2.5 Long-Term Care
Brandon Censon MPH, CPH, RRT-NPS, CPFT, CPT
It is important to understand the difference between long-term care and acute care. Unlike acute care settings, long-term care primarily provides care for patients with chronic illnesses and offers a wide range of services. In this unit, we will explore these services in greater detail.
Skilled Nursing Facilities
Skilled nursing facilities primarily provide care for the elderly and disabled who have complex medical problems that prevent them from caring for themselves. The length of a patient’s stay can vary. For example, if a patient needs extended care for an acute medical problem—longer than a hospital can offer—they may be discharged once their treatment is complete. Conversely, some patients may remain in a skilled nursing facility for the rest of their lives due to chronic and complex medical problems.
Assisted-Living Facilities
Assisted-living facilities typically serve people who need assistance with activities of daily living (ADLs), as well as those with mental health problems, developmental disabilities, or dementia. These facilities are residential, and they offer residents apartment-style homes and common areas for social and recreational activities.
Rehabilitation Facilities
Rehabilitation facilities provide acute care that may include various therapy professionals, such as physical therapists, occupational therapists, and speech therapists. This care focuses on restoring a patient’s functional and cognitive skills following disturbances that affect their ability to perform ADLs. Conditions treated in rehabilitation facilities include strokes, spinal cord and brain injuries, and surgical replacements or repairs of large joints, such as the hip. The overarching goal at rehabilitation facilities is short-term care that helps patients recover from injuries, medical procedures, or other significant health events.
Attributions
- Figure 2.3: image released under the Pexels License
- Figure 2.4: image released under the Pexels License
Communication Related to Safe Patient Care
Clear communication is one of the most important aspects of professionalism in healthcare. Most errors in healthcare can be attributed to a breakdown in communication. Inadequate or incorrect information about something or someone can lead to serious mistakes that not only harm patients or staff but could also have legal and financial repercussions for the organization. Even something as simple as properly labeling a container can be crucial in preventing a chemical burn. According to Julia Riley (2023), “building positive coworker relationships, teamwork, and collaboration supports clear communication, which has a direct effect on patient safety” (p. 6).
When urgent or emergency care is being provided and there are many people in the room attending to a patient, it can be loud and chaotic. However, it is vital that team members hear and acknowledge their assigned tasks. For example, if a provider calls out, “Give the patient one milligram of medication!” someone on the team should make eye contact with the provider and confirm by saying, “I am getting the medication.” This ensures the whole team is aware of the request and response, preventing inefficiencies and ensuring the message is not lost.
Delegation is common in healthcare. For instance, a nurse may ask a nursing assistant to check a patient’s blood pressure. The nursing assistant should then use closed-loop communication, checking back with the nurse to report the results or explain if the task was unable to be completed and why. This approach ensures the nurse is not left wondering about the patient's condition or if a concern needs attention. Verifying instructions, especially when something is unclear, is critical.
When communicating with patients, families, visitors, or other employees, it is important to be aware of any deficits in hearing, vision, or language skills. In such cases, find an appropriate communication method, such as speaking more loudly, using large print materials, or employing a language interpreter. Keeping everyone informed about choices and next steps helps reduce anxiety. For example, saying, “After the doctor sees you, you will go to the lab for a blood draw” can ease concerns by letting people know what to expect. This fosters trust as patients see healthcare workers as reliable and consistent in providing information.
It is also important to ask for help when needed. Letting a supervisor know when a patient is not doing well, the clinic waiting room is backed up, a team member is absent, or when the workload is overwhelming and cannot be completed on time is crucial for maintaining safe workflows and meeting care needs.
After a serious event or error, it is essential to debrief with the team. The team should gather to review a factual account of the events, discussing what went well and what could be improved if a similar situation arises in the future. Were there any safety concerns? Did any errors or system issues need addressing? This process leads to improvements in the quality of care. For example, during a “Code Blue” (cardiac arrest), a team of professionals, each with specific duties, responds. A physician leads the team, a respiratory therapist helps with breathing, a pharmacist offers medication guidance, nurses administer medications, and nursing assistants or technicians assist with chest compressions. A recorder documents each event, such as the administration of medication or use of a defibrillator. Even if the patient is revived, it is best practice to review the event. Questions to consider include: How long did it take the team to arrive? Were there any communication issues? Did everyone perform as expected? Do team members need emotional support after the event?
Dealing With and Resolving Conflict
One of the most challenging aspects of communication for many people is dealing with conflict. What should you do if someone yells at you or corrects you in front of others, leaving you embarrassed? How do you handle a disagreement with a team member about how something should be done? What if you witness someone speaking or behaving inappropriately?
The key is to speak up when things are not right and to set clear expectations and boundaries. It’s important to remain calm, especially if the other person has heightened emotions, as this may trigger an emotional response in you as well. Be mindful of your actions and the impact they may have, and take a few deep breaths before responding. If you use an angry tone, raise your voice, or display negative body language like crossing your arms, you may unintentionally escalate the situation. Instead, try to set your feelings aside, focus on problem-solving, and invite cooperation (Riley, 2023).
Being assertive (as opposed to being passive or aggressive) can be difficult but, with practice, it will improve both personal and professional communication. To be assertive means considering your own needs and boundaries while also being confident that you deserve to express your opinions or ask for things, without feeling guilty or fearful. It also involves being respectful and not causing harm to the other party. Riley (2023) defines assertive communication as “positive, caring, nonjudgmental, clear, and direct without threatening or attacking” (p. 6).
For example, imagine your supervisor asks you to stay over your shift due to short staffing for the fourth time in a week. An assertive response would be: “I am not sure you are aware, but this would be the fourth time I've stayed over this week. I need to see my family, and I am unable to help out this time.” This response is fair because you have already contributed significantly by staying over three times earlier in the week. You’re not unwilling to pitch in, but you need a break for self-care. It’s also important to remember that exhausted employees cannot provide the safest care.
A Note on Confrontation
Bower and Bower (2004), as cited in Riley (2023), developed a model for handling confrontation, known as the CARE model. This model is broken down into the following steps:
(C) Clarify
Clarify what language or behavior is problematic. Be sure to specifically address the behavior, not the person.
For example, instead of saying, “You always forget to lock the office door,” which might put the other person on the defensive, try saying, “When the door is left unlocked, I worry that our computers and belongings might be stolen.”
(A) Articulate
Explain clearly the consequence of the behavior or language. Describe how it impacts others or makes them feel.
For example, “When you take 15 minutes of our 1-hour meeting to talk only about your project, it makes me feel like you don’t value what the rest of the team has to say.”
(R) Request a Change
Offer a respectful suggestion for how to improve the behavior.
In the case of the meeting, the request could be, “We have six members on our team—what if we each got five minutes to bring up our questions and concerns, and the rest of the time could be used for brainstorming as a group?”
(E) Encourage Change
Encourage change by explaining the benefits of a new behavior or way of interacting, or by highlighting the negative effects of not changing.
For example, “I think that with the new plan for our meetings, we could be more efficient and make real progress toward our goals and deadlines.”
Navigating Emotions
Another challenge in professional life is dealing with emotions. It is best to keep conversations as factual as possible. If you are upset about something, take time to process the event or conversation. If possible, go for a walk or take a few deep breaths. Healthcare is stressful, and it’s important to recognize that another worker or patient may be hungry, fatigued, or simply not at their best in the moment. Be patient with your teammates.
However, if there is repeated disruptive behavior, being assertive and advocating for yourself or a patient can be intimidating, but it is necessary. If you need to follow up with someone to let them know their behavior or words were unacceptable, suggest a private setting for the conversation. If emotions are interfering with professional communication, a third party, such as a human resources representative, may be needed to mediate the situation.
Skill Stitch: Communicating Professionally
Role play a scenario with both positive and negative outcomes.
Scenario:
Eric is a new nurse working the night shift. He is struggling with time management and, by the end of his shift, is overwhelmed by how behind he is, particularly with the documentation he still needs to complete before he can get home to bed. Janet receives a report from Eric, and later, she tells her coworker Tran that Eric often leaves his rooms messy, making it difficult for her to take over his patients because she has to clean up first. She is considering going to the manager about it.
Tran could take one of two approaches. The first is to contribute to the conversation with Janet, saying, "Yeah, Eric is an inconsiderate jerk. I guess he went to a bad nursing school. I hate training new people—they just don’t get it. Did you hear that the other new nurse, Marta, was flirting with Dr. Sams?"
Questions:
- Does Tran’s response contribute to the team or workplace culture in a positive way?
- How does gossiping at the desk reflect on Janet and Tran as professionals, especially if others overhear them?
- What could Tran do differently to encourage Janet to find a solution?
Instead of adding to the tension between Janet and Eric, Tran listens quietly and then points out to Janet that Eric is new and may be feeling stressed. "Janet, have you thought about taking Eric aside privately and explaining how the messy rooms affect you? I was taught that the best way to handle things is 'send the mail to the right address'—in other words, take it up with the person creating the problem. They may not even realize it’s an issue. It’s not fair to go over his head to the manager before talking to him about it." Janet is surprised but, after thinking about this fair approach, agrees that she will have a quick chat with Eric next time he works.
Now, create a script for Janet’s respectful and understanding conversation with Eric and how he might respond professionally.
Attributions
- Figure 11.3: image released under the Pexels License
- Figure 11.4: image released under the Pexels License
Summary
In conclusion, a person’s health is influenced by a wide range of factors. While personal decisions, such as whether to smoke or how often to exercise, are frequently emphasized, these decisions are influenced by the social determinants of health, such as pollution, access to healthy food options, cultural beliefs, racial identity, and socioeconomic status.
Public health professionals work to minimize the negative effects of these factors through prevention programs, such as free immunization clinics, educational outreach, and epidemiological research.
For people like Mei and Chao from the introduction to this chapter, health is influenced by a combination of positive and negative influences. Close family connections and access to green spaces have a positive effect on their health, while living in the city with increased exposure to environmental pollution has a negative one. They may benefit from an excellent education system or suffer from an underfunded one. Their extended family or church community might provide a strong support system or they might feel isolated in a new city with their parents. These social determinants of health, among others, will have a profound effect on their physical, emotional, and spiritual health as they grow.
Review Questions
- In what ways is your life shaped by the social determinants of health? Can you think of two or three ways each social determinant has had a positive or negative impact on your physical, emotional, or mental health?
- Returning to the story of Cleo from earlier in this chapter, identify the social determinants of health that affect her life. What are some ways in which public health affects the social determinants of health that she experiences every day?
- Name a public health project that is an example of each type of intervention (primary, secondary, and tertiary)? Which type do you think affects more people and has a bigger impact, and why?
- If public health's role is to "protect and improve the health of people and their communities," can you provide an example of how it fulfills this role? Explain your answer by discussing the positive and negative impacts of governmental funding on your chosen example. How successful is the public initiative, and are there any outside influences that might affect its success?
- Which of the following is not a social determinant of health?
- You have a family history of heart disease and therefore have an increased risk of heart attack.
- You are a practicing Hindu and maintain a plant-based diet due to your religious beliefs.
- You have recently lost your job and are currently looking for work.
- You just moved into a new apartment in a part of town that has no sidewalks or buses close by.
- An individual's identity can greatly affect the care they receive. Can you provide an example of a common barrier to care faced by individuals of a specific identity? How can we as healthcare providers identify this barrier and remove it for our patients?
- Define what health means to you. How do you think your understanding of health is shaped by those around you?
- List the top three things that affect your health the most. Explain why these items either positively or negatively affect your health and how they are affected by environmental or personal factors.
- Identify three ways that healthcare is impacted by an individual's culture.
- Why is it important to track morbidity rates from a disease, even if they do not lead to death?
