Author Archives: Yang

60 Caregiver Issues: PHI and the Caregiver Shortage

 

Yang

Last week, the Paraprofessional Healthcare Institute (PHI), the leading expert on the nation’s direct care force, launched a two-year online public education effort called “60 Caregiver Issues.” Over the next two years, the campaign will identify 60 policy and practice ideas that can begin to address a problem that we, as CNAs, are all too familiar with: the growing shortage in direct care workers.

The first installment, “8 Signs the Shortage in Paid Caregivers is Getting Worse” can be found here.

The purpose of the campaign is to focus public attention on the problem and offer some real solutions. CNAs have a vital role to play in this effort. No one has greater awareness than we do of how chronic understaffing and turnover rates actually impact the care and well-being of individual residents on a day to day basis. We know what it looks like and we know what it feels like to our residents in a very real way. By sharing our real-life work experiences we can offer a perspective that gives these problems texture and a real sense of the human cost.

As advocates for our residents – and for ourselves – CNAs can become part of the solution by joining and supporting PHI in this effort. In the coming months, CNA Edge will share posts from the PHI campaign and, of course, we will offer our own take on the issues surrounding the nation’s caregiver shortage.

To kick off the campaign, PHI offers this 60 second video which highlights the problem:  Caregiving Crisis: 5 Million Workers Needed

 

The Caregiver Shortage and Immigration

In reaction to the Trump administration’s recent immigration ban, Lori Porter, founder and CEO of the National Association of Health Care Assistants, pointed out a connection between the immigration issue and LTC staffing levels. In a recent Facebook post, she stated:

“A large percentage of CNAs are from the banned countries. Long Term Care is always testifying before congress for immigration to solve their staffing issue… I know nursing homes in this country who are largely staffed by those affected. Did anyone stop to think about who would care for the residents? Especially in a country who will not come out in sufficient numbers to take care of their own OLD citizens! … I have heard from nursing homes all day who will not have enough CNAs to staff their building because so many CNAs have left out of fear.”

In support of Lori Porter’s assessment, we do know two facts:  that over 50 percent of CNAs leave their jobs every year (PHI Factsheet) and over 20 percent of caregivers in the U.S. were not born in this country (Market Watch).

My concerned is about the vulnerability of caregivers coming into this country on work visas, especially if their legal status is tied to their employment. Since advocating for our elders is such a big part of what we do as caregivers, we need workers who feel secure enough to speak out within the facility and, when appropriate, in the public forum. Sometimes, we are the last line of defense for our residents and if we do not speak, no one will. Too often, incidents and issues that should be dealt with in the open are swept under the rug, mainly out of fear of some form of retaliation.

If Long Term Care is to rely on immigration to solve the caregiver shortage in this country, what kind of protections can we provide these workers so that they feel secure enough to speak out and advocate for our elders when necessary?

 

For Veterans Day

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Yang

The only time I ever saw my father cry was on Christmas Eve, 1993. On that night, my wife and I invited my parents to go with us to a candlelight service at our church. Toward the end, we lit our candles and sang the final song of the service.  About half way through, I could see the flame on my father’s candle flicker and wave in his trembling hand. His voice cracked as he raised a sleeve to his face to wipe away a tear and he was unable to finish singing. The song was Silent Night. While his reaction was out of character, I had a pretty good idea of what was behind it.

My father was a WWII vet and served with the U.S. Army Air Corp in the Pacific Theatre. He participated in campaigns in New Guinea, the Philippines and Okinawa before joining the occupation forces after Japan surrendered in September, 1945. As typical of males of his generation, he was somewhat “hard boiled,” tough and not given to displays of sloppy sentimentalism.  Yet, he was affable and charming, and used his gentle sense of humor to make connections with people of all kinds. He was a natural salesman and had a knack of making instant friends with strangers. He loved kids and animals, but had little tolerance for pretentiousness and superficiality in adults.

For over 35 years, I observed this same kind of tough/gentle combination in the personalities of many of the residents at the veteran’s home where I worked as a caregiver. I think there is something about serving your country in wartime that sharpens your appreciation for what really counts in life. It’s difficult for those of us who did not serve to fully comprehend this perspective.

For many of the vets I cared for, the Second World War was the seminal event of their lives and helped define who they became as people. The average age of the U.S. soldier in WWII was 26, the draft age 18. At an age that these young men should have been starting work and families, or going off to college, they instead found themselves far away from home in harsh, lonely, and dangerous places. Unlike the other major combatants in WWII, the U.S. did not rotate troops. If you served overseas in WWII, you stayed overseas for the duration of the war. It’s not hard to believe that extended periods in this kind of environment must have profoundly shaped the lives of these young men in ways that heavily influenced their later life experience. And the wounds they suffered were not always visible.

My father enlisted in December of 1942 at age 19. He was sent to the Pacific in August, 1943 and did not return home until November of 1945. I grew up hearing stories about his time overseas. There were stories of the GI’s relationship with the local natives, the oppressive heat and humidity of the New Guinea jungle, the bugs, the snakes, the dysentery, waiting days on end aboard “that damn LST” before landing on the island of Luzon in the Philippines, of watching P-38’s dogfight with Zeros over Port Moresby, and of befriending Japanese children during his time at Tachikawa Airbase after the surrender. The kids were always the first to come out of hiding.

One story stood out above the rest. It happened on Christmas Eve, 1943. He was on New Guinea where the jungle made a cohesive front line difficult to define. He didn’t know if he would ever see home again, was unsure that he even had a future, and scared.

On that night, he and two of his buddies were assigned to deliver some kind of equipment (I don’t recall exactly what) to a location about an hour and a half walk from their camp. As they crept down the dark jungle path, they would halt every so often and listen for any indications of activity – friendly or otherwise – around them. About three-quarters of an hour into the trip, my father turned around and raised his hands, signaling to his companions to stop.

“Did you hear that?” he whispered.

They hadn’t heard anything. The three men listened in silence for a few moments, but heard nothing more, and they proceeded down the trail.

A short distance later, my father stopped again.

“You must have heard that. It sounds like something clinking.”

This time, all three men heard it. But there was something about this mysterious sound in the jungle that made them more curious than cautious. As they walked on, they began to discern musical notes. Someone was playing some kind of instrument out here in No Man’s Land.

Soon, they saw lights ahead. As they came to a clearing, my father and his buddies beheld a surreal scene, a sight that would be burned into his memory for the rest of his life: there, in the middle of the New Guinea jungle, was the Salvation Army handing out cookies and coffee to homesick soldiers.

My father simply couldn’t believe what he was seeing. But his astonishment soon gave way to a different kind of feeling. This was a tangible taste of home, something marvelously normal in this alien land. The idea that these people would volunteer to come out on this night and subject themselves to the extreme discomfort and very real dangers of this place just to bring him and his comrades a bit of home on Christmas Eve filled him with a feeling that transcended mere gratitude.  

I don’t know if my father ever told us what instruments they were playing. But he never left any doubt what song he and buddies heard as they entered the clearing. It was Silent Night.   

I’m pretty sure that there were other things about his experience in the war that my father felt just as deeply, but that he never shared with us. I did know that, as happens frequently with soldiers in war zones, he developed a very close bond with some of his buddies. And I knew that some of them didn’t make it home.

My father sacrificed his youth to serve his country. And he left a part of himself over there. Later in life, he became active in the DAV and other veterans groups. After his faith and his family, his participation and service in these organizations was the most important thing in his life.

When we take the time to recognize and thank our veterans for their sacrifice and service, it really does mean something.

 

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The Savvy Resident’s Guide

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Yang

Empathy is at the heart of caregiving. While the ability to understand and share the feelings of others has an intuitive element, a natural byproduct of genuine compassion, this awareness can be developed and enhanced through thought and imagination. Simply put, we can use what we know about another person to put ourselves in their shoes.

As I read through Dr. Eleanor Feldman Barbera’s nursing home primer, The Savvy Resident’s Guide, I found myself doing exactly that: imagining what it would be like to be an elder about to enter a nursing home. The book, subtitled Everything You Want to Know About Your Nursing Home Stay, But Were Afraid to Ask touches on all the basic topics, including what to expect when you first arrive, working with staff, managing medications, your relationship with medical and social work staff, dietary issues, rehab, activities, money issues and lodging complaints.

Throughout the book, “Dr. El” offers practical advice on everything from the best way to request assistance from care staff to techniques that help you stay motivated during rehab sessions to the best way to talk to your doctor. Dr. El keeps the tone light, often illustrating her points with personal interactions from her own experience. A common theme running through each chapter is that as a resident you are not powerless and that, in fact, there is a great deal that you can do to improve the quality of your experience in a nursing home. The book is an easy read, literally an easy read, with its large print format.

There is very little in The Savvy Resident’s Guide that could be considered new information for experienced caregivers. But in a way, for us at least, that’s the point. These issues are so woven into the fabric of our work experience that they become second nature to us and sometimes we lose sight of the fact that what might be obvious to us might not be as clear to someone else. A guide such as this, geared for new residents and their families, can help us become more aware of the basic kinds of information new residents need to help them cope with what can often be an overwhelming psychological adjustment.

In another way, as Dr. El invites us to in the foreword, the book helps us step into the new resident’s shoes because it reminds us of when we as caregivers were new to the system. The whirl of faces and personalities, the jargon, the strange cultural norms and customs of the facility and care unit, were all things we had to adjust to. Now, with a little imagination, we can put ourselves in the place someone who might not be feeling well to start, who perhaps has gone through a sustain period of loss and now has to adjust to this strange new world. Our empathy can begin even before the resident enters the front door.

Dr. Eleanor Feldman Barbera is an accomplished speaker and consultant with 20 years’ experience as psychologist in long-term care. Her blog, My Better Nursing Home can be read here. Dr. El is also a regular contributor to McKnight’s LTC News. The Savvy Resident’s Guide is available on Amazon as a paperback or as Kindle book here.

Who’s the One with Dementia?

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Minstrel

For those who might not have seen the ‘goddess’ of dementia care (imho) Teepa Snow in action yet:  Teepa has a wonderful skit she performs in her training programs.  At these programs the audience members are generally caregivers.  Teepa will play the role of the caregiver while an audience member takes the role of the person with dementia.  (Every caregiver becomes an expert in this role!)

Caregiver, smiling:  “OK, Jeannie, time for bed.  Let’s go to your room.”

Person with Dementia: “No.”

Caregiver: “C’mon, time for bed.”

PwD: “No.”

Caregiver, now frowning:  “Now Jeannie, it’s time for bed.  You know you’re tired.”

PwD: “No, I’m not.”

Caregiver, in a louder voice: “Jeannie, it’s time for bed.  Come with me.  You need to go to bed.”

PwD:  “No!  I’m not going.”

Caregiver, louder still:  “Yes, you are!  It’s bedtime and I have to get you ready for bed!!”

PwD, now pushing and screaming:  “There’s a stranger after me!  He wants to rip my clothes off!  Stop it!  Somebody HELP me!!  I want my Mother, where’s my Mother!!  I want to go home!!”

Caregiver, louder than ever and totally exasperated: “You come with me right this minute!  You are COMING WITH ME NOW!!

As Teepa asks at the end of her role-play: Which person seems to be the one with the cognitive problem?  The one who seems to know what she wants (not to be put to bed yet), or the one who is hell-bent on getting the dementia-impaired resident to change her mind.  The resident probably can’t change her mind at this point, especially not in response to a caregiver who repeatedly sends, in an ever louder and more frustrated voice, the same message: DESPITE YOUR WISHES, I’M GOING TO PUT YOU TO BED NOW.  If anything, the caregiver’s rising frustration triggers the resident’s fight-or-flight instincts.

For CNAs, this is the question of the hour: What do I do when a resident won’t cooperate?  Do I become more and more insistent, and in the process arouse further defiance in the resident?  Maybe I worry “I need to rush.  If I don’t get everyone ready for bed by the end of the shift, the unit manager will be furious with me.”  (PS: Remind her of that person-centered care she’s trying to sell to families—and which the brand new CMS regulations confirm.)  Do I gripe to my co-workers?  Or do I try something new.  We CNAs develop great ‘tricks of the trade.’  My secret weapon is music.  Others try chocolate.   Sometimes a short walk will help.  Or we might initiate discussion of a favorite family photo.  Trial-and-error is the name of the game.  Creative redirection.  The point, as Teepa Snow and Naomi Feil teach us, is to connect with the person.  To empathize with the underlying emotion being expressed and validate that emotion.  To engage the person in an experience they might enjoy before moving back to the ADL.

All this takes time.  But taking time to engage a resident isn’t a frill.  It’s an essential part — the best part, of being a CNA.

The Wit and Wisdom of Edison Terrell

 

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Edison Terrell

Caregiver, author, and occasional contributor to this blog, Edison Terrell offers a unique perspective on caregiving and life. He is currently working on a collection of caregiver related stories and musings titled I Take My Pills with Ice Cream. Edison is a frequent poster on CNA related social media and with his blessing we are sharing a sample of his recent offerings.

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Telling people to leave work at work is stupid and futile advice in Healthcare, but it’s telling that the advice is most often given by those who have bare minimal to zero patient interaction.

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I realize now that the greatest obstacle to compassion is compartmentalization. It’s snuffed out like a candle the moment a person’s humanity is boiled away to simplified descriptors. Compassion can’t survive the process of a human being turned into a list of qualities.

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Some days my motto is “Finish strong!” Most days it’s just “Finish.”

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I think we may have lost sight of the fact that trust and scrutiny aren’t mutually exclusive. When I put on my scrubs, I expect my quality of work to be under examination, always. I expect that my team’s work is at least up to par, and that we navigate our sometimes ethically muddy road as best we can. I have a duty to my clients, my patients, my residents. Because the nature of my job gives me power over them, and power to make decisions for some of them when needed, such as when they’re extremely aggressive or can’t do things themselves. I think that with power over people comes not just a responsibility from within to do your best, but from without to analyze your behavior–in all reasonable terms–that it’s truly satisfactory. I wouldn’t wish anyone to fully trust anyone in my position to the point they turn a blind eye to what one, a few, or many are doing to bend the rules to breaking.

*

Even people like me who claim to want to observe the truth as it is in all its harshness and starkness at all times, hate learning the truth and living it. It’s far easier to say “l want the truth” than it is to hear it, and most if not all people–including me–who want the truth won’t hear it the first time or even the first several times. Maybe not the first hundred times.

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Sometimes my compassion overflows to the point everything drops away and it’s just me and the person in need of me… Most times I’m groggy and hate being awake before noon.

*

I think to myself “I’m not as nice as I think I am,” and feel good with that assessment, like I’ve gotten to the heart of it: I’ve pulled back the layers of ego and exposed the shit heel underneath. But it occurs to me that by doing just that I’m letting myself off the hook. I might even be using it unconsciously as a shield. So maybe framing my thoughts in different terms will help me. I can be nicer to people. They deserve my kindness and don’t deserve my meanness; I will be nicer to people.

*

On the seventh day, the LTC administrator allowed her employees a 5-minute break, realizing for one sane moment she wasn’t actually God in human form. Four minutes into the break she angrily cracked the whip with a “Get back to work, slackers!” because she remembered she was actually the devil’s.

*

It’s not the thought or feeling that creates the mood, but my belief and investment in it. A passing cloud is only a passing cloud, no matter how dark or fearsome.

*

My client got the news that he would never walk again today. First time I’ve heard those words in real life and they struck so hard I felt them, too. This is a guy who never gives up, no matter the difficulty or how much of a pain in the ass he is. The droop in his shoulders were like a wall coming down.

*

Who gets a cold in August? Healthcare people, that’s who.

*

I got a call today about a potential new client from a home care agency that found me on Care. They were desperate to get someone but couldn’t match my minimum pay requirement because they “only charge the client a few dollars more an hour.” Bullshit, they bill Medicare at least $45/hour. She said she could give me 10 an hour, so I lied and said I was making 20 at my current job. She said the most she could maybe do is eleven. I waited her out. “Twelve,” she says, clearly getting annoyed. “That’s the best I can do, I don’t pay anyone that much.” I said I’d meet her Friday

That’s how my daddy taught me. Lie like a dog, cuz nobody’s first offer is gonna be what you deserve. 12 isn’t what I deserve, but it’s closer than 10. Whether I take the job or not is no consequence, the most and truly only important thing when dealing with these types is squeezing them for as much as possible.

*

Every aide and PT in this place is in awe that I can work with my client almost every day. They say “How do you do it? He’s so aggravating!” And I reply “I do it so I can leave my wife something behind when he finally drives me to murder-suicide.” We both laugh at that, but I’m not sure I’m not serious.

*

I think if I could ask the heart the value of this kindness or that kindness, big and small, the heart would answer that they have equal value. The ego calculates the weight of goodness but the heart perceives a million dollar donation the same way it does a few pennies.

*

There’s a vast gulf between a simple job and an easy one.

*

Gotta say, for a guy who recently learned he may never walk again, my client has been killing it in the gym. Privately to himself, and occasionally out loud at the end of his sessions as he collapses in his chair sweating from exertion, he tells me in a hoarse voice “I can’t believe what she said. What a discouraging notion.” But he still puts his feet on the modified exercise bike, still glances at the bars now and then from his position on the mat, and unfailingly puts everything into the workout, no matter how banal or degrading it might make him feel. This guy pushes all my buttons every day but I can’t help grudgingly admiring the guy and raving about his determination. I hope he keeps it up to the end and I get to witness one of those miracles I only see on television.

*

I’m more make-believe than solid on closer inspection.

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I find sad/sappy music is the best for my drive to work. I tried my workout playlist a few times to psyche myself up but it just made me more tired. Downbeat stuff, though, paradoxically lifts my spirits. Maybe misery really does love company.

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I have this prank I do at work where I sign up for tons of doubles and extra days and shit and this one part of my brain is like “Dude, what are you doing we’re gonna have no time off!” and I’m like “Lol don’t worry about it, bro, I’m pulling a prank. I’m not actually gonna do any of these shifts.” But then the day of the shift rolls around and I realize I’m broke and need my job more than I need to sleep and I go in anyway and it turns out I was pranking myself the whole time.

*

Changes that threaten me, when looked at a little more deeply, don’t actually affect me at all. Just the ideas that I hold to be me. What I want. Everything that bothers me only does so because it conflicts with an idea of the way things ought to be. But me, the closer and harder I look for me, the less I seem to exist as I believe I am. Fear is the glue that holds this false identity together, and when that fear loses its grip, so do I, and I disappear in the best way.

*

Every day is another priceless lesson in patience and compassion, and I mean that sincerely.

 

There’s Nothing Like a Good Dog

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Yang

As I begin the HS care routine, my thoughts wander to home, to Jenny and the girls. I always get a little tug of homesickness around this time in the shift. The girls are picking out their bedtime stories right now, each gets to choose one book and they pick one together.  They’ll gather around the bed of our youngest – along with our little Australian Shepard, Kip – and Jenny will read to them. Then, she’ll tuck them in, kiss them good night, and they’ll drift away with Wynken, Blynken and Nod. Not being there is the hardest part of being here.

Tonight, it’s worse than usual because I’ve been pulled to a unit that I’m not familiar with and I’m the outsider. I don’t know the staff well and I know nothing about the residents in my group, save for the information on my “cheat sheet” and what the other caregivers have time to tell me. For the rest I have to depend on what I can glean from the residents themselves.

Ziggy can’t help me much in that regard. He has a pleasant demeanor and he follows simple cues, but he doesn’t respond to all of my questions and when he does respond it’s with a nod or one word answer.  And he seems reluctant to maintain eye contact.

In the dietary column, the cheat sheet states that Ziggy is a “feeder,” an uncomfortably crude way of saying that he can’t eat without total assistance. But the information is accurate, as I discovered at supper time. He loves to eat – that isn’t on the cheat sheet – I couldn’t get his dinner on the spoon fast enough for him. He polished off his tray in ten minutes and accepted a second dessert when one of the regular caregivers offered. For caregivers, there is something satisfying about a resident who likes to eat. And I could tell from the regular caregivers’ interaction with him that he is just about everybody’s favorite. That isn’t on the cheat sheet either.

There is a lot about Ziggy that isn’t on the cheat sheet. You can’t tell a story in box.

He nods as I explain that I’m going to help him on to his bed, but he says nothing. Under the “transfer” column of the cheat sheet, he is listed as 1HH, meaning one human help. He is as tall as I am and not thin, but if the sheet is up to date, he should be able to bear weight and I should be able to get him into his bed without having to ask the other caregivers for help.

I position his Geri chair parallel to his bed, about midway between the head and foot. This leaves room for me to help him stand and pivot 90 degrees, then ease him into a sitting position on the edge of the bed. The next step is to use the edge of the bed as a fulcrum and help him swing his legs into the bed, effectively creating another 90 degree pivot. If all goes to plan, his head will end up straight on the pillow.

I pause after getting him on the bed. I always like to take a moment when a resident is sitting on the edge of bed, whether it’s in the process of getting out or going in.  Just to let him get his bearings after the change of position. Sometimes I’ll sit on the bed with him – for just a moment or two – steadying him if necessary.  

As I’m sitting next to Ziggy, my attention is drawn to two photos tacked to his personal poster board hanging on the wall over his night stand. Other than the Activity Department’s weekly newsletter, the photos are the only items on the board.  In most of the residents’ rooms these poster boards are covered with various personal items such as photos, greeting cards, notes, and assorted decorations. For our residents, these items sometimes serve as tangible, but slender connections to the lives they had before they came here. For us, they provide tiny shreds of evidence of who they are as people.

One of the pictures is an 8×10 of a gorgeous pure bred German Shepard standing in someone’s front yard. A smaller photo shows a much younger Ziggy kneeling next to the Shepard with his him arm draped across the dog’s back. Both photos are faded, dog-eared, and peppered with a dozen thumb-tack holes along the top edges.

From my spot on the bed, the larger photo is within arm’s reach. I lean over, remove it from the board, and hold it up in front of Ziggy.

“He’s beautiful, Ziggy.”

Ziggy reaches for the photo and I hand it to him. He studies it and nods. “Chummy is a good dog.”

Okay, present tense then. I’ll follow his lead and we’ll stay there. “Yes, he looks like a great dog.”

He nods again. “Chummy is a good, good dog.”

“Are you best buddies?”

“Yeah. He’s my dog.”

He still hasn’t taken his eyes off the photo.

 “Do you play with him?”

“Yes… he plays.”

 “There’s nothing like a good dog. I have one too.”

He looks at me, eyebrows slightly raised.

“Here, I’ll show you a picture of her.” I lean back and retrieve my wallet from my front pants pocket. I slip a small photo of Kip from its protective plastic sleeve. The picture shows Kip with all four legs off the ground, snatching a tennis ball in mid-air.

Ziggy is impressed. “He’s a good dog!”

“Yes, she is,” I agree, but I stand firm on the gender. “She loves to play fetch. We play until I get too tired to throw the ball. I always get tired way before she does.”

Ziggy chuckles, he’s familiar with that story.  I hand the photo to Ziggy. He’s still holding the picture of Chummy in his other hand and looks from one photo to the other, apparently comparing the two dogs.

“Ziggy, do you suppose Chummy is more expensive to feed than Kip?”

He grins, “Oh yes, Chummy eats a lot.”

“Kip loves to hunt.  One time she ran away and came home with the leg of a deer. And rabbits don’t dare to come in our yard anymore. Does Chummy hunt too?”

“Oh, no, no. Chummy doesn’t hunt.” He hands me Kip’s picture and returns his gaze to his Shepard. “Chummy is a good dog.”

“Do want to hear a secret about Kip, Ziggy?”

He looks back at me. “Yes… what is it?”

“My wife let’s her sleep in our bed.”

Ziggy shakes his head. “Chummy sleeps in his own bed.”

“I know, we’re not supposed to let her on our bed. But we do anyway.” I put my hand on his shoulder and say, “At least there is one thing that we both know…”

He looks at me again, “What?”

“… There’s nothing like a good dog.”

He smiles and nods. “Yes, Chummy is a good, good dog.”

I proceed with his HS care and wonder if Ziggy will dream about Chummy tonight. I hope so.

I also wonder what other connections we could make if I had more time and knew more about who Ziggy is.

Unsafe at any Weight

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Minstrel

I became a CNA at an age at which most people are retired. By this time most CNAs have backs, knees, shoulders that are broken down or on their way to that. On my first day on the job, the CNA I was shadowing asked, “HOW old are you? You’re never going to be able to do this job.” Biologically speaking, I could have been a grandmother to some aides. But I was in better shape than many, in terms of weight and flexibility. Some aides arrived at work groaning, “My back is killing me!” “My knees are soooo bad today.”

 In reality I could do everything a CNA needed to do. But there was one thing I couldn’t / wouldn’t do: move a two-person assist alone. At first the experienced aides helped me. But soon they expected me to care for these residents without help, as they did. There seems to be a machismo culture among aides: “I can do this on my own.” I was saved by the fact that our unit supervisor had posted a list of all residents who needed the assistance of two aides to be moved. When I needed help I asked for it and was given it. But other aides wouldn’t ask me or each other for help, except in the toughest cases.

Who is a two-person assist? A person doesn’t have to weigh much to be a dangerous dead weight when she needs to be moved. Even frail, thin persons become dead weight when they don’t have the bodily strength to stand or the cognitive capacity to follow instructions. The CDC, OSHA and other organizations have developed algorithmic guidelines which state in effect that unless a person is both fully weight-bearing and able to cooperate in the action (that is, able to understand what is needed and able and willing to do what is needed), then the resident needs two persons, sometimes more, and sometimes also requires mechanical equipment, to be lifted, repositioned, transferred. Fellow aides: How often is this the rule of thumb where you work? Given staffing levels, how many of you have time to stop to help others with residents who should, under the guidelines, have the assistance of at least two persons when they are moved? How many of your co-workers have time to help you?

Unfortunately, as far as I’ve been able to learn, failure to provide adequate staffing to ensure two-person assists for all non-weight-bearing residents isn’t an OSHA violation that has any penalty attached to it. This is a guideline and not a mandate. Thus LTC homes might not be as worried about compliance with these guidelines as they are about Medicare rules. But some states might have tighter rules. And guidelines do have some weight in policy-making in LTC homes.

Despite my facility’s two-person assist list and despite all the guidelines, many aides chugged right along, lifting residents without help. Both the resident and the aide are at risk of injury (or at least distress), but aides insist on flying solo. Sometimes we’re our own worst enemies. CNAs: Let’s call a truce with our aching bodies! It’s worth a try to work with our unit supervisors to develop a two-person-assist list, using it to transfer residents more safely and comfortably.

A Matter of Death and Life

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Yang

The subject of death comes up often in this line of work. On this blog, Alice and May have visited it on more than one occasion. They have shared how they experienced losing residents they’ve known and cared for, and how they cope with the deep sense of personal loss. These experiences and feelings are echoed every single day in the hallways of LTC facilities and on social media. Death and loss are realities that all caregivers have to deal with at some point. For some, it becomes too much to bear and they leave the field.

Death is also at the heart of the negative public perception of nursing homes. The term itself, nursing home, evokes images of forsaken and forgotten souls, a place where we “stick” people when they are no longer of any use and we don’t want to be bothered with what’s left of them. That even facilities that offer good care and where the residents seem content, are still essentially gilded human warehouses, nice places to go and wait for the inevitable. Abandon hope all ye who enter here.

Those of us who work in direct care know that the reality is not quite that dreary. While we can be the staunchest critics of the nursing home industry – because of what we know about the very real problems – we also know that these places are and can be so much more than just human warehouses. We know that not everyone who enters them is prepared to simply submit and waste away. That sometimes people who have experienced severe neglect on the outside can actually rally after admission. Good medical care, proper diet, therapy, and a sense of community and belonging, can go a long way in restoring a sense of wellbeing and hope. That yes, even here, life goes on.

While good care is essential, it does not address the deeper question of a meaningful existence. Here, in the final stages of life, where comfort is often regarded as the highest value and the will to live runs on sheer momentum, the question arises – and I’m going to be blunt – why bother? Why bother to go on when you no longer feel productive or useful? Why bother when you feel as though you’ve become nothing but a burden? Why bother when you’ve lost so much that you hold so dear? And the toughest question of all: why bother when the end result is going to be the same no matter what you do?

Good caregivers do all they can to address the “why bothers?” Through our awareness of our elders as individuals and by engaging them emotionally, we assure them that if nothing else, they still matter because they matter to us. We can’t give them back everything and we can’t reach everyone, but there are opportunities to make a real difference and we morally obligated to make the most of them.  

Still, there is that nagging reality always present in background, the sense of doom and meaninglessness associated with our mortality.

But we are not powerless. First, we have to reject the conventional view of aging: that the final stage of life is less meaningful than everything that comes before it. We need to embrace the idea that we can change, grow and develop right up to the end. And we must stop downgrading the intrinsic value of moments that are experienced during this stage of life. Even to the end, we can retain our capacity to be surprised or fascinated or enthralled, and to value the comic absurdity of life. And we can still lose ourselves in these moments and share them with those around us without reference to some ultimate meaning.

Second, we have to rebel against death itself. Not against its reality, but against its hold on us; against the idea that our fate to die must inform our actions and constrain how we experience life. We need not be held captive to the ego’s revulsion to nonexistence. By liberating ourselves from death’s grip on our being, we are giving ourselves permission to really live.

For our elders, it’s not enough that we tell them that life is still worth living.  Instead, as caregivers we must discover what that means to them, in the most specific, practical terms. We must facilitate and share with them, when we can, those things they find meaningful. Each time we do this, we are joining them in their rebellion against death and boldly answer the question “why bother?” And we celebrate with them one more victory in life.

“I’m Just Doin’ My Job”

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Minstrel

One of my all-time favorite movie lines was spoken by Paul Newman in Cool Hand Luke.  Luke, the non-conforming prisoner in a tough southern prison, refuses to accept the prison’s status quo.  His conduct is a cascade of rebelliousness, until finally the warden orders Luke to “the box.”  The box is a small tin-roofed building, the size of an outhouse, under the blazing sun in the middle of the hot, dry prison yard.  After Luke spends twenty-four punishing hours in the box, the guard releases him.  As he does he says, “Sorry Luke, I’m just doin’ my job.  Ya got to appreciate that.”  Luke replies,  “Nah, callin’ it your job don’t make it right, Boss.”   

Calling it our job doesn’t make things right.  Among the most pernicious problems in long-termcare homes is staffing shortages.  With a census of 25 to 35 residents or patients needing skilled nursing and/or dementia care, there might be only three to five aides scheduled to work a shift.  (Then there are the last-minute call-outs).  If the aide is lucky, very lucky, she may have only five or six persons to care for.  The more frequent reality is having seven to ten persons needing care.  Remember that cacophony of call bells that May wrote about?  Blame it on short-staffing.  And the resident pleading for you to take her to the toilet?  Oops, it’s already too late…  The resident teetering perilously as we rush to prevent a fall? … And the time you lifted a non-ambulatory person by yourself because there was no one around to help?  What about those wheelchair bound residents who haven’t been taken out to feel the fresh air in weeks?  The hits just keep on comin’.   And we keep right on keepin’ on, because it’s our job; right?   

No, it isn’t.  We simply can’t do our jobs as CNAs adequately when we’re so understaffed.  What most determines the quality of care is the staff-to-resident ratios (‘duh’).  I challenge anyone to find an aide who disagrees with this.   Yes, staff need to be trained in good care practices.  Yes, we need to have certain supplies available (soap, towels, functioning hospital beds, appealing food, etc.).  But the key to quality care, to person-centered care is PERSONS.  Staff.  

We continue to work in short-staffed conditions we know violate our residents’ right to good care.  (See medicare.gov for a description of rights of persons in nursing homes.)  If we ‘complain’ to management about short staffing (and that’s how it’s viewed, as a petty complaint), we’re told sweetly that the staffing levels meet the state requirements.  And that’s probably true, because industry lobbyists have made sure that state regulators don’t burden the long-term-care industry with costly staffing requirements.

We complain about these deplorable conditions all the time.  As CNAs we’re mandated reporters of abuse.  (I guess we’d better not think about that one too much!)  But we tolerate abuse that residents endure as a result of understaffing.  Abuse isn’t just about physical or sexual assault.  It’s also about neglect and emotional abuse.  If I neglect a call bell for so long that a resident is left to soil himself and remain in his soiled condition for hours, that is abuse.  If I say to a resident who asks to be taken to the toilet, “Janie, I just put a clean Depends on you; I can’t get you back into the Hoyer lift and take you to the toilet, you have a diaper on, you can use that,” that is abuse.  Abuse is ridiculing a resident who cries for her mother all afternoon; scolding a resident who spills her drink all over the floor; ignoring the call bell of a resident who constantly asks to be taken to the toilet minutes after the last toilet trip, because we know she ‘doesn’t really have to go.’  Well, she needs something and it’s our job as aides to find out what.  “But I don’t have time for all that.  I have seven other residents to get to.  I’m just doin’ my job.”  

So what can we do?  Unlike the workers of the 1920’s and ’30’s, we can’t go on strike to win better working conditions.  We’re caring for the sick and the frail, not assembling cars.  But if we can’t leave the floor for a sit-down strike, we can use our cell phones as weapons in the revolution for better care.  Call your county or state abuse hotline every time aides have more than six residents to care for on a shift.  (And don’t count the LPN or Medication Aide in your ratio if she isn’t providing care, even if management does.)  The state regulators aren’t always thrilled to receive reports of abuse because they are short-staffed too, and don’t have the means to investigate all complaints properly.  They don’t always to a good job, for the same reasons we don’t always: because they’re understaffed and a little intimidated by their bosses.  

Revolution isn’t about violence and nastiness. (Remember Gandhi and Mandela and Rosa Parks.)  It’s about patient persistence and never giving up as long as change is needed.  It means taking that first step.  Maybe our first step will be a phone call.