GeropsychiatricNursing Consultation: A ValuableResource in Rural LongTerm Care Marianne Smith, Susan Mitchell, Kathleen C. Buckwalter, and Linda Garand zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIH Psychiatric and geropsychiatric nurse specialists have the potential to positively influence the day-to-day care provided in rural nursing homes by acting as teachers, resource persons, facilitators, and role models to long-term care (LTC) zyxwvutsrqponmlkjihgfedcbaZYXW personnel. The combined approachof trainingLX nurses to train their own staff while supporting the application of learning with consultee-focused nursing consultation proved to be an effective and time-efficient method of improvingthe geropsychlatricnursing care providedin ruralnursing homes. Copyright 0 1994 b& W.B. Saunders Company zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGF lem that is not the responsibility of the LTC staff, MANY AS 75% of all residents in longbut as a psychiatric problem that demands a psyterm care (LTC) settings suffer from some chiatrist’s attention. sort of mental disorder (Bums, 1985; Rovner & Although many LTC residents may benefit from Rabins, 1985; Roybal, 1984), with depression and the services of a psychiatrist or other mental health dementia being the two most common disorders. professional, such assistance is often difficult to In fact, the prevalence of mental illness and beaccess, particularly in rural areas. Sparsely popuhavioral disorders has led some to describe today’s lated and geographically remote communities innursing homes as “modem psychiatric ghettos” creasingly struggle to maintain adequate general for the elderly (Liptzin, 1986; Moss & Halamanhealth care services for individuals of all ages, let dariz, 1977). Unfortunately, the behavioral probalone specialized services such as psychiatry and lems associated with mental illness, or threats to geriatrics. This article provides a brief overview of mental health, are typically not well understood, the challenges confronting rural LTC facilities and tolerated, or effectively managed by staff in longdescribes a model of service delivery in which gerterm care (LTC) settings. In too many cases, menopsychiatric nurses may indirectly exert a positive tal problems are “written off’ ’ as a normal and influence on the day-to-day mental health nursing unavoidable part of growing old (Harper, 1986), care provided in geographically remote facilities. perceived as unnecessary and controllable behavThe merits of consultee-focused geropsychiatric ior that is manipulative and attention-seeking nursing consultation as a vehicle for moving class(McLeod & Schwartz, 1992), or viewed as a prob- zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDC room learning into care practice routines is illustrated with case vignettes. A S From the Abbe Center for Community Mental Health, Cedar Rapids; and the Omce of Consultation and ReCHALLENGES CONFRONTING RURAL FACILITIES search in Medical Education, University of Iowa, Iowa City, l/ I In addition to the difficulties encountered by Supported by grant No. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA DlONUZ7118-01, Division of their urban counterparts (e.g., inadequate reimNursing, Bureau of Health Professions. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA bursement rates, staff turnover, demands of caring Addre ss reprint requests to Marianne Smith, MS, RN, The Abbe Centerfor Community Mental Health 520 11W for sicker and more dependent residents), many St N.W., CedarRapids,IA 52405. rural nursing homes face additional challenges that Copyright 0 1994by WB. Saunders Company impinge on the quality of mental health care they 0&33-9417l94~0804-ooo8$3.00oola 272 Archives of PsychiatricNursing, Vo l. VIII, No . 4 (Aug ust), 1994: pp. 272- 279 CONSULTATION IN RURAL LTC 273 their own survival, tend to view the mental health may provide. Although a variety of socioecoproblems of older adults as the domain of the aging nomic, economic, and cultural issues are influenservice system. Their observation that “elderly tial, three primary barriers to accessing mental won’t use mental health services” is too often used health services are discussed briefly here: the lack as a justification for not providing appropriate serof qualified mental health professionals, lack of vices (Rathbone-McCuan, 1992), rather than as an cooperation between aging and mental health serincentive to develop creative, cooperative ventures vice delivery systems, and geographic distance to between aging and mental health agencies. services. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA At the same time, area agencies on aging Lack oj’ Professionals (AAAs) distance themselves from the mental health care problems of the elderly, fearing that The overall lack of trained mental health professuch an alliance would draw them into the “realm sionals in rural communities is a matter that affects of politically charged and stigmatized psychiatric both the availability of services and the quality of care” (Rathbone-McCuan, 1992, p. 88) and thus care provided to rural elderly. The scarcity of hureduce the effectiveness of other programs they man resources in rural settings often demands trisupport (e.g.. outreach, home health, day care. age of patients based on their rehabilitative potenhealth assessments). These conditions reduce the tial: children and adolescents typically receive likelihood that service delivery systems will be depsychotherapy whereas adults are treated with criveloped and may, in fact, impede creative solusis intervention and brief therapies (Buckwalter, tions needed to serve rural elderly (RathboneSmith, & Caston, 1994). Many rural community McCuan, 1992). mental health centers do not provide any type of specialized service to older adults and only marGeographic Distance ginally serve elderly via traditional services (WeA third issue unique to rural LTC facilities is the ber, 1990). Services provided on site in nursing geographical distance to access health and mental homes, although clearly beneficial to residents and health services, a matter that is becoming increasstaff alike (Boorson, Liptzin, Nininger, & Rabins, ingly acute in rural America. The financial crises 1987; Rabins, Storer, & Lawrence, 1992), are typfacing many rural hospitals and health centers, ically impractical in rural settings where the volwhere rural elderly traditionally receive their menume of professional time spent traveling must be tal health care, have resulted in fewer providers considered in terms of cost-effectiveness of service and greater distances to receive services (Beaulieu, delivery. 1992). The long distance to services is frequently Even when psychiatric nurses and social workcompounded by bad weather, lack of public transers are available to provide mental health services portation, and inadequate road conditions (Coward to the elderly, the dearth of psychiatrists in rural & Cutler, 1989), which further reduces the likelicommunities often obstructs third party reimbursehood that frail elderly nursing home residents will ment. Coupled with lower Medicare reimbursereceive services. ment to physicians and rural health clinics as compared with urban ones (Patton, 1989), the lack of Thus, observed and projected deficits in mental professional mental health services provided to ruhealth care may be most acutely felt in rural nursral LTC facilities is an understandable response. ing homes. Facilities in remote rural areas, no matUnfortunately, the list of reality-based disincenter how well intentioned, often struggle to find tives to develop and provide professional services appropriate evaluation, treatment, and supportive to rural nursing homes usually overwhelms even services for their mentally ill residents. Likewise, motivated mental health providers. even the most motivated and caring mental health provider is challenged to provide needed assistance Aging Versus M ental Health Sy stems in light of the current climate of care. As a result, The lack of appropriate mental health services creative, collaborative, practical approaches are for aging individuals in rural communities is furneeded to counteract the deficit of ongoing, on-site ther aggravated by the question of ownership of assistance to nursing home residents and personnel by qualified mental health professionals. aging individuals’ problems. Mental health providGeropsychiatric and psychiatric nurses may posers, many of whom are necessarily focused on 274 SMITH ET AL. itively influence the day-to-day mental health care provided in even the most rural LTC facilities by using technology, training, and consultee-centered consultation. By improving the knowledge and skills of the frontline staff, many behavior management problems may be avoided or minimized. Thus, the demand for outside professional assistance may be reduced while the therapeutic climate and quality of care provided to residents within the facility is improved. PROJECT OVERVIEW The strategies described here were implemented and evaluated as part of a statewide geriatric mental health training project designed to increase the ability of nurses and nursing personnel in rural LTC facilities to provide quality mental health nursing care to their residents with psychiatric and behavioral problems. The 3-year, three phase project used a train-the-trainer model combined with consultee-centered nursing consultation in the effort to improve patient care. The dual approach of providing concrete information (via training) while supporting, assisting, and encouraging nursing leadership in the development and implementation of mental health interventions within the LTC facility (via consultation) was found to be an effective strategy for improving the quality of care provided in rural facilities. lmportantly, both foci used indirect methods of changing the attitudes, beliefs, and behaviors of nursing personnel. That is, geropsychiatric clinical nurse specialists (GSCNS) sought to change mental health care practices while minimizing their physical presence in the facilities. Instead of providing on-site training or patient assessment services, which are accompanied by all of the inherent difficulties described in the previous section, assistance was provided indirectly. By using telephone and telecommunication systems to train trainers and providing nursing consultation that focused on the problems, perceptions, and experiences of the nurse consultee (thus avoiding the need to travel to evaluate patients), project staff were able to provide highly specialized assistance to a large number of geographically remote facilities. The two main thrusts, training trainers and consultee-centered geropsychiatric nursing consultation, are described briefly in the following paragraphs. TRAIN-THE-TRAINER MODEL The train-the-trainer approach was used to overcome problems associated with limited professional time and geographic distance. In this project 200 registered nurses and directors of nursing representing 99 LTC facilities were trained in three separate 2-day Intensive Training Sessions (ITS) conducted by project staff. Training was provided in person during the first phase of training (provided locally) and via two-way interactive telecommunication systems in the second and third phases (regional and statewide training respectively). As part of the ITS, LTC nurses were provided detailed program materials on six separate topics (i.e., overview of behavioral problems and staff roles, communication issues, acting out and aggressive behavior, depression, dementia, control and power issues). In turn, these LTC nurses were asked to teach six in-service education programs for additional staff in their own facilities using the program materials provided at the ITS. Thus, the investment of 48 hours of training conducted by GPCNSs resulted in the provision of over 450 hours of in-service education on mental health topics that reached over 1,600 nursing personnel across the state. The most obvious benefit of the approach was the ability to reach facilities that would otherwise be geographically inaccessible to the project staff. Likewise, the pyramid effect created by training trainers resulted in large numbers of staff being trained with only a modest investment of training time on the part of the GPCNSs. Training time discussed here addresses only the time spent actually training LTC nurses. In this project, additional time (6 months to develop six program modules and the ITS format) was spent developing program materials for the nurse trainers to use as they trained their own staff. Project staff also viewed training trainers as a means to nurture new roles among the LTC nurse trainers. That is, LTC nurse trainers were encouraged to act as resource persons, facilitators, advocates, and leaders in the implementation of mental health nursing interventions in their respective facilities. The importance of these additional roles was reinforced during the ITS, promoted within the program materials, and encouraged via the consultation process. For example, each module contained instruc- CONSULTATION IN RURAL LTC 275 ity to manage the resident’s “manipulative, backstabbing, and sexually inappropriate behaviors. ” The initial telephone conversation showed that the resident, Mrs. Green, was admitted to the facility 4 months earlier because of urological difficulties that required intermittent catheterization. Although a long list of physical maladies were noted in her history, she was taking minimal medication (antibiotics, vitamins, and stool softeners) and was described by staff as being ambulatory and capable of self-care activities. Mrs. Green was described by her physician as mildly depressed following the death of her husband 6 months ago but had no other psychiatric diagnosis recorded in her chart. However, family history showed that she was estranged from her daughter June who described her mother as demanding, overly dependent, and “always sick” although June suspected CONSULTEE-CENTER CONSULTATION that much of the illness was “in her [mother’s] head.” When contacted by the facility for guidThe provision of consultee-centered (Caplan, ance regarding Mrs. Green’s behavior, June re1970) geropsychiatric nursing consultation as an sponded that the manipulative, overly dependent, adjunct to training was considered of paramount helpless, and back-stabbing behavior was typical importance in this project. That is, the consultee’s of her mother. June reported having little contact perception of the problem, whether regarding reswith her mother since going to college, “to mainident care or execution of the training programs, tain her own mental health,” and predicted that was the focus of the nursing consultation. In connothing would probably change her mother’s betrast to a client-centered model, in which the conhavior. sultant directly evaluates residents, provides therapy , and/or makes treatment recommendations, The LTC nurse trainer asked that the GPCNS assess and treat the resident and provide nursing consultants engaged consultees in a process of description, discussion, and problem-solving that care recommendations to staff, a request that was placed them in a position of authority about the in keeping with the client-centered nursing consulnature of the problem and possible methods to retation provided before the current project. Instead, solve it. Thus, the GPCNS consultant acted as a the consultant asked the LTC nurse trainer to first facilitator, information source, teacher, and role do the following things: (1) verify the absence of model to the LTC nurse trainer and her staff. Conpsychiatric history with Mrs. Green, June, and the sultation was provided primarily by telephone with attending primary care physician; (2) assess the occasional on-site visits made as needed. Over the resident’s cognitive status using the Mini Mental 3-year project, 17 on-site consultations and 127 State Exam (described in the dementia module and telephone contacts were made. The following case taught at the ITS) to rule out an organic cause for descriptions illustrate how training and consultathe perceived manipulative behavior; (3) teach the tion were combined to enhance day-to-day mental program “Acting Up and Acting Out: Assessing health nursing care practices. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA and Managing Aggressive and Acting Out Behaviors” (which was part of the training series) to staff Case 1: M rs. Green who were most effected by Mrs. Green’s behavior, applying the program concepts to Mrs. Green dur“Staff are at the end of their coping rope,” ing the in-service program; and then (4) convene a noted the nurse trainer from the nursing home, nursing consultation meeting to discuss and plan “This resident is driving us all crazy.” The comMrs. Green’s care. plaint, a common one among LTC providers, was The “Acting Up and Acting Out” in-service followed by the observation that the facility was program introduced staff to the antecedentconsidering discharge because of their lack of abiltors’ notes that recommended specific activities to personalize the program content to that facility’s resident population and staff, such as searching out real-life care challenges and actually trying recommended interventions before teaching the program, to improve illustration. Notes within the lecturer’s script cued the nurse trainer to stop, discuss, illustrate and/or role-play with staff. As liaison to the geropsychiatric nurse specialist, the nurse trainer was placed in a position of authority in terms of initiating requests for additional outside assistance to resolve or reduce behavior management problems and communicating the information gained with staff. In short, every effort was made to enhance the image of the LTC nurse trainer, and her staff, as capable providers of basic geriatric mental health nursing care. 276 behavior-consequence (ABC) approach to behavior management. Thus, nursing personnel were challenged to think about Mrs. Green’s problem behaviors individually and to consider both antecedents and consequences that might be changed. Staff were asked to write down specific information on the program handouts regarding Mrs. Green and then to bring that information with them to the nursing consultation meeting. The focus of the consultation, then, was to assist staff to (1) prioritize problems; (2) brainstorm about possible changes in nursing care practice to reduce negative behaviors; (3) develop a specific care plan; (4) anticipate the resident’s reaction to and possible resistance of this plan of care; and (5) role-play possible staff responses to behavior that was upsetting and frustrating. Although staff were anxious to have the GPCNS consultant meet and assess Mrs. Green so that she could really understand what they had been going through, the consultant deferred, saying “What I think of the resident really isn’t as important as what you think about the resident. You know the resident much better than I will after a brief visit. Even if I spend an hour a week with Mrs. Green, you’ll still have to spend 24 hours a day, 7 days a week managing her care. So tell me what you know about her, what happens here that upsets you, and what you’ve already tried. And then let’s think about how you might do things differently, or just think differently about Mrs. Green, to get along better.” Although initially puzzled by this approach, staff soon warmed to the idea that their understanding of the problem was the consultant’s primary concern. Using the ABC concepts and handouts, the GPCNS facilitated discussion and problem-solving by questioning, redirecting, and challenging staff to explore Mrs. Green’s behavior (historically and currently) and to examine their own feelings and reactions to her. The problem list, which was lengthy, was prioritized and issues of safety (smoking in her room) and infringement of other residents’ rights (public nudity) were targeted for immediate interventions. The process of setting limits in these two areas, including the development of reasonable and practical consequences when the behavior occurred, was discussed, roleplayed, and recorded in the care plan. Staff responsibilities, in terms of patient care and communication with other nursing personnel, family, visitors SMITH ET AL. and administration, were established to improve consistency and continuity of care. A time frame for evaluation of the care plan was decided on including a follow-up staff planning meeting. After much discussion, staff concluded that they needed more accurate information about Mrs. Green’s real-life abilities and limitations to guide their thinking and care practices. As a result, they decided to request a comprehensive work-up at the nearby university-based geriatric assessment clinic. The consultation visit, which lasted 90 minutes, focused exclusively on the staffs’ knowledge, understanding, and perception of the identified resident. The consultant, who came into the meeting cold, (i.e., without having assessed the patient or read the chart) relied entirely on the staffs’ observations, experiences, and knowledge of the resident. The earlier request for the nurse trainer to search out psychiatric history and possible organicity (both of which were negative), combined with information accumulated during the inservice program, provided staff and the consultant with a solid base of information from which to work. By acting as a facilitator, resource person, and role-model, the GPCNS championed the staffs’ ability to understand and manage the problem behaviors Mrs. Green exhibited. The resulting plan of action relied on the skill, ability, and commitment of direct service staff rather than on interventions provided periodically by a mental health professional. Although the GPCNS provided intermittent telephone consultation regarding Mrs. Green’s progress and additional interventions, no further on-site visits were needed to sustain and expand the plan of care. Over a 6-month period of time, the nurse trainer reported that Mrs. Green and the staff came to an understanding of acceptable and unacceptable behaviors. Mrs. Green abandoned many of the attention-seeking behaviors that previously upset and frustrated staff. Simultaneously, staff exhibited increased tolerance, caring, and compassion toward Mrs. Green and other so-called manipulative residents. zyxwvutsrqponmlk Case 2: M r. Brown “He’s so restless and confused. Half of the time staff are afraid zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPO for him, and the other half of the time they’re afraid of him!” noted the nurse trainer. “We don’t know where to begin!” The request for assistance came long distance from a CONSULTATION 277 IN RURAL LTC nurse trained during the telecommunication program provided to facilities across the state in the third year of the project. Because the facility was over 3 hours away, making an on-site visit impractical, the nurse trainer and consultant explored the resident’s behavior, staff reactions, and possible solutions over the telephone. The initial telephone consultation showed that the resident, Mr. Brown, was a spry 75year-old who was described as very agitated and restless. persistently wanting to “visit his father” or “go home,” and wandering throughout the building and sometimes outside as he attempted to escape “these jailers” (staff) who had “locked him up.” He had a diagnosis of “probable Alzheimer’s Disease” after a comprehensive work-up nearly 3 years earlier. Before his admission a month ago, Mr. Brown lived alone in his long-time family home with minimal supervision by his neighbor and had no family nearby. Recent safety issues necessitated admission to the small rural nursing home. Although the two educational programs most relevant to this resident (i.e., on dementia and assessing and managing aggressive and acting out behavior) had been taught earlier, the consultant suggested that the nurse trainer offer a special refresher course focusing specifically on Mr. Brown’s care plan. To assist the nurse trainer in conducting this session, the consultant offered the following suggestions: (1) review both programs in depth, thinking only about Mr. Brown, his history, long-standing behavior, current behavior, and possible antecedents and consequences that might be influential in his presentation; (2) photocopy specific handouts to use as worksheets during the program (i.e., “Assessment: Checking It Out”; “Interventions: Management & Care Planning” (in dementia); “Interventions: Reality vs. Validation”; and “Interventions: Managing Delusions & Hallucinations”); (3) talk to staff and make a preliminary problem list for Mr. Brown; and (4) invite key staff from all three shifts to participate in the special session. Before the meeting, the consultant and nurse trainer visited by telephone to review the information. The telephone consultation (which lasted 60 minutes) focused on the nurse trainer’s perception of Mr. Brown, the staff, and the proposed care planning session. The consultant clarified and expanded on the nurse trainer’s understanding of the program concepts as needed and offered additional suggestions, illustrations, and anticipatory guidance about process-oriented matters. The importance of clarifying, rephrasing, redirecting, focusing, and listening (taught during the ITS) were again reviewed. Finally, the nurse trainer was asked to predict potential pitfalls in the proposed refresher course/care planning session. In response, the nurse trainer expressed concern about staff reactions to the use of validation principles (Feil, 1982). Although enthusiastic about the use of validation herself, the nurse trainer (who also happened to be the director of nursing) anticipated that use of this approach with Mr. Brown would be a “hot” topic among staff. During the dementia program (which recommends validation to reduce “you’re wrong” messages in the environment and thus increases comfort), some staff expressed resistance saying that it “was lying to the resident” and that they didn’t “approve.” As a result, the conversation turned to the nurse trainer’s dual role as the geriatric mental health trainer (e.g., role model. facilitator, advocate, and leader in planning and executing mental health care plans) and director of nursing (e.g., policy-setter. supervisor, facilitator. and potential disciplinarian of staff). Possible responses to staff questions, concerns. or conflicts within the work group and after the meeting were explored, focusing on methods to increase compliance and reduce resistance. A very brief third telephone consultation occurred approximately a month later when the nurse trainer called to report the staffs’ new success in managing Mr. Brown. The nurse trainer reported that the refresher course/care planning meeting, although heated at times, resulted in improved communication and cooperation between staff. and consensus on care strategies for Mr. Brown, By manipulating both the physical and personal environment, including the use of validation to reduce Mr. Brown’s frustration, staff had been successful in increasing both his and their comfort level. No further assistance was required. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQP Consultation Survey Results In addition to anecdotal notes maintained by GPCNSs, the value of nursing consultation was also supported by results of a survey conducted as part of the overall evaluation (Smith, Mitchell, Buckwalter, & Garand. 1994). Surveys were re- 278 SMITH ET AL. turned by 63% of the evaluation facilities (N = 57). In brief, nearly all respondents agreed that the consultant understood their problem well (86%), offered them realistic solutions (81%), and that they valued the consultation overall (97%). The majority observed that the consultation helped staff understand the resident and/or manage the difficult behavior (95%). All agreed that they would use the service again. DISCUSSION AND SUMMARY The need for mental health professionals to assess and treat mentally ill residents in rural nursing homes is a current challenge that will only increase with the passage of time. Although the combined approach of training and consultee-centered nursing consultation cannot completely ameliorate the need for direct professional interventions, this service-delivery approach may reduce the demand for assistance with behavioral problems that nursing home staff may effectively manage themselves. Several factors are believed to be critical to the successful implementation of such a model. First, LTC staff must receive sound geriatric mental health training that focuses on the practical aspects of mental health assessment and intervention. Programs must be written in understandable language that nursing assistants can easily understand, avoiding common psychiatric jargon, and focusing on the real-life concerns of the staff. Second, the psychiatric nurse specialist must aggressively advertise the availability of consultation services, explaining nursing consultation in general and consultee-centered consultation in specific, to maximize the benefits of these services to clients. Third, clear criteria are needed to determine when consultee-focused consultation is, in fact, the most effective approach to resolving the problem. In this model, GPCNS consultants required that consultees had taught (or plan to teach) the six core geriatric mental health training programs; had reviewed the chart and talked with staff to determine possible causes (psychiatric or physical) of the observed problem behavior; and were willing to have the resident assessed by a mental health professional if a diagnostic evaluation and/or professional interventions were needed. Finally, the model relies almost exclusively on the motivation of the LTC facility staff and particularly on nursing leaders within those facilities. Without the clear commitment of nurse trainers in this project, little could have been accomplished. In conclusion, the dual approach of providing necessary information via training and promoting the application of that knowledge through consultee-centered consultation may be an effective strategy for changing day-to-day mental health nursing interventions in rural LTC facilities. 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