Problem Solver

 

 

Bob Goddard

Okay, so back to the Claire Chronicles. It’s been two months since I reported anything on her progress. So this will serve as an update. Actually, more like a battle report.

At 18 months, Claire is still not crawling. But that doesn’t mean she isn’t developing. She is more mobile than ever, her primary method is rolling. And she’s fast. Turn around for five seconds and she’s across the room attacking the cat or reaching for some forbidden object such as the TV remote. Or something ridiculous, like the Christmas tree. It’s as if she has no real plan.

While Claire is very visual, exploring the world around her by looking at things, this is often supplemented by the sense of taste, everything she grabs goes in her mouth. Including the cat’s tail and the TV remote. And thus I’ve become more mobile than ever too. I often find myself bounding across the living room over the field of scattered toys she’s left behind for greater adventure elsewhere: “NOOOO…. NOT THE DOG’S WATER DISH…”

This impulse to move is powerful in humans. If we can’t do it one way, we’ll find another. It’s just a matter of figuring out how. This brings up another of Claire’s developmental advances: problem solving. She’s become quite the solver of problems. And this creates problems for me to solve.

In our effort to get Claire to crawl, we’re trying different ways to trigger the reciprocal, across the body coordination (left arm working with right leg and vice-versa) necessary for that form of mobility. Because of her ACC, this does not come naturally for Claire. So, we place her on her belly on the floor and then put things that she wants in front of her, just out of reach hoping that’ll entice her to move the necessary body parts to retrieve the item. I use what I consider the ideal bait: Cheerios.

Claire loves Cheerios. And for good reason, they’re wonderful in so many ways. They’re particularly good for use as reinforcement or just straight-up incentive. I tried using toys for reinforcement of desired behavior, but there is a built-in cruelty to that: you have to take the toy away in order to move on to the next step. A Cheerio is immediately and happily consumed, leaving the consumer looking for more.

I start by handing Claire a single Cheerio in the “first one’s free, kid” tradition. This primes the pump. Taking tiny bits or sips of anything that tastes good stimulates the taste buds in a way stuffing your mouth can’t. Thus we go into the exercise in a heightened state of expectation and motivation.

I have to be careful. She’s been known to lunge herself over the hand offering the first free Cheerio to the mother lode in my other hand just beyond it. I’ve learned to keep all additional Cheerio reinforcements in the big yellow box until I’m ready to deploy them.

Anyway, this is what happened in my first attempt with the Cheerio Just Out of Reach technique to get Claire to crawl:

 

If you listen carefully, you’ll hear me say “Oh, my goodness…” What I was actually thinking was “Oh, you little shit…” In endearment and admiration, of course. I try not to use bad language around the children, even though it’s sometimes difficult to refrain.

So, I said “damn the bacteria” and I placed the Cheerio directly on the carpeted floor, 18 inches or so out of reach. Fool-proof plan, I thought. Until, in one seamless motion, the little shit rolls in a 180 degree semi-circle and snatches the Cheerio with her little hand like a frog flicking a fly from mid-air. It was over and the Cheerio was in her mouth before I knew what was happening.

Of course, she wanted more. I just reached in the big yellow box and tossed her a bunch all at once.

There, problem solved.

Well Bully for You


Corey
I wanted to write about memory care. I really did, about how it feels to come full circle and how much I love the challenge of constantly adapting but that post is going to have to wait. As much as I would LIKE to write about my new job assignment, I feel COMPELLED to tackle a different topic: bullying. On the surface, it seems a simple enough problem to discuss. Don’t be a jerk. ‘Nough said…except that as with so many other issues, bullying is a deeply rooted systemic problem that will never be solved without an open and honest examination of how and what it truly means.
Most work places have a zero tolerance policy for physical conflict. That’s a pretty low baseline. I’ve never actually met anyone who showed up for work one day and randomly started punching people, so as far as I can tell that is a cover your ass policy that does little to nothing to curb the problem. If things have gotten so bad that there has to be a no punching rule then somebody has dropped the ball somewhere.
Did you hear?…Well, First shift…If second shift…the new girl…How many conversations start like that? It catches faster than a forest fire and suddenly everyone is angry over something they heard second or third hand. Everyone gets in on the action, morale goes down, quality of care goes down, communication becomes petty and useless and I feel like I’m in fifth grade again. It’s ridiculous and I am over it.
It’s modeled behavior. Supervisors act as if they are confused as to why there is chaos on the floor. It’s baffling. Of course there is dysfunction on the floor because there’s dysfunction in the office. I have yet to work in a facility where I didn’t know exactly how the supervisors felt about each other; where I didn’t know which caregivers were favored on which shift. It’s impossible not to hear the claptrap. This along with an inconsistent application of consequences inevitably causes resentments. If management doesn’t hold themselves to a higher standard, why would they expect it from those who work under them?
It’s not just caregivers that are on the receiving end either. New supervisors come in and before they even have time to adjust, a collective snap judgement is formed by the members of management who have been there longer. Suddenly everyone from the office down is berating the new kid on the block. I have to wonder, for all the criticism regularly heaped on new people, how many senior employees have reached out their hand? How many have said, “Man, I know how tough it is to be new. I remember when I first started. I know how overwhelming it can be. If I can help you or you have any questions, just let me know”? Now THAT would be a refreshing show of true leadership. Sadly, it’s much easier to bitch about a person than it is to solve a problem.
It’s rampant in the online CNA support groups too. The helpful posts and genuine questions are often buried under posts that take unnecessary digs at other people. This co-worker is lazy. That co-worker calls out. So much of it is catty, as if one can’t feel good about themselves without putting another down. It maddening and ugly and I don’t understand the point. Unless a resident is being put in harm’s way, there are better ways to solve the day to day troubles of working with others than to engage in pettiness. Those in our care handle living with cancer, dementia, Parkinson’s, and mental illness better than some caregivers handle having to stay five minutes over or putting a trash bag in a trash can; better than some supervisors handle sharing an office. It’s a little pathetic.
The truth is, I’ve never had a problem with those from other shifts who work my hall. I do my best and respect my co-workers and in return they seem to be just fine with me. Our halls run smoother because of it and those in our care get the attention and energy that would be wasted on engaging in drama. For the most part, when I put good out I get good back and I trust my own experiences rather than the gossip that runs rampant.
Be it in the workplace or out, bullying has become an epidemic that rots the best and empowers the worst of the human experience.
It is the worst kind of groupthink and it scares me how normalized it has become in now. When did it become socially acceptable to rip another person to shreds simply for disagreeing with you. A single person behaving in such a way may hurt another’s feelings, but when it becomes groups of people tearing others down, real damage is done. It is leading us down a dangerous road at breakneck speed.
We who work in Long Term Care exist in a microcosm of the outside world. Because of this we have the ability to see the damage that collective bullying is doing on a small and intimate scale within the walls of facilities. In this world, we can do something about it. We can be helpful instead of hurtful. We can lift each other up instead of knock each other around. We can speak up, even when it’s hard, even when it is to those in charge. We can choose not to engage in toxic behavior. In doing so, we will be happier, our residents will be calmer and our co-workers will have a window into better ways of handling conflict. Maybe, just maybe, we can learn these lessons on the job and use them off the clock. We can be an example for others. After all, chaos and negativity may be contagious but so is positivity and hope. The choice is ours.

CNA Edge at the Green House Project Annual Meeting

 

 

Bob Goddard

Last Wednesday, we had the honor of speaking at the Green House Project’s annual meeting in Fort Lauderdale. It was a great experience for both Corey (the artist formerly known as “Alice”) and me (in a previous life, “Yang”). The Green House Project is on the cutting edge of elder care and serves as model of long term care done right. We were delighted to be asked to be a part of this event and it was uplifting to be among so many people who share our values.

Like any annual conference, it was a time for old friends and colleagues to reunite. I think this social aspect is what gives these meetings the ability to re-energize the participants and the movement. And really, at its heart, that’s what the Green House Project is – a movement.  The energy level was no doubt enhanced by the large number of caregivers (“shahbazim” in Green House parlance) in attendance. Given the elevated role of the shahbazim in the Green House model, we were not surprised to see so many caregivers there. Still, it was great to see!

It was reunion of sorts for both Corey and me, as well. While we have contact during the year via emails and text, it was such a treat to spend a little time with my co-contributor and friend. While I’ve always admired her talent and commitment, I have to say that in person, her energy and wit are downright contagious. It was especially nice since I got to meet Corey’s friend, Dave, and they got to meet my wife, Jenny, and daughter, Jamie.

(l to r) Jenny, Corey, Jamie, Dave, Bob

Our talk, as you might expect, centered on the significance of the caregiver-resident relationship. While we used selected posts already published on the blog, we added some things to help apply our material to the Green House Model. It wasn’t that difficult really, so much of what we write on CNA Edge has to do with what the Green House calls “deep knowing relationships.” I think it went pretty well.

Like the Green House people, our “blogging batteries” have been recharged by the experience. We are really excited about the coming year and what it may bring.

You are the Solution


Corey
Hey you. Yes! YOU, reading this. Don’t ever allow yourself to be convinced that you are less than you are. Don’t allow anyone else to define you. You are so much bigger than your mistakes, fear, and struggles. I know you’re tired. I know you sometimes ask yourself what’s the point and I know sometimes you think your best isn’t good enough. Not one of those thoughts are true. The very fact that you are reading this post shows that you are defining your position in the world of long term care rather than allowing the system to define you. I know. That’s how this whole blog began. Two caregivers found each other online and decided it was time to let the world know what it is truly like from our perspective. We are no different than you. If we can be a part of the solution, so can you.
Step one: we have to get rid of the “I’m just” mentality. I’m just a CNA. I’m just a single mom. I’m just
a high school graduate. I’m just one person. No. You are not. You are a dynamic human being with ideas and value. Your worth is not to be measured by something as simple as a degree. You are not “just” anything. KNOWING that is the key to willingness and willingness unlocks doors you can’t even begin to imagine. Willingness produces action and action produces change.
Step two: we have to stop letting others dictate our behavior. Everyone calls out. I’m going to call out too. Right or wrong, that thinking just excuses their reasonings for our poor pay, awful work loads and disrespect. Is it fair that the best and the worst of us are treated the same? No. Hell no. But the system sees no need to change it. They treat us as disposable. We react to being treated as disposable. They use this as an excuse to continue to treat us as disposable. Collectively, we have power over this. I’ve said it before and I’ll say it again: mountains move from the bottom. Rome wasn’t built in a day. We need consistent and collective moves forward and that will not happen until we excel. Until WE define what we do and how well we do it. Until we become the leaders we wish we were provided, it’s going to be business as usual. We have to stop bullying. It’s a problem from the top down. I should not know what the office people think about the new nurse. But I do. It’s no different than the floor. The new kid on the block always has it rough. We can lead by example there. We can help the new workers, regardless of their position, rather than tear them apart. We can help other shifts instead of bitching about them. Having worked all shifts, I know they each have their challenges. We can not involve ourselves in malicious gossip like twelve year old mean girls. If we feel someone isn’t pulling their weight, we can discuss it with them like grown ups. We can speak up for one another when necessary and we can speak up for the residents. We do not have to get drawn into the drama, even when those in supervisory positions often seem to be the ones stirring it up. We can CHOOSE not to play ball, to respectfully decline to participate in bullshit. In doing so, we become examples for good. We show that it doesn’t take making another feel or look bad in order to look good.
Step three: Never give up. It may seem like no good can come from all this effort. I know I’ve felt that way. Press on regardless. Change happens slowly. It takes patience and sacrifice and even then, the satisfaction of seeing the outcome of all the effort isn’t guaranteed. Trust me, it makes a difference. Once, I was a whistle blower. My entire life was thrown into turmoil. I lost my job. Had to start from scratch and couldn’t see how any good came of it, but as it turned out, it wasn’t just their one facility that had glaring and dangerous violations that had gone unchecked, but several. By shining a light on one, all of them were on the radar. It was three years before I found out that my action had any impact. I was green in the field and naive at the time. Now I realize the most impactful change in this system is not an explosion but the slow and steady burn of passion that motivates this blog. The simple act of speaking your truth consistently will leave a mark. So leave your mark. Write your own piece. Email it to us for posting. Or reach out your hand to another person in this field. Teach with patience. And know we are all in this together and you are not alone.

Clocks


Alice
She had a collection of clocks. Dozens of them, haphazardly placed among her other bric-a-brac. Each one was set to a different time. They were her moments. Her most momentous moments, forever frozen on the featureless faces of the unassuming time pieces. Her greatest pain and purest joys forever memorialized, never to be robbed by something as insignificant as second hand rotating repeatedly; endlessly around the same set of numbers.
She refuses to see life in phases; minutes to slip away or for which to be accounted and set aside for mundane tasks that will soon be forgotten. Her frozen clocks scream of a life that refuses to be empty and thoughtless, regardless of age. That clock holds the moment her that her love arrived. That one tells the tale of great loss and brokenness that she did not think she would survive. Each one holding a story; a defining moment of a life full of love and pain and meaning. The best moments gave her faith and hope and the most challenging and painful defined her character as they taught her. She holds every moment encapsulated in those still, quiet clocks with equal importance. For how does one appreciate joy without acknowledging pain? How does one not become embittered by pain without holding onto joy and humor?
The longer she walks in this world, the more vital those clocks become to her. In the chaos and noise, they are her truths. No one can rob her of her experience, not even time. As her wrinkles deepen and the world changes around her, she finds peace in wisdom. It may have taken her a lifetime, but she knows what matters and shares her experiences; her clock moments with others. In doing so, she is both teacher and student and remains full of curiosity despite her age. After all, as long as she still has breath, there is room for more stopped clocks. For her, that is a life well lived.

A Shared Experience

 

Bob Goddard

It’s not uncommon for caregivers to say they were drawn to the field or that they were “born to do this work.” Others will tell you that life circumstances brought them to the job, but after some time as a caregiver they began to regard it as a calling. Probably both are true in different degrees in different people. But either way, I think the experience of caregiving incites something within our psyche that might otherwise remain dormant. It can change us.

The notion is supported by science. Psychologist Daniel Goleman, the author of Social Intelligence: the New Science of Human Relationships, tells us that person to person interactions literally shapes the human brain. The more important the relationship, the more profound the effect of those interactions upon the brain. When we help someone we care about, there is a psychoactive reaction in our brains that also connects with the circuitry that makes us feel good. We are biologically wired to learn to love and each experience expands our capacity for kindness and compassion.  Dr. Goleman says that the brain area that becomes stronger in this activity is the same area as a parent’s love for a child. We often hear caregivers talk about residents being like family members. This may be one reason why.

I’ve experienced this in my own life. Late last summer, following a speaking engagement at the Pioneer Network annual conference, I was ready was to devote myself full time to promoting this blog and our message. However, two months earlier, my granddaughter, Claire had been diagnosed with Agenesis of the Corpus Callosum (ACC), meaning that she had been born without the part of her brain that connects the two hemispheres. ACC is a developmental disorder that does not have a cure and treatment involves a lot of early intervention.  Soon after I got home from the conference, circumstances related to Claire’s treatment and care resulted in me becoming her primary caregiver during the day. I wasn’t planning on taking on this responsibility and I knew it would interfere with my work, but I couldn’t turn my back on my granddaughter when she needed me.

While I was initially motivated by a sense of family obligation, I soon realized that not only did I very much enjoyed my time with Claire, I found the experience quite fulfilling. I discovered that many of the skills and attitudes I developed in my years as a caregiver in LTC were applicable and I quickly became comfortable with this new responsibility. Soon I began working with the in-home therapists from the Early On program and learned about ways we could actively address the developmental challenges presented by Claire’s ACC. I knew that Claire will always have her struggles, but I was encouraged by the idea that we could do things here and now that would make a significant impact later in her life.

It makes sense to me that this transformation from a sense of obligation to experiencing emotional fulfillment to a desire to give more has something to do with Dr. Goleman’s psychoactive reaction. While there is little doubt that this process is enhanced by the expected grandparental bonding, it is quite possible that my daily interactions with Claire conditions my psyche in the same way an exercise regimen conditions the human body.

I believe there are certain universal truths that apply to any form of caregiving, whether it’s practiced within a family, within a facility, or in some other setting. And the first of these truths is that the relationship between the caregiver and care recipient can be a mutually beneficial experience. Under the right conditions, it’s an experience that has the power to change the lives of both parties.

See Me


Alice
I am a person. I am not dementia. I am not diabetes. I am not simply a resident or client. I am not a care plan or a two person assist. I am not room 242 needs something for agitation.
I was a dancer. An ambassador. I fought for this country. I was a nurse. An engineer. I am a mother, son, daughter, sister. I am dying but I’m not dead yet. You make rules and say they are to protect me, and yet you don’t see me. You don’t ask me what I think. I am one more blurred face. I am one more bed filled. I am a number on a census.
Your voice and demeanor change when my family visits. Suddenly, we’re pals. Suddenly you are filled with concern but if I were to ask you how I slept last night or what my biggest fears were, or my favorite color or pet peeves, you wouldn’t know. That’s beneath your pay grade. That’s for the caregivers, if I’m lucky enough to have a good one that you doesn’t run off in search of greener pastures. And I don’t think you realize how truly demeaning it is to not be seen as an individual; how, more than anything else, the minimizing of who I am as a person to a checklist robs me of my dignity. There shouldn’t have to be a list of patient rights in order to be seen as a human being. Is there a more important rule than that? It shouldn’t be so complicated.
The higher up the food chain you are in this field the further you are removed from the people for whom it exists and the legislators making the calls are about as high up as one can get. The best way to find out how to improve the quality of life is to ask those who receive and provide the hands on care. It’s a no brainer.

Beneath the Roles We Play


Alice
Lucinda. To some, she is the manager at the super market on my corner. To others, she is the cashier, if they notice her at all. To me, she is a person with whom I interact with on a regular basis. She is a mother. She is a woman who worked from the bottom up and isn’t afraid or above hopping on a register when the store is short staffed. She is someone who managed to dig deep and find a genuine smile despite the fact that she had to show up to work after leaving the funeral of a loved one. I know this because I noticed the tracks of the tears that escaped her make up and I asked her about it. She knows my name and I know hers.
We interact with thousands of people in our lifetime. How often do we take a second to acknowledge their humanity outside of the limited role that they play in our lives? Do we see the person first or the service we expect them to provide for us,paid or otherwise?
My years as a caregiver have honed my ability to see a person beneath whatever descriptor they may hold. Quality of life is not improved by seeing a resident’s disorder before seeing them as a person. By knowing their individual personalities and preferences, I am able to provide better care and remind them that they are deeply valued as people. A person who feels worthwhile is less likely to be combative and angry. A person who knows you are a friend is more willing to trust, to be open about how they feel and less likely to feel alone and afraid. No one, myself included, wants to be seen solely as one thing. It is true on the job and it is true in the world.
Civility is slowly dying because our circles of empathy are shrinking. People view life through this filter of self. How do you and your actions affect me? We are all guilty of it. Just because I am aware of this doesn’t mean I don’t fall into that trap; that age old opera of ME ME ME ME ME when the reality is most of the time it’s not about me at all.
My work reminds me of that in thousands of ways, big and small. Those in my care manage to maintain their dignity through challenges that I can’t imagine facing. Even my most difficult and moody folks maintain the ability to occasionally laugh through constant pain. They help one another through the heartbreakingly tough days. Even those that don’t get along show each other support and notice when someone is missing from the hall. Somehow, through all of their troubles, most of them manage to smile at us and say thank you. It is impossible for me not to be humbled by that; to not strive to be just a little bit better every day at living well among other people.
We lost a resident this week. Sometimes it seems like I always see it coming but I never see it coming. I know the inevitable for the demographic with whom I work, but for me it’s always about their life. I never feel quite prepared for their death. This fellow left an impression that will stay with me for the rest of my life. A few weeks ago, I was working on his hall and saw his light on during my 2:00 AM hall check. Curious, I knocked on his door.
“Come in!”, he answered with more enthusiasm than I had at that hour. He was sitting in his recliner, listening to a book on tape as he carefully cut out a rectangle from the bottom of a square plastic cross stitch board. He had quite a stack of them piled on the side table beside him. This was no small feat as he was as close to legally blind as one could get. He explained to me that they could help the vision impaired to sign documents. Just line up the cut out rectangle above the space on which they need to sign and use the plastic as a guide for the pen. Voila! No more shaky, sloppy signatures. He asked me to hand them out to anyone I knew with poor eyesight. He went on to say that he was in a program that offered free audio books to anyone who no longer had the ability to read if I knew anyone who would be interested. I was thunderstruck with his courage. He didn’t even know he was brave and I knew instinctively that if I pointed it out, it would only make him feel uncomfortable. This was just who he was. To comment upon it as if it was an isolated event would cheapen it somehow. Still, I thought about it a lot for the next week. Here was a man who by all rights had every reason to feel sorry for himself. No one would blame him and yet there he was using his mind, creativity, compassion and his own personal struggles to make the lives of others better in a way that no one else could. It was nothing short of amazing and the fact that I was able to witness this empathy and gutsy perserverance in action was a gift that I will never take for granted. The very least I can do is get to know Lucinda; to do my best to see people beyond what roles they play in my life and what they do to me or for me. It is yet another reminder that the lessons are there. They are always there. I learn them when I become willing to see.

A Not so Obvious Picture at the Grand Rapids Home for Veterans

Bob Goddard

In early August, a disturbing news story broke about the Grand Rapids Home for Veterans, my old workplace.  After an investigation by the State of Michigan’s Attorney General’s office, eleven former employees – all direct care workers – were charged with falsifying medical records. The caregivers charted that they had checked on members (the Veterans Home refers to the residents living there as members) while surveillance video shows that these checks were not done. In Michigan, falsifying medical records by a health care provider is a felony, punishable by up to four years in prison and a fine of up to $5000.

The investigation followed a scathing February 2016 report by the Michigan Auditor General. According to that report, the home failed to properly investigate allegations of abuse and neglect, took too long to fill prescriptions and operated with inadequate staffing levels. Both the Attorney General’s investigation and the audit came almost three years after the State privatized the entire direct care workforce at the home, thus replacing a dedicated, stable direct care workforce with contract workers from a demonstrably unreliable agency, J2S.

The eleven workers charged by Attorney General’s office were employed by J2S. That company was replaced by two other contract agencies last year after J2S repeatedly fell short of adequately staffing the facility.

As we have come to expect in media coverage of anything related to long term care, the local media treatment of this story displayed a superficial understanding of how a long term care facility operates and relied on sensational wording to make the story more compelling. In the process, the reporting presented a misleading picture of how caregivers go about their work. While reporters expressed outrage over the quality of care at the home, they seemed clueless regarding what it takes to make good care happen. I think it would be useful to correct this and offer a different perspective.

In one report following the announcement of the felony charges against the caregivers, a local TV reporter assured viewers that the Attorney General’s investigation “paints a pretty obvious picture of the situation” and concluded that bringing the charges does two things: “it holds people accountable for what they did,” and second, “I can guarantee you tonight at the home for veterans they’re going to be doing their member checks.”

The assumption in that last statement is that fear is a necessary and effective motivator in providing good care. This is a common fallacy among observers unfamiliar with the nature and practice of caregiving. You cannot get genuine compassion and caring from fear.

Yes, as our visibly self-satisfied watchdog reporter suggested, I’m guessing “those member checks” were indeed “being done tonight,” but as I will explain below, that form of diligence has little do with the actual quality of care at the home.

The media reports and statements from the Attorney General gave the impression that these hourly checks were at the heart of what caregivers do. They are not. In fact, the hourly checks are superimposed over normal care routines. In a typical institutional setting, each caregiver is assigned a group, usually ten or more residents depending on the shift, unit and facility, and is charged with completing a whole series tasks including assisting with the residents’ personal hygiene, bathing, grooming, dressing, toileting, bowel care, skin care, turning positioning, transferring, ambulating, transport, serving meals and feeding patients, offering fresh water and snacks, take vital signs, make beds, keep the residents’ room clean, answer calls lights and respond to requests, record intake and output information, observe and report changes in residents’ physical and mental condition. And of course, document these activities via flowsheets and other similar forms. The location sheet is one of these forms.

It’s important to understand that given the direct care staffing levels in a typical long term care facility, and this certainly includes the Grand Rapids Home for Veterans, assigned caregiver workloads are rarely possible to complete – not to the standards set forth by regulators, facility policy, and customary nursing practices, let alone family and public expectations.  This means caregivers are constantly engaged in a form of care triage, made necessary because no one above them in the Long Term Care hierarchy, including policy makers and legislators, seem able to provide the resources necessary to do the job according to standards. Either they lack adequate awareness of the problem or are simply not willing to make the hard choices. By default, this is left to the direct care worker.

Given the inadequacies of the system, the best a caregiver can do is to arrange these various tasks in some order that makes the most sense for everyone in the group, taking into account the unit’s mealtimes and other facility routines. While a good caregiver tries to plan ahead, working with human beings means that unexpected needs routinely arise and no can anticipate everything.  Each shift becomes a unique time puzzle that the caregiver must solve if the residents are going to receive the best care he or she can provide. But the puzzle is dynamic, the “pieces” change according to the immediate needs and expectations of residents, coworkers and management. The caregiver must continually adapt his or her time organization to ever changing circumstances and priorities. In essence, the caregiver spends the shift involved in perpetual problem solving with ethical implications.

At the Veteran’s Home, the check sheets are kept behind the nurses station while the majority of care is conducted in the members’ bedrooms and bathing areas. So, to properly document the checks consistently in a timely manner requires this absurdity: the already overwhelmed direct care worker must pause care and walk away from the members for whom she is providing care for the purpose of putting her initials on a sheet of paper that indicates she knows the location of the members she was just with. This may provide the facility with documentary evidence and meet an institutional need, but it does not necessarily address the needs of the members.

If we are truly concerned about the quality of care for our veterans, the real question is not whether or not the checks were properly documented, but what the caregivers were actually doing when they indicated they made the checks. Were they in the shower room with a member or making sure an unsteady member wasn’t tumbling off a commode or perhaps transporting a member to a therapy appointment? Were they in the middle of assisting a member with his meal or helping a coworker transfer a 350 pound man from his bed to his wheelchair? Were they responding to a member’s urgent request for help? Were they redirecting a confused member for the tenth time in the last five minutes? Were they assisting another caregiver who was trying to manage a combative member? Were they comforting a member who was experiencing some kind emotional turmoil? Were they on their way to nurses’ station to get the location checks clipboard when they noticed a call light? Were they with a sick member, maybe dealing with copious amounts of diarrhea or vomit? Were they cleaning up a spill that presented a fall hazard? Were they speaking with the family of a member regarding their loved ones’ care and status? Were they holding a dying member in their arms? Or perhaps they were engaged in a member’s post-mortem care.

I will leave it to the Attorney General and media reporters to decide to which of these activities caregivers ought to interrupt so that they might properly document the checks – and presumably stay out of prison.

Let’s be clear, if the workers were sitting behind the desk or off the unit or otherwise not engaged with the members when these checks were supposed to be made, then our sympathy and support for them evaporates. Not because they didn’t make the checks properly, but because they weren’t with the members and on task. Even in bad work environments, caregivers are ethically and morally obligated to the use the time and resources that they do have to do the best they can for the residents.

Of course, it could be argued that the hourly checks provide a more systematic way of accounting for the members’ location and condition. Regular checks ensure that no one gets forgotten.  It seems obvious, right?

However, when you start to look at how caregivers actually gather information and keep tabs on the members in their group, the hourly checks take secondary importance. Caregivers are routinely provided with a “cheat sheet,” a one or two page list of all the members in their assigned group. The cheat sheet includes basic care information for each member. The caregivers carry these sheets with them and will refer to them throughout the shift. Even caregivers who are familiar with the members in their group will often use the cheat sheet as an aid to help organize their time and, of course, to help make sure no one is forgotten.

Given the real needs of the members, the fact that the checks are hourly is completely arbitrary. The reality is that some members don’t need to be checked that often and some leave the grounds for long periods – as is their right, it’s a home not a prison. Other members may need to be checked even more frequently depending on their particular physical and mental status.  A lot can happen in 59 minutes and the hourly checks can no way guarantee the safety and well-being of all members. The best way to keep members safe and their immediate needs met is to have well informed, well supported, on-task caregivers. And by well-informed, we mean caregivers who are thoroughly familiar with the members – not just with their current medical status, but who they are as individuals, their daily needs, preferences, and habits.

By threatening caregivers with prison sentences and the like, we can make them jump through hoops and give the appearance that good care is being done, but we should wonder what is actually being missed while they’re putting on this show for us. As our watchdog reporter implied, fear will elicit a sure response. But with fear, the issue becomes not about the real quality of your work and how those in your care are experiencing it, it’s about how you think it’s being perceived by those who can punish you. Under siege, our actions are informed not by our sense of right and wrong nor even by common sense, but by the assessments and attitudes of those who are judging us. When those assessments and attitudes are based on faulty perceptions – which is often the case in long term care and certainly the case here – our priorities become skewed and we add yet another obstacle to good care.

Fear won’t take caregivers into the places where genuine compassion and caring will go. As a motivator, it’s a weak and insufficient substitute for the truly powerful motivations that result in the best care possible. On the other side of those closed doors and privacy curtains where caregivers engage members and actual care takes place, you really want people who are inspired by the better angels of their nature.

The quality of care in any long term care facility is directly tied to the facility’s investment in the caregivers who provide it. Paying direct care workers good wages with decent benefits not only helps attract and retain workers, but it also gives them the means to adequately provide for themselves and their families. Many caregivers have no choice but to work a lot of overtime or find second jobs just to make ends meet. The work itself is physically and emotionally demanding, and when you add the stress of double shifts and long hours, the result is a caregiver workforce perpetually on the edge burnout. You can’t get the best possible care on a consistent basis from workers who are physically exhausted and emotionally drained.

It should be no mystery why J2S had such difficulty staffing the place and why even now one of the current contract agencies continues to have problems. The shortage of caregivers has become a nation-wide crisis and annual turnover rates for direct care workers typically run between fifty and sixty percent. Prior to the State’s privatization of the direct care workers, the Grand Rapids Home for Veterans was immune to this crisis.

The cost of losing that stable direct care workforce cannot be overestimated. Caregivers who are unfamiliar with the members in their care groups cannot possibly provide the same level of care as those who have had long standing relationships. But we continue to routinely throw these workers into chaotic situations and expect them to perform a high level. Usually they feel fortunate just to get through the shift with no major disasters. Or investigations.

While a sense of duty and a good work ethic are necessary in providing adequate care, there is no substitute for the personal relationship that develops between the caregiver and resident. This bond is the single most powerful motivator in providing excellent care. In environments where these relationships are encouraged to develop and flourish, workers become more caregivers, they become advocates.

If the caregiver has a moral obligation to do the best for his or her residents despite difficult circumstances, then those above us in the hierarchy and those on the outside who seek to influence the activity of caregivers have an equally compelling moral obligation to understand the consequences of that influence. This requires a basic awareness of the real challenges faced by caregivers and insight into what really motivates them. From what I’ve seen, both the Attorney General and the local watchdog reporters have failed to demonstrate that awareness and insight.

  

Business as Usual


Alice
Business as usual. She died. No one saw it coming and it’s business as usual. And I get it. Of course I do. We work with the most vulnerable of people, most of whom are at the very end of the long race that humanity is running. Many of whom have outlasted all of their loved ones. Our job is walking with those people, hand in hand, to the end. That’s how I see it. We care for them, preserve their dignity, protect their humanity and calm their fears as the sun goes down on the incredible day that has been their life. I tell them in all the ways that I know how that the sunset is always when the light is the most beautiful and that their colors will be forever painted on my heart.
She was here when I ended my last shift and she’s gone when I came in for this shift; gone in an instant. It’s how I would like to go if given a choice; in an instant after a full long life. Still, the shock rattles my mind as I absorb the news. Loss is part of the job and there isn’t always a warning. And I know it’s business as usual because we have others in our care but can we pause?! Can I have a minute to adjust to this reality before I have to hear who didn’t do an adequate job on the hall this weekend or which other resident was disruptive?! Can I have a minute to remember my favorite moments with her before dismissing her death as just part of the gig?!
Can I have a minute before I hear, “Alice, you like an adventure, right? Want to help give a shower to an “impossible” resident”? Can I have a minute before I hear the dread in another person’s voice that a resident living with mental illness is coming back on my hall tomorrow? You say oh God. I say thank God.
I will double my hall checks tonight just to be on the safe side. I will spend extra time with my night owls. I will gladly give that shower to the impossible resident. I will smile at the many times the resident we lost made me laugh. I will appreciate others more and be deeply grateful for my own life. It’s business as usual. That doesn’t mean I ignore loss. It means I use it to enrich me as a caregiver; as a human being. It doesn’t mean I dismiss death. It means I celebrate life.