they must also understand the benefits that a "true team" holds versus just having a desultory collection of individuals that are called a team. Finally, they need to understand that a true team works on the "all-or-nothing principle." Tolerating anything less is a failure to understand what a team effort is truly about. Therefore, remembering that the true team is an all-or-nothing phenomenon will lead to a more productive and efficient long-term care environment.          

                                               References

Hirschfeld, R.R., Jordan, M.H., Felid, H.S., Giles W.F., & Armenakis, A.A. (2006). Becoming team players: Team members' mastery of teamwork knowledge as a predictor of team task proficiency and observed teamwork performance.  Journal of Applied Psychology, 91: 467-474.

Price, K. H., Harrison, D. A., & Gavin, J. H. (2006).  "Withholding input in team contexts: Member composition, interaction processes, evaluation structure and social loafing."  Journal of Applied Psychology, 91: 1375-1384

Salas, E., Edens, E. & Nowers, C.A. (2000).  Improving teamwork in organizations. Mahwah, NJ.  Lawrence Erlbaum. 

GeroTalk is now an online column! You can read Dr. Garavaglia's essays on various long-term care topics on our Web site, www.advanceweb.com/ltc.

Click here for the first column.

It is no surprise to anyone who works in health care that census is always a critical issue for long-term care facilities. This especially is an important focus for many skilled nursing care facilities. As more assisted living facilities are now taking many residents that at one time was the purview of nursing facilities, many nursing facilities today are in competition for residents that are being more difficult to get to help bolster their census numbers. However, because census is such a driving force for nursing facilities, and since many facilities are in competition with many other nursing care facilities for the same residents, a common error often happens: Many facilities attempt to take anyone they can obtain in the referral process. This is a critical error than can come back to haunt the nursing facility. 

A few principles need to be adhered to regardless of whether the facility is a for-profit or a not-for-profit facility. First, the facility must remember that they are there to service the resident to the best of their ability. The ethical principle of beneficence has to be always followed here. Although census is a key driving force for the sustenance of the facility, so to is following this important ethical principle of doing no harm to help further the resident and their health status. Taking residents that you cannot support with the skill level of your facility is unethical and inappropriate.

Another major principle that follows from this is that the administrator and other administrative personnel such as the director of nursing, have to know their staff, the knowledge capital that is found in their facility, and the supplies and other supportive factors that will enhance their ability to provide the appropriate level of care. For instance, if a person comes in with a significant level of wound care that is needed as well as a wound vac, and your facility fails to have a sound wound care personnel that can address this issue, your facility can face great liability in this area. When you admit a resident it is implied understanding that you have reviewed the case and feel comfortable with the ability to care for the resident's needs.    

Revenue is very important on the business or administrative level in long-term care. However, this often is at variance with sound clinical judgment on taking a resident. Another important principle that needs to exist is never let your bottom line business mentality become so myopic that it clouds your ability to see the larger context of the resident care environment. Many individuals will often try to close the sale of a resident, similar to that of a car sales person. A sales or marketing plan in long-term care is always dealing with human beings and not inanimate widgets. 

Making sure the proper people, skills, accoutrements and such are in place all need to be considered.  Admissions decisions are too often driven from a purely business point of view-how can we increase our census and with it, our revenue. Administrators and other nursing home administrative personnel who manage on this level often fail to understand that management happens within a larger context, both internal to the facility and external to the facility, and both factors have to be considered in the larger context of appropriate resident to facility fit.   

Quality care and resident population stability is driven by making sure that the resident to facility fit is appropriate and conducive for not only the resident, but also the staff. If the resident has care issues that exceed the facilities resources it can be quite problematic. On one level it may actually be so expensive to care for such residents that the bed that they are occupying, nevertheless, is causing the facility to incur a tremendous financial hardship. Furthermore, the clinical complexity of the resident may actually outstrip the knowledge capital and resources in the facility. 

However, more often than not, the staff feels the pressure and stresses of not having the appropriate skills to care for residents that are not a proper fit with the skill level of the facility. Take for instance a nursing facility that chooses to admit more residents with psychiatric issues that many nurses, or physicians, may not feel comfortable with in treating since they have not worked with this type of clientele before, or very sparingly.  Can nurses and certified nurse assistants be trained to address the unique concerns that some of these residents have? Yes, but remember there is a learning curve. Is it fair to say to improve our census we will take more individuals with behavior problems even though our staff is not comfortably trained with this type of resident. Definitely not!  Not only is it not serving the resident well, but having staff work in apprehension because they know their skills are not appropriate to care for these types of residents on a wider scale will often lead to errors and poorer levels of care. 

Furthermore, it is a hardship for many residents. They need to feel comfortable with the facility and skill level of those that take care of them. Residents and family members often become cognizant of a facility and staff that lack the skills to appropriately address the resident care issues. Not only does this taint the reputation of the facility, but the legal liability that exists here can be quite costly. 

A final principle that needs to be stated is that quality is the driving force for nursing care facilities. Although everyone is looking for a quick fix to their census problems, quality drives census in a number of areas.  Understanding your facility's capabilities shapes quality. Tailoring your residents to the fit of your facility shapes quality. These in turn lead to a facility having a strong reputation in the community.  The reputation of the facility leads to census development. However, the leaders of the facility have to be realistic about what their capabilities are and where their strengths lie. Exploiting the strengths of the facility will lead to better quality of care, which subsequently leads to a strong reputation and better census growth and stability. Conversely, one has to also understand their weaknesses. All facilities have weaknesses,  yet attempting to enhance their census be admitting residents that fall into these areas of weakness is a recipe for disaster.

It is a categorical imperative that nursing care facilities understand the importance of matching residents to the facility's strengths and therefore proper facility fit. If you find yourself saying that "I think we can take care of this resident," this often is a sign of attempting to place a round block in a square peg. If the fit fails to exist and you are not able to knowingly and adequately address the resident's needs, then you need to be conscious of this and let that resident be admitted to a facility that is more able to do so. Just because many skilled nursing home are called ‘skilled," does not mean the same skill level exists in all facilities.  Skill is not a constant, but is a variable that has to be closely monitored to provide appropriate and quality resident care. Continuing to view census myopically, viewing just the numbers and failing to understand the larger qualitative context of the resident to facility fit is often a major error that is learned by many the hard way.                      

It is no surprise the older adults take more medication that other age groups. Furthermore, it is probably no surprise that older adults in long-term care take on average double the amount of medication of the average older adult who lives outside a nursing care facility. Typically speaking, as one increases the amount of medication, the likelihood for medication side-effects from interaction happens as well. Furthermore, metabolic changes in the older adult often lead to greater medication sensitivity and the potential for adverse effects that are often not found among younger individuals taking similar dosages. One of the common side-effects are manifestations of depression and even depressive disorders. 

Take for instance common blood pressure or anti-hypertensive medications. Common antihypertensive agents such a beta-blockers, e.g., atenolol or propranolol, can cause fatigue, lethargy, symptoms related to depression, as well as depressive disorders themselves. Other types of anti-hypertensive medications like calcium channel blockers such as nifedipine or verapamil can also cause lethargy and depression. As one can imagine, treatment of hypertension is very common in long-term care facilities. Blood pressure medications as well are quite common, with many older adults often using more than one type of blood pressure medication.  In addition, blood pressure medication at times can cause drowsiness and this coupled with feelings of lethargy are often mistaken for depression. When the medication is adjusted, changed or eliminated these apparent depressive symptoms, which are nothing more than pharmacologically-induced side effects that mimic depression, are eliminated. 

Many older adults in long-term care settings also have Parkinson's disease. A very common treatment for Parkinson's disease, a disease that results from a depletion of dopamine in a part of the brain called the substantia nigra, a critical area of the brain for movement, is often treated with Levodopa and its analogs.  Although in many cases this drug and drugs pharmaceutically similar that help aid in reducing Parkinson's symptoms benefit the resident, especially in abating their symptoms. However, often higher doses are needed over greater periods of time and these drugs can led to depression. In fact, major depression that is caused by these medications is frequently viewed as a nonreversible symptom of their disease.   

Many individuals in long-term care are also frequently treated for cardiovascular disease such as arrhythmia or heart failure. Arrhythmias are irregular heartbeats that vary in their level of severity. Heart failure is the progressive weakening of the heart muscle. Both conditions often are treated with medications that can cause symptoms of depression. Drugs such as Digitalis and other cardiac glycosides can lead to symptoms of fatigue, feelings of apathy and low motivation and depression.  Furthermore, drugs that are antiarrhythmic in nature, used to regulate the heat rhythm, such as Lidocaine, or Procainamide also can lead to feelings of depression. 

Cancer is a condition that is often found among many residents in long-term care facilities. Some of these individuals are being treated for their cancer with antineoplastic agents, drugs that are used to treat various forms of cancer. Although we have all heard of many of the other forms of unpleasant side effects that accompany cancer treatment such as nausea and vomiting, depression is also found among these agents.  Here again it is often hard to determine whether the drug is causing depression or whether the person is depressed due to their clinical condition. Furthermore, many of these drugs also have side-effects leading to anemia.  Anemia can lead the person to feel weak, tired, and listless, symptoms often mistakenly taken as depression.     

Drugs such as antibiotics used to treat bacterial infections also hold the potential for depressive side-effects. Commonly used agents such as Cipro and other fluoroquinolones, tetracylines or Cycloserine have been assoicated with depression. Most individuals would frequently not associate antibiotic agents with possible symptoms of depression, yet as is evident, these drugs can and do hold the potential for pharmacologically-induced depression. 

Most individuals who work in long-term care have also witnessed that breathing issues are also quite common. Many nursing home residents often use more than one pharmaceutical agent to treat a pulmonary condition. The use of cortisone based agents, such as prednisone taken orally or even breathing treatments that have cortisone based agents or analogs have been associated with symptoms of depression as well as depressive disorders. 

Finally pain control is often a very important part of resident care in long-term care environments. Narcotic agents, such as morphine or codeine, not only control pain but depress the central nervous system. These drugs do hold the potential for causing depression. Even less powerful pain control agents such as salicylates and NSAIDs hold the potential for creating symptoms often assoiciated with depression. One has to wonder how often many symptoms of depression are pharmaceutically induced by pain medications given the amount of medication that is used to control pain.

The list could go on, but it would not be beneficial to continue and develop a litany of medications that are associated with depressive symptoms. Suffice it to say that medications have many side-effects and the potential for adverse pharmacological effects increases with age. Furthermore, since many medications have these effects and since many older adults in long-term care use a large number of medications, it is often difficult to determine which medications, or which combinations of medications, may be causing depression or depressive symptomatology. But, it should be evident that many symptoms of depression within the long-term care environment can often be caused by the very medications that are being used to help them with problems in other areas.    

Because older adults in long-term care settings use many medications and because depression is quite common in older adults in these environments, it is very important for many professionals in nursing care facilties to become sensitized to the potential that pharmacological treatment and intervention hold in causing mood disturbances such as depression. All too often many individuals look to treat depression by adding medication to an already large medication regime, e.g., antidepressant medications.  In many cases this is quite appropriate. However, instead of always looking to treat the symptoms of depression through adding another medication, it may be beneficial to first look at all the medications that the resident is taking and possibly take away certain medications that may hold the potential for causing these symptoms.  

What interests me is how often stereotypes dedicate care. In society, individuals still assume older adults should be depressed and that it is part of normal aging. Furthermore, in long-term care this stereotype is even further consolidated. It is often assumed that older adults in long-term care settings, even more so than their same age counterparts in mainstream society, should be depressed, especially due to their presence in a long-term care setting.  It becomes an interesting phenomenon, where behaviors that are abnormal, which depression definitely is, now become "normalized" for long-term care residents because of their age and the social context that they live in. 

Therefore, it is important to address the issue of depression in long-term care settings. Furthermore, it is important to address how many individuals with depression also get misdiagnosed with dementia, a condition that is called pseudo-dementia. In the upcoming paragraphs I will briefly discuss this problematic issue that is often found in long-term care residents. Moreover, I will discuss how this problem can be addressed by changing our stereotypic views of older adults in long-term care settings. 

The elderly in long-term care often face two stereotypic misconceptions:  It is normal to be old and depressed and it is normal to be old and cognitively impaired. Therefore when an older adult is found to be depressed or to be impaired on a cognitive level, this behavior has often become "normalized" in long-term care settings. Furthermore, it is often falsely assumed that both conditions are intractable. Yet, there are many instances when cognitive impairment that is being experienced by older adults can be improved and even eliminated. One of these circumstances happens when elderly individuals become depressed.  When individuals become depressed they will often have memory issues. When younger adults become depressed and have memory problems it often becomes a symptom of their depression. However, when many older adults become depressed and develop memory issues, especially in long-term care settings, the attribution that is often made is the person has an inevitable level of dementia. 

Depression among older adults in long-term care is quite prevalent. Furthermore, it often goes untreated and unnoticed.  Frequently, one of the characteristic symptoms of depression is memory impairment. As stated above, when it is manifested by those who are younger it becomes a prominent feature of their depressive illness. However, what about the older adult in the long-term care setting that starts to forget and has other cognitive issues? How can one determine if it is depression or dementia? After all, it is quite commonplace to see dementia among many long-term care older adults? 

What even complicates the issue further is that the elderly pose a complicated clinical profile. Especially in the long-term care environment, the elderly often have a myriad of clinical issues that can complicate the diagnosis of depression and make it very difficult to rule out dementia. However, a diagnosis of dementia often becomes an easier grab bag diagnosis. This is influenced by the stereotypes that we hold about the elderly in general, and the elderly in long-term care in particular, which regards this age group as inevitably destined to be demented to varying levels.     

Another confounding factor is that depression in many older adults is often atypically manifested. The sad affective presentation and loss of pleasure that is found among many with major depressive disorders can actually be masked in different symptoms such as anxiety, behavioral outbursts and the inability to sleep, which coupled with confusion and memory loss, may be taken as the so-called "sundowners" features of those with dementia. The atypical nature of many depressive disorder in older adults, coupled with prevailing cognitive symptoms, often lead many to overlook depression as being the cause of these memory issues. 

Another important issue is that although many long-term care professionals are quite dedicated toward the provision of care, many come to the profession having very little training in this area. Most physicians who work in long-term care were not trained as geriatricians, and often work in long-term care facilities in addition to their other practice. Many nurses have completed much of their training in acute care health care facilities. Also, most social workers, psychologists and psychiatrists have spent most of their training addressing the problems of a more youthful population. 

Therefore, many of these professionals are not as uniquely sensitized toward the special needs of the older adult populations in long-term care as those who have special training in this area. Furthermore, many of these professionals bring stereotypes that they have learned about old age and the elderly to the clinical setting, which in turn fails to allow them to see beyond this misconceptions and leads them toward missing a diagnosis of depression.      

Many fail to understand the overlapping significance between depression and dementia in the older adults.  Therefore it is often assumed that these two disorders exist in exclusivity. However, in reality, depression in older adults can lead to memory disturbances and other cognitive issues that mimic dementia (see diagrams below). Although most forms of dementia cannot be eradicated, pseudo-dementia caused by depression is quite treatable once the underlying depression is lifted.

Therefore, very important in addressing the complicated issue of targeting depression in those elderly is overcoming many of those harmful stereotypes that can make us loss sight of this important underlying problem.  Furthermore, hopefully one will come away without automatically assuming that memory issues found to exist among older adults are not just inevitable consequences of their age or of being a resident in a long-term care environment.  Hopefully, after reading this brief article, the reader and long-term care professional will come away with an increasingly sensitized eye for understanding the implications of depression among elderly in long-term care and how many memory problems may be corrected with the appropriate diagnosis and treatment of depression.     

When someone hears the word spirituality, along with a statement of attempting to introduce it into the workplace, what immediately comes to mind is someone attempting to interject their religious beliefs into the workplace environment. Although this may be one interpretation of workplace spirituality, in this case the theistic nature of such a definition is not the focus. The emphasis that will be part of this discussion will be more secular in nature. Workplace spirituality as a secular rather than a sacred phenomenon is a topic that has recently been spoken about, and even though there is not a great deal of empirical research on this topic, its introduction into a long-term care environment does make some intuitive sense. 

Workplace spirituality or organizations that foster such spirituality look to nurture the worker and the needs they bring to the organization. Spiritual organizations that foster individual needs in these areas often garner reciprocal benefits in their own right. At the basis of workplace spirituality is an understanding that people have spiritual needs, needs within the individual that are not necessarily religious, but are based on an inner need for meaning. People need to achieve a sense of meaning. They also have a humanistic need to potentiate themselves as human beings, to develop to their full human potential. 

Sense human beings spend a great deal of their lives in work environments, spiritual organizations look to tap the inner resources of individuals. This in turn applies to long-term care environments, which as organizational environments can also become spiritual organizations that tap the often untapped resources of their workers. Since individuals spend a considerable portion of their lives in work environments, nourishing the spiritual needs of individuals, helping them find meaning through their work, is critical in organizations that nurture an organizational spirituality.      

Why is this important for long-term care? Many individuals who work in long-term care environments have done so for many years and continue to dedicate a considerable portion of their lives to this type of work and work environment. In fact, many of us, when asked who we are, come to provide answers such as nurse, administrator, caregiver, physical therapist, etc. Generally speaking a key factor in shaping all human beings' identities is the work that they do. Spiritual organizations come to understand this and attempt to help the individual with their inner needs through shaping the organizational culture and environment to target many of their inner, spiritual features. Organizations that help foster this also obtain reciprocal benefits in that workers that are more fulfilled also can work more productively for the organization itself. 

This is important for many long-term care facilities. Nursing care facilities that have successfully achieved a spiritual organizational environment not only enhance worker productivity through satisfaction with their work, but also have lower worker turnover and increased levels of trust. This latter quality is extremely important. Successful organizations depend upon successful teamwork. Moreover, for successful teamwork to exist a sense of trust has to exist as well among the team players. In a healthcare environment that is predicated on the care that it provides frail and sick individuals, teamwork not only on the administrative levels, but also on the line levels is extremely important for the success of the organization and for the lives of those that they serve. Therefore, organizational spirituality not only helps foster the needs that individuals have, but also fosters the growth and development of the organization itself.     

Another important need that helps foster the growth of the individual in spiritual organizational environments is enhancing their sense of security, but here again the need is reciprocal. Human beings need to feel secure and that includes feelings of security in their work environment. But this need is not just unilateral. Spiritual organizations recognize the importance of their workers and in these types of long-term care environments the benefit of fostering a sense of worker security helps reduce worker-management conflict, turnover, and enhances the care, morale, and the general well-being felt about the environment. Therefore, spiritual organizations do not just provide inner levels of personal growth on a psychological level for the workers, but they also derive the benefits from their worker's personal growth as well.     

Key to human development is establishing a sense of purpose and meaning and possibly no other factor in our lives provides use with this sense of purpose than the work that we do. Work in all areas of society has to nurture more than just the base needs for people, but they have to nurture many of those higher level needs that provide us with a sense of meaning and purpose in our lives. Health care workers, especially due to the close interaction with other human beings that they serve, have a special affinity with the customers they service. Their sense or purpose is tied to more than just the production of widgets, but to the nurturance of other human lives. 

However, this type of work is also very difficult and emotionally draining at times. Therefore, it is important for long-term care organizations to recognize the purposeful importance that long-term care workers derive from their work, yet spiritual organizations also recognize that they need to help promote their worker's feelings of purpose and help guard against those destructive forces that may lead to burnout or stagnation of human growth.    

A long-term care organization that invests in the development of a spiritual organization helps to nurture the fundamental needs that human beings have, which is for personal growth. Workers in all walks of life often identify with the work that they do. It often provides them with a very important piece of their personal identity. 

Long-term care workers are no different. Many individuals who work in long-term care often do so for more than a casual passing. Many workers in long-term care have worked in this area for numerous years and identify with the work that they do as a critical part of their identity. It is because of this that long-term care organizations have to pay greater attention to stroking the important spiritual foundation that helps to provide purpose and meaning for them in their daily lives. Furthermore, as was mentioned, the benefits of developing a culture based on a spiritual organization that targets the internal needs of the worker are not unilateral, but reciprocally come to hold benefits for the organization as well. 

Organizations that infuse their culture with the beliefs in a spiritual workplace come to find that the benefits they sow ultimately lead to greater team cohesion, less turnover, higher levels of morale, less tension between different work groups, a more enjoyable work environment, and workers that have a greater ethic toward the provision of care. Because of this the investment toward achieving a spiritual organization will ultimately lead to a work environment that is more productive and workers that are more satisfied. Such a win-win situation for the organization and the individual need to be further investigated for possible implementation in many of our long-term care facilities.