See No Evil, Hear No Evil … Fix No Evil

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Minstrel

As aging impacts physical and cognitive health, many of us will eventually live in long-term care homes.  Thanks to poor standards of care, most people dread this prospect.  To improve care, experts advocate a person-centered model of care as an alternative to the traditional medical model.  Moving from one care model to the other calls for culture change.  Last year I visited the website of a leading culture change organization for information on their annual conference.  It was discouraging to see that among their many events, none included one of the critical elements of culture change, CNAs: our workloads, wages, and caregiving standards.  Hour after hour, day in and day out, CNAs are key caregivers.  Without us, there can be no culture change.  Yet CNAs aren’t heard.  Here is one CNA voice.

I first became familiar with LTC homes when a family member needed care.  I explored many places to find him a good home, then visited him frequently.  Since then I’ve worked in LTC homes and gone into others as a hospice volunteer.  When my uncle moved to a memory care home, I saw the aides who cared for him as angels: they did for my uncle and the other residents what we family members no longer could.  They did this with magical skill and saintly kindness.  And for wages that were obscenely sub-standard.  I was enormously grateful to them.  But in these years of being in and out of long-term care homes, this is what I’ve also seen: aides who sit talking to each other or texting while residents sleep in front of TVs or sit staring into space, alone.  I’ve seen a resident fall because an aide was busy texting.  Aides spend mealtimes noisily socializing with each other instead of engaging with residents, most of whom (at least in memory units) need some level of assistance.  Some aides announce, by their behavior, “Once she’s bathed and dressed and in the dining room, once he’s fed and toileted: once the ADLs are completed, it’s my time.”  Sometimes instead of interacting with residents, aides simply take time apart to rest.  It’s not that aides are intentionally mean or abusive.  And comradery among aides isn’t a perk; it’s essential.  But on every shift there are failures in attentiveness to residents, failures to engage them in an enriching way, lost opportunities for Creating Moments of Joy, as Jolene Brackey has written. 

Some will object, “Not in OUR facility!  We have awesome aides who go out of their way every day to make life better for residents.”  Yes, aides are often inspirationally caring.  But too frequently the quotidian reality is lackluster care, not the person-centered care promised.  Tellingly, the administrators who dispute this picture are often conspicuous for their absence from the daily fray.

Here’s something else I see: thanks to abysmal wages, many aides work two jobs.  Where I live, starting wages are $9 to $12 an hour.  Self-employed aides can earn more, but have no benefits.  Full-time aides are sometimes scheduled to work only 32 hours a week, to avoid overtime when an aide is asked to work a double shift to cover for someone who calls out at the last minute.  Many aides have children at home to care for.  By the time the aide starts his or her shift, which typically involves caring for six to ten residents, she is already tired in body and spirit.  How can this aide bring to work the physical and emotional energy needed to care for the chronically ill, the elderly frail, the cognitively impaired?  Is this what you want for your parent or spouse, or yourself?

How to improve care?  Administrators provide innovative training programs.  Workshops offer state-of-the-art information and creative care ideas.  Two questions not examined:  1. How do we get aides to buy into culture change and embrace person-centered care, once the trainer leaves?    2. Where do we find the money to increase staffing and pay direct-care workers a living wage, one that honors the physical and emotional demands they meet every day?  

Culture change seems focused primarily on training of direct-care workers and renovations to the physical environment.  A more effective approach might come from a change in what we expect of leadership.  Once upon a time, ‘Management-by-Walking-Around’ was the mantra.  An effective manager was expected to circulate on the factory or office floor, paying attention.  Not spying on employees, not micro-managing, but noticing things.  Sensing conflicts and stresses before these undermine performance.  Offering feedback when needed.  In care homes, how often do you see someone on hand whose role is to encourage, compliment, coach or critique?  To see that necessary supplies are on hand.  To offer an on-the-spot performance suggestion, transforming a moment of poor care into an opportunity to reinforce good care skills, per Teepa Snow’s  coaching model.  And at times, with a chronic slacker, to go down the road of discipline.  How much do managers engage with direct-care workers? 

Today’s code word for good care is engagement: aides need to engage with residents.  If administrators aren’t modeling this by meaningful interactions with direct-care workers, will aides believe that engagement is to be the ethos in their workplace?

We can’t improve what we don’t see.  If administrators don’t see the problems, it might be because they are buried in ‘CYA’ paperwork, medication management, marketing efforts, and time-stealing meetings.  Sometimes their offices are in some distant realm of the facility.  Culture-changing organizations might hire a clerk for paperwork and scheduling, freeing the front-line manager for a more constructive presence among staff.  Give this manager a mandate to convert ‘person-centered care’ from a slogan to a fact.   

Can LTC homes provide person-centered care, without the personnel?  Staffing levels are egregiously low.  They may meet states’ woeful requirements but we all know they are inadequate to ensure patient safety, let alone the person-centered care everyone espouses.   Inadequate staffing also leads to on-the-job injuries and CNA burnout.  Are any of the culture-change conferences addressing these issues?  Are leaders lobbying for better staffing and better wages for their CNAs?

Ah, wages!   One is tempted to wonder whether managers tolerate poor performance out of guilt or shame for what they pay their aides.  Even compassionate professionals don’t want to mention the issue of wages in public.  It may seem too daunting and discouraging a challenge—and an embarrassment.  Compensation levels reflect the fact that the job doesn’t require high-level academic or technical credentials.  But aides shouldn’t be thought of as unskilled.  Our skills lie in meeting the global needs of residents who are sometimes completely dependent on us.  A good aide needs to excel in kindness, patience, gentleness, flexibility, effective time management, communications creativity, appreciation for the diverse ethnic, racial, religious, cultural backgrounds of those in our care.  We care for residents regardless of their illnesses or diseases.  We don’t need to describe here the physical tasks we perform, sometimes difficult, often unpleasant.  When the person has dementia, the challenges are doubled, tripled.  We’re accountable to employers, to families, and to our residents.  Not everyone is up to the job.  Wages should reflect the importance of this work and the competencies it requires.  We need a mindset conversion among executives who still think it’s acceptable to sustain their LTC organizations by reliance on a bare-boned staff of underpaid workers who need public assistance to supplement their wages.  Care homes charge their CNAs to respect the dignity of residents.  What about respect for the dignity of CNAs, starting with a living wage?

“Where will we get the money to raise wages and increase staffing?” ask horrified LTC operators. The question is valid.  However, it begs the further question: How much are you spending now, and for what?  Until there is budget transparency (another piece of culture change), the industry’s position that these proposals aren’t affordable, isn’t credible or convincing.  Their question should be not the end of the discussion, but the beginning.  Reviewing the content of culture-change workshops, we don’t see these issues on agendas.  No one wants to touch staffing or wage issues.  Could it be that the profit motive plays too big a part in the culture of some LTC organizations? 

This isn’t rocket science: Be as zealous about improving supervision, staffing, and wages as you are about upgrading the chandeliers and countertops and holding conferences.  Put your assets where you claim your values are.  (Make your budget transparent!)  Invite CNAs to be co-leaders in culture change.  Then we might see culture change that leads to transformed care, transformed lives.