Loneliness, helplessness, and boredom. These three plagues of growing old as described by Dr. Bill Thomas serve as primary adversaries in the field of long-term care. The unsung heroes who quietly support nursing home residents for a living have learned to build powerful strategies to combat these plagues. They take the time to help build meaningful relationships. They foster frequent moments of joy and empowerment. They create engaging programs people can look forward to attending.
What happens when our basic call to alleviate loneliness, helplessness, and boredom is in conflict with the even more basic call to keep people alive and well? In more normal times, maintaining the physical health of residents is a priority that nursing homes can effectively ensure while also providing an improved quality of life on a day-to-day basis. Now with quarantines, visitation restrictions, new responsibilities, and protocols for staff that in some cases are isolating by nature, even the best-run nursing homes are feeling an incredible stress. The current reality is that every strategy designed to make the lives of long-term care residents more meaningful has been put to the test in the age of COVID-19.
“Nursing homes are supposed to be places to live, to find meaning in the difficult years at the end of life. We are so good at that,” said Rev. Chava Redonnet in April. Known as Chaplain Chava at St. John’s Home in Rochester, New York, she described a new landscape in long-term care that so many other communities have faced. “What we are doing now is hard—brutal, relentless, seemingly endless—and beyond our experience.”
Still, over two months into the most challenging period in the history of long-term care, nursing home teams are finding new ways to keep residents safe while continuing to provide for those basic human needs.
Battling Loneliness and Isolation
Group activities and visits from family and friends are not the only opportunities for socialization that residents are missing out on right now. Meal times have always given residents structured occasions to socialize with their neighbors and the staff members who help support them. Because of COVID-19 communal meals have been suspended or significantly altered. “For some of our folks, that visual stimulation of seeing others eat and use their utensils encouraged intake,” explains Linda McCoy, St. John’s Practice Partner for Dining Services. She points out that—in addition to the social benefits of mealtime—many residents are now forced to eat in their rooms and rely exclusively on staff cues to assist with eating.
With no scheduled group activities, no opportunities for in-person visits, and no convivial gatherings at mealtime, staff has implemented creative solutions to help residents feel less isolated. The small homes approach to long-term care—a philosophy similar to the Green House Project that St. John’s Home adopted years ago—has made it easier to deliver more individualized support on a neighborhood level. Support teams on each neighborhood have partnered with other non-clinical staff in volunteer roles to provide individual attention to the needs of residents throughout the building. Assistance and companionship at meal times, traveling snack and drink carts, impromptu sing-alongs, and regular friendly visits are commonplace. Additionally, a new “buddy system” program was recently launched that matches each resident with a staff member other than his or her normal caregiver.
Technology has played a key role in helping residents feel less isolated with video chats being an important tool. “When I start a video chat and the family member answers the call and their face appears on the iPad screen, every single resident sits up a little straighter and the biggest smile comes across their face,” says Mandy Duritza, a therapeutic recreation specialist at St. John’s Home. “It happens every single time.”
Video chats became the new normal immediately after the community was closed down to visitation and they are sure to continue once things open back up. “Residents have expressed how much more they enjoy the video chats compared to just a phone call,” says Duritza. “It is very heartwarming to watch residents as they smile and sometimes even place their hand on the iPad. It’s like they’re right in the room with them.”
Working to Maintain Hope 
For Chaplain Chava and her spiritual care colleagues, end-of-life situations are a regular part of the job. She admits that the past few weeks have been different—a level of anguish unlike more normal times when outside family members are able to be present during these moments. She speaks of praying with residents suffering from COVID-19 as well as exhausted, grieving direct care workers. There are tears when she calls the family of a resident who has succumbed to the disease, a person she had known for over a decade.
Each chaplain has had days when it feels like they are simply treading water, in hopes that better days will come again soon. Still, they continue to offer words of encouragement to residents, including those who have recovered from COVID-19 but continue to feel lingering effects of the virus. “As we travel around the floors, staff will often guide us to someone who needs a special lift,” says Rev. Sarah Culp, practice partner for spiritual care.
In some cases, these messages of hope are temporarily being delivered virtually. Because Chaplain Chava works on some COVID-positive neighborhoods, she is unable to make it in person to other locations, like St. John’s Green House Homes in nearby Penfield. She says that her Zoom services work well for those who can focus on the screen from which they are watching. “One thing I do differently is to pray for each of them by name, and I speak directly to the realities we are dealing with,” she says.
Getting Creative to Curb Boredom
St. John’s Home is situated right in the middle of Rochester’s historic Highland Park. Each May, over 300,000 people attend the park’s Lilac Festival, putting St. John’s residents right in the middle of the area’s largest annual party. Under normal circumstances, volunteers line up to bring residents down to the festival to sample the sights, sounds, smells, and tastes of this annual tradition. This year’s festival—that was set to begin on Mother’s Day—was cancelled due to the COVID-19 pandemic. Outside volunteers who help escort residents outdoors for the festival to ring in the unofficial start to spring each year are not currently allowed into the building because of visitation restrictions.
Despite the loss of so many of these traditional opportunities for entertainment, it is truly inspiring to see how many long-term care teams have pivoted to develop alternate methods for keeping residents engaged. “We have had to get creative and explore new ways to keep residents active,” says Duritza. She explains how the therapeutic recreation team has been busy assembling activity packets for residents to complete during times when staff is not available to visit. Additionally, they have all ramped up the number of individual visits they make during the day to check in on residents and help keep them entertained. “I’ve gone door-to-door with my back scratcher, just so people can feel a gentle touch. As much as possible I stop by resident rooms and tell them a joke, look at pictures with them, read poems. Anything to let them know we are there for them.”
Staff at the two St. John’s Green House Homes has similarly found creative ways to continue engaging elders. In addition to Chaplain Chava’s faith-based services, entertainers and other outside programming has been delivered remotely via Zoom. Due to the setup of the houses, residents are also able to enjoy screened in porches for bird watching and walks in their beautiful shared courtyard on nice days.
While engagement has not been as big of an issue at the Green House Homes, missing out on in-person visits from family and friends has been difficult. “I think that has been the hardest—elders not being able to touch, feel, or hug their loved ones,” says guide Polly Bolland. She believes the shared feeling of loss while not being able to see the ones they love has made deep connections between residents and staff even stronger. “No matter how old you are or where you are in life, this is affecting everyone. This forms even greater bonds between staff and elders.”
Bright Spots to Build On
Once employees at the Green House Homes were mandated to wear full personal protective equipment (PPE), they were surprised when residents hardly seemed to notice the change at all. “We thought that some would be scared or not know who we were,” says Bolland. She attributes the strong bonds built prior to the pandemic to this continued sense of normalcy. “We noticed that the deep knowing we have for our elders is also in turn the deep knowing the elders had for us. They know our walks, our voices, our eyes.”
It can be daunting to think about all that long-term care residents have lost in such a short time. However, when things return to normal—or whatever the “new normal” will look like—maybe we will be better equipped to protect the vulnerable population that we serve against the three plagues of growing old. Perhaps, when those better days do arrive, the lessons we have learned and the solutions we have uncovered will help us keep them better connected, more hopeful, and increasingly engaged.
All imagery courtesy of @artists4longtermcare
