Author Archives: Bob Goddard

Lost in Translation

 

Corey

Where is my mother? Father? Brother? Husband? When these questions come from my residents at three in the morning, I have to do an on the spot assessment. If not handled correctly, these conversations can quickly spiral into an emotional meltdown that unnecessarily traumatize those living with memory disorders.

Too many people, from the doctors to new caregivers, make the rookie mistake of attempting to pull those living with dementia into their level of awareness rather than meeting them where they are. Instead of trying to convince those living with Alzheimer’s or dementia of our reality, it is better to actively listen through the words they say to assess the resident’s needs.

When I hear “where’s my mother,” I think about what my resident’s mother might have provided her that she may be missing in that particular moment and attempt to fill that need as best I can. It is not 100% effective but it has worked better than any other method I’ve utilized so far in this field. Where’s my mother at three in the morning could mean any number of things. Did she have a nightmare and need reassurance? Did she wake up hungry? Does she need to use the bathroom? Is she in discomfort? All of these basic needs were once taken care of by her mother and in recognizing that, I am usually able to put her at ease and through the process of elimination, discover and solve the problem my resident could not articulate.

Have you ever been anxious or frustrated or simply in a funk for no specific reason? Maybe you didn’t even realize you were feeling down until someone said or did something that pulled you from it? It’s happened to me plenty of times and it’s a strange feeling when my emotions don’t match with my reality. Imagine walking through that with severe cognitive impairment, when your reality is just as fluid as your emotions. It would terrify me if someone attempted to convince me that what I know in my mind to be true isn’t real. I would be too scared and frustrated to comply with even the simplest of suggestions. Part of caregiving is learning how to translate. There is a language and understanding that can only be developed by active listening, keen observation skills and empathy. It up to us to first understand that language and then translate it for those who don’t know those in our care as well as we do. It is how we make certain our residents do not get lost in translation.

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.

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.

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.

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.

  

Claire’s Chairs

 

 

Bob Goddard

One of the primary concerns in Claire’s early development is her tendency to rely on arching her back as a means of movement. Like any other infant, she has a natural impulse to move her body, but because of her ACC she is unable to easily perform more complex forms of movement that require coordinating her hips, legs, and arms, such as crawling or sitting up by herself. Her dependence on arching inhibits her gaining the strength, flexibility, and confidence required for these more refined movements. We must condition her not to pop into that backward extension.

One of the key elements in helping Claire overcome her “arch addiction” is posture training. The mantra here is 90-90-90: hips at 90 degrees, knees at 90 degrees, heels at 90 degrees. For this, we have a small arsenal of chairs at our disposal.

The most useful of the bunch is the corner chair:

Not only does the corner chair help Claire maintain the 90-90-90, it also provides support on each side. A tray fits over her lap, allowing her to manipulate and play with objects and enables us to engage with her without the necessity of us physically supporting her. The corner chair is comfortable and secure enough that she can spend up to an hour or more at time in it. Since Claire spends most of her time at home, we keep the corner chair at Hiliary’s house.

At our house we use the Lechy chair. This essentially works the same as the corner chair, but without the side supports. We have to make several modifications to make it work for Claire: we use a book to bring her small body forward in the chair so that her knees are at 90, an empty box for a platform to rest her feet, and a scarf loosely secured around her ankles to help keep her feet at or near the all-important 90. As with the corner chair, there is a tray for activities.

I also use what I simply call the “red chair.” Claire is secured in the red chair by vertical straps and a pommel. The floor serves as a platform for her feet. Unlike the corner chair and Lechy chair, I have to stay within arm’s reach of Claire while she’s in the red chair because she is quite capable of rocking it and there is a real potential for a pretty severe face plant. One advantage of the red chair is that there is zero pressure on her abdomen, so I actually prefer to use it after she eats. This is especially important given Claire’s problem with acid re-flux.

While the chairs serve a critical function, they are only a part of the program. The real strengthening comes from floor play, and from the habits and practices of her caregivers: how we carry her, hold her, and pick her up. I’ll talk about these in upcoming posts.

At some point, Claire will learn to sit up by herself and crawl and eventually walk. But the quality of these accomplishments will depend in large part on how well we can help strengthen and redirect her body now. And since it all works together, this will have a major impact on her cognitive, social and psychological development as well.

My New Work Partner

 

 

Bob Goddard

In my last post I talked about the value of good work partners. For a caregiver employed in LTC, working with a good crew can make even the most difficult situations tolerable. A healthy and happy work environment isn’t really sustainable without making some effort to maintain a positive working relationship with your fellow caregivers.

In this job, you really do have to take care of the people around you. This includes an awareness of your coworkers’ needs and circumstances. Yes, we are there for the residents, but when we neglect or mistreat our work mates, we are poisoning our own work environment and this will inevitably impact the people who live there. I’ve known some aides that had some great qualities as caregivers, but couldn’t keep their mouths shut when it came to what they perceived as the inadequacies of other workers. Rather than simply dismiss fellow caregivers as unworthy of the work, how much more effective it would have been had they offered their assistance without judgement when they saw a need and perhaps through their actions provide a better example of how to approach the job.

In my current daily routine with Claire, I am blessed with a great work partner: my 4 ½ year-old granddaughter, Aubrey. From a caregiver’s perspective, Aubrey would be considered a part of my “case load.” Indeed, she does demand considerable time and attention – and she can be quite a distraction for Claire. But she also assists me in ways both big and small. In fact, when it comes to Claire’s care and training, she can do some things much better that I can.

Like my old work partner Russ at the Veterans’ Home, Aubrey is very familiar with our care routines and habits, and she knows when to jump in and help. Most of the time, she’ll do this without direction from me. If I’m involved in some task away from Claire and she gets fussy, Aubrey is right there to give her sister a pacifier or entertain her with a toy until I’m able to focus on Claire again.

Whenever I’m engaged in an activity with Claire, I always make sure that Aubrey has the opportunity to participate if she chooses. Just as Russ and I complemented each other with our differing approaches to our residents, Aubrey adds a quality to the activity that I am unable to provide. Claire simply has more fun and stays engaged longer if Aubrey joins us.

Of course, I often have to redirect to keep both girls on task, but I try to do this by example and not through verbal correction. Sometimes the structure of the activity breaks down entirely, overwhelmed by sisterly chaos and mirth. That’s okay, at that point, we just move on to something else.

When Aubrey chooses to occupy herself in parallel play, she can still be extremely helpful. In our effort to correct Claire’s dominant tendency to arch her back as a means of mobility, we do a lot of floor work in which we try to keep her focus forward. Sometimes this is simply a matter of sitting her on the floor, placing her favorite toys in front of her, and having her reach for them. If Aubrey is playing nearby, I always try to orient Claire toward her sister with the toys in between. To Claire, Aubrey is the most fascinating thing in the world and she’s more motivated to sustain her forward focus when her sister is in front of her.

Like any work partnership, this is a two-way street. One of Aubrey’s favorite activities is taking care of her babies. When I’m busy with Claire, Aubrey is busy with her “group.” This consists of one or usually several “Baby Alive” dolls, most of which are capable of some bodily function.


Aubrey takes her care activities very seriously and I am obligated to pay proper respect to her efforts and assist her when necessary. Sometimes this means I have to stop what I’m doing with Claire to help Aubrey put some article of clothing on one of the dolls or take a turn feeding one of them or perhaps help search for some microscopic toy part of critical importance. Other times, it can mean turning off the music and tip-toeing around the house, because it’s nap time for her babies.

Here, I was rightfully chastised for taking a photo that happened to show in the background her changing her baby  (“You DON”T do that!). I duly apologized for the indiscretion:

Clearly, it would be a mistake for me to dismiss Aubrey’s play concerns as frivolous. If I want her cooperation with what I do with Claire, then she should be able to depend on me to do the same for her group – whatever that may consist of from day to day. That is what good work partners do.

There is something else going on here. Aubrey will often use her babies to imitate my activities with Claire. She’s learning by watching and doing, developing skills that will serve her for a lifetime. In a very real sense, I’m training her as much as I’m training Claire. And while Aubrey does not yet grasp the meaning of Claire’s ACC, she is already learning some valuable lessons on how to treat it. As both girls grow, Aubrey will have more influence on her sister’s development than any of us.

In a couple months, I will be losing my valued work partner. Having recently graduated from preschool, Aubrey will be attending full-day kindergarten this fall. While this will leave me more time to work with Claire, I’m really going to miss my little work partner.

My Old Work Partner

 

Bob Goddard

For a caregiver, there is nothing like a good hall partner to make the shift go right. Reliable coworkers that you get along with can help you maintain your sanity even on the most challenging days. They can make the difference between looking forward to coming into work or dreading it. During my 25 years as a caregiver in the veterans’ home, I had many such hall partners. One that stands out for me is my old buddy Russ.

While we worked well together, Russ and I had completely different personalities. Russ was loud, gregarious, and not afraid to speak his mind – to anyone. He was a big guy, with long hair and sported more than a few tattoos and body piercings. I was always more reserved, careful with my words, and more deliberate in my actions. And I was far more conventional in my appearance. However, he did talk me into getting a couple of small tattoos, one of which he did himself as a budding tattoo artist.

On the unit we complemented each other well. We were each assigned permanent groups, but we knew each other’s residents as well as we knew our own. When one of us had the day off, we knew the other would be watching out for our respective residents. “Take care of my boys tomorrow,” Russ would remind me before a day off.

We also knew each other’s routine and work habits. Russ was always around when I needed help. I always pretty much knew where he was and I didn’t have to spend a lot of time running around the unit looking for someone to spot me on a Hoyer lift or assist with a two-person transfer. And I did the same for him. I just kind of knew when to show up in one of his rooms. In fact, Russ referred to this as my “Jedi Wall Trick,” this uncanny ability to suddenly, but quietly appear – as if I walked out of the wall. It actually kind of freaked him out a little; he would grin and shake his head, and ask me to stop doing that.

We each took different approaches to our residents. Russ was more forward, sometimes a little too forward, and I would have to steer some of his interactions in a more appropriate direction. The same level of familiarity with certain residents in a care situation might not be as acceptable in a more public setting. At the same time, Russ had a knack of bringing residents out their shell and could reach them in ways that didn’t come natural to me. He showed me that being authentic, especially when laced with humor can help break down social barriers and actually strengthen the bond between resident and caregiver.

Due to the nature of the beast, caregivers in an institutional setting often have to work with a looming sense of turmoil and even fear. We may like the work and enjoy our residents, but sometimes we’re not so crazy about our place of employment nor the system under which we work. In this kind of atmosphere, we learn to rely on each other to keep it real. And more than anything, Russ helped to keep it real.

In my next post, I’ll talk about my current work partner.  She’s a few feet shorter and a couple hundred pounds lighter than Russ, but just as valued.

The Power of Peek-A-Boo

 

 

Bob Goddard

I play peek-a-boo with Claire every chance I get. In fact, it’s our default activity. When I can’t think of anything better to do or time is limited, we play peek-a-boo. And it never gets old for either one of us.

In the first place, it’s just fun. Peek-a-boo is an easy way to make Claire smile and laugh. Making my face “disappear” builds tension and its reappearance becomes the exciting resolution. Exaggerated facial and vocal expressions enhance the comedic and dramatic effect. It’s become like an inside joke between the two of us.

The game has a serious purpose. It teaches object permanence, the understanding that when things “disappear” they aren’t really gone forever. That is, things can be mentally represented even when we can’t see, hear, touch, smell, or taste them.

Object permanence begins to develop between 4-7 months. It is a precursor to symbolic understanding, a major building block for language skills and cognitive development. It’s a very big thing.

Claire and I work on object permanence in more direct ways as well. I present an interesting object:

… and then I hide it on her tray table under a screen, such as a small cloth. Her job is to remove the screen and retrieve the interesting object. If she’s not showing sufficient interest or motivation, the object, I expose part of the object.

Sometimes Claire finds the screen to be sufficiently interesting in itself and simply picks that up, mainly for chewing purposes, and ignores the original interesting object. One way I counteract that is to use my hand as the screen:

And it works thusly:

 

Another twist in object permanence training is to add a second layer of screening, such as placing a box over the object with a towel over the box.

Peek-a-boo can also evolve into more complex games. In one variation, the adult leaves the room all together and then reappears, or speaks to the child from the other room. This form of play can help ease separation anxiety.

But even in the most basic version with hands covering the face, there is a lot going on when we play peek-a-boo. According to child development professionals, peek-a-boo can help with things like developing self-recognition and teach cause and effect. And it is a form of social interaction. Combining this social aspect with the gross and fine motor activity associated with the game has a synergistic effect on development.  Experts tell us that symbolic understanding is a complex operation requiring the integration of a number of processes and as in any aspect of child development, it all works together.

Claire and I will continue to play this game every chance we get.  And I expect we will find new ways to play.

Do What You Can, With What You Have


 

Bob Goddard

In my last post, I listed a selection of conditioning exercises I do with Claire during the day. These exercises address some of the developmental deficiencies associated with her ACC. The hope is that by doing these things now, we can avoid bigger problems as Claire grows.

Like a caregiver working in a long term care setting, my efforts are subject to the limitations – and the opportunities – presented by my work environment. While good caregivers strive to focus on the wants and needs of a resident as an individual, they must do so while accounting for things like the facility routine, the well-being of other residents on the unit, the concerns of family members, and the need to assist coworkers. One of the great disconnects in LTC is that regulations, policies, and training fail to adequately account for the environment in which they are to be implemented. Caregivers do not have that luxury and must learn to balance the needs of the individual with these other concerns.

While the venue is different, my work with Claire involves the same kind of balancing act. I would prefer to spend most of the day focusing on her developmental training, but the reality is that other matters limit the time I can devote to these exercises and I have to adjust accordingly. I think the best way to illustrate this is to share what our Tuesday was like last week.

On Tuesday mornings, Claire goes to physical therapy from 8 to 9. Her mother, my daughter Hiliary, takes Claire to these appointments while I take Claire’s sister, Aubrey, to preschool. After Claire’s appointment, Hiliary drops her off at my house and goes to work…

Our Tuesday

It is 9:30 now and Claire has been up since 6:30. She always needs a nap within a couple hours of waking. She often does not sleep well at night and these mid-morning naps are essential. And she’s obviously tired from her PT session. I would really like to work on some gross motor and strengthening exercises, but my first task is to change her diaper and get her down for a nap.

Claire wakes up at 11. I have to pick up Aubrey from school at 11:30, so we have to leave the house by 11:15. She was due for her bottle at 10:45, but that isn’t going to happen until we return home with Aubrey.  I hold in her my arms and walk around for a moment or two, just to help her transition to being awake. I change her diaper and then go out and warm up the truck. It’s a cold and rainy day.  Now it’s time to leave.

We return home with Aubs around 11:50. Claire is overdue for her bottle and that’s the first thing on the agenda. Meanwhile, Aubrey retrieves from the refrigerator a small lunch that I prepared for her when Claire was sleeping. As Claire takes her bottle, Aubrey and I talk about the things we did the day before and whatever else pops into her active little mind.

By 12:15 both girls are done eating. I place Claire in her bouncer and turn on PBS, hoping for an animated kid’s show to keep her occupied while I get Aubs ready for her swimming class held at the middle school pool.  Super Y turns out to be sufficiently engaging. I wouldn’t mind sitting down and watching it myself. Another diaper change for Claire and we are out of the house by 12:30.

We get to the school by 12:45. I unload both girls and sign in at the school office. We scurry down the hallway toward the pool locker room, dodging several knots of loud and obnoxious middle schoolers along the way. It’s the last few minutes of lunch time and the chaos is palpable as the kids stream out of the cafeteria. I look down at Claire, still in her car seat. She’s smiling, clearly amused by the excessive animation of these strange and boisterous beings.

In the locker room Aubrey continues to entertain Claire by throwing her shoes and socks at me. I allow this. I take the girls into the pool area and we wait for the instructors and the rest of the students to arrive. Claire watches everyone, but is especially interested in the kids, who are all close to Aubrey’s age. As the teachers start the class, Claire and I retreat to the bleachers. The teachers ban family members from the pool deck during lessons to keep them from offering their unsolicited expertise.

I packed a number of toys to keep Claire busy during the lesson: her touch activated music maker, a small gang of Sesame Street figures for her chewing and tossing pleasure, a multi-function teething toy with mirror, and a stuffed Mickey Mouse that she has put through all the hell her little piranha like mouth can deliver. I take Claire out of her car seat and try a little object permanence exercise (more on this in the next post), but she isn’t interested. Freed from her cocoon, she now has an entire visual world to explore. The high ceiling and the lights in the pool room are captivating. The activity going on now in the pool is way more interesting than any object I might be hiding at that face towel.

The people around us in the bleachers are the most interesting things of all and she’s not shy about looking at them to get their attention. Her little head swivels back and forth, checking out everyone in her radius. An adult to the left of her is deep into his phone and doesn’t notice. Ditto for the mother on the right. Somehow they’re unaware of all this amazing stuff happening all around them.

It’s a strange and wonderful place that I’ve taken her to, but even with all that it has to offer, she becomes fussy after a time. It’s hot and humid in the pool room and I can tell she’s getting uncomfortable. I remove her socks and we leave the pool area. The hallway is pleasantly quiet now as the little heathens are safely sequestered in their classrooms. The cool air refreshes both of us and we spend some time checking out the shiny objects in the trophy case. She studies them for a moment, then turns her head toward me and smiles. Do I get how remarkable these things are?  We wave at our reflection in the window of the deserted auditorium entrance. And we spend a little time gazing out the window toward the parking lot. All the while, Claire is content and engaged.

We slip back into the pool room just as Aubrey’s lesson is ending. I strap Claire into her car seat and we hustle back to the deck area to help Aubs wrap up in her towel. As we return to the locker room, Claire is visibly tired, but not yet fussing. She’ll probably fall asleep in the truck on the way home.

On the way home, the girls’ father, Andy, texts me that he just got out of work. This means I’ll be taking the girls to their house and I won’t get another chance to work on Claire’s exercises. My day with her is over.

A Good Day

While I was frustrated over not being able to work with Claire on Tuesday, I know that regarding her development, it was far from a wasted day. I had to remind myself that Claire’s day started with a physical therapy appointment. So while I didn’t work with her, someone else did. After her PT session, my job was to address her most immediate need and that was to get some rest.

While we didn’t have a solid block of time that we could devote to Claire’s training exercises, we were able to fit some things into the day’s activities. Following each of her diaper changes for example, we played peek-a-boo, which is actually an object permanence exercise. When we took our little walk in the school hallway, I made sure that she always had to look to her right to see the interesting stuff. Her weakness is on her right side and she has a strong tendency to look left. So in effect, this served as a kind of conditioning exercise. When I handed her one of the Sesame Street figures, I made her track them left to right and then reach up to her right to get them. And while I’m not sure exactly how all her social observation and interaction works in her development, I’m guessing the experience connected a synapse or two.  All of this counts.

Once a week, Claire and I meet with an occupational therapist. She’s a really good one. She has over 30 years’ experience and is tremendously knowledgeable. But what I’m most impressed with is her ability to improvise with whatever items she finds on hand and alter equipment in order to meet Claire’s specific needs. I’ve worked with a lot OTR’s in the past and the great ones have always been master improvisers.

An experienced caregiver is also an improviser. But instead of improvising with things, we improvise with time. Even on the busiest days when other concerns dominate our time, we can find opportunities to address the individual needs of those in our care. The circumstances may not be ideal, but our efforts will make a difference.

And as a postscript to our Tuesday, Hiliary posted the following on Facebook that same night.  So, it was a good day after all.

https://www.facebook.com/hiliary.goddarddykstra/posts/1692208354177393