Gerotalk : General Information

Doing More to Assist with Pain Management

Brian Garavaglia — Fri, 18 Sep 2009 14:33:00 GMT

Pain management is a prominent issue in long-term care. For many years providing pain medication on a regular basis was irrationally feared based on risking a potential addiction to the resident. As we have become more enlightened, the fear of addiction has abated and our focus has become more rationally directed toward maintaining resident comfort. However, are we doing all we can to assist in pain management?

For sure we are using important pharmacological agents that have important pain killing effects to enhance the comfort of our residents. Also, providing a pill often provides a quick remedy to the situation. However, is pain management dependent on more than just pharmacological intervention? Does providing a pain medication always enhance the best practice in addressing pain? Moreover, does this type of pain management in exclusivity enhance the quality of life that is sought for long-term care residents?

Although monitoring and assessing pain has become a greater focus in long-term care and although many individuals are much more skilled today in detecting pain than was often the case in years past, there still exists a considerable dearth of knowledge and skill in pain management. In nursing care facilities the nurses are often the key individuals that are suppose to be responsible for pain management. In reality, pain management is the responsibility of all individuals who work in the nursing home. This may be controversial, but it is a very important mindset to be put in place.

Many nurses today are still ill trained in pain assessment and management.Furthermore, many other individuals such as nurse assistants and rehabilitation specialists are even in need of more training in this area. In addition, individuals such as administrators, housekeepers, maintenance, social workers, and business office staff get little, if any, training in this area. Since pain can often manifest itself suddenly, such as breakthrough pain, frequently when other members who are not part of the clinical staff are with residents, this makes it even more important that all staff is trained in recognizing and assisting in the pain management process.

Currently the pain management process is almost exclusively the purview of the medical staff. We have strongly medicalized pain management and subsumed this important topic under the physician and nurse. As a result it should be no surprise that we have so many individuals that can contribute to the process, yet fail to receive any training in pain management whatsoever. As many parents know, you do not have to be a physician or nurse to know when your children are ill or in pain. Furthermore, as many parents will tell you as well, they have often managed their children's pain and sickness without the intervention of physicians or nurses. This is in no way to deny the importance of physicians and nurses in the pain management process, but to say that these are the only two professionals that should be involved in pain management prevents the pain management process from being fully actualized.

We need to accept the pain management process as not just a medical intervention, but a social intervention as well. How can this be a social process? One may state that pain is a biological and biochemical process, and since it is a biochemical process, a type of biochemical intervention, especially pharmacologically based, is the only sensible approach to address this type of issue. However, pain in itself is far from an objective process, which can be empirically measured with pinpoint accuracy. Individuals experience pain differently, and pain is not just influenced by a person's biological threshold, but is also influenced by their perception, their culture, and their psychological state of being. Therefore, pain in itself is often quite subjective in its nature, and how it is perceived, reported and demonstrated is strongly individual, predicated upon the phenomenological nature of each person.

We have all heard of the "placebo effect," in which a patient is provided with a supposed medication and experiences results that are highly efficacious. The person often subjectively creates pain, and the same subjective process often abates it. I am not contending that pain is not real for many of the residents that we service. In fact, I am arguing for the exact opposite: since pain is highly individualized among all individuals, including long-term care residents, we need greater intervention to deal with this important problem, more than just intervention by a physician, nurse and a pill.

Because the phenomenology of pain is so complex and multifaceted, the way that it is addressed also has to complement this complexity. In limiting the nature in which we treat pain, using only the medical model of physician, nurse and pill, we continue to fall short in treating the resident holistically. As the placebo effect has demonstrated, pain is more than just a biological and biochemical feature of the body. It is based on the subjective and phenomenological states of the resident that we cannot always reach with medicinal agents. All heath care centers underutilize the range of approaches that can be used to address pain, but the long-term care industry is not doing much to enhance their productivity in this area.

Many complementary nondrug methods such as acupuncture, biofeedback, distraction, imagery and visualization and meditation are very seldom, if ever, used in these types of environments. One may say that is because of the type of clientele found in nursing homes, which often have a large number of fail, dying, and demented individuals. However, this type of argument is often weak. Many long-term care residents can be quite receptive and workable with these types of interventions and yet they often never get the opportunity to benefit from these types of intervention. Others argue that these types of therapies should not exist in a medical environment. Yet again, this argument is just the same type of rhetoric that needs to be disposed of in regards to resident pain, especially if we want to address this important resident concern in a holistic manner.

In conclusion, this author is arguing for a greater breadth and depth of pain management and intervention by the staff. Pain is more than just a biological process than can only be targeted by medical personnel who are able to write prescriptions or dispense medications. Pain management is a social enterprise. It is a uniquely subjective state that needs to be recognized, and because of the social factors involved in pain, pain management should also become a process of social intervention. Currently, too many nursing homes continue to treat pain one-dimensionally, failing to recognize the multidimensional makeup of this complicated process.

The Need for Preventative Health Care Practices in Long-Term Care

Brian Garavaglia — Wed, 22 Apr 2009 12:57:00 GMT

Although nursing care facilities have made considerable advancements in the quality of life offered, there still is substantial room for improvement. One of the areas that need to be focused on is creating a culture that nurtures greater activity and promotes health. In many facilities the esthetic improvements that have been made are great, but overall most nursing care facilities are still environments focused on tertiary care. It may sound counterintuitive, but nursing care facilities have to invest more of their resources in preventative care! You may be saying this sounds crazy. Since most individuals found in nursing care facilities often suffer from considerable levels of chronic illnesses, what importance can be gained from offering more preventative care services. Moreover, what other types of preventative services can be offered other than those normally offered, such as the influenza and pneumonia vaccines. Let me briefly address this matter in further detail.

Although there are many areas that I can address, the one that I am going to focus on here, albeit briefly, is the need for increasing the levels of physical and mental activity in the elderly. Even with advancements in the quality of living that we have witnessed in nursing homes in our country, today we still see most individuals in these setting relegated to a static and sedentary existence. Increasing the level of physical activity has tremendous benefits for advancing the health of the elderly, preventing unplanned hospitalizations, maintaining a stable census, reducing nursing home costs, and ultimately enhancing the quality of life of older adults residing in these facilities. Although nursing care facilities typically have physical, occupational and activity programs, many do not receive any physical and occupational therapy after they have exhausted their Medicare benefits and activity therapy is often too infrequent and frequently not targeted at preventative health care. Also, the care staff is often focused on the secondary and tertiary care needs of the residents and often have little training in providing preventative health care services for the elderly.

So what are these preventative services that I am mentioning in this paper. Most of them involve exercise, both physical and mental, which enhance the wellbeing of the older adult's daily functioning. Take for instance the problem of falls in nursing care facilities. This is an epidemic problem in long-term care and one that has continued to plague even the best nursing care facilities. One of the major problems is muscle weakness in the legs. The leg muscles are one of the largest groups of muscles in the human body and they are responsible for providing support and balance. In younger individuals who are active, walking frequently often will keep these muscles toned to prevent injury. However, as we age and engage in more sedentary activity, which is especially found in many nursing care facilities, muscles atrophy. First, greater levels of walking will help strengthen leg muscles, enhance balance, and prevent many unnecessary falls that often have the negative consequence of a fractured femur or hip. Staff has to be trained in encouraging more leg strengthening activity and walking is probably the best exercise to enhance leg strength and general health. However, what about leg squats! You may be saying that this exercise is only used by younger individuals that go to the gym, but this is not true. Think about moving up and done in a chair. Many falls happen when the elderly are getting up or setting done in chairs. One way to enhance leg strength is to encourage elderly, during the breakfast, lunch or dinner setting to sit up and down in a chair a few times. During your post meal cleaning of residents this can be part of nursing intervention.

What about something like arm strength? Older adults in nursing care settings loss a considerable amount of their upper body strength through disuse and sedentary lifestyles. Here again, simple clinical interventions frequently throughout the day, such as having them lift small weights or involving residents in other forms of frequent isometric or isotonic exercise can help strengthen the arms that often support movements that are frequently done in their daily activity.

Providing appropriate mental stimulation is important as well. Frequently many within the nursing home environment think that playing pleasant music or playing bingo is adequate for mental stimulation. However, here again, one has to wonder how much cognitive impairment happens in these types of environments due to not having adequate, challenging stimulation. The key word here is challenging. It is becoming evident that neurogenesis is often incumbent upon challenging the mind and that neurogenesis can happen throughout life. Providing clinical education to have nurses and nurse assistants use reminiscence therapy, pose challenging questions for residents to think about, ponder and answer, and having activities that challenge the cognitive abilities of older adults is critical for proper mental stimulation.

Many of these changes will provide a better quality of life through preventing injuries and illnesses that will happen through a static existence. Our bodies are built for movement and this axiom does not just apply to those who are younger, but it applies to those of all ages. Regardless of age, inactivity leads to weakness, frailty and preventable illnesses. For older adults the acceleration in the reduction of functionality is even more of a problem that has to be guarded against. This is an endemic issue in nursing care facilities. All too often many residents will demonstrate precipitous declines that are quite preventable with the appropriate active intervention. One has to wonder how many falls leading to fractures, slips leading to injury, illnesses due to compromised immune systems, confusion and delirium that is often attributed to age, and reduced ability in movement could be abated, forestalled or even prevented if greater levels of physical and mental activity would become part of the preventative culture of nursing homes. All too frequently many nursing home residents end up with preventable physical and cognitive declines as well as end up being discharged to hospitals from nursing homes, also frequently preventable, due to succumbing to the ill effects of inactivity. Turning our attention to not only treating disease, but also enhancing the health of the community is an important paradigmatic shift that needs to exist in nursing homes across the nation.

The Need to Understand Philosophy in Healthcare

Brian Garavaglia — Mon, 20 Apr 2009 18:10:00 GMT

Philosophy? What can those of us in healthcare learn from philosophy? Does philosophy have any practical benefits that can be applied to society and healthcare? When many of us hear about philosophy we are compelled to think about a course that we may have had to take for a humanities requirement in college. Or the thought of philosophy may conjure up some thought about individuals who sit around a table drinking coffee, intellectualizing for the sake of intellectualizing, without any practical purpose for this activity. Who in the world wants to sit around and debate whether a tree that falls in the forest still makes a sound if no one is there to hear it! However, the practical implications for understanding philosophy are greater than most people come to assume. I personally am not a philosopher by training, but I have come to understand the importance of philosophy, especially as it pertains to the field of healthcare.

As a person who has been involved in science and trained in this area, what practical importance can I see in philosophy, especially for healthcare practice and administration? First, I have come to be quite aware that science and scientific explanations are not always satisfactory. We live in an era where we think that reductionistic strategies found in scientific explanations can work in all areas, including healthcare management. Although some post-modernistic thinkers have questioned this as well, many of their explanations go to a different extreme, which often fail to be satisfactory as well. So where does having some level of philosophical understanding fit for those in healthcare and especially long-term care?

Many problems in healthcare are not easily reducible, and many fail to be explained by empirically clear and concise scientific tenets. Many of these problems lend themselves strongly to engaging in thinking that may not have one correct answer. Understanding the philosophical complexity of our world helps us to think about the problems that are presented with a profundity that extends beyond the sciolism and triteness that many use to solve complex issues.

Think briefly about the areas of ethics. Ethics is an area that has been, and still is, strongly influenced by the discipline of philosophy. Ethics is part of every aspect of our lives. The healthcare area is no exception. In fact, healthcare may be the one institution of our society in which ethics plays its greatest role. How many of us who work in long-term care are confronted daily with decisions that ultimately have a compelling and profound impact on our lives, on the lives of those that work with us, as well as on the lives of those that we serve. Of course healthcare is filled with many issues that are clear, in which we have an unambiguous and ethically firm understanding of what we need to do and how we need to act.

When things are going well and when decisions are clear we often do not think much about the importance of having training and understanding in the area of philosophical ethics. However, during periods of ambiguity, when decisions that need to be made about issues are not clear cut, this is the period when we become acutely aware that science or some decision-making algorithm are often not available to help us through this difficult process.

Furthermore, many of use are not aware that even though most of us are not formally trained philosophers, we all have a philosophy that helps shape how we come to see the world and understand problems. We all have particular sets of values, ideas and assumptions that shape how we come to understand and frame the problems that we are faced with daily. Therefore, it behooves us to understand more about the way we think, the way we come to understand problems, how we can better understand our own particular strengths and weaknesses, and how we can improve our thinking about the daily problems we face in long-term care.

Look at the problems that we are faced with in long-term care that often tax our problem-solving ability. How many of us have had to advise or help counsel a family member about important matters such as their concerns about a dying family member and what type of treatment they should choose. What should be our ethical approach in this matter? Is there one correct approach? Should we not provide any input since they are the guardian or durable power of attorney? In other words, is there a concise and empirically scientific explanation we can look to or a step-by-step algorithm that we could follow? Typically not and this is why understanding the importance of philosophy and the philosophy of ethics is very important.

The cancer or heart disease that the resident may be dying of is often easy to explain on a scientific level. But what about those stomach-turning human decisions that are not easy to reconcile? Decisions such as what type of care to provide or not provide, or in other words many of those decisions with a considerable level of relativity and ambiguity that fail to have clear parameters of correctness or incorrectness are the ones that we struggle with most. Moreover, these matters do not just cover health care issues, but issues related to workers, the work environment, as well as those problems that we personally face as being part of this environment.

In writing this blog I am not attempting to instigate a heightened enrollment in local college philosophy classes. However, I am attempting to convey the importance of philosophy in the area of decision making in health care, in particular, long-term care. Often, we eschew the importance that philosophical theory can have in our lives and yet, as mentioned, we all have a philosophy that shapes our views and our decisions. Quite important is the field of ethics, which health care professionals deal with daily. Having an understanding of utilitarianism or deontological theory as it applies to ethics can have a powerful impact on how we come to view those ethical issues that we are frequently inundated with and fail to have any clear, correct answer for. Furthermore, understanding more about the philosophical importance of these issues also will come to shape us as professionals in long-term care.

So to answer the question that we started out with, "does philosophy have any practical importance to long-term care professionals," the answer is yes. The ability to use a discipline that helps us think more soundly about the myriad of compelling decisions that we are faced with daily will ultimately help with the betterment of our profession.

What Can Long-Term Care Learn From Enron?

Brian Garavaglia — Mon, 30 Mar 2009 17:01:00 GMT

Today, most people are familiar with the story of Enron. A company that was once looked at as one of the exemplary companies in the United States became a buzzword for corruption and mismanagement. Although the problems that came to eventually destroy Enron were monumental, as mentioned it was once viewed as an exemplary company. What happened at Enron is a lesson for those in business and this lesson is transferrable to the health care sector as well.

Enron as mentioned was once viewed as an exemplary company, which was growing and had sound leadership driving its corporate culture. Under Richard Kinder, the president of the company, the company flourished, and a corporate culture of trust was established. Kinder was viewed as a person that was quite meticulous and held others accountable for their behavior and for their roles in the company. Although strict, he did build a culture of trust that many felt comfortable with. They understood their roles and their expectations and although Kinder drew a line in the sand, establishing his area and what his expectations where for others, many felt that he did so without equivocation.

With the movement of Richard Kinder out of the company and Jeffrey Skilling into the role of Chief Executive, things started to change. Skilling had a Machiavellian temperament for control and an unbridled hubris. Skilling introduced evaluation systems that would be made available to others in the company. He also created an environment that found frequent turnover, fostering hegemony and fear throughout the corporate environment. This left many looking over their shoulder wondering if they would be the next person to be cut from the workforce. The environment that had previously been based on a level of trust and stability was now being replaced by a culture of paranoia based on Skilling's capricious and fear-inducing tactics.

Skilling appeared to feel that introducing fear and fostering a sense of insecurity among the workforce culture was a positive management strategy. As the new culture and management style became set in place at Enron, it was almost inevitable that the organizational features that Skilling put into play would led to the formerly successful company to witness a destabilization of their cultural environment. We now know that it did and the stability and trust that was established by Kinder was destroyed by Skilling within a very short period of time. This for sure in not the only problems that Enron faced, which ultimately led to their demise, but the establishment of a "social Darwinism," with a cutthroat mentality and a lack of care for those in their work culture was significantly related to the downward spiral of this company.

So what type of lesson does this hold for those in long-term care? The lesson is significant. In a health care environment, the importance of trust and collaboration is very important. Prior to Skilling's arrival at Enron there was a feeling of consistency and trust. The company flourished under leadership that encouraged a firm management style that emphasized a collaborative and trusting team approach. People were viewed as resources that needed to be tapped. However, when the culture moved to a dog-eat-dog environment, trust waned, collaboration waned and the workers came to view themselves as disposable cogs that occupied positions on a day-to-day basis. How often do we witness this type of style within long-term care?

Think of how often we feel that we need to manage in secrecy, behind closed doors. For sure, there is need for this type of management. But all too often this type of management comes to dominate the administrator or other manager's styles, providing for a less than transparent environment. Workers come to feel that the culture is veiled in secrecy, with workers becoming paranoid about what is being discussed behind those closed doors. This in turn often erodes feelings of trust that are needed for a sound and efficient work environment. Furthermore, a level of hypocrisy often results where managers state they have an open door policy, yet spend most of their days is clandestine discussions or meetings. Workers pick up on these subtle clues that are provided by those in authority.

As we witnessed with Enron, when trust started to erode and when capricious policies were set, the breakdown of trust as well as the breakdown in the cultural environment as being a stable and predictable place eventually led to the downfall of the company. Workers became anxious about their jobs and they also became weary of working in such a strenuous and draining environment. The social Darwinist philosophy of "survival of the fittest," promoted distrust and continuously made workers view others in askance. Moreover, it ultimately led to workers viewing themselves as disposable commodities without any attention being paid to the person's self-worth. All too frequently we provide little attention to developing an environment or organizational culture based on trust. As those at Enron did, letting their profit and loss be the all determining factor that a worker's worth was measured by, many in long-term care fail to nurture the important factors of trust, stability, and security in the organizational environment.

Health care is a business, and long-term care is no exception. Yet, failing to recognize the importance of our human capital, those people that we depend on to carry out the important duties found in long-term care on a daily basis, is critical. If we fail to build a culture based on trust and respect, and fail to recognize that these needs are paramount for those that we manage, we too could face the same type of problems as an Enron. Therefore, rather than look at a company such as Enron and say it could not happen to us, we need to learn and understand how we can obviate such problems from occurring in the environments that we oversee and manage. History does not need to repeat itself if we can learn the lessons that it teaches us.

The Future of Long-Term Care

Brian Garavaglia — Wed, 11 Mar 2009 19:45:00 GMT

In today's challenging economic times, what does the future hold for the LTC industry? Read my latest column on ADVANCE for Long-Term Care Management's web site.

The Nursing Home Rating System Revisited

Brian Garavaglia — Mon, 19 Jan 2009 15:55:00 GMT

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.

Changing Brains

Brian Garavaglia — Wed, 31 Dec 2008 15:46:00 GMT

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

We Still Have A long Way To Go

Brian Garavaglia — Wed, 19 Nov 2008 18:24:00 GMT

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.

The All or Nothing Principle

Brian Garavaglia — Thu, 16 Oct 2008 16:37:00 GMT

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.

A New Column

Liz Rosto — Tue, 23 Sep 2008 19:36:00 GMT

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.

Depression and Pseudo-Dementia in the Long-Term Care Population

Brian Garavaglia — Tue, 12 Aug 2008 17:30:00 GMT

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.

The Importance of Creating Workplace Spirituality in Long-Term Care Environments

Brian Garavaglia — Mon, 28 Jul 2008 16:16:00 GMT

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.

Trust Starts at the Company Level

Brian Garavaglia — Tue, 27 May 2008 14:31:00 GMT

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

Brian Garavaglia — Tue, 13 May 2008 16:17:00 GMT

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

Brian Garavaglia — Tue, 29 Apr 2008 16:58:00 GMT

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.