Worker shortages

10 July 2007, Tuesday

Today is the second day for Salem nursing home. I got on a wrong train to Gentofte. When I realized I could still change the line, I quickly got off the train and changed the line. I am on time to meet Mrs. M, the director of Salem. In Denmark, people expect others to be punctual. Here, being punctual means being on time, neither early nor late. People apologize when they are early for an appointment. It is a country that lacks flexibility. Anyway, I was on time at 10 a.m. sharp. Mrs. M has designated a nurse for me this morning even if the nurse does not speak English well. The nurse Anni says she only started working at Salem two months ago and still learning things. She is one of three registered nurses in Salem. She says there are not enough educated nurses. The SHAs take over during the night, performing some of the nurses’ duty such as leading the four teams of SHHs, calling ambulances in case of emergencies, etc. But SHAs cannot pour pills to the medicine box. One of the main duties of nurses is to fill the two-week worth of small med box bins. The medicine box is similar to those in the U.S. with one box each for morning, day, evening, and night drug doses. Also nurses are responsible to schedule various shifts for SHAs and SHHs. It seems that nurses do more hands-off work and overall operation of the nursing home, while SHHs and SHAs mainly interact with residents.

Anni allows me to follow her on the morning medicine rounds. She tries hard speaking to me in English. Examples of medicine for one resident are Citalopram, Entreotabletter Pantoloc, Ibumetin, Kirexa, Marevan, Mirtazapin, Pamol, Simvastatin, Sumatriptan, and Viramune. Many residents have hypertension, high blood lipid disease, diabetes, and depression. Hjertemagnyl is an anti-coagulant that can cause internal bleeding. SHAs sometimes call doctors if they are suspicious of side effects of this medicine. Anni fills up total of 14 small boxes for next two weeks. Many different doctors prescribe all of these drugs. When one medicine runs out, nurse or SHA has to call each doctor for a refill. Sometimes after general physician refers a resident to a specialist, the dosage can change but the medicine chart does not get updated.

An SHA calls for Anni. Anni wraps up a resident’s prescription fill-up in hurry and goes to the staff office. For the next couple of hours, I have observed Anni’s frustration regarding an anti-dementia medicine Aricept. This is for one of three residents I have interacted with yesterday, Mrs. V. Her psychiatrist called in to check her current medicine and found out that Mrs.V has stopped taking Aricept. Nobody knows who stopped it. Anni and an SHA try to find the documentation in Mrs. V’s log. I sit and watch. Anni looks up on the computer records. Nothing. The SHA goes out and finds an SHH. The helper comes in to look at the log. Finally the helper finds a few lines of documentation about how Aricept was stopped. The log has a section that nursing home staff uses to document the nursing care. There is another section that doctors’ order is recorded. It turns out that Mrs. V’s daughter is a doctor and wanted her mother to stop taking Aricept. An assistant called Mrs. V’s general physician and got an approval to stop it. The assistant who handled it is on vacation now so nobody knows about it except the few lines of written documentation in the staff section of the log. There is no mention or record in the physician section of the log. Mrs. V’s psychiatrist did not know who stopped Aricept. The general physician apparently did not feel the need to contact the psychiatrist. Anni says doctors rarely visit nursing homes and ask nurses to take care of most of the health care. At this point, Anni looks confused and does not seem to be able to continue precepting me. That has been my brief interaction with nursing home nurse in Denmark. I am back at the garden where I was spending time yesterday.

Today is Mrs. V’s birthday and they made a birthday cake for her. Mrs. V’s family already took her to their house last weekend for celebration and today Mrs. V is alone in the nursing home with her friends. She probably does not know today is her birthday. I fed Mrs. M again today including ice cream and pear dissert. After the lunch, a helper and I transported Mrs. A to the weekly church service in the basement. About dozen residents came down for the traditional Lutheran service. Mrs. A says that usually a male minister comes to run the service but today his wife is running the service. She wears a neck collar that looks like the one a clown wears. She also wears a long black gown. I have sit in the whole service listening to a Danish sermon and many hymns. Out of five traditional hymns, I recognized the melody of one hymn. I tried to read the Danish lyrics.

In this first nursing home I have visited in Denmark, I am impressed with individualized care, innovation and idea of functionality in ergonomics, and standardization of health care policy. Individualized care goes all the way even to respect a resident’s wish to smoke. A helper has to move the resident to smoke outside every time he or she wants to. A group of residents help each other to form a smoke-break sometimes. But many times they forget to smoke from the result of dementia. At night, if residents do not want go to sleep and want to stay in the living room, they cannot be forced to go back to their rooms. Individual freedom is strictly respected exactly as they live in their homes. This IS their home. The helpers know each resident’s preference and character as time goes on. A couple of ladies always drink a glass of red wine together at lunchtime and they sit together for lunch. They look so cute.

The functionality of devices and furniture is improved but the difference is almost unrecognizable. A small wheel is attached to the front legs of normal dining room chairs and it helps move the chair close to the table with a resident on the chair. Without the wheels, it would scratch the floor and make squeaky noise but most of all it would be too heavy to move the chair. Nobody here uses the four-legged walker that is so popular in the U.S. Instead everybody uses the grocery cart type walker that has wheels. The walker has a small basket that they can carry their belongings. In the middle of the walker, there is a flat portion that they can sit on and rest. One of the residents goofed off by sitting a helper on her walker and pushed him to the living room for ‘her’ coffee break. I already mentioned the height-adjustable washbasin and dish sink in each resident’s room. Motorized lift device to move paralyzed resident to and from the bed is the most impressing machine. It would save helper’s back and at the same time be safer for residents too. There is no rotating motion to put the resident on the bed. This device will ease the hip pain many elderlies are suffering from. Bedside commodore also has wheels and a helper can move a resident from his/her bedside to the bathroom on the commodore. It would increase the mobility and safety. Wooden floor might improve resident safety and reduce the fall risk. Taking care of residents in 10 to 12 people in a group would be easier and cozier for residents and helpers as well. I asked the helper from Nigeria, Mr. Y, what level of facility class that Salem would belong to, high, middle, or low, among the Danish standards. He said Salem is an upscale high class nursing home but there are no big difference between all three levels of nursing homes. General nursing care and individualized attention are all the same in different class of nursing homes, he said. I imagine SHHs must work extra hard to fulfill the details of individualized care in Danish nursing homes.

height-adjustable washbasin in Salem resident's bathroom

I am back with the director to wrap up my two-day visit to Salem. It has been too short and I started to feel attached to residents and helpers. Especially Mrs. A has been really nice to me, asking for my marital status and my life in the U.S. Her sister and brother-in-law are visiting her this afternoon. She tells them I have come from the U.S. through Diakonissestiftelsen School of nursing. They praise the school and the foundation. Mrs. A keeps talking and I cannot leave. With the director in her office, I apologized her if I made Anni get confused. She said it was ok. She blamed doctors for not communicating with nursing home staff or other specialists in general. One of my questions about nurses was lack of clinical assessment by nursing staff. There are no regular vital sign checkups. Nurses almost never listen to heart and lung sounds. When I asked Anni, she said she was not taught how to do it. The director says that nurses should be aware of residents’ medical diagnoses and call doctors every morning to adjust any needed changes in the medication. Nurses discuss with residents’ family about the nursing home care. Nurses do staff scheduling every two months. Mental health care for the elderlies is one of the important aspects of nursing home care. She would like to introduce a therapy dog sometime and shows me an article about the effect of therapy pets on Alzheimer patients. Making the residents to feel good about themselves is the key through personalized care. She also emphasizes the policy implementation in nursing homes such as preventing bedsores by not allowing residents bed-ridden. Even if residents get seriously sick, they are moved about at least two hours a day and encouraged to stand up. When I mentioned Ms. E’s resignation, the director expressed the difficulty finding the new hire to fill up SHH positions. Probably SHH work is a bit harsh for Danes and foreign workers would have to fill up the positions. But it takes 7 years to get permanent visa and two years after that to obtain Danish citizenship. This number needs a confirmation but it sounds like the immigration rule in Denmark is strict. The director says there has been a heated construction boom recently and Denmark imported many foreign construction workers. There are 6,000 Indian doctors being imported to fill up the physician shortage. I asked if they would speak Danish and she said they would get by just speaking in English in the hospital. An Arab store manager in the poor section of Copenhagen near the Central train station tells me that Danish health system might be good but the medical and nursing education is behind and not producing enough well-educated doctors and nurses. Maybe that is why Danish health care is behind France or other Scandinavian countries, I thought.