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The frequency and sophistication of cyber-attacks continue to climb. It’s rare for a week to go by without word of a significant cyber breach, and we’re not even aware of all the breaches that occur. That’s because many go unreported. We do have access to reports indicating employees are among the greatest cyber risks within any given workplace. After all, many among us tend to click and tap away on phones, laptops, computers, and other hardware without giving much thought to cyber consequences. Add to that our tendency to use personal devices at different points during the workday. If your teams are accessing browsers, emails and more over your workplace network, the prospects of a breach can escalate even further.

We need to be aware that, independent of personal devices, employees as well as third parties represent access points – opportunities – for those contemplating cyber-attacks. Threat actors, also known as hackers, will find some targets more lucrative than others, yet it’s data they care about. They care about data and how they can profit by interfering with it, and your workplace is a ripe data source.

These days, 85% of all phishing is conducted through email. You’ve likely heard of ransomware demands, and of businesses and institutions paying ransom demands to recover their data. The decision as to whether or not to pay ransom can be hotly debated, and that’s problematic enough. Now, the risks of falling prey to phishing and other attacks are even more concerning. That’s because there’s a new ransomware threat in town, and it’s known as Exmatter.

Threat actors, the cyber criminals who wreak cyber havoc, use Exmatter malware to exfiltrate (remove) specific types of files before executing the ransomware on systems they breach. Rather than encrypting and obstructing access to your data, this malware destroys data.

You may be unsurprised to learn EY (Ernst & Young LLP) has identified employees as the weakest link in an employer’s cybersecurity chain. Even if you have an IT department or a dedicated cybersecurity budget, you may share a status with many employers who were contacted for the EY Global Information Security Survey. The survey report reflects responses from more than 1,400 global C-level leaders, information security and IT executives and managers. Forty-three Canadian respondents were among the participants, and only 37% of those Canadian organizations reported that their cybersecurity budgets exceeded 10% of their total IT budgets.

What are you, as a leader, to do – particularly if you don’t have an IT team, let alone a substantial budget line dedicated to internal or outsourced cybersecurity? You can begin with that “weakest link”. When engaged and informed, your people may also be your best defense against cyber-attacks. This comes down to education, culture, and collaboration, and it begins with you.

In our January 19/23 webcast, you’ll gain insights on how to recognize cyber risks. Phishing is a major concern, yet there are other data privacy risks and not all breaches occur online. As you build your own understanding of today’s cyber risks, and how to mitigate those risks, you can leverage your influence to lead in cultivating a culture of cyber awareness.

You or another cyber-informed colleague may lead the training, or you may find it helpful to bring in an external party. While there’s complex terminology and there are some daunting statistics that could scare the heck out of any employee, it’s never my goal to intimidate people when it comes to cyber awareness. I find people benefit, and mitigation strategies are most likely to stick, when I use plain language and temper all those risks by giving practical tips people can incorporate. I do all this in the context of helping people reduce cyber risks both on the job and in their personal lives. That’s how we begin to mitigate cyber risks within our teams.

About the author:     

Authentic, informed and inspiring, Shelagh (pronounced “Sheila”) Donnelly is a professional speaker and trainer. Shelagh understands what’s involved in leading and inspiring teams, having held that responsibility in both the private and public sectors.

Recognized as an excellent educator who provides wise counsel and practical strategies, Shelagh presents at conferences and works with clients around the globe. In 2023, she’s engaged to bring her Canadian expertise to presentations domestically and in Australia, Europe, South Africa, the United Kingdom and the USA.

Shelagh’s client list includes government, healthcare, senior/long term care and education bodies and a host of conference organizers. With a knack for injecting humour into even potentially daunting topics, Shelagh’s also worked with a Washington, DC think tank, the UK Parliament, a stock exchange, utilities providers, governance bodies and corporations such as Diligent and the NBA.
 

What drives any business is the ability to sell and often times operators overlook the idea that everyone on your team, especially when in communication with your customers, is in sales. This means that everyone should be able to effectively articulate and communicate your value proposition to customers and/or potential customers. Furthermore, it should be everyone’s responsibility to ensure that your customers are always satisfied with the service provided, and part of that equation is proactively bringing new ideas and solutions to customers. An often-overlooked sales resource for office coffee and vending operators is your delivery drivers.

What Makes Delivery Drivers the Perfect Sales Representatives?

The basis of any successful sales representative is the ability to build trust and rapport with prospects and customers. Your drivers will have undoubtedly created a trusted relationship with customers, so why not use this relationship to further expand the scope of your product / service offering? This concept is well known by the foodservice industry who will use frontline employees to upsell customers; “do you want fries with that?” is an all-too-common question. Foodservice operators understand that the profitability margin on French fries is substantial which makes the practice of upselling customers using your frontline employees easy, logical, and profitable.

Sales Best Practice 101: Identifying Customer Needs

Identifying the needs of customers is easy and demonstrates that you are paying attention. For example, your driver may notice that one of their accounts is constantly running low on soap and paper towels in the kitchen area; this is a perfect opportunity to offer supplying another service, in this case paper towels and soap. Furthermore, it offers a convenient solution for the customer, demonstrates that your driver pays attention to detail (big and small), and helps to increase the profitability of the account. In fact, your drivers may be a treasure trove of ideas; engaging with them on the subject of expanding the scope of services provided to clients can help to energize them to participate in the initiative of identifying needs and upselling clients.

Additional Services to Consider

If you are interested in taking your vending and office coffee service to the next level in terms of products / services provided, like any sales process it is recommended that you start with a needs analysis. This can be as simple as talking to your clients about what their pain points are, and, as noted above talking with your drivers about what they may have noticed while on their delivery routes. For example, your client may be struggling to get employees to come back into the office to work a few days per week, they may be having challenges with employee retention, etc. Are there services that you could offer to help make the work environment more enjoyable? For example, perhaps the customer is open to providing free breakfast for employees (cereal, milk, toast, coffee & tea, etc.). This would be an easy program to initiate, will help the client create a more welcoming and fun environment for staff, and increase the profitability of the account.

Help Is at Your Fingertips!

We would be amiss to finish this article without a little upselling of our own. For vending and office coffee operators who are also members of Complete Purchasing Services (formerly known as Univend) take advantage of our free membership which provides access to “Best Value” pricing on thousands of essential products and services in addition to the opportunity to earn CASH REWARDS on your purchases. In addition, our team of locally-based Account Managers are available to help you maximize your program benefits and profitability. If you are not yet a member and want to learn more, please visit eCPS.ca.

No matter what your current offering and scope is there is always room for innovation and your drivers may be the key. In the words of the renowned leadership coach Ben Simonton “turned on people figure out how to beat the competition. Turned off people only complain about being beaten by the competition.” Good ideas can truly come from anywhere and finding ways to engage your employees in the success of your business will drive employee engagement, customer satisfaction, and ultimately your profitability.

About the Author:

Jennifer Bobson is the Director of Marketing for Complete Purchasing Services Inc, a leading supply chain solutions provider for hospitality and non-commercial clients in Canada.

To say the processes of attracting, hiring and retaining the best people is a challenge in the health care sector is, at its best, a colossal understatement.  In “normal” times, care organizations have had to be resourceful to meet the demands of employing enough highly skilled staff to ensure quality care.

The pandemic has exposed the fragility of providing adequate staffing levels, resulting in a staffing pandemic – a cascade of compounding shortages in all health care sectors, and in all facets of care and services to clients. For many organizations, the provision of quality care has been superseded by cries for “any” care.

Signs for Optimism

In spite of the current wide-spread severity of staffing shortages, there are signs that the situation can be alleviated in the short term, and with a view to the long term, the likelihood of a similar reoccurrence greatly reduced or eliminated.

A Positive Sign

In the midst of all the turmoil, anxiety, misrepresentations and at the most extreme, deaths, there have been rare instances where Homes have transcended the plethora of challenges relatively unscathed.

The most common and prevailing differentiator of Homes that successfully responded to the pandemic were those in which a culture of progressive leadership practices had been in place for several years. These practices were so deeply entrenched in the culture of the Homes that even the onslaught of challenges brought on by the pandemic were not enough to substantively alter their continued success.

With respect to staffing, the response was strategic approaches to recruitment, continued and accelerated supportive environments for staff, and adaptive responses to constantly changing expectations.

Witnessing such positive outcomes leads us to…

The Second Positive Sign

When faced with seemingly insurmountable challenges, knowing something can be done to address the obstacles, gives us reason to believe that if we change, the situation can be improved. And so it is with the long term care response to the impact of the pandemic.

For this second positive sign, we are drawing on the experiences of others to provide examples of how any Home can address the situation, by creating a culture built on progressive leadership - assuming there is a willingness and commitment to change.

The culture of any organization represents a culmination of recent, remote and distant practices. In other words, culture evolves over time, and can be impacted at any period in the time continuum. Some of the examples shared here are the result of long-standing leadership and organizational practices, while others were initiated in the moment. Regardless, they all have the potential to positively impact any Home along their evolutionary cultural journey.

For some organizations, the changes required to make a significant difference may be subtle and readily implemented. For others, a longer-term commitment to changing the culture may be warranted. Regardless of your circumstances, drawing on the familiar adage, “The best time to plant a tree was 20 years ago; the second-best time is today,” gives credence to taking action now.

This review of best practices is broken down into the categories of recruitment, hiring, onboarding, and retaining employees. Some strategies can be implemented with little adjustment, while others require a longer-term perspective in terms of time and effort before there is a payoff.

Recruitment

Successful recruitment today requires diversity in terms of recruitment channels and messaging.

Recruitment Channels

• Build relationships with external potential employee sources, such as career departments and services in education
• Connect with related education institutions with offers to speak on topics related to their curriculum
• Continuous lobbying for student field placements and paid internships (which can result in a cost-effective way to orientate prospective new employees)
• Offer to speak to senior elementary students about health care career opportunities in LTC
• Utilize social media and job posting sites where millennials are likely to job search
• For such workplace roles in dietary, housekeeping, maintenance and laundry, promote work opportunities in non-health care venues, such as the hotel conferences or publications
• Promote openings on association job boards (albeit more challenging, given how are competing with every other long term care Home for the same people.)
• Church/Religious Centres sometimes offer job support programs, and may post positions

Recruitment Messaging

• Change Your Messaging! When you are recruiting, you are “selling” your product! If you don’t like the sound of that, get over it! Or get yourself out of the recruitment role. The best recruiters are those that know people “buy” on emotion, and use logic to justify their choice. One of the best ways to connect with people at an emotional level is by sharing moving or inspiring stories from your workplace. Your Home and the experiences you have to share will resonate much more than a discussion focused on statistics, specific roles and duties, compensation and benefits. Make sure that any printed material you share communicates the same messaging.
• Consider who you are talking to, and then communicate emotional-based messages that resonate with your audience. In other words, your messaging with a group of student nurses might be focused on how a new nurse helped a resident in need, and made a difference in the life of the resident. Conversely while talking to prospective maintenance employees, you might include a story of how a new worker identified a noisy piece of equipment, which resulted in early intervention, saving the Home money, and rewarding the employee with commendations and a bonus. Always remember, if you meet them where they are, they will be influenced at an emotional level first.
• Full time positions or ideal shifts. If you do have full time openings, or shifts that are seen as great, you have an advantage over other potential employers. Emphasize the benefits (such as more time with family, or reduced stress as a result of the enhanced benefit package that come with full time employment.)

Hiring

The process of hiring ideal candidates is fraught with challenges. While it is tempting to use the vapour test method of hiring during extreme staff shortages (place a mirror under the person’s nose, and if there is a vapour, they are hired!), the results are seldom positive. Even the best interviewers cannot guarantee a “good fit” when a final selection is made.

However, a quick summary of some approaches might help to increase the likelihood of finding more people that work out in the long run.
Asking good questions is important. Rather than the “What would you do if…” type of question, ask questions that require them to provide examples of what they actually did.

• Tell us about a time when you were confronted by…
• Provide an example of when you went above and beyond your employer’s (or teacher’s) expectations.
• Describe how you clean a resident room, when the resident is there.
• What do you see as the key challenges in this job?
• Share your knowledge of…

Finally, make the person’s demeanour and attitude the primary factor in hiring. Skills can be taught. Who the person is won’t change. Organizations that pay special attention to how the prospective employee responds to others (staff and residents) while they sit in the hallway waiting to be interviewed often gain valuable insight into the real person behind the interviewing mask.

Onboarding

Now that the person has been hired, the transition to successful employment has just begun. Most Homes have experienced the frustration of finally recruiting new employee(s), only to have them leave within a few days or weeks. While a great onboarding process doesn’t guarantee positive outcomes, it substantially reduces the likelihood of such turnover. Here are some strategies (some simple, and some requiring more planning!) that increase the likelihood that your Home will be seen as the place to be employed!

• First Connections. When someone is hired, connect with them first in their home. Sending a hand written note from their new manager congratulating them on their decision, and thanking them for joining the team, resonates that you care about people. If you send more “official” documents prior to their start, send them separately, and include a message saying that if they have time and find it helpful to go over them before coming to work, great, but otherwise you will provide time for them to review the documents once they start working. Otherwise, you are asking them to start working for you – on THEIR time!
• Send Out the Alert! Once a new hire is confirmed, send out notices, and a brief orientation about the new hire, and their start date, to their new team members. Encourage everyone to mentally rehearse the new hire’s name, so when they are first introduced, the welcome is all the more meaningful.
• The First Day…or The Worst Day. You have one day to create a good first impression. Unfortunately, all too often, the first day of orientation is one of the worst days people will experience on the job. They are confronted by legal documents, signing all over the place, and then loaded up with reams of policies and procedures to review. When we ask employees what they remember from all that inundation of information on their first day or two at work, the typical response is along the lines of “I remember nothing from everything I had to read, but I do remember feeling overwhelmed!” Consider the first day on the job as a “Threshold Moment” – a day more important than any other – that you are acknowledging the presence of a new person, marking this moment as special. One of our favourite stories comes from Daniel Coyle (The Culture Code, Bantam Books, 2018), recounting how new basketball players are orientated to the Oklahoma City Thunder team. The first thing that happens is they are taken to the Oklahoma City National Memorial, which honours the victims of the Oklahoma City bombing that killed 168 people. After simply walking around the reflecting pool and the sculpture of 168 chairs, the players are reminded to look into the stands during games and to remember that many of the fans were personally affected by the tragedy. As Coyle says, it sends a powerful belonging cue – that resonates emotionally. Imagine the impact of walking down to a hallway in your Home with a new hire, focusing on one or two photos of residents in your Home (current or past), and sharing stories about their life accomplishments, or how what they did in your Home that was so special. You have hundreds of stories in your Home – focus on these stories - make the person’s first day in your Home an inspiring Threshold Moment.
• The Essentials. The first day must include a tour of the essentials for the new hire’s experience – where and how to navigate to the staff room, the lunch area and the bathrooms, and their primary work area. As the new hire is orientated to these areas, be sure they have a copy of the floor plan(s), so they can be shown where they are at any given moment of this first day tour.
• Mentors/Buddies. A mentor or buddy program, utilizing an employee peer is an excellent way to help the new hire gain confidence on the job. Ideally the period of support remains in place for 60 – 90 days. The selection, training and guidance you provide to the mentor or buddy should be commensurate with importance of this role. If you want to bring out the best in the new hire, make sure they are well guided by the best.
• The Head Honcho Moment. Regardless of their position, the new hire should be introduced to the most senior manager in the Home, such as the administrator or CEO. This person should be made aware of the new hire’s name and some personal details (such as family, children, birthdate, etc.) in advance, so that in these few moments, they can make the welcome all the more personal and meaningful.
• Orientation Program. The amount of orientation time provided to new employees does communicate a message. In recent years of staff shortages, Homes have tended to expand orientation time, giving new hires more time to adjust to the work routines, in the hope that people will not become frustrated and leave. These changes in approach do appear to be having more positive outcomes in terms of new hire retention. While this does add costs to the orientation process, the added cost of repeated staff replacement makes a more extensive orientation program more acceptable – and communicates a more positive message to both the new hire, and to established staff (new hires are not seen as such a burden).

Retention

Obviously, the true nature and culture of working in your organization becomes apparent to all employees within a matter of weeks or months of their employment. Ongoing and consistent progressive leadership practices are key to fostering a culture that reinforces ongoing employee engagement.
Our focus here is on essential leadership practices that impact the more recent hires, and their decisions to stay with the Home.

• First Formal Follow-up. While the new hire is encouraged to come forth with questions and concerns immediately, also schedule and confirm a follow-up touch-base meeting time – ideally within two weeks of the start date. They will have experienced enough by that point to have questions, and it shows that you care and are supportive. Be prepared to ask questions, such as “What do you like most about your work so far? What do you find most challenging? What can we do to help you in your work? How could we have better prepared you in our orientation program?”
• Second Formal Follow-up. Having a second scheduled meeting (at least 6-8 weeks after their start) helps to draw attention to deeper concerns and needs that the new hire may be experiencing. Some research suggests that the primary stressors experienced by health care workers are personal debt, medical issues and mental health. Carefully listen to the new hire’s comments, which may prompt you to offer much appreciated support and direction. Asking about their aspirations, what do they see as possible new opportunities in your Home in the future, and reinforce any educational opportunities or support you are able to provide.
• What We Do For Everyone – All The Time. Looking to retain people, beyond the new hire process we are focusing on here, requires a diverse approach in order to appeal to the many different needs, interests and abilities of employees. The options are endless, including such initiatives as celebrations of achievement (both personal and Home-wide), personalized acknowledgements (birthday cards, anniversaries, etc.), announcements (newsletter, media releases, etc.), and celebrations and acknowledgment of diversity (cultural, ethnic, age, etc.)

Reinforcing and encouraging ongoing personal and professional growth and development of employees is also highly corelated with employee retention. Rather than waiting for employees to come forward looking for support, progressive leadership is characterized by a desire to “grow” people – encouraging people to take advantage of training and development opportunities. This serves to expand people’s scope and ability to take on new challenges and opportunities, and when positions are filled from within, it reinforces for everyone that the organization is committed to its employees.

Summary

Successful recruitment, hiring, onboarding, and retaining employees is a direct outcome of progressive leadership. Where practices such as these have not been employed, the pandemic has served to further undermine many organizations ability to fully staff and provide the level of care they aspire to achieve. The planting of trees metaphor noted earlier reinforces that for Homes that are struggling, the need to get on with it, to take action now, is imperative.

The full impact of changing the culture of the Home through progressive leadership will require time and effort on the part of the entire leadership team. This leads to one more metaphor. Just as dieting for many results in only temporary weight loss, applying a few simple strategies will not change the culture of the Home, nor solve the staffing issues. Instead of a fad diet of strategies, a balanced and sustainable approach of progressive leadership is required to develop a healthy organizational culture of engaged and committed employees.

About Author

Ron Martyn (BSc Recreation, MSc Gerontology) has served as a Recreation Director and Administrator in long term care, and as a Retirement Home Owner. For over 20 years as the Co-Owner of Silver Meridian, Ron and the team have helped LTC managers hone their leadership skills, by empowering and energizing people, and becoming recognized as Inspired Progressive Leaders in the provision of care (English only). Go to Silver Meridian (https://silvermeridian.com) for more details.

The eCPS Purchasing App OrderMaestro is a user-friendly and convenient way to place orders and take inventory. If you haven’t downloaded this free app yet, here are five reasons to start using OrderMaestro today: 

1.    Fast, Convenient and User-Friendly: OrderMaestro is very easy-to-use extension of eCPS Purchasing enabling staff to quickly and easily place orders and/or take inventory on a tablet or mobile device…anytime, anywhere!

2.    Everything at Your Fingertips: OrderMaestro gives users access to pertinent information to make placing orders easier and faster. Look for access to shopping lists, order history, order guide, and the distributor catalogue.

3.    Place Repeat Orders…Again and Again: If you are placing the same order, OrderMaestro makes placing repeat orders fast and easy. Need to modify the cart before you check out? No problem!

4.    Simplified Product Search: Finding the product you are looking for has never been easier! Search by text, voice, order code, or *barcode.

5.    Inventory Management Made Easy: Taking inventory has never been easier or more convenient; it’s as simple as scanning barcodes* and entering the quantity. No internet in your product storage area? Take your inventory offline and the system will sync up once you are connected to the internet again. 

*Barcode scanning works on standard system-based barcodes (e.g. barcodes available through the eCPS Purchasing desktop interface).

To Get Started if you are a Complete Purchasing Services member: 
•    Download OrderMaestro from the Apple App store and Google Play. Important note: Be sure to use the company code “CPS” when logging in.
•    Contact your dedicated CPS Account Manager

To Get Started if you are not yet a member:
•    Click on the Contact Us tab above

“I like the convenience of being able to quickly access the eCPS Purchasing OrderMaestro app on my phone. I can add items to my shopping cart on the fly without having to log into the website. Honestly, it only takes a few taps on my phone to get the job done quickly and efficiently. 

For those of you who are still hesitating, all I can say is…just download the app! It is simple and easy to use. You have nothing to lose but lots to gain from using it; convenience, flexibility, and peace of mind.”

~ Michael Jacquard, Dietary Supervisor and eCPS Purchasing OrderMaestro app user 

Senior Care Tribute
Stephanie Staples

When I was a child I dreamt I would be
In senior care and everyone would see
How special I was and that I never lacked
For money or resources or time to relax

I’d spend all day, helping the aged
Who would always be happy and never get jaded
They’d thank me profusely and hug me a lot
Their families would love me and stop on the spot

To praise me for, the hard work that I did
But what, was I dreaming? Here’s what happened instead
I dedicated my life to those in long term care
I thought it I was unselfish but I wasn’t aware

That though stressors and challenges would never subside
The privilege of being their at the side
Of elderly people who shared their life
The struggles, the victories, the pains and the strife

No one prepared me for what an honour it’d be
To serve them, to love them, to have history
Personally delivered
especially for me

So whether you’re in admin, or in Food services
Housekeeping, office or CPS’s
Be you CEO, activities or PSW
Environmental services, nursing or whatever you do

Please remember that each day you set foot in your resident’s space
You bring a gift that they can not replace
You bring your service, your compassion and your big heart
You make their day brighter and that just the start

Because the walls that surround them don’t make their home
It’s the love that you give them, that they call their own
So when the day has been long, and the frustrations run high
Know what you do is not just passing by

It’s important and valued and one of kind
And I thank you on behalf of those left behind
Not everyone has the capacity to do what you do
If you want to continue, please take care of you

The RPN/LPN Nurse Leader in Long-Term Care

RPNs/LPNs working in long term care (LTC) love their profession, despite the many challenges and hardships they encounter, and there certainly has been a myriad of challenges during the COVID-19 pandemic. Their profound concern for the well-being of the residents is driven by their deeply held values and a desire to provide the highest quality of care possible. This translates into a passion for, and commitment to, the residents who live in the Home.

RPNs/LPNs represent the largest category of nurses working in LTC (approximately 70%) and the majority of these RPNs/LPNs work directly on the care units. As their education and scope of practice has continued to expand and be recognized, the role of the RPN/LPN has grown and evolved in LTC. RPNs/LPNs are responsible for increasingly complex activities, including leading teams, supervising PSWs*, critical decision-making, dealing with families, and collaborating with others.

Examples of Roles of the RPN/LPN Nurse Leader in LTC
Leadership
•    monitor and supervise care provided by PSWs
•    collaborate with the interdisciplinary care team
•    communicate with staff, residents, families, as well as other members of the care team
•    problem-solving and decision-making
•    respects, values, and empowers others
•    build trusting team relationships
•    manage conflict
•    mentors and coaches’ others
•    offers emotional support to others  

Clinical
•    conduct resident assessments (formal and ongoing)
•    identify resident risk indicators
•    complete documentation
•    work with resident and family to develop care plans – set goals, interventions, time frames
•    administers medications and treatments
•    transcribe medical orders
•    maintain unit medication management process
•    ensure resident and staff safety

The job position of the RPN/LPN working on the care units may be referred to as  “clinical leader,” “team leader,” “nurse supervisor,” or “charge nurse” etc., and these titles are familiar to most people who work in LTC. These titles are often used interchangeably, resulting in ambiguity in the responsibilities and accountabilities encompassing  this role. This vagueness causes confusion for staff, residents, families, and even for the RPN/LPN Nurse Leader his/herself. In this article the term “RPN/LPN Nurse Leader” refers to both the leadership aspect of this role, as well as the clinical, knowledge-based skills and competencies  essential to achieving quality resident care.

The Impact of Effective RPN/LPN Nurse Leadership

The RPN/LPN Nurse Leader is in a unique position of being able to influence not only the quality of care being provided to the residents, but also positively impacting PSW job satisfaction. Research reports that effective nurse leadership directly impacts resident outcomes and staff satisfaction (McGilton et al., 2016a). When /LPN Nurse Leaders stand strong and uphold their personal and Home’s values, they garner respect from everyone, but in particular from the front-line staff. PSWs quickly recognize they share many of the same values of their RPN/LPN Nurse Leader, and as a result, they are inspired to follow their leader. The result is a work environment where staff are truly committed to providing quality resident care. As RPN/LPN Nurse Leaders effectively lead and support the direct care staff, they are not only impacting quality of care, but they are also respecting, valuing, encouraging, and empowering the care team. As the saying goes, “happy staff means happy residents.” PSWs who are “happy” experience more joy at work, provide better care, and are less likely to leave their jobs. This has even more relevance as a high turn-over of PSWs can result in poor resident outcomes such as increased infections, pressure ulcers, increased falls, and resident behavioural issues. RPNs/LPNs who inspire their staff contribute immensely to positive resident outcomes and less PSW turnover. This fosters their personal sense of achievement and “of making a difference” - in other words, they achieve a sense of self-actualization.

Challenges Facing the RPN/LPN Nurse Leader in LTC

Up until 2020 and the COVID pandemic, much of this article would be focused on leadership development or clinical strategies, in an effort to enhance the role and practice of the RPN/LPN Nurse Leader. But the pandemic has now placed such a heavy burden on all staff working in LTC, that this challenge has taken priority. For the RPN/LPN Nurse Leader the stress and added workload has been demoralizing. Many RPNs /LPNs are now considering leaving LTC, with some even leaving nursing altogether. Others who stay are feeling frustrated, exhausted, and under-valued, although even with all the added pressures they have endured, they carry on. This raises real concern for RPNs/LPNs personal health and well-being. Strategies to help address this can be found in a previous article, “Protecting Nurse Well-being in the Face of Burnout and Moral Distress” Sept. 29, 2021 (located on CPS website/resources).

In the context of this article, given the discussion about the positive impact RPN/LPN Nurse Leaders have on quality resident care and PSW job satisfaction, this is of critical concern. Some of the challenges faced by RPN/LPN Nurse Leaders include:

1.    Given the ongoing challenges that COVID has created, the RPN/LPN Nurse Leader may become so absorbed in meeting new and ever-changing requirements, they may unintentionally lose focus on their staff needs. They may not recognize the PSWs’ frustrations and fears, seek their input less often, or not listen and really “hear” their staffs’ concerns.

2.    Staff shortages have required the RPN/LPN Nurse Leader to step in and help other nurse leaders, especially new nurses, or agency staff, who are not familiar with the residents and/or policies. This may include assisting when there is a change in a resident’s health status or completing work left by the previous shift. RPNs/LPNs are also filling gaps when they are short PSWs, spending more time helping with direct resident care. This increased workload affects the RPNs/LPNs ability to connect with, and support, the care staff, often leaving them frustrated in their abilities to do their job well.

3.    There may be a lack of support from senior nurse managers, given they are being pulled away to deal with other COVID related demands. This limits their availability to connect with the RPN/LPN Nurse Leaders on the units, and to hear their issues and concerns.

4.    Role clarity and scope of practice for RNs and RPNs/LPNs has not been well understood and still is open to misinterpretation. Nurses have had difficulty differentiating between the scope of practice of the RN and RPN/LPN leading to tension, confusion, and ambiguity as to their roles, responsibilities, and functions. It is not uncommon in LTC to hear that the RN and RPN/LPN role is the same. Although there is significant overlap and many of the tasks and functions are similar, this does not always take into consideration the complexity of knowledge, judgement, and critical thinking required of nurses to support clinical decision making. This has become even more of an issue during the pandemic. Due to the shortage of RNs working in long term care, it is more challenging for the RPN/LPN to find an RN to collaborate and consult when necessary. RPNs/LPNs may inadvertently step outside of their scope of practice and assume additional responsibilities in an effort to meet the needs of the resident.

5.    There has been limited availability, or requests for, professional development. When feeling overwhelmed and exhausted this is very understandable. However, further learning and education empowers the RPN/LPN and can increase their confidence and work performance. The RPN/LPN is more likely to be motivated and loyal to their organization that invests in them and supports their development. One example of this in Ontario is the RPN-RN bridging program, with reimbursement of tuition fees and other financial support. Participants must agree to work in long term care post-education for a designated time – a fantastic opportunity, as well as recruitment and retention strategy.

6.    Fair compensation has also been a challenge. In Ontario when the MOHLTC announced a $3.00 hour wage for PSWs, the RPNs supported this initiative, as they understood more than anyone the challenges PSWs have faced in the past prior to COVID, and now continue to confront during the pandemic. However, no additional financial support has been offered to the RPN Nurse Leaders, or others, in long term care. This has fostered a tense work environment at times, as RPN do not feel recognized for the contribution they have made, and continue to make, to ensuring quality care. The $3.00 an hour raise was a PSW recruitment and retention strategy, and yes, we need more PSWs in LTC. However, RPNs/LPNs feel they have been treated with a lack of respect and dignity, and it has given them one more reason to re-consider their future in LTC, especially given the growing workload, stress, and responsibilities they are facing.

7.    COVID-19 has highlighted the significant shortcomings in our health system, and in particular LTC. Nurses have been calling for reform in LTC for many years due to the struggles they have encountered in the optimum delivery of person-centered care and quality of life for residents. Increased funding is a high priority; for more LTC care staff, more full-time positions, and adequate staffing levels, are essential. As governments move ahead with plans to significantly improve long term care, RPNs/LPNs working in the sector need their voices heard, as they are experts.

Realizing the Opportunities

The list of challenges facing RPNs/LPNs working in LTC are substantial, but there is reason for optimism. Never before has there been so much attention focused on LTC … by the government, media, families, other groups, and associations. Governments are committed to making significant improvements to ensure the safety and quality of life for residents and to improve the work environment for staff.

While the disproportionate number of resident deaths, and countless hours of overtime to the point of exhaustion, has taken a profound emotional and physical toll, there is hope. Staff, residents, and families are accepting the new realities, and making adjustments. Public sentiment has shifted in support of change in long-term care. These changes signal a new era, a period of hope and renewal – a just reward for all who have served their residents so courageously through the pandemic. RPNs/LPNs need to seize this opportunity! This is the time to renew your passion for LTC. Dig down deep and find your inner strength, courage, and commitment to the residents. Consider this …

“Hearing patients reflect on their families, their grandchildren, their lives—and often being with them in their final moments—offers a professional and personal significance that keeps many long-term care nurses right where they are.” - Wolters Kluwer Health May 05, 2015


About the Author

Darlene Legree is the Co-Owner of Silver Meridian. For over 20 years, Silver Meridian has helped LTC managers, and nurse leaders hone their leadership skills. As they empower and energize others, they have become recognized as Inspired Leaders in the provision of care. Go to the Silver Meridian for more details, including the Fall intake for the Online DOC/ADOC Leadership Certificate Program (Accredited).

*PSW – personal support worker, may also be referred to as a personal care attendant/aide

Have you ever noticed how some people step into a room and the room immediately brightens? Have you ever wondered why that is? Have you ever thought about how that works? It is the presence of kindness the person carries with them and it doesn’t come naturally to everyone, at least not at first. It is a skill that you can teach or learn. After practice, it does come naturally without even thinking about it. Every person on your food serving team, including each employee that lifts a food tray or even carries a glass of water, in every senior living community, needs to learn this skill. Not only does it transform your mealtimes, but it overflows to brighten your community every day, all day. Kindness becomes a way of life that improves the life of the giver and the receiver.

Kindness is infectious. When a kindness is extended, even the small act of retrieving a book dropped to the floor by an elderly person who can’t get down to pick it up. The person receiving the kindness is relieved and thankful. The person giving the kindness probably doesn’t even realize what a huge gift they gave. It is so simple to pick up a book off the floor, but not so easy for everyone. This is an example of small ways that kindness slips into a person’s habit and becomes a way of life. Kindness enhances everyone touched by it, the giver and the receiver.
The small kindness of casual conversation or asking an open-ended question when serving a meal to an older adult can wash away a feeling of loneliness. It conveys the sense that you care about them.  It’s a selfless act of compassion and empathy.

This is just what some residents long for after losing so many friends, leaving them with a feeling of isolation during the pandemic. To reverse the epidemic of loneliness, we need to create communities where residents know they belong. And the easiest, cost effective and most rewarding place to begin to create communities of belonging is through the dining experience, delivered with intentional kindness. Chasing loneliness away increases a person’s immunity, lessening the chance of illness moving in and taking over. Studies claim it lowers blood pressure, lifts depression, and helps to relieve aches and pains. Small acts of kindness show phenomenal results in a person’s physical and mental resilience. Again, that works for the giver and the receiver.

One of the most vital changes that can happen in your senior living community (and it doesn’t cost a cent) is adding this learned skill to your staff’s training and weekly discussions. When you introduce the subject, give everyone a minute to recall a kindness done for them. Many stories of small encounters that they may not have realized were truly acts of kindness. Have you ever stretched on tiptoes to reach the top shelf at the food market when a complete stranger just plucked the item you wanted and handed it to you? I have. Many times and was thankful for this small act of kindness. Lead your staff into becoming aware of what kindness is, what results come out of it, and how it will affect them personally as giver and receiver.

Kindness generates kindness. When one person is touched by a kind deed, it will open them to do a kindness for someone else. Kindness dissolves walls of anger and resentment some people carry with them to hold people at bay. Change that begrudging attitude in your community to employees who love to come to work every day. Encourage them to develop and use intentional kindness toward everyone. It only takes 5 seconds to allow this skill into your thought.  Then kindness practiced will come naturally and enhance your way of living. When you have an atmosphere of kindness abounding in your community, your employees won’t need those walls they have built within. When you are discussing kindness with your team of food servers remember to remind them that kindness is to be shared with each other. It’s what makes a team great! And it benefits the giver and the receiver!


About the Author
Cindy Heilman MSFN, NDTR,FAND, Owner of Kind Dining® and creator of Kind Dining® training series, founded her company in 2006, as a coaching and training company to create affordable training tools exclusively to serve older adults in the senior care marketplace. Her company, Kind Dining training, is one of a kind. It’s a 9-module online and on-demand training series that delivers consistent training in a flexible format. Each module varies in length depending on the topic, and it takes 8 hours to complete all 9 sessions. It offers immediate skill building to develop staff professional, interpersonal, and technical skills to close service gaps, raise quality standards, resident satisfaction, and staff retention across departments, beginning with dining service. Throughout the series, students are taught to respect residents and their home environment as they perform their work. At the same time, they learn foundational principles of kindness, civility, empathy, and our unique brand of hospitality, communication, food safety, and serving skills and they benefit from the improved atmosphere of teamwork and communication. The Kind Dining training series has been approved by the Commission on Dietetic Registration (CDR), the credentialing agency for the Academy of Nutrition and Dietetics USA, for 11 continuing education credits, including 1 for Ethics for Registered Dietitians, Dietetic Technicians, and Certified Dietary Managers. To see a full list of modules, and to contact Cindy directly, visit www.kinddining.com.

Whether you’re rushing off to work or looking to refuel after the gym, smoothies can be a healthy, grab-and-go option. Well-made smoothies are a delicious way to help get the fruits (and veggies!) you know you need, complete with an extra boost of vitamins and minerals to give you energy to conquer your day.

But it can be difficult to find the right flavour combination (and too easy to turn your smoothie into a high-calorie, high-sugar dessert). And even if you are the most tried and true fan of smoothies, you can find yourself a bit bored of the same old smoothie, with the same few fruits, day after day.

We’re here to help bust you of out blender boredom with unexpected ingredients like mint, ginger, cinnamon, and more that add new, delicious, and healthy flavours to your smoothie list. Grab your blender and try these four Aramark chef-created smoothie recipes to make at home!

1. It’s Easy Going Green

This is sure to be your new go-to drink. In addition to the power-packed kale and spinach, it has almond milk, zingy ginger, and earthy and colorful turmeric, which is gaining popularity for its anti-inflammatory properties. Ground turmeric can be found in the spice aisle of most grocery stores.

2. Berries and Spice and Everything Nice

You don’t often see cranberries in smoothie recipes, but we think that’s about to change! Here, vitamin C- and fibre-packed cranberries get added to sweet strawberries and blended with ginger and cinnamon for a little spiciness.

3. It’s Peanut Butter Berry Time

We took the classic combo of bananas and peanut butter to the next level. This smoothie has it all – fresh fruit, extra protein, and it’s dairy-free. The chia seeds add fibre and healthy omega-3 fatty acids.

4. Tropical Fruit Meets Cool Mint

This tangy smoothie is perfect for a hot day. The fresh mint adds a cooling taste, while the pineapple and apple sweeten it up. The vanilla yogurt adds creaminess.

When it comes to smoothies, don’t be afraid to mix things up! Get creative and play around with different ingredients to find the perfect recipe that fits you.

Dysphagia is defined as difficulty swallowing and affects a multitude of people worldwide. The modification of food texture and fluid thickness has become the cornerstone of dysphagia management around the world.

Food textures can have many different names and be defined in a variety of ways depending on where you live in the world. Even right here in Canada, there are a variety of names and definitions for the same textures. For example, a minced diet could also be referred to as soft, mashed, ground, or chopped. These multiple names can be very confusing for everyone but also present a great risk for the individual with dysphagia, possibly leading to aspiration and choking. The solution to this was the formation of The International Dysphagia Diet Standardisation Initiative (IDDSI) founded in 2013 by a diverse group of professionals from around the world. Their goal was to develop new global standardized terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia.

IDDSI is a framework that consists of a continuum of 8 levels from 0-7. Each level is identified with numbers, text labels and colour codes. Food textures are shown as a downward pointing triangle starting with Level 7 (Regular) in which no texture modification is required and progressing toward Liquidized (level 3) where the most texture modification is required. Fluid Consistencies are represented by an upward pointing triangle starting at Level 0 (Thin) and progressively getting thicker through levels 1 (slightly thick), level 2 (Mildly thick), level 3 (Moderately thick) and Level 4 (Extremely Thick). You will notice that Liquidized food texture and Moderately Thick liquids are on the same level (3). Likewise for Pureed and Extremely Thick both being level 4. This is because they take on the same characteristics.

The foods in each level of the framework have their own detailed descriptions, characteristics, physiological rationale for the level and specific easy and practical testing methods to decide if the food meets that specific IDDSI level. Audit sheets have also been developed to assist when testing recipes to determine if it meets a specific IDDSI level.

The implementation of the IDDSI journey can feel a little daunting; however, it is possible (and fun) so long as you have actionable “bite-sized” steps to follow. The first step to the implementation process is appointing an IDDSI champion who will act as the spearhead for this initiative. This individual will start by learning about the importance of IDDSI for resident safety as well as the framework and testing methods. Once they feel comfortable, they will share the importance (and create a general awareness) of IDDSI throughout the home to all departments as well as residents and family members. The next step would be to set up your home’s IDDSI implementation team. This team will be led by the IDDSI champion. This would be a multidisciplinary team and include all departments affected by IDDSI. This should include a mixture of both management and front-line staff involved in resident care or feeding. This team would be responsible for reviewing current policies and practices related to resident eating and to determine the implementation tasks that need to be completed along with an implementation timeline. This team would also determine the team members who will be responsible for specific tasks and identify possible challenges that could be encountered.

Although IDDSI is not mandatory, having one national and international language to talk about dysphagia and texture modified foods is considered best practice. More and more organizations are implementing IDDSI. Manufactures are also embracing IDDSI. They have started to map their existing products to determine how their product fits into the IDDSI framework. They have also been developing and/or reformulating current texture modified products/fluids to meet the IDDSI framework. Labels of texture modified products have started to appear with either dual labelling or full transitions to the IDDSI terminology.

Members of Complete Purchasing Services are encouraged to visit the eCPS members portal to find valuable information on IDDSI which includes many articles, webinars; as well as an IDDSI Implementation Guide and Planner.

You can also visit www.IDDSI.org to find detailed information on descriptors of each IDDSI level. There’s an IDDSI YouTube channel with food- and fluid-testing videos, as well as recorded webinars on IDDSI updates and experiences of implementing IDDSI in various healthcare settings. The IDDSI site also offers publications, including research articles and reports, FAQs, and many printable consumer handouts.  This information also can be accessed via the free IDDSI app (available for iOS and Android devices) and by following IDDSI on Twitter @iddsi_org. If you are considering implementing IDDSI in your facility, the IDDSI.org website also has an implementation guide which can help.

Use of the IDDSI Framework
The IDDSI Framework and Descriptors are licensed under the CreativeCommons. By Attribution Share Alike 4.0 License https://creativecommons.org/licenses/by-sa/4.0/legalcode. Attribution is requested as follows: (c) The International Dysphagia Diet Standardisation Initiative 2019 @http://iddsi.org/resources/framework/. Attribution is NOT PERMITTED for derivative works incorporating any alterations to the IDDSI Framework that extend beyond language translation. Supplementary Notice: Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to elements of the IDDSI framework may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death. http://iddsi.org/framework.


About the author, Heather Stukalo

Heather joined Complete Purchasing Services in 2016 as a Registered Dietitian with the Menu & Culinary Support Team. Heather has extensive knowledge in menu planning and the International Dysphagia Diet Standardization Initiative (IDDSI), having lead the CPS Menu Development team's integration of the new framework, and is a member of OSNAC (Ontario Seniors Nutrition and Advocacy Committee) and FNAT (Food and Nutrition Advisory Team. Prior to working with Complete Purchasing Services, Heather worked in LTC for 26 years in both corporate and clinical roles. She has also worked as a Home Care Dietitian for 5 years.

The summer season comes with many joys. But one stands out from the rest: gardens and farmer’s markets bursting with crisp vegetables and juicy fruits in their prime. From sweet corn, green beans, and summertime squash to stone fruits, heirloom tomatoes, blackberries, and more, the abundance of fresh produce this season makes it easier to eat our way to better health and all the nutrients will help you feel energized and ready to take on the day.

Here’s the scoop on how to choose, store and use your colourful summer’s bounty:

Corn

Nothing says summer quite like sweet corn. Sweet corn straight from the cob is high in fibre, packed with antioxidants and is downright delicious. Sweet corn will stay fresh for about five days if stored properly in the refrigerator, and it can be grilled, boiled, or even microwaved. Aramark Chef Scott Zahren loves sweet corn tossed with a small amount of light mayonnaise, lime juice, smoked paprika and cayenne pepper for a quick and easy version of Elotes or Mexican Street Corn. We’re a fan of adding it to our lunch grain bowls, too!

Cucumbers

Crunchy cucumbers can help us hydrate and stay, as the saying goes, cool as a cucumber. Plus, cucumbers couldn’t be easier to eat! They are best eaten raw and can be enjoyed with or without the peel, making prep a breeze. For a simple, no-fuss dish Aramark Chef Scott Zahren recommends a fresh cucumber salad made with cucumbers, onion, fresh dill, a dash of sugar, salt, and pepper and a splash of cider vinegar. In the mood for something creamy? Take on Tzatziki, he says. This yogurt-based sauce, traditionally used in Greek-style meals like Gyros, utilizes fresh cucumber, onion, and garlic. You can even sub in Greek yogurt for regular for some added protein.

Peaches

Peaches have more than 20 micro and macronutrients, including fibre, vitamins, A, C, E, and potassium. They also contain the antioxidant beta-carotene. While they are delicious with no preparation, sometimes peaches bruise. Fortunately, there are plenty of ways to use up those not so pretty ones. Try Aramark Chef Bill Allen’s Fired Up Peaches, a zesty hot sauce that you can use to add a bit of bang to your burger. To make it, put peeled peaches and tomatoes, chilis, salt, sugar, and a little water in a saucepan, bring it to a boil and reduce. Cook it until the peaches are soft, and then cool the mixture for a bit and puree. Store it in the refrigerator or enjoy immediately! Other peach options include drying slices for a nutritious, chewy snack or grilling with cinnamon or nutmeg for a tasty, healthy dessert.

Tomatoes

Tomatoes have plenty of nutrients, including vitamins A and C and the antioxidant lycopene. And, with so many varieties to choose from, it’s easy to include tomatoes in lots of dishes. Just remember to store your tomatoes stem end up on the counter to prevent bruising and to keep them tasty. The cold temperature in the fridge weakens the flavour and prevents tomatoes from fully ripening. Aramark Chef Scott Zahren is a fan of using tomatoes in Israeli Salad. He combines Israeli couscous, fresh tomato, cucumber, herbs, and a vinaigrette dressing. The wonderful thing about this dish is that it’s so versatile! Try parsley, mint, or chives for the herbs. For additional nutrients throw in bell peppers and spinach. You can even swap out the couscous for another grain, like quinoa.

Watermelon

Don’t know how to select a watermelon? Look for a firm, symmetrical melon that doesn’t have bruises, cuts, or dents. Lift the watermelon and select one that is heavy for its size with a creamy yellow spot on the underside from where it sat on the ground. Watermelon is tasty and easy to enjoy sliced, but there are plenty of other ways to eat it, too. While we love a good watermelon feta or cotija salad, we’re also big fans of Aramark Chef Bill Allen’s savory Watermelon Prosciutto Salad. Mix cubed watermelon, arugula or other greens, a small amount of thinly sliced prosciutto and parmesan cheese, and olive oil and balsamic vinegar for his Italy-inspired dish. Another option is to make watermelon ice cubes. Watermelon is 92% water, so you can cut it into cubes and freeze it on wax paper. Then, use the cubes for added colour and flavour in lemonade and iced tea!


Note: Since everyone’s health history and nutritional needs are so different, please make sure that you talk with a registered dietitian to get advice about the diet and exercise plan that’s right for your residents.

For many residents, admission to Long Term Care (LTC) is either preceded by poorly managed mental health, or the admission itself may trigger a decline in mental health. It is imperative to determine the resident’s mental health perspective, from the time of admission and moving forward, each subsequent day. Just imagine experiencing all the losses that newly admitted residents are confronted with, without having anyone to talk to about it. Experiencing loss is an expectation as one ages, but the benefit of talking about it and having others share in the grieving experience is so important and can significantly change the quality of life for the resident.

The rate of diagnosis of depression for residents living in LTC is 44%. (Canadian Institute for Health Information, 2010, 2015) It is believed that this number is low! We know that in the general community people who are depressed are stigmatized. This stigma is even more prevalent in the elderly, so the resident does not tell anyone that they have a low mood. Staff see it, but this is often after some time has passed. The resident may not participate in activities provided in the Home, there may be a lack of social interaction with others, as well as a growing isolation away from others.
For Homes who follow a Recovery Philosophy of Care, a partnership that focuses on the individual’s strengths and values, will allow the resident to truly be their best selves and to feel supported in their daily lives.

Admission to Long-Term Care

People who have lost the ability to function independently in the community are admitted to LTC for assistance in activities of daily living (ADLs) and Instrumental Activities of Daily Living (IADLs). Changes in ability to function in the community may be related to a medical acute crisis causing delirium, advancing dementia, loss of caregiver in the home and/or poorly managed mental illness, including depression and anxiety. A history of drug and alcohol abuse may also contribute to the admission, given that as one ages the ability for the body to manage excessive drugs or alcohol diminishes.

Depression Diagnosis

Little is known about the difference between grieving (complicated or typical) and depression. The DSM-5 outlines the following criterion to make a diagnosis of depression. The individual must be experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.
To receive a diagnosis of depression, these symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must also not be a result of substance abuse or another medical condition. (American Psychiatric Association. 2017. Diagnostic and Statistical Manual of Mental Disorders. 5th edition)

1.    Depressed mood most of the day, nearly every day
2.    Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
3.    Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day
4.    A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down)
5.    Fatigue or loss of energy nearly every day
6.    Feelings of worthlessness or excessive or inappropriate guilt nearly every day
7.    Diminished ability to think or concentrate, or indecisiveness, nearly every day
8.    Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Persistent Complex Bereavement Disorder

The diagnosis of Complicated Grief is now Persistent Complex Bereavement Disorder. It is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to individuals who experience an unusually disabling or prolonged response to bereavement.

Persistent complex bereavement disorder causes sufferers to feel extreme yearning for a deceased loved one, usually over a prolonged period. Feelings of longing are often accompanied by destructive thoughts and behaviors, as well as general impairment in resuming normal life. (American Psychiatric Association. 2017. Diagnostic and Statistical Manual of Mental Disorders. 5th edition)

Use of the Social Readjustment Scale can help the staff determine if someone is grieving for all the loss they have had in the past year, along with any changes that are stressful. A score of 300 increases the risk of the person having a mood disorder to 80%. Some common losses/changes newly admitted residents experience are: death of a spouse; marital separation (frequently only one of the married couple is admitted to LTC); personal injury or illness; retirement; change in financial state; change in living conditions; change in residence; change in recreation; change in social activities; change in sleeping habits and change in eating habits. A loss of a care giver in the home or a change in medical condition (diagnosis of dementia, progression of life limiting illness such as COPD or Heart Failure) can cause all these other changes to occur for the person being admitted to LTC.

Grieving

Understandably admission to LTC is a busy time for the staff, resident, and family. There is a period of adjustment. One step that can ease the burden on the resident is to support them in their grieving. Grieving is a natural way for people to allow emotions of shame, guilt, sadness, and anger to be present and managed. One way of supporting the person is to open the conversation by asking, “What have you left when you moved to LTC? How do you feel about everything that is happening? Have you had some control over how things have gone for you recently?” To grieve one needs to express how things are feeling for them. This may be the first time anyone has had this type of conversation with the person. Holding an unconditional positive regard for them allows for a supportive and respectful environment. It can go a long way in helping with the adjustment to living in LTC.

These conversations rarely happen when one is admitted to long term care. Not being able to grieve can lead to Persistent Complex Bereavement Disorder which may result in depression and a loss of hope. The presentation of grieving a loss, or many losses, is significantly different than depression. A simple discussion with the person about what they have lost can often spark a smile or laugh as they remember how things were. In depression there is apathy (do not care about anything, unmotivated), anhedonia (lack of pleasure in anything) and in the older person we see anxiety as a primary expression of depression.

Treatment

Depression signals a problem in the neurotransmitters in the brain, especially serotonin and dopamine. Antidepressants will generally be effective in treating Major Depressive Disorder (MDD). Antidepressants will not change the mood for someone who is not depressed but are instead grieving. There is also evidence that Antidepressants can account for significant medical concerns and are not effective for those who have been diagnosed with depression and dementia.  This may be because the diagnosis of MDD is not accurate in this population. Perhaps they are grieving their many losses. It is interesting that this group finds supportive counselling, including Cognitive Behavioural Therapy, helpful in improving mood, quality of life and ability to perform ADLs. (Orgeta, V., Leung, P., del-Pino-Casada, R., Qazi, A., Orrell, M., et al (2022). Psychological treatments for depression and anxiety in dementia and mild cognitive impairment. Cochrane Database of Systemic Reviews).

Dementia and Depression

Many people admitted to LTC have either early cognitive impairment or a diagnosis of dementia. Staff are challenged to get a thorough history of the persons health when they are admitted and even more difficult to determine the resident’s mental health history. Families are not always aware of a diagnosis of depression, and up until this time have allowed the person to manage their own health, with their primary care provider. As challenging as it seems, a good mental health assessment should be completed.

There may be some information about the resident’s medications, and on admission a thorough medication review is completed. Frequently residents are on a very low dose of an antipsychotic or antidepressant, often prescribed to help with sleep, not to treat a mental illness. Many of these medications are sedating. (Health Quality Ontario. (2015) Looking for Balance) If the reason for these medications is insomnia, a sleep assessment needs to be completed to determine why the resident is having trouble sleeping. There may be an underlying physical or mental health concern that has not yet been discovered and diagnosed.

Personality Disorders

We have discussed the scenario for most people admitted to LTC. They have their families and supports with them and sometimes even have a say in their care if they have not been deemed incapable. But what about the other people - those admitted through hospital or from home because they are no longer functioning independently? They come with no one. No supports, or perhaps a family member who is present at admission and only visits periodically. These residents are often described as having a “difficult personality”. They present as mean and angry all the time, and if things are going well in the common area, they will disrupt the calm with outbursts and maladaptive behaviour.

Often, there is a belief by staff and other residents that these residents behave this way on purpose and families, when they are present, say that they have been this way their whole lives.

Maladaptive behaviours are often a symptom of a Personality Disorder. People who have trended a certain way in their personality will often, because of stresses and losses, follow that personality to an extreme. When the behaviour affects their social and occupational functioning, it becomes a disorder. Examples are Narcissistic Personality Disorder, Borderline Personality Disorder and Obsessive Compulsive Disorder.

Personality Disorders begin with trauma and/or neglect in childhood. During childhood the immature brain tries to make sense of the abuse/neglect from someone who should be caring and nurturing them. Core beliefs are changed in these individuals. The core beliefs of someone with a personality disorder are:

1.    The world is a dangerous place
2.    No one loves me
3.    I am unlovable

Of course, the person does not have access to these core beliefs and their behaviour is subconsciously driven. Because of the trauma the amygdala (fight or flight center of the brain) is left in the “on” position, citing danger to the person subconsciously when things are good, when things are neutral and when things are bad. There is a sense that because the person survived the trauma in childhood, they are more comfortable when things are bad. Often in good times they will sabotage the environment affecting those closest to them. This then causes a break in the relationship. Another aspect of the person with a personality disorder is that they are always the victim. Because the behaviour is driven subconsciously, they have a difficult time taking responsibility for the behaviour, and when addressing the maladaptive behaviour, we often hear, “you made me do it”.

Personality Disorders are described in the Psychiatric world as Axis II, preceded by  Axis I diagnoses such as Major Depressive Disorder, Schizophrenia, Bipolar Disorder. There is no medication to manage Personality Disorder. In LTC what works is a consistent, assertive approach by all staff. This approach must be gentle, kind, and supportive, and when staff realize that childhood trauma is the cause of the personality disorder, they find it much easier to be supportive. Unfortunately, very little attention is given to the person with a Personality Disorder. We rarely see a diagnosis, and often the person has never had any mental health care. What they do have is many broken relationships, and in LTC they have burned all their bridges and are left with little to no family support.

Summary

The mental health of residents admitted to and living in LTC is impacted significantly by mental illnesses such as Depression and Personality Disorders (with a history of trauma). Many residents have also experienced losses over a short period of time and have not been assisted in grieving these losses. Instead, they have been moved away from a familiar, personal environment to a congregate LTC setting with many other older people. When left unsupported many residents may feel hopeless and depressed. A Recovery Philosophy of Care can support these residents by respecting the individual and encouraging them to share their story in all its beauty, hope, and sometimes yes, with despair.


About the Author
Franzis Henke, Nurse Practitioner.
As a Silver Meridian Associate, Franzis provides extensive expertise in Palliative Care, working with the dying and their families, Geriatrics, and Geriatric and Adult Mental Health. She is also a Mental Health Specialist and is the co-facilitator of RecoveryCare Mental Health Program. https://silvermeridian.com/resident_focus/mental-health-recoverycare/  
Silver Meridian is pleased to present a new program, developed and presented by Franzis, “New Approaches to Palliative Care in LTC: Embracing the Opportunities” starting in early July. Details for this 10 hour accredited CEU certificate program are available at https://silvermeridian.com/new-approaches-to-palliative-care-in-ltc/
For details on all Silver Meridian programs visit https://silvermeridian.com

Care for the dying has been an important and expanding function in Long Term Care (LTC). Over the past 10 years the typical length of stay has been shortened to approximately 18 months and the stay usually ends in death (Canadian Institute for Health Information, 2015). Many care centers have been supportive of a person-centered, palliative approach to care, but unfortunately, others have not made this adjustment.

Palliative Care, death and dying have been practiced, experienced, and accomplished in Long Term Care (LTC) for as long as these institutions have existed. However, until the first death from COVID 19 occurred and subsequent deaths, very few of the general population had any sense of what LTC looks like and how it is for the residents living there, and the staff working there. As residents and staff continued to contract and die from COVID 19 the lens on LTC, especially by the media, was adjusted and the government ultimately held accountable. Statistically LTC residents accounted for 3 % of the COVID cases and 43% of all deaths by COVID in Canada (Canadian Institute for Health Information (CIHI), and National Institute on Ageing; COVID 19’s Impact on Long-Term Care, December 9, 2021). This truth has led to changes in The Long -Term Care Act that include a need for adoption of a Palliative Care Philosophy in LTC. (Ontario’s Regulatory Registry. Fixing Long-Term Care Act, 2021; Phase I Regulations).

The Long-Term Care Act is now asking for the following to be adopted into LTC during Phase I. “Requiring that integration of a palliative care philosophy include a holistic and comprehensive assessment of a resident’s needs and when needed, improvements to a resident’s quality of life, symptom management, psychosocial supports and end of life care, always subject to a resident’s consent.” (Ontario’s Regulatory Registry. Fixing Long-Term Care Act, 2021; Phase I Regulations).

So, what does it mean to incorporate a Palliative Philosophy of Care? From Bill 37 (Part II) the elements that must be included are:

1.    Quality of Life Improvement
2.    Symptom management
3.    Psychosocial support
4.    End of life care

Let’s step back for a moment to pre COVID. In 2019 people were moving into LTC for various reasons. Most could no longer function independently at home, even with some support. This may have been for medical reasons, such as final stages of a life limiting illness (Dementia, COPD, Heart Failure, Cancer…), a serious and poorly managed mental illness leading to an inability of the person to care for themselves, or the loss of a primary caregiver (often a spouse) due to death. The Social Readjustment Scale is a helpful tool that indicates all the losses many people experience prior to and on admission to LTC.

So why are people coming to live in LTC.? For physical care of course, and potentially for some improvement in function now that they have support, and the little talked about, but yes, to die. The first two items are always talked about as encouragement to come and live in LTC and in an attempt to persuade the person to leave their home and all that they know from a social perspective. Rarely is the person told that their dying time will probably come while they are living in LTC and that this will be their last home of this life.

So now the expectation is that discussion about the Palliative Philosophy of care is completed prior to admission to LTC. Wow! How is that discussion going to go when we live in this death phobic society where death happens to us, but really against our will. Many say, “we are born to die” and yet we see the struggle to even discuss what our death may look like and how we would like it to go. When we do talk about our death at all, it is way in the future, or we ask to prolong it and get “more time” for as long as possible.

Let’s briefly discuss this concept of “more time”. Stephen Jenkinson discusses this in his writing in Die Wise: A Manifesto for Sanity and Soul, 2015. People who are dying will ask for medical treatment to get “more time”. What they mean by this is more life or longer life, but what often happens is that dying is prolonged. The quality of life is not what people were hoping for and yet when treatment is offered, they grab the chance to have more time, not knowing what this will look like. With a Palliative Approach to care, we must be honest in our discussions with people. If they are asking for “more time” or being offered treatments which may give them this time, we need to paint the picture of what this “more time” may look like. Most are surprised that the treatment, at best will prolong their death, not improve, or increase the time of their living.

The requirement to now discuss Palliative Care prior to admission is really a requirement to discuss life in LTC and death during the stay. Re-thinking a palliative approach is so important for people so they to have a say in their last days of this life. Using a Palliative Approach to care means that conversations about how the person may die (disease projection) are discussed with the person along with any treatment options, quality of life and symptom management, and who their people are, including Substitute Decision Maker (SDM). They may come into LTC with an Advance Care Plan already in place and this would need to be revisited. Often no discussions about their dying time have happened and now it is up to the LTC staff to have this frank and difficult discussion perhaps for the first time.

Included in the new LTC Act is the need for consent to give care following a Palliative Approach to care. This has long been a concern for some working in the LTC sector, as people are often admitted to LTC because they are deemed incapable to live independently. This includes difficulty completing Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs) independently. Persons admitted to LTC often come with a broad diagnosis of Dementia and families, caregivers and staff often believe that this diagnosis predetermines that the person can no longer make decisions or give consent for any treatment or care. This belief is false. It makes great sense to always include the person coming to LTC in all discussions so that they have the opportunity to give consent.

The easiest way to talk about someone’s dying time is to respect their input. And listen. These difficult conversations need not be so difficult. Ask the person why they have come to live in LTC. They will tell you about of all the changes and losses in their lives. And here there can be hope! By living in LTC they are able to talk about their dying time coming, without it being minimized or brushed aside. They will see co-residents complete their dying here, and with an open discussion about this life ending soon, people can enjoy their lives without the doom of the unspeakable and not talked about event of their last days here.

Staff in LTC have such difficulty in having these discussions with people and yet these discussions should come so naturally, especially if people know that they are approaching the end of this life. And that is the key - people do not know that their dying time is coming soon. Instead, what is discussed is that the reason they have come to LTC is because they are no longer able to manage their life and health independently, and they need a higher level of care. Families may, on some level, know that this is what is happening and still it is rarely discussed. Maybe if we don’t talk about it, it will not happen. Still, we will all die and come to this time in our lives.

We discussed the shorter length of stay in LTC from  compared to the past. Most people who enter LTC will die there so length of stay is mostly a measurement of time from admission until the time the person dies. LTC staff members, thus, see a lot of dying. So why the discomfort in talking about it? We would expect that most staff have seen people go “kicking and screaming” to their death. But most have also seen what would be called a “good death” with pain well managed, and family supporting, sometimes in vigil with, their loved one until death. Most of the discomfort in talking about dying must then come from the not so pleasant view of dying. As well, when the dying person does want to discuss their imminent death (which they instinctively know is coming soon) they get told statements such as “don’t talk like that, you have years to live” or “don’t worry, you will get better.” Yet we must question why we would worry about dying when we all know that all of us will die?

Of the 4 elements that need to be included in the palliative philosophy of care, one of the most difficult requirements may be quality of life. Quality of life is a subjective experience, so how do we even measure that? This question should be asked of the resident. But is it? For many people entering LTC making decisions is not left to them. Caregivers and family members make these decisions because “the person is not capable.” That is why they are coming to LTC. And yet the language is very clear that we must have the resident’s consent for decisions. Capability is not a black and white status. It fluctuates and where people may no longer be capable to look after their own finances, for example, they can decide if they want a certain treatment or another, whether they want to proceed with their dying in LTC or whether they want to have treatment (if possible) in another setting. To ask these questions of a resident, they must first know that they are coming close to their dying time.

Having that frank and honest conversation with someone can be a synergistic time for all involved. How freeing it is to talk about your own dying, when you know you are doing it, with someone who is comfortable talking about it. I have been with so many people who are dying and there are common themes which can make these discussions much easier to have. First of all, look to the psychology world where Erikson says that people progress through stages in their life, and which way they go can greatly influence quality of life and death. For the population living in LTC we will look at 2 Stages. Age 40-65 years old is covered by Generativity versus Stagnation. Age 65-death we look at Integrity versus Despair. So. if we do not encourage conversations about what coming to LTC means we will often see stagnation and despair. When speaking to many staff working in LTC, what they see is older people, with many losses recently in their lives, brought to LTC by family and left there without having a sense of what changed in their lives to bring them here. The Palliative Philosophy brings an honesty to the conversation. Yes, you will probably die here, but how can that life look before death. Is there an opportunity for Generativity and Integrity? Probably not if the person being admitted is not involved in the conversations. It is important for staff to have the person being admitted present and giving their consent to all care offered. No matter their capability, they should be present and included always in these conversations. (Erik Erikson’s Stages of Psychosocial Development. (Kendra Cherry, July 18, 2021).

What we have also seen is that at the end, just before death (weeks to days), people struggle to leave their legacy. Legacy leaving is interesting, but what we see is an attempt, often very late, to show one’s true self or self actualize (as Maslow would put it). How one shows their true self would mean another article, however in simple terms it means showing who you are from a strengths and values perspective, being free now of all defense mechanisms and maladaptive behaviours. We often, throughout our lives put up walls and wear different faces, our perception being that we will be more pleasing to others if we act the way we think they want us to. This does us and others a disservice, and at the end of our lives we try desperately to come clear of this.

We also see such mystery around our dying time. Again, do we ever talk about this to our resident’s. Do they know that near their death they will probably see their dead (loved ones who have already died) and that they will find great comfort in this? Most of us, who have worked in LTC have seen these mysteries. What a great opening to relate these stories to move to a discussion about your resident’s dying time. We need to find out what quality of life means to them, and it goes beyond symptom management. It is so much about leaving a legacy of who they are for those they are leaving in their dying.

In summary, we are regulated now to provide a Palliative Philosophy of Care to all residents in LTC. As noted, consent for this care must be given by the resident. Let us proceed with the honest conversations, which, yes, are sad in that we will all die and leave this life as we have known it, but what a glorious time this dying time can be if we just open up to its importance as the last significant act we will do in this life.

About the author, Franzis Henke, Nurse Practitioner.

As a Silver Meridian Associate, Franzis provides extensive expertise in Palliative Care, working with the dying and their families, Geriatrics, and Geriatric and Adult Mental Health. Silver Meridian is pleased to present a new program, developed and presented by Franzis, “New Approaches to Palliative Care in LTC: Embracing the Opportunities” starting in early July. Details for this 10 hour accredited CEU certificate program are available at https://silvermeridian.com/new-approaches-to-palliative-care-in-ltc/
For details on all Silver Meridian programs visit https://silvermeridian.com