Ombudsmen: Elder Advocates Are Allies for Care
Tuesday April 1, 2003
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But this "bane" can be a boon to long-term care nurses, as well as to the patients and communities that ombudsmen traditionally serve through advocacy and consumer information. And some nurses are so supportive of the ombudsmen's mission that they have become paid or volunteer ombudsmen themselves.
"Nurses have so much to cope with, they resent outsiders second-guessing their decisions, critiquing their work, and questioning what they see," says Diane Carter, RN, MSN, CS, executive director of the American Association of Nurse Assessment Coordinators, Denver, and former associate director of the Colorado Association of Homes and Services for the Aging. "As nurses, we assume we're trying to do what's right for residents, but there are limitations to the nursing model of care. Ombudsmen think outside the box, and they get the sticky issues our culture refuses to address - restraints, guardianships, and end-of-life [care]."
In 1989, as a director of nursing, Carter had a "life-changing" meeting with an ombudsman she now considers a mentor.
"Ombudsmen had the courage to tell us restraints aren't good for human beings," she says. "The question never occurred in my years of nursing practice. We were doing it to 'protect' residents. But we really don't know what it's like to be helpless or dependent on others."
Voices for Change
Although they're better known by the public for helping consumers evaluate specific facilities, ombudsmen have advocated and helped effect many changes, including the patient's bill of rights, advance directives, personal needs allowances, improved safety standards, the Federal Nursing Home Reform Law, and the reduction of physical and chemical restraints through national legislation and local intervention.
As a reaction to concern about institutional care, the 1978 federal Older Americans Act required every state (and now, Puerto Rico and Guam) to establish a long-term care ombudsman program to resolve individual resident's problems and grievances; assist resident, family, and community councils; and represent residents' interests to public officials by working with media and by monitoring and working on laws, regulations, and policies.
By the Numbers
Programs are operated through or by the Agency on Aging, and their agendas and operations vary considerably among the 53 state and 600 regional programs. All states serve clients in nursing homes; others also include assisted living, board and care, day care, home- and community-based services, and community elders. Some ombudsmen conduct and report site visits comparable to state surveys; some investigate elder abuse, functioning much like adult protective services; and some assist families and residents in court cases.
Staffing and funding have increased slightly since a 1995 Institute of Medicine report commended the program but urged more fiscal support to increase staffing ratios to one ombudsman per 2,000 beds. Current data1 shows that ombudsmen are overwhelmed and overworked, and not just because staffing ratios are one per 3,346 beds.
In 2001, the 1,029 paid ombudsmen and 8,442 certified volunteers visited 35,427 long-term care facilities to investigate 264,269 complaints, including 67,483 for resident care and 65,372 for residents' rights violations, including abuse and gross neglect. They also made 36,751 noncomplaint-based "friendly" resident visits to long-term care facilities; participated in 10,003 state and local surveys; held 8,079 community education sessions; assisted meetings of resident (14,895) and family (8,995) councils; and provided 282,964 consultations to individuals.
They also provided 8,449 facility staff training sessions and 107,602 facility consultations. Training and consultations can be invaluable to facilities.
Invaluable Resources
"Long-term care is a specialty, not a subset of acute care, yet we have little evidence-based research on chronic conditions and the elderly, their increased acuity, multiple comorbidities, and how life changes trigger the need for medical attention," says Sandra Fitzler, RN, director of clinical services for the American Health Care Association, Washington, DC. Because few programs prepare nurses for the clinical and leadership demands or address psychosocial holistic issues, long-term care nurses need all the help they can get.
"Ombudsmen are an invaluable resource" because they're in a unique position to bring the patients' perspective and their own expertise, Fitzler says.
"Deciding when to sleep and get up, food and beverage preferences, what to wear, when to bathe, when to receive care, and what activities to do may be all the independence residents have left," says Sandra Bulanow, RN, MSN, a long-term care ombudsman in Valdosta, GA. "Nurses need to understand the losses: physical, social, privacy, health, function, social circle, money, possessions, function, and freedom from pain. The ombudsmen can help staff understand we'd be difficult with these losses, too. Residents tell us what they're afraid to tell staff, perhaps because they fear retaliation or being labeled difficult. It's not easy to deal with dementia or to be empathetic with short-tempered residents who keep you waiting and can't be pleased, but at the same time, you haven't lived until you have to go to the bathroom on someone else's schedule."
In addition to investigating abuse allegations, Bulanow, a former nursing home director of nursing, works to prevent it by sharing strategies from her experience and national resources and by supporting staff emotionally.
Despite intervening in life-and-death cases of abuse and neglect, Bulanow puts equal emphasis on smaller, daily changes.
"I went into nursing to make a difference and climbed the administration ranks to make a greater difference," she says. "As a DON, I set the tone for quality of life for every resident in my facility. As an ombudsman, I can make the difference in quality of life for thousands of residents in dozens of facilities."
Although all ombudsmen interviewed for this article emphasized the value of varied professional backgrounds, they also recognized the special merits nurses bring to the role.
"The worst thing ombudsmen can do is come in with such idealistic expectations that there's no willingness to compromise or solve problems, or conversely, to have such low expectations that they compromise care," says Richard Martin, RN, ND, MBA, COS, executive director of The Long Term Care Ombudsman, Cleveland. "Nurses have a body of knowledge, including practical idealism from recognizing the difficulties of providing competent, compassionate care. We can resolve situations not only for residents with complaints, but ensure positive changes will affect all residents."
For more information about the ombudsman program, resources on quality care, to reach your local ombudsman, or to learn about jobs and volunteer opportunities, visit the National Long Term Care Ombudsman Resource Center at www.ltcombudsman.org/default.cfm or call (202) 332- 2275.
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