Why it’s impossible to maintain prior levels of care quality, and what to do about it

Here’s my latest article on McKnight’s Long-Term Care News:


Why it’s impossible to maintain prior levels of care quality,

and what to do about it

In Editorial Director John O’Connor’s April 16th column, he reported on a study from the Kaiser Family Foundation indicating that increasing numbers of new residents have dementia, are more physically ill and are more likely to be on psychoactive medications.

The study showed that there has been a shift away from long-term services and toward short-term rehab treatment. O’Connor noted the pressure that this puts upon facilities to provide high-quality care in the midst of the churn of residents.

There are many difficulties that can arise from this shift in pace and population, but I’ll focus here on the mental health aspects and their effects on nursing facilities.

One problem that occurs when the length of stay decreases is that the team has a shorter period in which to get to know their residents. They are less likely to notice subtle changes in behavior and mood and they have less time to make the type of personal connection that reassures residents.

Adding to this, the fact that many facilities are operating short of staff in an environment of high employee turnover creates a “perfect storm” of emotional neglect.

Residents enter long-term care facilities in distress. When I adapted the classic Holmes-Rahe Stress Inventory to the circumstances of nursing home admission, I found that residents are experiencing a level of stress considered to be a “life crisis” that puts them at a high risk for further health breakdown. Their families also tend to be in crisis.

Residents and their family members are likely to expect that when they enter long-term care, staff members will provide compassionate medical treatment. Instead, what they frequently find are stressed out nurses and overworked aides who have just enough time to dispense medications or to make up a bed, but none to sit and talk with an understandably anxious resident and their family members about what they can expect regarding their stay and their future.

Social workers — most of whom got into the field in order to provide such counsel — are now buried under a flood of admissions and discharges. They cannot offer emotional sustenance when they need to complete the paperwork on three new admissions and order a walker for the lady whose family wants to take her home tomorrow because her insurance coverage ran out.

It is impossible for direct care staff to provide the same level of service that they did prior to this change in acuity and length of stay. In turn, distress over providing suboptimal care contributes to staff turnover, exacerbating the problem.

For the entire article, visit:

Why it’s impossible to maintain prior levels of care quality,

and what to do about it

3 thoughts on “Why it’s impossible to maintain prior levels of care quality, and what to do about it”

  1. Great Article Dr El,
    It is really sad to know that the family members expect from the staff that they will provide good care when they enter long-term care. Because of this many nurses and other staff members gets stressed out due to such higher expectation from the family members and due to which the performance of staff decreases.

    • Thanks for your perspective, Christina. I don’t find it unreasonable that good care is expected — after all, if you or I or one of our family members were in long-term care, we’d certainly expect good care. It’s a given that residents and their families are going to be anxious at this juncture of their lives. One of the reasons I wrote The Savvy Resident”s Guide was to help them manage their expectations of what it’s like to be in LTC and to give them coping mechanisms that will improve their experience and ease the pressure on the staff.

      I do find it unreasonable that staff members are expected to provide the same high quality care when there are fewer workers and sicker residents who are in the facility for shorter amounts of time with more urgent needs and requiring more intensive care with more documentation. It’s penny wise and pound foolish, as the saying goes. I get what you’re saying as a worker about the stress of dealing with the high expectations of the families, but many of the family expectations can be met with attention to staffing, training and expectation-setting.

      As a direct care worker, most of these areas are not in your control, but there are several things you could do: Ask the inservice training director for classes on how to deal with “demanding” residents, get some copies of The Savvy Resident’s Guide for the rehab floor, and “lean in” to anxious residents and their families with the goal of quelling their initial anxiety. When staff members back off from anxious residents, that increases their anxiety and makes them more “demanding.” When staff members reassure them by pleasantly meeting or even anticipating their needs, they become calmer and easier to work with.

  2. Hello as a Long term care for years; I can tell you that doing more with less is not a practice that benefits the patient/ resident or the overall clinical outcome. This mantra has been on the table in health care and it has caused re- hospitalizations and very long wait times for skilled residents to receive care and attention. No, continuing to operate with less staff is not producing anything but chaos, burn out and litigious actions. The shift needs to be a truthful look at hours of care per patient need. Influencers are presenting diagnosis consideration of the morbities cognition and overall individual need. Reducing length of stay and decreasing available care is not a winning way to set up patients and staff for best outcomes.


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