You do not like anyone to see you looking less than impeccable. You don’t remember that right now, so I will remember it for you. Your perfectly coiffed hair in the framed photos and closet full of matching Alfred Dunner suits tell me what you cannot. So I wash you up, despite your grumbling and put on your favorite turquoise outfit. I hand you the lipstick and steady your hand as you apply it and the previous frustration you felt melts away to a smile. I know you. You can’t make it too easy for me and at the end of our morning routine, you look pretty and I look like a sweaty mess. You chuckle and say thanks.
You have lucid moments when you realize that your mind isn’t working the way it should. These moments break your heart and mine, as I watch you work through the reality that your mom died decades ago and your sister is in another country only to forget again by my next shift. Right or wrong, I wish those particular moments of clarity wouldn’t come; that you wouldn’t have to grieve anew every time your mind decides to tear that scab off. There is nothing I can do but walk with you through it. Thankfully, those dark, cobwebby moments are few and far between. You are my night owl, regaling me with your extensive knowledge of music. The mind is an amazing thing. You struggle with the concept of saliva and yet you know every word to countless songs from Mack the Knife to Proud Mary. It is your love of music and dance that inspired the idea of early morning dance parties. You never like for me to be out of your line of vision, and yet when another resident is having a difficult day, you are the first to sit beside them and hold their hand. You are able to put aside your own anxiety for others.
You are a natural born healer. You were a medic in a war in which you never killed a single person. You told me that your calling was to bring life not to take it. You have told me this countless times and I never tire of hearing it. You are bi-lingual. You are witty. You get frustrated sometimes because you spent a life time caring for others and it’s hard when you realize that you need care too, now. I tell you that what little help we do for you is nothing compared to the wealth of wisdom you bring us every day. You are dapper and do not like to leave your apartment without your hat…your chapeau. That’s French. You taught me that.
You are an artist. Your apartment is a gallery of your work. As your thought process changes with this disease, so does your artwork and yet I see you in all of the paintings. You are head strong and I have to resort to some creative trickery to get you to allow me to help you at all, not that you need much help. I know it isn’t that you don’t want assistance as much as you don’t want the reminder that you need a little help every now and then. I get that. I would feel the same way. And you are far too young for this. I am mad at the disease for you, but rather than focus on that, I look at your art work and remind you how amazing you are. How incredibly talented you are. How lucky I am to have such a friend. And I mean every word of it.
At the very heart of what we do as caregivers is the art of knowing. This is a tiny sample of what I’ve learned about those in my care over the years. Knowing them as individuals not only helps me improve the quality of care for them, but also deeply enriches my own life. I am a better person for having known each and every person who has ever been in my care. They are more than a room number. They are more than a diagnosis or level of mental acuity or a two person transfer. They are people; flawed, nuanced, interesting, complex people who have lived full lives. As they walk through their sunset years, they certainly have earned the right to be known as something more than room 346.
When the issue of CNA wages is raised, the response is never “Sorry, we don’t think you deserve better wages. We’re not going to pay you enough to live on if we can get you to work for peanuts.” No: administrators will say, “Yes, we know aides are worth more and we would love to pay higher wages. We just can’t afford to. The money isn’t there.”
Are you sure about that? Show me the money. Let us see your budget. Every organization has a budget, detailing what comes in and what goes out and where it goes. Long-term-care administrators tell us they can’t find the money to increase wages or benefits of aides. Maybe so, but we aides would like to be included in the search.
This is about transparency in money matters. If you attend conferences and webinars and read articles on how to achieve quality care in long-term-care homes, you will often hear the word ‘empowerment.’ Residents need to be empowered. Persons living with dementia need to be empowered. And direct-care workers need to be empowered—that’s what the experts say. What could be more empowering than having a say in how money is spent? Including aides in a transparent discussion of resource allotment would demonstrate trust in us, respect for us, and appreciation for the creativity we might bring to problem-solving. There may not be a wealth of money being wasted or misspent. But aides are in a unique position to see opportunities for cost savings that others might overlook. As a CNA I saw the amount of food that, at the end of every meals wasn’t in the stomachs of residents but in black plastic waste bags. I saw the wastefulness in our use of disposable items like plastic cups, paper plates and napkins. Without impacting the welfare of residents, aides might find multiple ways of cutting costs so that money might be re-directed. We might bring fresh vision to decision-making about saving and spending. Give us a chance!
Perhaps administrators protect budget secrecy out of embarrassment over the wide gap between the salaries of aides and the salaries of the executive and managers. Or out of worry that this knowledge might lead to poor morale and workplace unrest. Maybe the organization worries about privacy rights; why should anyone’s salary be public knowledge? First of all, budget transparency doesn’t mean that individuals’ salaries have to be known. (However, if it did, would this be so bad? Americans are more open about their sexual practices than about their finances! We know the salaries of the President and members of Congress and of the CEO’s of publicly-traded corporations. It is a tool of accountability.) There are ways to protect information about individual salaries (as the federal government does for federal civil servants) while making information available about salary ranges, the percentage of the budget spent on various classes of jobs, etc. This privacy issue is an excuse, a ploy to halt discussion before it starts. It’s not a justification for saying no to transparency.
Aides aren’t children. We’re capable of understanding issues, of being reasonable. We can understand that some positions merit higher wages than others and that some employees will deserve to earn more than others. We can be patient about wage increases. But we shouldn’t be shunted off to the side when budgets are discussed, as if we were just another piece of mechanical equipment in the workplace. We need to breach this wall that seems to create a ‘them’ and an ‘us,’ the intelligent responsible people on one side and lower class workers on the other. We are all part of the care community; we all want to improve it. One way to do this is to make budgets more transparent. If we want to retain employees and attract new job seekers, salaries and working conditions must become more appealing. I suspect that money might be found to do this, if budgets were transparent to all stakeholders.
We hear a lot about the need for culture change in long-term care. Budget transparency is a culture change issue that we don’t hear about yet. Let’s hear a call for transparency from the leaders of the culture change movement. Let’s hear it now!
They’ll want to show you their renovated patient rooms and their glitzy calendars. They will want you to see the art room and hear about the visiting music therapist. They’ll make sure you notice the flower-bedecked reception area and see the nicely-appointed dining room. They might even cite the training their aides receive. And these are all positives. But administrators of long-term care homes may not encourage you to examine the nuts and bolts. To spend the time it takes to make a true assessment of the standard of care and the residents’ ‘joy’ levels. (Yes, that’s what I said, JOY.) You need a more evidence-based way of assessing the quality of care your loved one will get in the long-term care home that may cost $4000 to $12,000 a month. What do you look for to judge the quality of the home?
When you visit a long-term-care home your tour guide might want to direct your attention to superficialities or to things no longer relevant for your family member, especially one declining physically or cognitively. (Smart TVs, anyone?) Here are some features that are essential for your family member’s well-being. Look for them. These are the minimum No-Frills tests your prospective long-term care home should be able to pass.
1. The Wheelchair Test, suggested by ‘May,’ a former CNA Edge contributor. When you visit a home take a good look at wheelchair footrests and frames. Are they clean? If not, other unseen areas may be neglected. Are footrests attached to the wheelchair? Sometimes a resident benefits from ‘paddling’ along with her own feet; this can strengthen ankle or leg muscles. But if you see residents being wheeled uncomfortably without footrests, this may signal minimal attention from aides and inadequate monitoring by nursing supervisors.
2. The Bathroom Linen Test: Are there clean facecloths and towels in bathrooms? Shortage of towels is a perennial problem in care homes. If management is asked they will tell you that the residents hide towels, and this is sometimes the problem. But sometimes the problem is that there simply aren’t enough towels, or not enough laundry workers to ensure that clean towels are always available. How can we maintain hygiene standards if there aren’t clean bathroom linens? Ask to visit a few resident rooms. If the tour guide discourages you from seeing occupied rooms (“Privacy Rights.”), befriend a resident and ask if you can see his/her room. This will nearly always gain you access.
3. The Warm Water Test. All medical authorities tell us that hand-washing with warm water is the best way to prevent the spread of infection. CNAs are expected to wash their hands with soap and warm water frequently. When you visit a room, check out the sink. Do warm-water faucets in residents’ bathrooms and hall toilets actually run warm? How long does it take to get hot water? If you aren’t able to enter a resident’s room, try sinks in the visitor’s toilets, in the kitchen area, wherever you can find a sink that should have hot running water. The water may warm up after two or three minutes. But when an aide might have only five or ten minutes to get a resident washed and dressed in the morning, she might not have that two minutes to wait. Your family member might get a cold face cloth first thing in the morning. Is this what you want? Do you want the most basic infection-control measure, warm water, to be MIA?
4. The Bath Room Temperature Test. Visit the bath or shower room. Is it warm enough? Older residents usually want warmer rooms for bathing. When they leave the bath or shower, they shouldn’t shiver and shudder.
5. The Call-Bell Test. Do you hear annoying call bells that go unanswered? How long does it take an aide to attend to the person calling for assistance? If these annoy you, imagine how they affect a resident who feels anxious and confused.
6. The Chair-Alarm Test. Notice the residents’ bed and seats (both wheelchairs and other seating) to see if there is a chair alarm on the seat. Virtually every group with an interest in improving the lives of residents in long-term care homes, including CMS, recommend eliminating the use of chair alarms. “But these keep residents safe,” supervisors will say. Evidence suggests that they don’t keep people safe and indeed lead to more falls. (Google it!)
7. The Noise Level Test. It’s not only alarms that can distress residents. If aides routinely shout down the hall to each other, this can be upsetting.
8. The Dining Room Test. How is the noise level? Is hot food served deliciously warm? Are residents offered condiments (salt, pepper, sugar, mustard, ketchup) they would have used at home? Are the aides attentive to residents or do they converse mostly with each other during mealtime, as if this were an extra break time? For those who can no longer use a knife, is the food served in bite-sized portions that the person can comfortably chew? Are residents offered refills of drinks?
9. The Calendar Test. Every long-term care home has its monthly calendar of activities posted prominently. Pay attention to the type of activities offered, how often the calendar matches what is happening in real time, and whether residents seem engaged when they are at the activity session.
10. The Family Council Test. In elder care homes a Family Council is one of the strongest ways we have of monitoring care and advocating for high-quality care for residents. Many homes do have resident councils, but frail elderly residents, especially those with dementia, either don’t know their rights or just can’t express their needs and preferences and criticisms. They rely on us, their family and friends, to be their eyes and ears and their mouths. Once they needed you as a caregiver, and you did that lovingly. Now they need you to be their advocates. So ask whether the home has a Family Council.
11. The Staff-to-Resident Ratio Test. You want your family member to get the attention and care she/he needs. You ask the supervisor about staffing levels and are told, “We meet all the state’s requirement for the number of staff.” And they probably do. The problem isn’t that the home isn’t staffed according to standards. It’s that the standards don’t meet today’s needs. Our expectations for care are higher today. Residents’ needs are also greater; many have cognitive as well as physical disabilities. In some homes there is one aide assigned for eight or ten (sometimes more) residents. And if an aide calls out sick or has a family emergency at the last minute, the ratio is worse. Care quality is worse. Though you may not find an ideal staff-to-resident ratio anywhere, at least ask about this. Ask whether census or resident acuity determines the staffing level. Ask how the home assesses resident acuity, and whether dementia symptoms are factored into acuity.
12. The Supervisor Test. Who is responsible for monitoring care standards of the unit your family member will live in? Where is that person’s office located: within the unit or in some distant section of the home? Ask to see that person’s job description. (After all, you’re paying the salary!)
13. Last but not least: The Aide-Engagement Test. Do aides smile and make eye contact when they engage with residents? Do they seem to know and respect the residents’ needs and preferences? When a resident calls out for something—a snack, an answer to a question, a response of some kind, how do the aides respond? This may be the most important thing to look for on a visit: how aides interact with residents. To get a truer picture of aide engagement you’ll need to visit several times, including weekends and at different times of day or evening. Midmorning. Mealtimes. After supper. Try to visit during a change of shift. Are aides still available to pay attention to residents during shift changes?
When you’re evaluating long-term care homes, don’t be overly swayed by the charm initiatives of the marketing staff. Instead, use this checklist to observe those conditions your family member will live with day in and day out. There is more involved in achieving excellence of care. But these concrete items can be clues to less visible elements of quality care. If those in charge aren’t getting even these basics right, are they really committed to the loftier goals they claim to have?
We cannot provide person-centered care without the personnel. My previous comment, Part Two, presented a list of symptoms that arise from dementia. These symptoms are the constant companions of those living with more advanced dementia, and their care partners. The symptoms create behavioral challenges we CNAs must and want to respond effectively, so our residents can feel secure, content, at home.
We have our list of dementia symptoms. But wait—there’s more. Let’s look concretely at the workday of a LTC direct-care worker. Aides work an 8-hour shift, with one-half hour mandatory meal break. (In some places they are also entitled to or permitted to have a second 15-minute break.) The first and last ten or so minutes of a shift are spent getting and giving shift updates to the previous or next shift of aides. Aides will also need one or two bathroom breaks during a shift. Thus an aide has about 7 hours (420 minutes) left for care tasks. This scenario doesn’t take into account the moments an aide might need for a calming ‘time-out,’ for a few minutes of helpful conversation with another aide or a supervisor, for an important phone call from home, for time spent walking from one task to another or one resident to another. And it doesn’t allow for other encounters we expect aides to have with residents, creating ‘moments of joy.’
Aides will customarily be responsible for the care of six to ten residents on a shift that has plus or minus 420 minutes of usable work time. (And would you believe the number of residents might be higher?) If you do the math, you see that aides may have 42 to 70 minutes for each resident. Seventy minutes to help a person exhibiting symptoms of dementia with toileting, washing (on certain days showering), grooming, dressing or undressing, moving to the dining room, eating, returning to the day room, using the toilet during the day. And these are just the essential ADLs.
Other tasks aides are responsible for during a shift:
- for safety purposes, keep alert to where each resident is;
- distribute drinks to prevent hydration;
- serve snacks;
- check toileting needs and assist residents with this as needed;
- help with transfers (from bed to wheelchair, wheelchair to lounge chair, lounge chair to wheelchair, wheelchair to toilet and back several times in a day, wheelchair to bed) for those residents who cannot transfer themselves;
- help other aides with two-person-assist transfers;
- answer resident questions throughout the shift (“When can I eat?” “Where is my mother?” “When will my son be here?” “I’m cold, where is my jacket?” “Don’t I have a doctor’s appointment today?”) ;
- in between ADLs engage with residents through conversation, music, activities;
- accompany residents to other areas of the building as needed for medical care, hairdressing appointments, other events.
In some LTC communities aides are also responsible for making beds, doing laundry and putting it away, or other housekeeping duties. Throughout the day there are spills to clean up, phones to answer, paperwork to be done, questions from visitors. If an aide is tired from working a second job, or a double shift, this will slow the aide down. If an aide has a bad back that day, or sore knees, or is pregnant, these things will also mean the aide has a lower energy level or slower response time. All these factors take a toll. If some aide should call out at the last minute and the shift is short-staffed, this further impacts care. Even if forty or fifty or seventy minutes of care per resident were sufficient—and really, it’s not—at the current staffing levels in most LTC homes, residents don’t get even this. I challenge administrators to refute this with data.
Is it really acceptable to pare staff levels so thin that we impair not only the quality of care but the safety of residents and aides alike? Is it acceptable that the owners of long-term care homes are sustaining their organizations by controlling their costs with sub-par staffing levels? Those responsible for setting care and staffing standards should feel responsible for doing something about the unacceptably low staffing requirements they’ve established and tolerated, thanks to lobbying efforts of the long-term care industry. (Shame on you, CMS.) The rest of us should hold them accountable. Families and direct-care workers and anyone who is an advocate for those living in long-term care communities: Unite! Lobby! Write, email, text, twitter. Demand that your care home managers and your state legislators see what is before their eyes. For added clout, partner with organizations that advocate for better long-term care. To any CNAs up for a little non-violent guerrilla warfare: sneak a copy of these comments to a few trusted family members of residents. Ask them to bring the staffing issue up at a Family Council meeting. Send a copy anonymously to your Administrator.
Owners, operators, executives and regulators of LTC homes will say that we don’t need more staff, we need more or better training. Our CNAs need to work ‘smarter.’ And there is something to this, we do need to look at work assignments and patterns and at aides’ understanding of how to interact with persons with symptoms of dementia, etc. But tell me how all this will change the fact that an aide may, on a good day under ideal conditions, have 70 minutes to give a resident. (A resident who may be paying $5000 to $8000 a month for memory care.)
This isn’t a game. Would we let a dog lie in a kennel and give that animal only seventy minutes of direct attention a day? Long-term care homes don’t care for dogs, they care for human beings. Tell me please, how can we sit still and stay quiet about this appalling reality, one minute longer?
There is a great deal of confusion within the CNA community regarding the issue of wages and how it fits into the larger long term care picture. While there is general agreement that caregivers are underpaid, that perception is primarily based on personal experience, that of our own and of others. This anecdotal evidence is useful in its own right, if for no other reason than it is overwhelming. However, discussions regarding the wage issue are characterized by emotional responses and typically lack references to data that back up the arguments. Solid facts are sometimes offered within the CNA online forums, but usually not in any kind of comprehensive or purposeful way.
In order to help us get a more accurate picture of the state of direct care work in this country, below is a list of just a few of the more significant statistics. The primary source for these is a PHI fact sheet published in August of 2017.
I think this kind of short list might be useful for those who argue for better wages for caregivers. In future posts, I’ll give my take on what I think these statistics mean.
First, just to get a sense of the scope:
15,400 long term care facilities in the United States
1.4 million residents live in these facilities
600,000 CNAs work in them
But those 600,000 are only 13 percent of the total of direct care workers employed in the United States, because…
4.5 million direct care workers are employed in all types of situations, including home care, Continuing Care Retirement Communities, Assisted Living Facilities, Hospitals, Centers for Developmentally Disabled, Mental Health, Substance Abuse, Employment & Rehab.
Second, the demographics of caregivers:
91 percent are female
Half are under age 35
Half are people of color
Half have some college, (about 1 in 7 have associates degree or higher)
20 percent were born outside of the United States
Third, the money issue:
$12.34/hr is the median wage of CNAs (half make more, half make less)
$20,000 is the average annual income
Half work part time at least part of the year
17 percent live below the poverty line (compared to 7 percent of all American workers)
40 percent receive some form of public assistance
72 percent of long term care is finance through public programs (mostly Medicaid and Medicare)
Finally, the demand for caregivers is growing:
60,000 more caregivers will be needed by 2024. It is one of the fastest growing occupations in the United States workforce.
1 in 2 caregivers leave the job within 12 months. And more LTC workers are leaving this sector than entering it.
I would encourage anyone who is interested to visit the PHI site where more information like this can be found. Of current interest is the ongoing 60 Caregivers Issues series where they tackle a whole range of issues regarding our work, such as caregiver wages, training, recruitment and retention, and advocacy.
Next week, I’ll share what I think some of these numbers mean for the larger long term care picture.
This is about person-centered care. To repeat: We cannot provide person-centered care without the personnel! CNAs, do the administrators of the LTC homes you work get this? Do they really comprehend what your work day is like? Do they appreciate how much time it takes for you just to assist with ADLs, when a person is showing symptoms of dementia? Do the state regulators? Or are they ‘cognitively impaired’ when it comes to understanding life on a memory care unit. As my uncle used to say when his dementia advanced: “Donna, I hear you but I don’t understand what you’re saying.” Administrators may see things, but do they really understand? A Resident Acuity Assessment tool might help them understand.
A Resident Acuity Assessment tool is a descriptive list of the symptoms of dementia. This list isn’t comprehensive; it can’t be. We’ve all heard this: “If you’ve seen one case of dementia, you’ve seen…one case of dementia.” Everyone is different; each care partner may observe a new symptom. This list isn’t meant to be discouraging for those who, thanks to the support they have, may not show severe symptoms. The better care a person has, the more a person diagnosed with dementia can retain functionality, with fewer and less severe behavioral symptoms. But insofar as residents of LTC homes do experience serious consequences of dementia, those who regulate care homes need to appreciate their needs and regulate accordingly with regard to staffing.
Here is what I think a Resident Acuity Assessment tool might look like.* If you are a CNA working in a memory-care community, or a home care aide, or someone caring for a family member at home, these symptoms of dementia are familiar to you. I’m not sure they’re as familiar as they need to be to those who set long-term care standards. If they were, we would have better staffing.
Part Three, the next chapter in my mission to lobby for better aide-to-resident staffing ratios, will mention other factors that need to be taken into account by administrators and regulators.
RESIDENT ACUITY ASSESSMENT
Key: N = Never = 0 S = Sometimes = 1 F = Frequently = 2 A = Always = 3
** under 60: low to moderate acuity; 61 to 100: moderate to high acuity; over 100: very high acuity.
RESIDENT _________________________ Date Assessed _______ by ________________
*There may already be such a tool, a better one, that I haven’t found. (The tests used to diagnose dementia serve a different purpose.)
This is a story of staffing, substandard staffing in memory care homes. It’s an attempt to offer evidence of what life is like in a memory care home and to document why staffing guidelines are missing the mark, are ignoring the ramifications of residents’ symptoms and CNAs’ workloads. In memory care, the gold standard of care is ‘person-centered care.’ But we cannot provide person-centered care without the personnel! In a hospital setting, administrators use something called a Patient Classification System to plan care. This is a method for determining how serious the medical condition of a patient is, what level of care the patient needs, and how many nurses they must have on duty to ensure that patients get the care they need. The severity of a patient’s medical condition and needs is known as acuity. In long-term care homes this notion of patient or resident acuity doesn’t seem to have the same imperative that it does in hospitals. It should.
We hardly use the term ‘nursing home’ nowadays, it’s almost politically incorrect. We speak of long-term care ‘homes.’ It’s to the credit of the nursing home industry and consumers of that industry that if our loved elders become too frail to remain at home, people want to make their final residence more homelike. Not an institutional, hospital-like environment—with all the sterility and standardization and disregard for individuality that the word ’hospital’ ironically implies. And so we move our family members to long-term care homes: skilled nursing facilities, assisted living communities, or personal care homes. Still, residents of these homes, whatever we call them, are there because of declining health. They need care. Maybe not the kind of care that calls for physicians, medical specialists, hi-tech equipment and RNs to be on hand on a daily basis. But they do need attention paid to their declining physical and/or cognitive health.
The area of long-term care I’m involved in is dementia care. I challenge everyone reading this page to name one memory-care home that has the staffing it needs to ensure a high level of person-centered care for every resident on every shift, every day. Not perfect care; just consistent high-quality care. (And if you know of such a place, please let us all know about it. I’m signing up for their waiting list!) Long term care homes simply don’t have the staff they need. CMS and state regulators don’t set specific standards that could ensure better care. The sad standards they do establish don’t come with penalties that encourage compliance.
I first became interested in this kind of tool while working in a memory support home. When we CNAs asked for more staff, the Administrator would respond, “Document that you need more help.” I began putting charts together to demonstrate the time CNAs actually had to do ADLs. One reason legislators don’t pay more attention to staffing levels is that they just don’t understand what the symptoms of more serious dementia are and how these symptoms impact aides’ workload throughout the day. A Resident Acuity Assessment tool could, I believe, help us educate administrators, families and legislators about the staffing we need. In Part Two I’ll present one suggestion for a Resident Acuity tool, hoping that other CNAs will find ways to improve it. Use your own tool to persuade your employers and regulators to require improved staffing of memory care homes.
A prospective caregiver asked this question in one of the CNA Facebook groups: “What do CNAs start at?”
The first person to reply said this: “If that’s the first thing you want to know about being a caregiver, you don’t belong in this field.”
That reply got several positive responses. After all, CNA work isn’t about making money, right? It’s all about taking care of people, not your bank account. Right? So take your question elsewhere, you money grubbing sociopath.
Of course, they didn’t actually say those words, but the condescension was certainly there.
This attitude is shared by a small, but vocal minority within the direct care workforce. It’s an attitude that arises from a small-minded, but persistent misconception: expecting reasonable compensation for the work is incompatible with the compassion necessary to do the work. This notion is erroneous and harmful.
Really, take a moment and consider what the young lady was actually asking. I think it was this: “Can I afford to be a CNA?” “Will it pay my bills? Will I be able to support myself and my family? What sacrifices will I have to make? What sacrifices will the people who depend me have to make? Or do I have to go elsewhere in order to better meet my obligations?”
My guess is that she went elsewhere.
“Can I afford to be a CNA?” This is grown-up talk. It’s about the hard realities and difficult choices people have to make. Asking it has nothing to do with a person’s capacity for caring and compassion. Anywhere else this would be regarded as reasonable and responsible question. But for some in the CNA community, it’s a red flag and those who ask it should be dismissed as morally unfit for caregiving.
I have a question for the caregiver who gave the “you don’t belong in the field” reply – or for anyone who thought that it was a good way to respond: Where is your compassion for that young lady? Where is your compassion for people who might very well become great caregivers and love the work just as much as you, but are denied the opportunity because they simply wouldn’t be able to make ends meet?
Where is your compassion for caregivers who are single mothers and have to work two jobs or unreasonable amounts of overtime just to feed and clothe their kids? Do you have any compassion for the young children who don’t see enough of their mothers?
We know that wages have a direct impact on attracting and retaining workers. The high turnover rate of caregivers has an appalling effect on the continuity and quality of care in LTC, and makes it almost impossible to keep many of these homes adequately staffed. Where is your compassion for the workers who struggle day after day in these chaotic conditions and unmanageable work situations?
Also, let’s not forget the managers that are forced to hire people they might not necessarily want to hire, because poor wages artificially limits the pool of candidates. And then they – and everyone else in the place – has to tolerate inadequate work performance or absenteeism or tardiness or outright disrespect from these workers because the managers know how difficult it is to replace these caregivers.
Where is your compassion for the families of residents who live in poorly staffed homes?
Finally, where is your compassion for the residents who have to live in these homes? And really, isn’t that the bottom line here?
There are those in positions of authority who are influenced by and even exploit the notion that “good caregivers don’t care about money.” Make no mistake, when that idea comes from our ranks, they will use it.
It’s four in the morning; that weirdly silent time on a quiet night. In the daylight, with it’s harsh noises and exuberant colors awash by the sun, quietness can be a welcome respite from an over anxious world. In the light, those still, soft moments cushion the edges of life with soft downy thoughts full of possibilities and hope. In the darkness, the mind is different.
The night holds its own haunting beauty. Quiet on top of quiet in the world when most are dreaming. The landscape both in front of me and in my mind is very different in the shadows and at four in the morning, sometimes the shadows have teeth. Sometimes the stillness is lonely and my mind drifts down paths better left alone. And there is really nothing that can be done about it. Attempting to ignore my mind’s ghostly whispers at four in the morning is every bit as effective as telling a curious ten year old to not push a big red button. So I ride it out.
I read somewhere that the sign of a rational mind is the ability to entertain a thought without accepting it. I take great peace in that when my traitor brain decides to have a house party with all of my fears and insecurities. I’m just entertaining obnoxious guests for an evening. They damn sure aren’t moving in.
I have an idea! Let’s count all the people you’ve known and loved in recovery and as a caregiver who have died. Let’s not. You are so far behind where you should be in life. Maybe. But I’m not where I was either. Working the graveyard shift is going to give you a fat ass. Just more of me to love. You’re going to fail. Definitely. A lot. Major, epic fails. There is so much I want to do and explore in this life that failure is a statistical certainty. I accept that. I’m okay with it. I’m not afraid of failure because I’ve learned the most from my biggest mistakes. You are too much and not enough at the same time. I don’t even know what that one means…and I realized, as my mind decided to be a total ass for no fathomable reason, that there was nothing it could throw at me that would stick. Even at this hour, underneath the utterly predictable and surface level fear was the deeper awareness that I am comfortable in my own skin and am incredibly happy with every aspect of my life that matters. Mine has not been the smoothest of paths and I have certainly not been the most graceful of hikers, but I like to think I’ve learned from it all. I refuse to spit in the face of my happiest moments by fearing the loss of them.
It may be hard to remember that at 4:00AM, but at 5:00 AM the very best and bravest reminders of this truth begin to wake up and it is no longer quiet on the hall. Once again, it’s time to get to get back to the work that brings such purpose to my life. As dawn broke and the day ended for me as it began for others, I said a silent prayer of thanks that, for now anyway, the night whispers had empowered me with moments of clarity rather than embittered me with self pity and fear and when I clocked out, I did so with a smile and confidence.
Working the graveyard shift on a memory care unit…there really are no adequate words to describe the experience. In many ways, it’s the most challenging experience I’ve ever had in this field. I have twelve residents on my hall and on any given shift there are four to six that won’t sleep. It’s a crapshoot whether it will be an all night dance party full of fun or a nightmarish landscape over which I have little control. Mostly, it’s some combination of the two.
“I think I’m dead.”
“You’re not dead.”
“I might be.”
“ You’re not.”
“Ok. If you say so.”….I have that exchange at least once a week. This particular resident is very matter of fact about the whole idea that she might be a ghost, as if she finally figured out why her life has become so strange and unrecognizable. Death, however final, at least made some sense to her. The disease that has ravaged her mind and slowly robs her of who she once was makes no sense at all. She is still in there, though. Her caustic wit cuts through her mental fog; a beam that lights brief paths to moments of clarity in which who she is underneath the Alzheimer’s disease shines through. She loves music. All kinds of music and she loves to dance. She hates tuna fish. If she doesn’t trust you, she lets you know it. She doesn’t respond well to formality, preferring warmth to surface level pleasantries and when she laughs, it is full throated and from the soul rather than polite titters hidden modestly behind a handkerchief. This is a woman who does not bother with giggles. She laughs like she means it and I love that about her.
Those are the moments that I hold onto when the bad nights come; when my people wander in the darkest hours of the night, confused and afraid. When she is having a difficult night, she doesn’t sleep.
“I’m frightened!”, she tells me. Eight hours straight of I’m frightened. And when I’m on a round and out of her sight that fright turns to panic until I am finished helping another resident and she can lay eyes on me again. The best I can do to help her through those nights is to continuously remind her of who she is; that she hates tuna fish and loves music and loves to dance. That helps some, for a little while…but I have eleven other residents who also need me and when three or four of them are having a difficult night at the same time I feel like I’m drowning in my own powerlessness. I can’t cure dementia. I can’t bring back dead mothers or lost dogs from their childhood. In the light of day, with the activity and structure of the daily routines, redirecting is much easier. At three in the morning, it is much more difficult to escape the ghosts of the mind. That’s true for me, so I can’t imagine how hard it is for them.
When I first started on this hall, those shifts were so emotionally exhausting that by the time I punched out, I was feeling something very close to despair. I do not do despair very well. I haven’t for a very long time. Despair leads to giving up and that is quite simply not an option. Besides, those were only the shifts when it seemed that everyone was having a bad night at once and as painful as they were for me, it was exponentially worse for those in my care who were actually living through it.
So much of this field is trial and error. I decided to go back to my basics; ideas and tools I learned years ago when I worked in memory care on first shift. The hours are different and as are the mental state of those in my care but certain truths transcend from day to night. Consistency is always vital in memory care. If I say I’m going to do something, I follow through. I learned my residents, their patterns and preferences and the best night time bathroom times for each one individually and developed my routine. I keep it consistent but flexible. I work around them. If a lot of my folks are restless, I have a midnight snack party and play calming music. My night owls like Law and Order. It’s funny…the can’t follow the show but they seem to remember enjoying it and that’s enough. All of this has helped a great deal.
Of course there are still really tough shifts when events seem to snowball, but they are less frequent and I am better able to deal with them. One of my favorite aspects of my work is that in order to be most effective, I have to learn continuously. Anyone who says differently isn’t doing it right. I have been blessed with the support of those who love me most, both in and out of the field. It is impossible to give up when surrounded by people who believe in you. I walk in the footsteps of those caregivers who trudged the path before me and passed on what they know. At the end of the day, good or bad shift, daylight or in the still of the night, I love what we do. I love writing about what we do. I love that I see the value in what we do and I love those in our care for whom we do it.