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Protecting Residents' Dignity: The Social Worker's Role

The following lecture discusses the key points of what nursing home social workers can realistically do to make changes in their practice to enhance how resident dignity is perceived and respected in the nursing home environment.

Dignity issues can often take a back seat in the busy nature of our jobs as social workers, but as busy as we have become, I personally cannot imagine what the nursing home environment would be like without social workers. The dignity of our residents can only improve if the social worker first feels dignity in his or her role in the facility. To accomplish this you need four things to occur. First, your administrator must understand and support your role. It is difficult to advocate if you do not feel safe and supported doing so. Second, the director of nursing must connect with you, the social worker, as an ally. Similar to the administrator, the director of nursing needs to be constantly reminded that you are on nursing's side when resident issues present themselves. Third, the nursing staff and unit supervisors have to feel you can make their jobs easier and that you are not criticizing their value when things go wrong. Lastly, when these three areas are addressed, the social worker needs to value who they are in the system of care. When the social worker feels a sense of professional dignity, improving resident dignity issues can progress forward.

I am reminded of an email that was sent to me as a true story. A social worker received word of a resident's upcoming 100th birthday party. The resident was usually found in a wheelchair and due to a stroke could not speak out loud. She used scraps of paper to write short messages to communicate. Well, the social worker did the whole "Willard Scott" thing. She encouraged family to participate and reserved a room in the nursing home. The party started with all the regular party talk, and the resident was wheeled in to all smiles from her family. At one point during the party the resident started leaning way over to the left. The social worker saw this and ran down the hall to get some pillows and brought them back to stuff them into her other side to help her from falling over. Moments later the resident started leaning over to the right. The social worker was right there, taking more pillows and shoving them into the left side of the resident to straighten her up. A little while later, once again, the resident started leaning, but this time she was leaning forward. Once more, the social worker took pillows, put the resident's legs under them. In other words, the resident could not move at all.

At one point the resident's nephew came in and approached the resident immediately and said, "Auntie, aren't you enjoying the party?" The resident brought out her pen and a piece of paper and slowly wrote something down, handing it to the nephew. The nephew read the note. It said, "I'm 100 years old today and they won't even let me fart."

My mother and I joke about the day that she will have to go a nursing home. Knowing my family, I will inevitably inherit my mom and I'm already thinking about where to put the mother in-law's apartment. I told her I would help her stay home as long as possible, up to the day I see brown in the diaper. We both usually laugh. That's when I sign the paperwork, when I look down and see brown. Surprisingly, she says, "Okay." She does not want her son, of course, to clean her diaper as she would lose her last bit of dignity if that happened to her with me present. She said this was the deal. If I look down and see brown, it's off to the nursing home but I must: 1)make sure that in the nursing home her hair is done every week; 2) that her nails are done every other week; 3) that I never call her cute in any way, shape or form; 4) that I never let anyone stick her in a Bingo game; 5) that I never sit her in a dining room with all the old people; and 6) she also says that if I ever come to the nursing home to visit and find her showing me her popsicle stick art craft creation, that I am supposed to just put her out of her misery. Done deal… but can I ensure that?

It was frustrating to find actual information on how to promote a resident's dignity in the nursing home. Although the word is mentioned in various articles, it is usually mentioned to describe other words, and not actually defined on its own.

The dictionary defines dignity as "the quality or state of being worthy, honored or esteemed. The actual tag under OBRA for dignity reads: "The facility must provide care for individuals in a manner and in an environment that maintains or enhances the individual's dignity and is in respect to the full recognition of his or her individuality."

As social workers we are on the front lines of defense in protecting a resident's dignity. Without us, a lot is lost and residents can suffer emotionally without our effort. We need to realize residents do suffer without us. What is a resident? A resident is their history: "I was." They are what they present to us: "I am." They are human beings who have the right to live their lives, however long or short, in a manner they see fit: "I want to be."

I was a person who was worthy, honored and esteemed.

Subacute units and the urgency to admit and discharge residents has taken time away from the Team's ability to really sit back and develop insight into a resident's "I was, I am and I want to be's". Nursing cares about these features of a resident, but the time they need to fully delve into this information is replaced by their devotion and their duties on the floor and to the medical chart. Fifteen years ago I can say that almost every nurse read my six-page, single spaced typed, psychosocial history. It was common 15 years ago for a nurse's aide to stop me in the hall and actually explain that in her off time the night before she sat down and read my psychosocial history, but this does not occur any longer. What that psychosocial history did - and can still do - is powerful. It truly helped the nursing staff understand many of the questions related to why residents acted the way they did. It helped them humanize the resident as being a person, just like them, with a rich, diverse history worthy of the type of respect they as nurses wished for themselves.

Virginia was at a nursing home for an extended period of time. Every effort was taken to please her by the nurses and even her family. When she started to lose weight, nursing even went as far as to order her chocolate milkshakes from the local Dairy Queen. Her family had a massage therapist come in and give her massages for her arthritic neck, hands and legs. She even had hired, private duty nursing to help wash and dress her. Nursing made sure that she always looked her best. A nurse's aide would be on her call light faster than any one else's call light on the entire floor, just to give her a glass of water. But when she looked at the water glass it didn't look half full or half empty. Her water would always be too warm, or filled with too much ice, or it would be in the incorrect cup, and so on. She triggered for behavior problems in the MDS as being socially inappropriate and the nurses could not understand why this woman was so intensely sad. Well, Virginia had been a dental hygienist. She had never married. She went ahead in the mid forties and fifties and started putting half of her entire income into this new investment opportunity called "Mutual Funds." At the time, for a woman to be doing this was considered rather risky.

Virginia worked until the age of 82. Yes, at 82 years old she was still cleaning teeth. She was able to send every one of her nieces and nephews, all eight of them, to college, and rarely vacationed so as to keep an eye on her income and literal wealth. At 82 she decided to retire. One week following her retirement she had a stroke, was in a hospital, was transferred to a nursing home two weeks later. Her insurance would not cover any of her daily expenses. So what do you think the nurses did when the social worker went on vacation? They Section-12'd her. When the social worker came back from vacation and asked why she was Section 12'd, the nurses responded, "Because she was too angry." It seems that no one likes to work with angry people for too long a period of time. Who would not be angry? She came back from the hospital and the social worker's effort began. Helping the nursing staff understand the resident's life and why her anger existed made the absolute difference in Virginia's life at the nursing home.

The staff immediately began to make a much more active effort in simply washing and brushing Ms. Virginia's teeth every day. All the staff began to provide Virginia with a life review as they worked with her, to praise her effort in sending eight children to college. The Team also began to tolerate her anger more and allow it to occur. The staff began to realize it was a normal, understandable way for Virginia to cope and protect herself. Without her anger, where would Virginia go? Anger can be a symptom of depression as well as the greatest defense against it. I understand that most depressed residents, if they go without treatment in a nursing home, do not live much longer than a year. If you look at the last 50 residents who died in your nursing homes, you may find that those who lived under a year had a diagnosis of depression. Virginia lived in the nursing home for a total of six years. She came in angry and in many ways, probably died as angry as she first came in. The staff's awareness of history as to why she was angry helped protect her dignity overall, and was a great awakening to the staff in general who cared and helped her. In other words, the information the social worker provided assisted in everyone's awareness of why Virginia was the way she was and helped her overall dignity.

In another example, a gentleman named Walter was extremely conservative and of a strict Baptist background. When he was stricken with dementia, his daughter had very few options but to pursue a nursing facility. In the early stages of his dementia he began to be obsessed with money. He was aware that he had not saved enough money for his children for when he died. When the daughter paid the phone bill she started to notice over 30 calls to California. She started to call a few of these numbers, and every single person that answered had the last name McMahon. Around Walter's house he had on his desk, in his living, room, all over his kitchen table and the dining room table, all the different varieties of stickers that he believed he had to put together in order to send it to Publisher's Clearinghouse to claim his ten million dollar prize. These phone calls were actually being made to Ed McMahon, thinking that Ed had to be contacted to actually collect his prize money. In the end, after the resident went into then nursing home the daughter had to cancel over 40 magazine subscriptions. She also found a sign created down in his workbench area that said, "I won," that he had planned on putting out in the front yard. In interviewing neighbors it was found that Walter was often seen going outside on his front lawn in his suit and tie. His daughter believes that he was awaiting Publisher's Clearinghouse to actually stop by and hand him his check.

Walter's religious underpinnings, being "born again," made him believe that people of Catholic and Jewish persuasion were unfortunately not going to heaven. He would talk to his family about the great perils of hell and even refuse his children to have Catholic or Jewish friends. When the daughter decided to search out nursing homes in the area, she found that the only one available to her at the time, as well as the one best for her father's care, was the nursing home close to the Catholic Church and owned by the Catholic Archdiocese. There were three things very unique about Walter. He was depressed about his money and lack of it; 2) he never wanted to ever have anyone dressed in a nun's garb touch him or be near him in any way because it represented Catholicism; and 3) he hated when people touched his hair. He always had his hair perfectly flattened and pulled all the way back. In the nursing home, Walter, the born again Christian, became a gentleman who knew more curse words than any resident in the entire building. He cursed at any moment care was provided, and would yell and scream at the top of his lungs when someone in nun's garb passed by. He also had a hard time coping with family visits as he felt his hair was off kilter and the staff was always trying to fix his hair, hair that he had fixed himself for all of his 96 years.

With the social worker's help at this site in particular, understanding Walter's religious background became key and improved his dignity ten-fold. The occupational therapist began training the resident in order to teach him how to comb his hair and the site invested in a type of mousse or hair spray that would make it stay put as much as possible. There was a care plan actually instituted to ensure all the nurse's aides only helped fix his hair once during the day, with the resident's help. The resident began also being praised for the house he left his family rather then the money he didn't have to leave them. All the efforts were taken to keep people dressed as nuns away from the resident at all times. This resident did calm down when the staff began to do nothing more than understand him. Information is power in a nursing home.

In hindsight it is interesting to note that the resident's daughter did receive a condolence card from a member of the nursing staff, a nun. She explained in the card that she was visiting the resident in her non-nun garb for some time and bringing in a violin that they played together, as Walter could play the violin. She wrote in the card that she felt that Walter was definitely in heaven because she could hear him still playing the violin.

It is usually the little things that make the biggest difference and yet can be the hardest to accommodate in a nursing home.

Since nurses are busier, they have less time to read. And although we do not write six-page psychosocial histories anymore, we as social workers have to verbally give this history to nurses, rehabilitation and recreation staff at every moment. Good information can change opinions: give it. Not only specifically to the disciplines I just mentioned, but also directly to the nurse's aides, as we can no longer assume that nurses will carry our information about a resident forward to the people on the front lines providing one-on-one resident care.

Let your words emphasize a person's worth and abilities. reference them by name, not by "resident" or "patient." We have often seen the memory biographies placed in the rooms of residents with Alzheimer's disease. Some nursing homes are going to great length to actually include the biographies on the non-Alzheimer's residents as well. These memory boards are very simple to create and as long as the resident and family sign a consent that they are allowing their display. They can include such information as what is easiest for the resident to talk about or a list of their life accomplishments. An example of the type of historical information that can be found in a Residents Profile can be found here.
I am a person who is worthy, honored and esteemed.

Giving out this information does take time. Real time. So does getting the information. The pace of our day is not like the pace of the day in the life of your average elderly person.

We need to slow down enough to adjust to the pace of our residents. If we rush a resident, we are not doing our jobs well. If we finish sentences for them or direct them to get to the point quicker because we have to go to a meeting or answer an overhead page, we are placing them in our agenda, an agenda they can never get used to since their pace may be slower. In other words, for your residents, as social workers, slow down!

Related to this point is our role in actually taking the history down. Residents want to tell their stories if someone wants to listen to them. The very simple act of shutting down our distractions, not only builds immediate rapport, but helps us with not making them strangers on the units. At one facility in particular the social worker instituted a policy that she could not be disturbed by overhead paging or telephone calls between the hours of 8:00 a.m. and 12:00 p.m. Although it took some time to institute, it has improved the social worker's ability to get her job done free of distractions.

Nursing and MD's are medically minded and trained in a medical way. We as social workers need to take the time out from the "medical minded" approach to ask the residents specifically what is important to them. Who or what calms them down. What makes them fearful, and what it will take to make their stay less stressful. I am not trying to say that nurses don't do this. I am trying to say that they are doing it less, and we as social workers need to pick up the slack and actually ask these questions more.

We as social worker's don't spend enough time to really, really get to know how a resident spent the majority of their time before they actually went into the nursing home. The section of the MDS which is about the resident's usual routine is often overlooked in our facilities. I imagine the creators of the MDS created this section to prompt each site to attempt to make a resident's daily stay duplicates of their actual lives that they led at home. Does anyone use this section of the MDS in their nursing home? We as social workers need to be more involved in this section. We need to use this section to educate the entire Nursing Team. Doing this can make the average nursing home stay something above average and much more unique and home like for the resident, and again protects a resident's self-worth. It also decreases fearfulness and improves a resident's response to overall care.
  • How would it feel if you have never been naked in front of anyone but your spouse for over 50 years, and you were used to taking a bath every morning, to actually live then in a nursing home where once a week you were placed in a shower chair, wrapped in a sheet, paraded down a hallway by passersby, placed in a shower room, disrobed and showered by one or two nurse's aides you just met yesterday.
Social workers should start looking around in their nursing homes. Have the administrator take a shower in the shower room and see if he or she would do it. If your administrator won't take a shower in the nursing home, then something really needs to change. The shower room is probably the coldest environment in the nursing home itself.

I recall working with a resident who I was asked to see because she had a habit of stealing packets of sugar from the dining room. When I came into the resident's room I noticed a big basket of sugar with a little sign, "25 cents each." When I approached the resident as to why she was stealing the sugar and selling it for a quarter, she explained that it was her goal to actually save up enough money to build an addition the nursing home, off her room, so that she could have her own private shower and decorate it herself.

One nursing home took the effort to decorate their shower rooms to make them more home like. They placed shelving up on the tiles, replaced the lighting with lower light fixtures, actually put plants in corners of the shower stalls and installed a speaker system for music. They placed a do not disturb sign on the door that they insisted everyone respect. They insisted that every resident have a simple bathrobe and slippers that actually matched. They educated every resident as to what to expect on bath or shower days, and this helped a great deal in decreasing resident's fears about shower time. Hence this increased resident dignity.
  • How does it feel to know you would once have your family over every Sunday for dinner when you were home and spend a great deal of effort after church in preparing dinner, to now being in a nursing home worried about being ready for the family's visit on Sunday, to not be able to go to church, and to have nothing to offer a family member food-wise when they visit? We all know the aged enjoy visits, but they are also used to having visits over food. Food is love, and this could not be more true for the elderly.
At a different site, they went to great efforts to find an interim chaplain to make sure that Sunday services were done actually on Sundays. They also coordinate all hair styling for Fridays and Saturdays so residents will be prepared for their weekend visits. Although they do not do it seven days a week, they decided that on Sundays, the dining room would be called "the restaurant." At any moment of the day on Sunday, a resident could bring their family members in, read from an actual short-order menu and order food. And guess what…family members were actually visiting more often following this change.

I want to be worthy, honored and esteemed.
  • How would you feel to know that when you die, all the residents in the nursing home will be shuffled off to their rooms so that a stretcher can be brought down at some time in the night, for everyone to wake up and wonder, where dear Ethel ever ended up and why her bed is so neatly made and clean.
One site in particular saw this as a real problem and challenge within their nursing home. They had some professional help in designing what they call "The memory room". The room featured black and white photos of the elderly, professionally framed and hung on the walls. In poses of laughter, photographs of their family as well as pictures of themselves in the nursing home were prominently displayed. In the middle of this room was a table with a glass vase. In this glass vase, depending on the time of the month, there were an amount of roses, signifying one rose for each resident who had died in a give month. Two cards were on the table for people to sign, one given to the resident's roommate with the rose, and one to the family. When someone dies in this facility, the residents on the floor are alerted immediately after the family is alerted, and are asked if they wish to say goodbye in any way. The body is taken out on a stretcher, but the stretcher has a soft pillow under the head, and is also draped in colored fabric. We in general don't treat the act of death with much dignity, and it is often never discussed or talked about in nursing homes.

We may have made strides with the act of dying with dignity. Hospice has helped us in nursing homes a great deal in dealing with the dying resident. We may approach a resident's dying and help a resident have a dignified existence toward the end, but after the death occurs, we have a lot of work to do with how we handle the actual resident's death for the sake of other residents in the building. What we don't want is for residents to think that when they die, that all of their resident friends they've lived with will be shuffled off as their body is hidden and carried out in a way that no one can see.

Residents are not able to adjust without some semblance of being able to have relationships with others. This is the number-one characteristic needed for a healthy adjustment in a nursing home, building relationships. We as social workers need to assist in meaningful efforts to actually remove the barriers which interfere with relationships, for residents to have improved adjustments. You have to build the resident up because many of them arrive at nursing homes feeling defeated and fear and anxiety prevent their emotional adjustment. By the single act of meeting their expressed fear with actual information we can help our residents feel better. Educating a resident promotes adjustment because it defeats fear and is one of our greatest interventions.

Other factors we need to care about to promote a resident's ability to help them develop relationships with others:
  • Advocating for their ability to communicate to be enhanced (hearing aids, communication boards
  • Demonstrating to the staff of the floor what the resident IS oriented to, rather than focusing on what they can't do for themselves
  • Help them learn how to have a roommate or live with someone that's a stranger to them
  • Ensuring that family contact is always available
  • Getting psychiatry involved in helping if necessary
  • Helping to gain access to what the resident utilizes for coping (spiritual)
Advocating for a resident's self dignity is not something that can make us completely popular at all times with the entire nursing staff.

Dignity rounds can have a strong impact on the quality of a facility. These rounds should be totally run by social workers, coordinated once a month to address changes in the system of care in the site from the resident's perspective. They include the director of nursing, the administrator, the recreation director, the nurses aides staff as well as a family representative and even the resident. The purpose of the meeting is to identify the issues involved in promoting resident's dignity and incorporating it into the facility mission.

I do not know how many times I have seen a urinal next to a food tray or a pair of dentures. I also have had many occasions from knowing a resident's history, I know how upset they would feel if in a non-demented condition, they knew that their hair would be tied up in ponytails or dressed in clothes that don't match or without stockings. I am guilty of "not rocking the nurse's boat" sometimes. I am guilty of searching out an already overworked nurse's aide to address a resident's concern, when I knew they were concerns I could address myself. I take small steps for that reason now. I ask now the nurse's aide to come into the room and actually help the aide directly with the resident's physical or environmental concerns that I am able to help with. This helps demonstrate my respect for their jobs, as well as educates and informs them as to what to look for in an environment that can make the difference in the resident's life.


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