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Empowering Staff and Partnering with Families in the Midst of a Pandemic

      Facilities across the country may find themselves in different stages of the pandemic. Adjust the recommendations to suit your facility’s needs.
      The coronavirus epidemic in the United States has been declared a national emergency. Amid this unprecedented situation, all post-acute and long-term care professionals are working to take care of residents and patients as well as support each other to the very best of their ability. It is easy to get overwhelmed by staff shortages, visitor restrictions, and the often conflicting needs of staff, residents/patients, and family members. We would like to offer some suggestions to help PALTC colleagues find a way through.

      Support Your Staff

      • Recognize how stressful this situation is for the staff. Provide a safe environment for them to talk about their fears and worries. They may be dealing with complicated logistical challenges involving their own families, especially if they have children whose schools are shut down or they are caregivers for an older adult. The staff may also be struggling with their own family’s fears for their safety at work, and they may feel fearful about coming to work.
      • Incorporate daily reminders for the staff to remain calm, compassionate, and kind. Ask the staff to share moments of kindness and compassion. Keep a log of these moments and share them regularly. Recognize how difficult this is on the staff, especially when they have to impose restrictions. They’re suffering and grieving, too.
      AMDA – The Society for Post-Acute and Long-Term Care Medicine has developed guidance on protecting residents from potential emotional harm of COVID-19, available at https://paltc.org/COVID-19.

      Build Partnerships With Families

      • Develop and implement a plan to communicate regularly with families. Be proactive in offering information — don’t make them have to seek it out. Sample letters from administrators to families can be found on the website of AMDA – The Society for Post-Acute and Long-Term Care Medicine (https://paltc.org/COVID-19). Providing timely and factual information helps to garner families’ respect and trust.
      • Everyone, families included, need to do, as much as possible, what they can to help identify creative ways to engage residents and alleviate loneliness and boredom. Think outside the facility! Think big! No idea is too silly – we all need something to look forward to and feel connected. Ask families and the surrounding community for ideas. There are likely many people who would love to help but don’t know how, especially given the logistical limitations.

      Harness the Power of Words

      • Even though we do not have all the answers, family members look to us as health care providers and professionals and expect us to lead the way. Coach the staff on how to focus on the facts of the situation. Provide the staff with simple, consistent talking points that they can comfortably share. Prepare responses to predictable questions such as “How long will the facility restrict visitors?” Discourage speculation and opinions; that includes being selective about what is playing on televisions in common areas. If the staff are asked a question and they are unsure of the answer, they should direct the individual to a member of the leadership team.
      • Recognize there could be fear or even paranoid reactions from the staff, residents, and families when a resident has to go on isolation for any reason (e.g., Clostridioides difficile infection). Misinformation and fear spread very quickly, so have a plan in place to handle these situations, without betraying resident confidentiality and while remaining HIPPA compliant.
      • Remember that what the staff tell their family members will likely be repeated to other family members and friends. Our job is to convey accurate information and help them “tell the story.”
      • Empower the staff with knowledge and provide both the words to say and the words to avoid. Consider developing scripts so all staff convey the same message. For example, “We understand that families are concerned. Here are the things we are doing to manage the situation...” Emphasize what the facility and staff are doing, and avoid statements that cast doubt or insecurity. Be intentional with word choice, and recognize the impact words can have. Terms like “quarantine” or “lockdown” have the power to conjure vivid images that may not be correct or applicable to the current situation. For example, after one facility initiated visiting restrictions, an upset patient told his medical provider he felt he was being quarantined. Very quickly the other residents picked up on his belief about quarantine, which made them feel afraid and abandoned.
      • Be cautious about using the term “prevent” because it implies a level of protection that may not be realistic. Instead, consider using the term minimize: “We are working hard to implement precautions and minimize exposure.”
      • Clearly define the situations in which the administrator — or a lead person/team — must be notified, such as when a family member or resident becomes particularly angry or fearful after the staff could not provide an answer to a question. Make sure the staff are aware that they should promptly contact the lead person/team and know how to reach them. Emphasize to the staff that it is okay to respond with “I don’t know the answer,” and they must refer the individual to someone who does. The staff should help facilitate that connection, whether in person or by phone.
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      An often visible emotion, anger can be triggered by other hidden emotions including fear, grief, frustration, trauma, insecurity, and regret. Reproduced with permission from The Gottman Institute.
      Image credit: The Gottman Institute

      Anticipate Challenging Conversations

      • Find ways to agree with a person who is upset. Rather than automatically saying “No” to a request, find a way to say “Yes” to at least some part of the request. Even if the “yes” only validates a concern, it is still a very powerful word. For example, “Yes, I see how this would concern you,” or “Yes, this is really difficult on all of us,” or “Yes, we are doing the best we can to...” As Carol Marshall, MA, writes in Satisfied Customers Seldom Sue: A Guide to Exceptional Customer Service in Long-Term Care (HCPro, 2009), “‘Yes’ does not mean the request will be honored; ‘Yes’ means you find a way to build a partnership with the family.”
      • Talk with the staff about the perfectly normal, human reaction of anger. Anticipate that some family members and other visitors may be angry about the visiting restrictions or other measures. In the presence of an angry person, it helps to understand this emotion a little better. Typically anger is only the most visible emotion — the tip of the iceberg. Beneath the anger are any number of other hidden emotions, including fear, grief, frustration, trauma, insecurity, and regret. Use the image of an iceberg in staff training and coaching to help everyone garner a deeper empathy for what an angry person might be experiencing beneath the surface. But note that staff should not dismiss anger that is abusive.
      • Talk with staff about what actions to take if a family becomes irate or increasingly argumentative. Provide an “out” for the staff if they find themselves in an uncomfortable or frustrating situation. How should they get the attention of the administrator or other senior leaders in person or on the phone?
      • Under no circumstances should the staff become defensive with a family member. Coach the staff to “listen to the problem, not the delivery” (Turning Complaints Into Compliments [NCAL, 2005]). Coach the staff on how to avoid getting caught up in the emotion of the situation but instead remain calm, well-grounded, and kind.
      Tips for honest, empathetic, compassionate, and, most importantly, sustainable communication amid the COVID-19 pandemic, https://www.vitaltalk.org/guides/covid-19-communication-skills/
      • Avoid statements like “It’s against our policy,” which can alienate people and exacerbate their sense of having no control in the situation. If someone becomes argumentative, the staff can say, “We recognize how difficult this is and how worried you must be ... we have implemented these measures to minimize exposure for all residents.”
      • Avoid telling an angry person to “calm down” — this may only elevate their agitation.
      • Do not say, “I understand,” or “I know how you feel.” Instead, say, “I can see how this would concern you.”
      • Keep in mind that fear of the unknown ramps up emotions and emotional responses. Any of us may exhibit maladaptive behavior under these circumstances, but stressful situations can elicit significant maladaptive behaviors from those whose coping abilities are already compromised. For example, in one facility that had just instituted visiting restrictions, a mother demanded that the staff send her son to the emergency department so she could see him.
      • Be prepared to answer questions from residents like, “If I get it, am I going to die?” The medical director should be taking a lead role in helping address issues like these. Consider issuing a statement on the common questions and concerns — and, most importantly, what actions the facility is taking to care for people. Staff and medical providers will likely need to repeat this information frequently because fear limits an individual’s ability to remember and retain information. People also may misconstrue information, leading to more fear and conjecture.

      Address Mental Health Needs

      • Residents with cognitive impairment may have difficulty processing verbal communication, so we must consider what our tone of voice, behavior, and body language are communicating. If we are consistently fearful or upset, these emotions will be communicated nonverbally to residents. In turn, residents with cognitive impairment commonly reflect the emotions of staff back to them as behavioral symptoms. Maintaining a calm approach, ensuring caregiver consistency whenever possible, and trying to keep up with usual routines can go a long way when caring for residents with cognitive impairment.
      • From an infection control perspective, staff are accustomed to employing universal precautions, and this exact concept should be applied to mental health as well. A trauma-informed facility has trained its staff to use universal precautions to help protect trauma survivors from retraumatization. Previous traumas can be triggered for residents by isolation from the community and family members, by a sense of having no control, by changes to schedules and routines, and by fear for their health or even life.
      • We must all be prepared for post-traumatic stress reactions in residents and staff that may surface in the future, even among those not currently experiencing triggers directly related to the COVID-19 situation.
      • With constant media coverage, it may be beneficial to limit TV viewing whenever possible.
      • If you have not already implemented a trauma screening tool, please consider doing so now using the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5, https://bit.ly/2KFePWI) screening tool. Even if residents and patients are not currently exhibiting signs of trauma, we must be prepared for those symptoms to present at any time during and after the isolation. Routine, regular screening is imperative.
      Thank you, everyone, for taking wonderful care of the residents and patients in your facilities. And please show the same compassion and care to yourselves and fellow coworkers. We will get through this.
      Ms. Hector speaks at health care conferences on end-of-life care, clinical operations for the interprofessional team, process improvement and statistical theory, documentation and care plans. She is a member of the Annual Conference Program Planning Committee for AMDA — The Society for Post-Acute and Long-Term Care Medicine, a member of the Editorial Advisory Board for Caring, and the Chair for the Spring Conference Planning Committee for the Arizona Geriatrics Society.