Managing resident calls for help: the Shouters, the constant Call-Bell Ringers, and the Complainers don't have to be that way—you can reshape their behavior - Column

Nursing Homes, Oct, 2003 by Eleanor Feldman Barbera

Once, when I was new to a facility, I arrived on the second floor to find a resident named Paula shouting, "Nurse, nurse, nurse!" Trying to be helpful, I went to the nursing station and passed along the resident's call for assistance. They were very nice about it. The next day I returned to the floor, and again there was Paula shouting, "Nurse, nurse, nurse!" And the next day. And the day after that. Her calls had become the unit's background noise.

Paula was a Shouter.

Anyone who has spent any time in a nursing home knows what I am talking about. Every nursing home has them. When my sister and I visited my grandmother in a home, we used to get very distressed about the lady down the hall. We wondered, why don't they help her? We didn't realize that that lady was calling constantly and often. Because nursing homes are set up to respond to specific needs, there is little time to soothe existential anxiety or to grapple with longstanding psychiatric problems.

So, what can staff do about the Shouters? Fortunately, many things.

Defining Neediness

How do we determine which residents cross the threshold of normality into the area of problem behavior? I don't believe there is one specific answer. Most of the time a resident's "neediness" is subjective, and different staff members will have different reactions to it. Some staff members take the needy under their wings; others resent the needy resident as a disruption. Defining genuine need is part of the problem.

Consider the call bell. Most residents have no idea what constitutes a reasonable amount of call-bell use. There are overusers and underusers. One underuser told me that he waited in bed for 45 minutes after vomiting before anyone came in to help him clean up. I asked, "Did you use your call bell?" "No," he said, "I didn't think it was an emergency."

That was when I began offering "Call-Bell Education," to teach residents when and how to ask for help. Educating residents empowers them. If we provide them with information, they can make choices about how to handle situations and become part of the treatment team. It establishes a collaborative approach to the challenge of getting one's needs met despite a hectic environment. Once educable residents are taught, the staff can gauge when resident behavior is truly outside the normal range. If a resident knows that the average person rings the call bell 6 times a day, yet persists in ringing it 15 times a day, that resident is either having physical problems that need a higher level of attention, or needs a referral to a psychologist and/or psychiatrist.

Call-Bell Education should be done, ideally, as soon as the resident arrives at the facility, before negative patterns and expectations are established. The approach should be one of impartially disseminated information: "This is what is available to you, this is how it generally works, etc." With modifications, the strategies outlined here will work for residents with mild to moderate dementia. For residents with more severe forms of dementia, the focus will need to be on staff interventions that are outside the scope of this article.

Educating Residents

I generally provide residents with information about their rights, saying, "You're allowed to have access to your call bell all the time, you know." Sometimes a resident doesn't understand how to exercise his or her rights. In such cases, I consider it the resident's job to find ways of working with the staff. "You may be retired," I say, "but living in a nursing home is a full-time position, and you have to find ways of letting your new coworkers know what will get the job done."

I remind residents that if they are having a conflict with a particular aide, they need to use their best workplace skills to get it resolved. For example, they could make efforts to improve their working relationships, such as learning the names of their aides, or they could take their needs to an aide on another shift or, if necessary, raise their concerns with a nurse.

It's important to help residents recognize the workflow of the unit. I often point out to them that the busiest times on the unit are mealtimes and shift changes, and that they should, if possible, plan ahead to avoid these times for registering their needs. I remind people to ask for everything they need at once, rather than making numerous requests.

The bottom line is that underusers of call bells need to be encouraged to speak up, so that problems won't fail to be identified until they have become difficult to treat (for example, skin sensitivity leading to bedsores). Call-Bell Abusers, on the other hand, need to be told that it's not okay to call an aide repeatedly to change the TV channel, adjust room temperature, or scratch an itch on their noses, but it is okay to ask for all of those things simultaneously, if the aide is there already helping a roommate. I ask call-bell overusing residents with some psychological sophistication to look for other reasons they might be continually asking for help. If they are lonely, for example, perhaps we can find other ways of addressing their loneliness.