Understanding the Transition to Life in a Nursing Home

As the median age of Americans continues its upward spiral, more and more seniors will find themselves faced with entering a nursing home at some point in their lives. This is a major life event and if the new resident and their family are not prepared for this possibility, it can be a major life trauma as well. It is important for the nursing home staff to understand the many losses the resident faces as they enter the facility and the possible reactions they may have because of this life-changing event.

Basic Facts About Nursing Home Admissions

• About 5% of seniors live in a long term care facility at any given time.
• One-third of all Americans will require nursing home care at some time in their lives
• More women than men reside in nursing homes
• One-half of the people entering nursing homes will remain there for the balance of their lives

Loss of Health

Entering a nursing home means that the resident has a condition that signifies the loss of their good health. This condition may also prevent the resident from being able to care for himself or herself, making them dependent on others for some of their most basic needs.

Loss of Home

Once the decision is made that the resident will not be able to return to the community, the apartment or home in which they lived will be lost. So often the task of sorting through the resi-dent's possessions is the responsibility of the children and the resident is not included. Precious items that represent a lifetime of memories are scattered throughout the family and sold or given away to strangers. The house where the resident and his/her spouse raised their children is sold so that the funds can pay for the cost of their long term care. The possibility of providing an inheritance for their children and grandchildren fades. The resident will no longer have a place to call their own, to decorate for the holidays, to invite others over for a visit, or to sit in the shade of the oak tree they planted forty years ago when the house was brand new. What little they can take must fit in a small space, often shared with a stranger.

Losses and changes in the roles that the residents may assume within the nursing home, can cause them to develop a poor self-image.

Loss of Status

The roles that the resident had in the community -- mother, wife, neighbor, aunt, brother, community leader, gardener, woodworker, grandfather, etc. -- provided them with fulfillment and recognition. There is a status attached to these roles. When a resident enters a nursing home, some of the major roles are lost and there are changes to others that can greatly affect the way the resident views himself or herself. The loss of these roles can have a negative affect on the resident's self-image.

Loss of Finances

The cost of long term care can quickly drain the resident's assets. Their life-savings is used primarily for the continuing care and often it is their children who write the checks each month from their parent's account. Sometimes the resident relinquishes control over their finances so they don't really know how much money remains. Often they are fixated on "paying their own way" and feel guilty about spending anything on themselves or giving gifts to their children and grandchildren on special occasions. Running out of funds and having to apply for public assistance can be devastating for this generation.

Loss of Relationships

Visiting someone in a nursing home can be an uncomfortable experience. The same relatives and friends that visited the resident in their home are often intimidated by the sights, sounds, and environment within the nursing home and stop visiting as time goes on. Sometimes the lack of private space in which to visit puts up barriers -- the resident's room with inadequate seating, the presence of a roommate, a lounge with residents and staff coming and going, overhead paging, etc.

Loss of Control

Residents do not enjoy the same freedom as they did when they lived in the community. For the sake of organization and efficiency, or mandated by the regulations, meals are served at specific times, activities are offered as scheduled, rooms are cleaned on specific days, assistance with bathing is scheduled, rehabilitation is scheduled. There are numerous rules and policies and procedures to follow -- visiting hours, which side of the hallway to walk down, where to sit in the dining room, who your roommate will be, etc. Even the resident's doctor visits and lab work are scheduled based on regulations. The more dependent the resident, the less control they have.

Other Losses

Since most residents in long term care are elderly, they have experienced many losses before admission. These losses include the loss of employment due to retirement; the loss of loved ones through death; the loss of their youthful appearance and stamina; the loss or decline in their senses such as hearing loss, cataracts, etc.; the loss of mental "sharpness," and the loss of unrestricted function.

Reactions to Institutionalization

The more input the resident has into the choice for placement in a long term care facility the better. Often this is not the case as a result of a catastrophic health problem that has hindered the resident's ability to continue to care for themselves. Adjusting to life in a nursing home can be challenging and the residents can exhibit many different behaviors and emotional reactions to their placement.

Anger

When living in the community the resident had many options to address their anger. They could go out with a friend and talk about what was making them angry and together they could come up with a solution. They could go for a walk, weed the garden, stroll along the beach, go for a drive in the country, etc. and ponder the situation. These options may not be available to residents in a nursing home. It is understandable for the resident to feel angry about the changes in their life and the many losses they have just experienced.

Depending on how the resident chooses to vent their anger is the key to how they will be perceived in the future. The resident may throw items on the floor, refuse to cooperate, criticize staff, the food, and the facility. When a resident is obstinate and "acting out" staff may label them as a trouble-maker, uncooperative, chronic complainer, etc., instead of finding out what is troubling them and helping them work through it.

Depression

The grieving and sadness connected with admission to a nursing home can cause the resident to feel depressed. They may begin to sleep a lot more, refuse to participate in the activities related to their past interests, "pick" at their meals, have insomnia, demonstrate increased dependence, openly express feelings of hopelessness, and refuse treatment.

Regression

Life in a nursing home and coping with their many losses may intimidate and overwhelm the resident to the point where they cease to do things that they are still capable of doing. They may become dependent on their family or staff to make their decisions for them. They may look to nursing to help them eat, bathe, dress, etc., yet they are still capable of doing this for themselves. They may ask their family to write the checks for their bills, send a birthday card to their grandchild, write a letter for them, etc. instead of them making the effort to continue doing these things.

Residents may learn that engaging in negative behaviors, becoming increasingly dependent, and constantly complaining about small issues can get the staff's attention and service.

Denial

Some residents may cope with the situation by choosing to deny it exists. Residents with a terminal disease sometimes make plans for the next year, even though the likelihood of them being alive at that time is very slim. Others may tell everyone that they are going home soon, when in reality there is no longer a "home" to go to. Some refuse to have anything to do with their finances, so that they don't know "for sure" what their financial status is.

Rationalization

Giving explanations or excuses is another way of dealing with life in a long term care facility. Residents may make excuses for the infrequent visits of their family. They may tell others that their loved ones are very busy with their own lives, they live too far a way to visit so often, they have problems of their own, etc.

Behavior Problems

Emotional turmoil can make residents agitated and anxious. This may result in yelling, resisting care, and other inappropriate behavior. Sometimes residents who are demanding, complain about being ill, yell, etc. receive faster service and more attention than those who are polite, calm, and healthy. The residents realize this and sometimes resort to negative attention in an effort to get faster and more frequent interventions from staff.

Physical Health Problems

The resident's emotional state can have a direct effect on their physical health. When they are anxious, depressed, or upset, they may experience:

• headaches
• indigestion
• loss of appetite
• sleep disturbances
• diarrhea
• breathing difficulties
• muscle aches

These symptoms can threaten the resident's already poor health and lead to other complications.

Helping Residents Cope

Adjusting to life in a long term care facility can be very challenging for the resident and their family members. A poor adjustment can lead to additional health problems and diminish the resident's quality of life. A good adjustment can enhance the resident's abilities, social interactions, and overall outlook on life.

The staff plays a pivotal role in helping the resident and their family ease the transition from life in the community to life within the facility. Here are some ideas:

• Greet the resident and their family as soon as possible when they enter the facility -- be sure to introduce yourself
• Make sure the resident doesn't need anything before beginning the admission process
• Take them to a private area, offer refreshments and explain the admission packet to the resident and their family -- try to streamline this process as much as possible
• Take the resident and family to his/her room
• Introduce them to the nurse, CNA, roommate, etc. and orient them to their immediate surroundings
• Explain the "basics" -- where the resident will eat their first meals, overview of the assessment process, etc.

Put yourself in the resident's and family's shoes. Imagine what it would be like for you to enter a nursing home or place a loved one there. Treat the resident and their family just like you would like to be treated if the roles were reversed.

• Give the resident and their family your business card and explain how to contact you
• Provide assistance to the resident and their family as they "settle in"
• Work with the interdisciplinary team to stagger the assessment process so that everyone isn't trying to access the resident on his/her first day in the facility
• Give the resident a chance to adjust to their environment -- allow them to move at their own pace
• Introduce the resident to another resident who has been in the facility for a while so that their "buddy" can help orient them to the facility and introduce them to other residents
• Check on new residents and their families at frequent intervals -- encourage involvement in the activity program, especially those activities related to the resident's past interests, provide information about the Resident Council, Family Council, and/or available support groups
• Explain the facility's routines such as times for meals, the housekeeping schedule, visitation times, etc.
• Encourage the resident to talk and express their feelings
• Work with the interdisciplinary team to provide the resident with as many choices as possible
• Watch for signs of "learned helplessness" and increased dependence -- educate the family and staff about what the resident is still capable of doing and emphasize the importance of encouraging the resident to accomplish these tasks instead of others doing the tasks for them
• Understand that it is normal for residents to be sad and cry about being in a nursing home. Encourage them to talk about their feelings instead of saying, "it's not so bad," or telling them to "cheer up."
• Report any unusual observations to the nurse -- difficulty breathing, signs of pain, keeping their room dark, sleeping too much, refusing to leave their room, excessive crying, etc.
• Welcome visitors and help them feel at ease -- greet them with a smile and ask how you can be of assistance to them.
• Put yourself in the resident's and family's shoes. Imagine what it would be like for you to enter a nursing home or place a loved one there. Treat the resident and their family just like you would like to be treated if the roles were reversed.