Chapter 3 – Guidelines for Long-term Care Visitation

Practical Issues to Consider in Nursing Home Ministry

Our intention for providing the following list of pointers for visiting a long-term care center, or doing any kind of nursing home ministry, is to help you focus on some of the important practical issues of good communication, courtesy and protocol.  The well-being of the residents is our foremost concern, as, we are sure, it is with you.  Though they are not laws, these guidelines should be familiar to you and they should reflect your general attitude when volunteering in a care center.

Note:  This list expands on a similar but shorter list of guidelines we make available in the section of this website labeled “Downloadable Resources.”

1) Remind yourself as you enter the facility, that you are a visitor in the home of private citizens and you are there by their leave.  If you offend a resident the staff may have no alternative but to ask you to stop your visitation.

2) Speak slowly, distinctly and simply.  You may have to practice at this, but your effectiveness as a Christian minister will be hindered if the residents have trouble understanding what you are saying.

3) The person you are talking to is more important than what you want to say.  LISTEN TO THEM!

4) Communication relies on much more than just words.  PAY ATTENTION to the person you are communicating with!  Use body language, and monitor the body language of the person with whom you are communicating.

5) Do not argue.

6) Use humor with discretion.  Prolonged and extreme suffering can sap any sense of humor you once had.  Be ready to relate to those who are hurting.

7) Communicate at eye level if at all possible.  If you are not careful, some residents may feel like you are talking down to them or they may not be able to understand you as well if they cannot see your lips when you speak.  Many residents cannot lift their head up to look directly at you if you are standing over them.

8) Use guided choices when asking a resident to do something.  For example, if you need to move their wheelchair out of someone’s way who wants to leave the room, let them know that Mrs. So-and-so is trying to get out, and say something like, “Do you want me to move you this way or do you want to go over there?”  Try to lead with questions, not orders.  “How about if we do this?” is better than, “Ok, we’re doing this now!”  Or “Could you see more clearly if we turned the light on?”  is a lot better than just flipping on the light when you walk in their room.

9) Break tasks into small steps.  Don’t just throw a coloring book and a box of crayons in from of them.  Help them decide which picture to color, which shape to do first, and which shade of green crayon to start with.

10) Remain calm!  Accidents and confused behavior occurs often in a nursing home.  If you are calm, you can better anticipate mishaps and help avoid them and when they do occur, if you are calm, your demeanor will go a long way toward helping the staff to iron out the dilemma.

11) When giving food, candy, and drinks, be sure you are informed of any health conditions that may restrict a resident’s diet.

12) Allow an LTC resident to be sad or upset. Validate their feelings out of respect for them as a person. If you want to cheer them, redirect their thoughts on the same subject rather than trying to change the subject.

13) Do not presume to know a resident’s state of mind.  You do not know what little calamity may have just happened before you got there.  Maybe they just received bad news about a loved one.  It may be that they are simply not “in the mood” today.

14) Do not confront the resident with your questions about their dementia.  If necessary, ask the professional care-giver on staff about a specific resident’s lucidness.  Most importantly, personally get to know their level of awareness through a relationship based on your patience and understanding.

15) Some LTC residents will not remember being told previously about significant events or facts.  Their reaction to “old” information will often be as though they are hearing it for the first time.  For example, grief over the news that a loved one has passed away may be equally intense each time the news is discussed.  Therefore, in such cases, do not lie to them but focus on helping them deal with their FEELINGS AT THE PRESENT TIME rather than being sure they have all the information exactly right.  This is called Validation Therapy.  For more on Validation Therapy, we refer you to these websites:

www.verywellhealth.com

medical-dictionary.thefreedictionary.com

16) Speak to each facility resident by name, making a point to know how each resident wants to be addressed (i.e. , Mr. / Mrs. / Dr. / Rev. / etc.).

17) Do not presume that a nursing home resident knows your name.  Though they will usually remember your face they want to talk to you by name.  Help them avoid frustration by mentioning your name early in the conversation.

18) To most care center residents, touch is a very important communicator of genuine concern, personal affirmation and sincere affection.  On the other hand, you should be sensitive to the fact that some residents are uncomfortable with being touched.

19) Due to immobility, poor hearing and reduced peripheral vision, elderly residents have difficulty changing their direction of focus when someone approaches on the side or from the back.  Therefore, draw near to them from the front and speak to them face to face.

20) When speaking to a resident, pronounce your words distinctly and with a clear voice.  Use no greater volume than is necessary for them to understand you plainly.

21) Do not use baby talk in your conversation.

22) Ask open-ended questions to encourage conversation.  For example, “Did you ever go on a vacation?”  LISTEN!!!  No matter what your role in the facility, be quick to listen to the resident.

23) Give them as much control of the conversation or activity as possible.  Nobody likes it when someone is pushy toward them.  Because we are generally younger and more focused on our job at hand, from the point of view of the elderly and infirm, we may be guilty of bulldozing our way through interaction with them.  Do the best you can to take your time and really relate to them.  The reward may be more yours than theirs!

24) Before moving someone in a wheelchair always ask or tell them where they are going.  In this way, being polite and considerate, you may also prevent hand or foot injury.

25) Most LTC residents in the United States consider themselves Christians and many are stronger in their faith in Jesus than you are.  Be careful not to “talk down” to them.

26) Avoid making a commitment unless you are sure you will be able to keep it.  Good intentions count a little but they’re not good enough when a resident is devastated with disappointment!

27) The people who live in nursing homes used to be out in the community, working to make a living, going to the grocery store, raising children, singing in the choir at church, and on and on.  In short, older persons are a whole lot like you, only their attitudes and moods are to more extremes at times because they have the added weight of age, suffering and experience!  If you convince them you want to hear what they have to say, you will discover that many of them have some fascinating stories to tell.  Just remember, their age works for them in some ways and works against them in other ways.  Be patient.  Be kind.

Thanks to Audra Gray, past activity director of Dominion Village of Chesapeake, for her assistance in compiling this list.

Special Skills

Many tasks that you will be asked to do as a volunteer will not require special education or training.  In some cases, though, you may feel hesitant or find yourself struggling over a certain job or responsibility for which you consider yourself inadequate.  Usually, the activity director will be able to provide training in these situations.  Your pastor or a more experienced volunteer may be able to help.  Please do not hesitate to seek out such instruction.  Of course, you are always welcome to call Christian Concourse (757- 714-3133) for ideas and information!  For even more independent, in-depth guidance, go to your local library.  There, you will find books that provide tried and true advice in caregiving and other issues related to the elderly and infirm population.  Naturally, you can do a search online, or check the resources and materials we refer to in the section at the end of this handbook, “More Info On Nursing Home Ministry”.


More Hints for the Volunteer

When You Meet a Person with a Disability

(Prepared by the Mayor’s Committee for Persons With Disabilities, City of Portsmouth, Virginia. Used by permission.)

Offering assistance to someone is only polite behavior. Giving help before it is accepted is rude.  Ask how to help.  The person with a disability will instruct you.

Offer help but wait until it is accepted before you give it. It is appropriate to offer to shake hands.  People with limited hand use or who wear an artificial limb can usually shake hands (shaking hands with the left hand is an acceptable greeting).

Accept the fact that a disability exists.  Not acknowledging a disability is similar to ignoring someone’s sex or height.  On the other hand, it would be inappropriate to ask personal questions.

Talk directly to a person with a disability, not to someone accompanying them.  Address people who have disabilities by their first names only when extending that same familiarity to all others present.  (Never patronize people who use wheelchairs by patting them on the head or shoulder.)  To ignore a person’s existence in a group is insensitive, and it is rude for two people to discuss a third person who is also present.

Don’t park your car in a handicapped parking space.  These spaces are reserved out of necessity, not convenience.  Some people with a disability cannot walk distances; others need extra space in order to get wheelchairs in and out of the car.

Treat a person with a disability as healthy.  A person with a functional limitation is not sick.

Listen attentively when you’re talking with a person who has a speech impairment.  Be patient and wait for the person to finish, rather than correcting or speaking for the person.  If necessary, ask short questions that require short answers, a nod, or a shake of the head.  Never pretend to understand if you are having difficulty doing so.  Instead, repeat what you have understood and allow the person to respond.  The response will clue you in and guide your understanding.  Consider that the individual may have a disability which affects social or motor skills.

Don’t exclude or excuse a person with a disability from participating because of their disability.  Let the individual make that decision.


Hearing Impairment

When you meet a person with a hearing impairment, speak directly in front of them, clearly and distinctly, don’t exaggerate.  Use normal speed unless asked to slow down.

Provide a clear view of your mouth. Waving your hands or holding something in front of your lips, thus hiding them, makes lip reading impossible.

Lip reading is at best an educated guess.  Expect a person with a hearing impairment to ask to have information repeated.  He/she will often repeat the information back to you for verification.

Use a normal tone unless you are asked to raise your voice.  Shouting will be of no help and may distort the sound for a person wearing hearing aids.

Speak expressively.  Persons with hearing impairments cannot hear subtle changes in tone which indicate sarcasm or seriousness.  They rely on your facial expression, gestures, and body movements to understand you.

Some have the impression that the inability to hear implies inability to speak.  Not so!  Persons who have lost their hearing as adults will speak normally, although their voices may be harsh.  Persons who have been taught to speak without having heard their own voices may be difficult to understand.  If you are having a tough time understanding someone with a hearing impairment, ask them to repeat themselves.  If that doesn’t help, use pen and paper.  Communicating is your goal.

If a person with a hearing impairment is with an interpreter, speak directly to the person with a hearing impairment, not the interpreter.

Persons who were born with a hearing impairment think in pictures, not words. Speak in simple sentences, avoid abstract concepts.

Visual Impairment

When you meet a person with a visual impairment, offer help, but wait until it is accepted before you give it.  Always identify yourself and others who may be with you.  When conversing in a group, remember to identify the person to whom you are speaking.  If you are not sure exactly what to do, ask the person to instruct you.

To guide a person with a visual impairment, let them take your arm.  Don’t grab an arm and try to steer.  The person with a visual impairment will walk about half a step behind you, following your body motions.  If you encounter steps, curbs, or other obstacles, identify them. In narrow places, bring your arms back and let the person follow you.

When talking to a person with a visual impairment, speak directly to them using a normal tone and speed of voice.  Blindness does not affect hearing and intelligence.

When you are leaving a person with a visual impairment, say so.  Anyone would feel foolish talking to thin air.  If you get someone to help the person with a visual impairment, introduce the helper so they can become acquainted.

Don’t avoid using words like blind, look or see.  People with visual impairments use them too.

When giving directions to a person with a visual impairment, be clear and specific.  Make sure to point out obstacles in the direct path of travel.

When guiding a person with a visual impairment to a chair, simply guide their hand to the back of the chair and tell him/her if the chair has arms.

Resist the temptation to pet working guide dogs.  They have been trained to work with persons who have a visual impairment, hearing impairment and mobility impairment.  If a dog is distracted, its owner can be in danger.

In a restaurant, people with visual impairments usually have no trouble with ordinary table skills.  They may need help with ordering from the menu and with placement of utensils and food.

Ninety percent of the persons with a legal visual impairment have some vision.  They can see a great deal if you will help them locate the object you are discussing.  They will need help with color, line, and fine details.

When giving a description of something, if anything is touchable, say so.  Touching will enhance the person’s understanding of your description.

When You Meet a Person Who Uses a Wheelchair

Do not automatically hold on to a person’s wheelchair.  It is part of the person’s body space.

Offer assistance, but do not insist.  If a person needs help, he/she will accept your offer and tell you what to do.

Talk directly to the person using the wheelchair.  Never talk to a third party.  A person in a wheelchair is not helpless or unable to talk.

Be alert to the existence of architectural barriers.  These would be steps, curbs, narrow or heavy doors, high counters or displays, and bathrooms not equipped for persons with disabilities.

If the conversation is lengthy, sit down.  It is uncomfortable for a seated person to look upward for a long period of time.

Do not attempt to lift a person in a wheelchair without his/her permission.  Tilt the front wheels up and roll the wheelchair backwards up the steps and forward down steps.  Be sure to have someone in the front or in back to steady the wheelchair.

Mental Impairment – Dementia

Adapted from material compiled by Marci Stocks and made available in the past on the web. Her contact information is no longer available.  Thank you Ms. Stocks!

Dementia is a generic term referring to the emotional and cognitive disorders caused by mental and physical infirmity.  Aging is not a direct cause of, and does not necessarily result in, dementia.  Dementia is the result of a disease of one kind or another.  Also, the symptoms of dementia can result from over-medication, chronic lack of stimulation in daily life, or chronic over-stimulation.

Behaviors Associated With Dementia

Wandering

Wandering can occur for many reasons.  A resident suffering from dementia may be searching for something or for someone.  Unfortunately, in cases where they cannot communicate with words, it may be difficult to find out exactly why they are wandering.  Obviously, due to the dementia, they may not know why they are wandering themselves.  If wandering is a real danger, the care facility will take measures to make the living area secure.  It is important for you to respect these protected boundaries.  Always communicate first with facility staff when transporting a demented resident outside secured doors.  Safe guarding a nursing home is different from one facility to the next simply because layouts are different, so, ask questions and stay informed of the measures taken by the facility where you volunteer.

Anger/Frustration

Anger and frustration can occur for many reasons.  A demented resident may be angry because they cannot remember or because they cannot do certain activities anymore.  They may even take this anger out on you.  Do not take it personally.  Be understanding and listen to their feelings.  The resident is probably just as frustrated as you.

Hallucinations/Delusions

Due to dementia, a resident may see people or objects that you do not see.  You may find them staring into space.  To you, no one is there; to them, someone is there.  Ask them what they see or hear.  They may be remembering the past, “seeing” a deceased loved one, or looking at an animal that isn’t in the home.  Reminiscing can be very helpful, so this may be an excellent time to steer the conversation toward the resident’s childhood or more youthful times that stand out in their memories.

Depression

Depression occurs for many reasons, many of which you, as a volunteer, cannot control and may not understand.  Be patient and peaceful and loving.  When you are in a facility for a while and you get to know some of the residents for a longer length of time, you may notice that they aren’t as involved with activities as before or they might begin withdrawing from you.  Again, just be loving and available as God gives you strength.

Paranoia/Suspicions

This can be extremely difficult for a caregiver or volunteer.  Often, the resident will accuse you, the caregiver, of stealing even when they misplaced an item. Look for the item with them.  Be prepared that they may still accuse you.  Patiently repeat your statement.

Refusal to bathe

No one wants to be dependent.  Depending on someone to help you bathe may be embarrassing.  It is better not to push the resident suffering dementia.  If possible, let them wash by themselves while the caregiver discreetly provides assistance when needed.

Sundowner’s Syndrome

Sundowner’s Syndrome occurs at night.  This happens when a resident is restless and after “sundown” they are up.  They will have problems falling asleep and will be up and about during the night.  Wandering is frequent.

Repeat actions

Repeating actions and sentences is very common in Alzheimer’s disease and other causes of dementia.  It can happen for many reasons.  A resident may have forgotten what activity they were doing before being interrupted or they may have forgotten what they just said.  Also, they may feel that you are not listening and think it is necessary to repeat themselves.

Inventing new words

Sometimes a resident with dementia will forget a word and create their own.  Some caregivers and volunteers simply learn the new words, so they will know what their friend is trying to say.  Others correct the word.  Use your best judgment.

Sometimes a resident with dementia will forget a word and create their own.  Some caregivers and volunteers simply learn the new words, so they will know what their friend is trying to say.  Others correct the word.  Use your best judgment.

Using curse words

This may be difficult to correct, especially if the resident is inclined to violence.  Some caregivers ignore the words, as with children.  If no one responds to them, they may not curse anymore.  Some caregivers will try to change the direction the language is taking.  Be sensitive to the resident and be a peace maker.

Language disturbances

Brain functions slow down with dementia, especially Alzheimer’s Disease.  A resident may slur words together or may have a tremble in their voice.  They may even whisper words. If this happens, repeat what you think is being said.  Don’t be afraid to ask the resident to repeat themselves.

Do NOT Diagnose Dementia

Please Note: We all lose things, we all forget names, we all become lazy when it comes to self care at one time or another.  Therefore, be careful not to try your hand at diagnosing dementia.  Let the professionals do that.  As for memory, we often hear “But she remembers dates and things from 50 years ago…  She remembers the names of her teachers and her first pet.”  With dementia, it is not uncommon for the person to have a very active long-term memory while short term memory is lost.

Reminiscing

Reminiscing is fantastic with an elderly person, even with dementia.  People, in general, love to talk about their past.  If you try this, it is not uncommon for names and places to be made up.  A person might keep talking about their dog.  Later, you find out that they never had a dog.  But, they are so happy to just talk and in their mind they really had a dog.  So, listen, nod your head, be interested.  The resident feels happy talking about their past and you feel happy because the resident is happy.  As mentioned in this section earlier, this is known as Validation Therapy.  However, if the resident becomes agitated, change the subject until a later date. With dementia, moods can change in an instant.