When the call lights are on constantly

In a nursing home, there are many psychological issues at play, for both the staff and the residents. I find that the certified nursing assistants (CNA’s) frequently try to use behavior modification techniques with the most difficult and confused people almost like you would for a difficult child. I’ll admit that that’s what it feels like, dealing with confused people, but I tell them there’s one important difference: residents with dementia can’t learn. If they could, there’d be a therapy that would allow them to return home. Usually the comment goes along the lines of, “they have to learn we can’t come right away”, or “She has to learn not to turn her light on all the time”. I try to get the aids to understand that if the residents could learn, they wouldn’t be there and in need of care and the aids need to learn to deal with them on their terms, not the aids. I learned an important, counterintuitive technique during my two years at one of my first jobs. That is, that answering the lights of demanding residents immediately and every time calms them down much better than telling them that they need to wait. I guess the underlying thought of ignoring the call lights is to teach them that it’s useless to put their light on so they may as well wait until they actually need something to put it on. It’s a horrifying thought when you put it into words. I got to thinking, though, one night that maybe the opposite is true. We had a nice old gentleman I’ll call Miguel Santos. Miguel was mostly stiffened up with arthritis, but he could do a lot for himself, tippy toe in tiny steps to the bathroom and back, into his wheelchair and get himself dressed with minimal help. He seldom put his light on during the night shifts that I worked. One morning, he put his light on and asked for help, saying he couldn’t get himself up. That was a change of condition and my aid alerted me. At first, he insisted that nothing was wrong with him, he just didn’t feel good and wanted help. I asked detailed questions such as does your feet hurt? (vital signs were ok). Pressed, he admitted his head hurt. An exam showed swelling on the back of his head by the neck. Miguel first denied falling then claimed he couldn’t remember. He had been mobile enough to conceivably to get himself back in bed after falling and knowing his character, I felt he might have been embarrassed to admit that. Needless to say, the incident report was thin. However, I had a patient with a head injury and a change in condition, in his mobility, so after putting ice on his head and raising the head of bed up, I called the ambulance. He was diagnosed with an epidural hematoma and kept in the hospital for a couple of days of observation. When Miguel came back, he was stable, but now he needed help for everything. Whether it was from brain damage or just fear of getting up by himself, no one could tell. But now he was on the list of full care patients. Immediately, he started to put his call light on constantly. The staff was patient with him for a while as he was well liked, but it didn’t take long for a conference gathering formed. As usual, shrill protests arose complaining at how much time Miguel was sucking up. Next came the inevitable statement that we “needed to teach him that we don’t have time to come every five minutes”. As the discussion went on my thoughts centered on what Miguel must be feeling and then I interrupted. “No,” I said. “I’ve never seen any resident that yelled or used the light a lot learn to stop. Especially by being scolded or ignored. We know that Miguel is a nice guy and would rather do for himself if he could. What if he’s just scared and is putting his light on to test us?” The CNA’s just stared at me, then one protested. “I can’t answer his light all the time. I’ll have to neglect others to do it and that’s not fair to them.” Miguel was in her assigned group. “I know that,” I reassured her. I formed a quick belief. “I think that when a resident is a demanding one, he should be everybody’s resident, not just one persons. If you’re in the hall when the light goes on, please answer it and I’ll answer it as much as I can too.” I continued to coax with further protests coming. I tried to convince them that maybe if he felt sure that someone would come when he needed them, he’d stop putting on his light. It was a tough few nights. I’ll say this about my staff, they did their best to answer Miguel’s light promptly. I’d talk to him about his new condition, telling him how sorry I was that he needed the extra help and that we’d be there for him and it was no bother. He definitely didn’t take my word for it that we’d be there (how could I be there every night?) but I think it relieved him that I understood his worry. After a few nights of constant light pushing (he’d never been much of a sleeper at night) he started to relax his button finger and give us a break. Once the aids saw that my plan had worked, they’d stop in when they had a minute, even without him pushing his call light and if he was awake, chat a few minutes, just to let him know we were thinking of him. It was hard for an independent man to give up and ask for help. But with a little responsiveness and reassurance, he made the adjustment.