In the nursing home, I often felt, as the head OT, I was expected to be not only a therapist but also a miracle worker.
The swelling in the resident’s legs won’t go down - refer them to therapy, they can fix it.
The resident is suffering from vertigo - refer them to therapy, they can fix it.
The resident is incontinent - refer them to therapy, they can fix it.
The resident has developed a wound - refer them to therapy, they can fix it.
The resident is sliding out of a chair - refer them to therapy, they can fix it.
Of course we are HAPPY to get those referrals, and, yes, we do have MANY treatment techniques that can be used for a multitude of disorders. However, we have to realize that not every treatment works for every resident. We simply try techniques that have been proven to work in the past and hope they continue to work with that resident as well.
But the pressure to “fix” everything is very overwhelming, wouldn’t you agree? With that pressure, I felt like I had to keep trying until I DID fix it and felt as if I let the resident and facility down if I “failed.” It took me years to realize not everything can be fixed.
There are a variety of reasons why a seating system may not work. Often times we have to search for an alternative due to the following factors:
Elderly residents: We are working solely with the geriatric resident that has significant skeletal, skin, cognitive and musculature changes. We often times try to fit them into a low end, off-the-shelf chair, wheelchair cushion or wheelchair back support that will not meet the needs of a degenerating body. We need higher end, more expensive products that will protect the resident from further deterioration and prevent wound development. However, convincing the facility of that need is not always easy.
Resistance to new equipment: Resident, family, and/or facility may be resistant to new equipment no matter how appropriate or beneficial it is for the resident. How many times have you heard, “Mother has always had the donut cushion. Why does she need that new one?” The family doesn’t understand how that low end cushion is not appropriate for her now stage IV wound and continual sliding out of the chair! Frustrating, right?
We have to be sensitive to the resident’s perception. We need to understand that this is a generation set in their ways and it is hard for them to accept that some “young” therapist might know what is best for them. In the end, the resident’s wishes need to be respected, whether it is what is best for them health wise.
Budget limitations: Finances just won’t allow you to purchase a piece of equipment that you are 100% confident will benefit the resident’s needs. We have to work within a budget given to us by the nursing home and sometimes we can’t afford the BEST equipment choice! Sometimes we HAVE to settle for second best.
Difficulty in carryover after discharge from therapy: Multiple caregivers make it difficult for appropriate carryover after discharge. We know that too many hands removing or adjusting equipment can cause damage and can even be dangerous for the resident. We have to choose options that are low maintenance and easily removed and adjusted, despite knowing that a more advanced piece of equipment is the better choice. No matter how many hours of staff education on the multiple shifts that you have provided before discharge, sometimes we have to go with “the next best option” to consider all players involved in the resident’s care.
Lack of sample equipment to trial: We are not in seating clinics with extra backs, cushions, and accessories to trial in order to find the best option for our residents. Many times the equipment available to us is old, worn out, and at best may “kind of” simulate what we are trying to achieve with the equipment. Lack of trial equipment to prove effectiveness of a product makes it difficult to justify the purchase of that expensive cushion, back, or accessory.
Please, please remember that we cannot fix everything. We may have to choose what is best within the parameters we are given, and that is okay. You may have spent hours putting a patient in the “perfect” seating system to then have to turn around and place him or her in the “next best thing” for any or all of the above reasons.
As long as you document that you have positioned a patient in a seating system you clinically know is the best for him or her under the circumstances and will not cause harm, then you can discharge with the peace of mind that you have done your job!
Ana Endsjo, MOTR/L, CLT
Clinical Education Manager LTC Division
Ana Endsjo has worked as an occupational therapist since 2001 in a variety of treatment settings. She has mainly worked with the geriatric population, dedicated to the betterment of the treatment of the elderly in LTC centers. Her focus has been on seating and positioning and contracture management of the nursing home resident. With this experience, her hope is to guide other therapists, rehab directors, nurses, and administrators through educational guides, blogs, webinars, and live courses in her role as Clinical Education Manager for the long term care division.