Category Archives: boundaries

The Things They Never Tell You

Sunflower  May

Here’s something that’s not quite––or not at all––a newsflash: human beings are sexual creatures.
Here’s something that’s (an often quite hilarious) newsflash: old people are still sexual creatures.
They still notice and remark on certain aspects of life that maybe we young folk would prefer they do not. Occasionally, we young folk are the ones they are noticing and remarking about.

At times this attention is sweet, like the nine marriage proposals I’ve received in the course of my career–only three of which were delivered in a location other than the shower room.
Or the time I went to wake up a resident and was subjected to a long, loud verbal tirade about how I was thoroughly unpleasant person and he was his own boss. This tirade derailed the instant he opened his eyes…prompting him to interrupt himself with “My God, you’re beautiful!” From that moment on, he treated every word out of my mouth like Gospel truth, to be obeyed immediately. I admit it: I quite enjoyed being treated like the Queen of the Universe. Being told that I was beautiful enough to derail a full-fledged, would-make-a-toddler-jealous temper tantrum didn’t hurt my confidence any either.
Then there was the time that I noticed a resident’s pant leg needed adjusting. When I bent over in front of her to fix it, I ended up getting a reminder that not everybody born before the 1960’s necessarily conforms to the Norman Rockwell image of heterosexuality. I will say that of all the passes ever made at me, hers was tasteful–far more in the nature of a compliment on my, er, physique than objectifying my body for her viewing pleasure. That woman had game.

∞oOo∞

And then, of course, there’s the far less enjoyable kind of attention. This comes in many forms, from overhearing a group of male residents ranking the female employees by sexiness, to outright asking me to climb into bed with them. You’ve got the “handsy” old men, the incessant dirty jokes, the lewd comments, the creepy stares…and the list goes on. I’m sure every aide out there has had an experience of some kind or another of this nature.
There was a time when I cleaning up an extra large BM that was, in spite of my best efforts, just getting anywhere. I became distracted from the mess when I felt the resident’s hand on my leg, slowly creeping further up. When I told him to remove his hand, he just looked at me, smiled and said: “What, don’t you like it?”
“Are you going to take your hands off me?” I asked him calmly. “Or do I have to use my hands to get yours  off me?” To illustrate my point, I held up my gloved hand…which just happened to be dripping BM. To anyone who says that there’s nothing like cold water to curb a libido, I can only guess that you’ve tried using BM. I’ve never seen anyone back off quite so fast as he did, or stay backed off for quite as long. I hardly needed to report the incident to my supervisor, whose first comment was that I “had managed the situation rather handily“.

Of course, it’s not just the residents who put on such displays of sexism and lechery. I learned very quickly to wary of certain visitors. I’ve had a visitor try to get me in trouble with my boss because I told him to keep his hands to himself. He was always trying to touch the female aides, especially trying to put his hand on a shoulder or upper arm and “steer” us around by squeezing. I objected to being touched so frequently and familiarly without my consent, especially after I politely asked him to stop. Unfortunately for me, he was one of those men who have trouble to concept of “No Means No” and began complaining to my supervisors that I was “rude”, “mean” and “hateful”.
Unfortunately for him, I’m fairly eloquent with written words and not afraid to defend myself.

Nor should you come to the conclusion that it’s only the men who make unwanted sexual advances upon staff. While I have noticed that some of the female residents do as well, they are far fewer…in no small part, I think, to the cultural conditioning that encouraged men to be aggressive and women to be passive. Also, there’s the same mentality at work that leads some of our residents to treat their caregivers as “the help”, instead of a skilled worker. When you’re perceived as standing a rung below them on the social ladder, many people feel as though they’ve been given a pass to act as they want to, without regard to your feelings.
But it exists still, with or without the spotlight. All the crap women have deal with in our still amazingly sexist culture, with a side of proximity. There is, shall we say, an intimacy of the caregiver-resident relationship that often exasperates the “normal” harassment. Personal space boundaries are in a constant state of flux in Long-Term Care. You’re often operating in what Edward T. Hall, the cultural anthropologist who pioneered the field of proxemics, called “intimate distance” (6-18 inches between you and the other person). This close proximity influences the dynamics between you and the resident, especially if that resident has dementia. They either react with hostility, “What is this stranger doing in my personal space?” or an assumption of familiarity, “She’s right next to me, so we must be close.” Or “She’s leaning over me, so she must be open to my attentions”. Inhibitions are lowered or forgotten, causing many people with dementia to act without the social filter. Is it any wonder then, when they make a move and react with confusion when they are shut down?
Of course, empathy in this situation is a tricky thing. No matter how well you’ve managed to put yourself in the resident’s shoes, how much you understand the factors that lead them to act as they do––you cannot deny the validity of your emotions. Sexual harassment is a demeaning experience, even if the perpetrator is your resident. We can’t just shrug it off and say, “Oh, well, it’s not worth the fuss,”. If we aren’t taught–or don’t learn–how to shut down such advances with compassion and firmness, we only encourage more of the same behavior, making life harder for ourselves and all our residents.

Either way, it’s one of the things they never tell you about. It’s one of the areas that we are, for the most part, told to report to our supervisors and then left to figure out on our own. How do you deal with the handsy residents, the lewd comments and other objectifying behaviors without demeaning the resident who is exhibiting the behavior? It’s one of those ethical obstacle-courses we deal with every day.

A Personal Question

Sunflower May

One of the recurring questions I heard at the Pioneer Network Conference earlier this year concerned how CNAs and other direct care workers refer to their residents/patients/clients.
I heard a variety of opinions, ranging from “Absolutely no pet names ever, it’s undignified and disrespectful” to “What does it matter?”
I don’t remember which individual it was who finally put forth the question: “Well, what does the resident think about this? Does the resident mind aides using terms of endearment?”
When I was asked for my opinion, I just shrugged and said: “I guess it depends.”

Having worked for years in Long-Term Care, this wasn’t the first time I’ve run into this issue and I doubt it will be the last. It’s one of those loaded topic, where everyone involved has surprisingly strong opinions. I think people lay bits of themselves on the line with this question…maybe it’s one of those questions that you can’t ask without thinking: “What do I want? What are my wishes and will they be respected if I can’t enforce them?”
My answer to the question is quite often met with confusion and occasionally disdain, but the truth is, I really do think it simply depends. You can’t answer this question with an absolute…it’s not that kind of question.

Some people like being called “buddy”, or “honey”, “sugar” or some other term of endearment. Some do not. Some go off the wall if person A calls them “sweetie”, but smile happily when person B calls them the same thing. (That’s me, by the way, squarely in category 3.) Residents are much the same way…being, you know, people. Individual human beings with unique preferences.

Here’s another big shocker: CNAs are also numbered among humanity. We’re people too. We each bring a different set of life experience and habits to the job. Some aides use pet names, some don’t. In my experience, good aides fall on both sides of the line. There doesn’t seem to be a one-to-one correlation.
As for me, it just slips out. It’s slightly odd, but I slip into a more Southern accent while at work (a benefit of living in multiple places is having multiple accents to switch between). “Honey”, “buddy” and “sweetie” just slide out with the Southern twang and none of my residents seem to mind…I’ve actually had residents complain if I call them only by their given names, with no endearments to follow. In front of State, no less.

Of course, I have to tailor my habits to my residents preferences. I’ve had residents ask me not to call them “honey” or “buddy” or “sweetie”––these residents are few and far between, but I’ve had them. Some prefer terms of endearment in private, one-on-one interactions and more formal modes of address in public settings like the dining room. I do my best to accommodate their wishes and preferences.
In fact, one of the very first things I’ll do when I have a new resident is to introduce myself and ask what they want me to call them. Do they want to be Mrs. P, or Mrs. Betty or just Betty? Then I play it by ear: after the initial unease, how formal is this resident in their interactions with others, with me? Do they respond better to jokes or serious discussion? How much humor on my part is tolerated? What do they call me?

In the end, this question of terms of endearment is one that I do not believe can be answered in a blanket policy. It’s a personal question needing a personal answer…and no one can supply except the resident. Even when the resident is so out of their head with dementia that they cannot remember the year or recognize their children, still they have the right to decide for themselves what they prefer. They may not be able to answer in words, but they always answer.
You just need to train yourself to hear the unspoken words hanging in the air. Don’t assume you know what another person wants. Listen before you speak for them.

That it is the question, part two

Sunflower

May

Being an aide, I’ve decided, is a bit like throwing yourself at a brick wall, thinking that either the wall is going to come down or you are going to splatter yourself all over it.
Unfortunately or not, what actually happens is you come away bloody and for all your pain, all you’ve done to the wall is put a couple hairline cracks in it.

“If I don’t do it, who will?” This question might feel like it is being asked out of a lack of faith in our fellow aides…like nobody but myself is capable of doing it.
Unfortunately, it is a honest question. Anyone who has been around Long Term Care for any length of time, for any reason, can attest the chronic short-handedness that plagues so many facilities.

“If I don’t pick up that shift, who will?”
The answer might be nobody. Everybody is exhausted and everybody has lives outside the nursing home. They’ll go short that day and frustration will increase.
“If I’m not here in a year, who is going to be there for these people?”
Very possibly, a stranger who will put in her two-weeks notice the next day. The staffing coordinator didn’t tell her she was signing up for a tour in hell, after all. There’s got an easier way to make a living.

The system, as it is set up today, depends on sacrifice. It relies on dependable aides who pick up shift after shift, who will stick it out for little money and little hope of relief. And that’s a problem…and CNAs are not the only victims. The residents suffer too, often feeling like it is their fault. The elderly often feel themselves to be a burden and it is horrible that the current system only enforces that feeling, as they watch the parade of faces come and go.

Perhaps the answer lies in the middle. Set your own boundaries because your supervisors certainly won’t. There’s no ceiling on overtime and if you’re willing to do it, they aren’t going to stop you.
Know how much you are willing and able to give. Stick to your story: if you’ve got plans, you’ve got plans you can’t reschedule. The pathos is palpable in the nursing home and it is so very, very easy to give more than you have when surrounded by desperation. Remember your own needs while you take care of others. There is something in the make-up of a caregiver that wants to make things better. Watch that instinct and don’t be the hero all the time. You can’t give from emptiness.

Give what you can, but know when you can’t. Our only responsibility is to provide high-quality care and compassion while we are there…however long that is. Picking up is (or should be) optional. Pace yourself.
That wall isn’t going to come down all at once and I’ve seen aides break their hearts and shatter their compassion trying.
Hairline cracks are progress, no matter how insignificant they feel.
Don’t burn yourself out.

What is teamwork?

Sunflower

May

What is teamwork?

The door kicks open and I almost scream, it’s so loud and sudden.
I find myself looking up into the pissed-off face of a fellow aide; I don’t know why she’s angry but I have a feeling I’m about to find out.
“And that’s why nobody wants to work with you,” she says, for all the world like she’s continuing some conversation we had earlier. “It’s because you’re so stuck-up and you don’t do teamwork. Never mind about the rest of us, you just stay in your own group. We don’t need your help anyway.”
And then, while I draw breath for something I probably shouldn’t say, she’s gone. I’m around the bed, almost out the door to follow her when another voice speaks.
“What a thoroughly unpleasant person,” remarks Mrs. F, the resident whose bed I was making. “Screaming at you like that without so much as a ‘by-your-leave’ to me. After all, it is my door she just kicked open. What does she mean, you don’t have teamwork?”
“I haven’t helped much today with communal chores,” I mutter, close to tears. It’s an odd reaction of mine that has often confused people: in public, I’ll cry more often when I’m angry than when I’m sad. And I’m ready to spit fire right now.
Mrs. F raises her eyebrows. “You haven’t had a chance; seems like you’ve mostly been in the bathroom with me today. You think she’d scream at me if she knew it’s my fault you’ve been stuck in here?”
I shrug. “She better not.”
“Well, I think you would be wasting your time trying to make that one happy.” Mrs. F nods firmly, like she’s laid down the law or something.
I can only nod, a sick feeling in my stomach beginning to dilute the anger. Was it anger or truth talking when she said that nobody liked to work with me? It’s been a bad day today and it’s true, I’ve hardly left my group. I’ve hardly had a chance, seeing as how I’ve basically just gone from room to room all shift, cleaning up the crap. It’s just been a bad day. I’m tired and hungry (my shift ends in two hours and I’ve yet to take lunch); I help out usually, this is just the exemption, right?
I have teamwork. Right?

~oOo~

What does it really mean anyway, to have teamwork? Some aides that I’ve worked with seem to operate under the principle “Teamwork is when you help me,” but when it’s one of your call lights on, they walk on by. Others get upset when you try to help them…I had a coworker yell at me, accuse me of “going behind her, checking her work,” because I changed one of her residents.

Truth is, you can’t just do your own work: there’s two-person assists, there’s trays to pass, dining room duties, etc. You’ve got to help each other out…and yet you can’t do everyone’s work for them.
I used to. I won’t do that again. Every shift seemed to end with me, worn ragged and leaving late because I’d helped everyone else and then had to do my work by myself. Hardly anyone would offer to help me and I had decided I wasn’t going to ask. Surely they’d come around, help me out without being asked. That was teamwork and I thought I could inspire it with a good example.
Instead it just seemed to make everything worse. Other aides got used to me doing more of their work, picking up the slack; eventually, they came to expect it. I resented them and they resented me when one day I just stopped doing everything.

Teamwork to me is developing a rapport with your coworkers, learning their routines and adjusting your own until you can coordinate with little communication. You help each other out. It’s a give-and-take.
The problem, of course, is long term care’s high turn over. That kind of teamwork is built over months, sometimes years of working together…truth be told, it’s a rarity. Most aides I’ve worked with are in-and-out within a matter of months. It’s hard to build a strong team when the members are constantly changing. This leads to another problem: the Exclusive Club mentality.
The core team members have known each other for a long time. They’ve been through hell together and they communicate in a kind of short-hand. Newer aides feel left out, feel like they’re being snubbed or treated as second-class citizens. I’ve seen this from both sides. I’ve seen old aides who wouldn’t even speak to me until I had been there over a month. I’ve seen new aides who’d cry “mean!” to my supervisors if I didn’t break off conversations to greet them immediately. On the one hand, it is good odds that this surly new person won’t last the month (let’s say 70/30), on the other, why should I stay in a place that doesn’t appreciate me?
And yet, if you bend over backwards to accommodate the new aide, that just feeds back into the “they expect it from you” angle. That golden “give-and-take” is such a delicate balance, a sliding scale between two mistakes: not helping enough and helping too much. Balance doesn’t happen on its own. You have to nurture it, work at it. It’s hard.

~oOo~

I take a deep breath. I don’t want to have to work with this person. I don’t know if I can ever really forget how much she’s hurt me with those words “and that’s why nobody wants to work with you”. I don’t think that’s true…but I’m not perfect. It could be true in part. I could have slid farther on the scale.
But teamwork…that can’t be make or break with me. I’m one person, not the whole team. The truth is, I’ve run around all shift, clearly swamped and she’s never offered to help me. Never even asked me if I was okay. I haven’t even eaten and she’s yelling at me…even if her claim is true, her response isn’t kind, helpful or appropriate. For all her talk of teamwork, I don’t think she’s showing very much. What bothers me most is that she did this in front of a resident.
And yet.
Whether I make or break the team, in the end, all I’m responsible for is myself and the residents in my group. I have a responsibility to them, my residents, to be the best aide that I can be…both on my own and functioning in the team. So I take a deep breath, calm myself and head back into the hall. I’m not being paid to have a personality conflict, I’m being paid to take care of people and there isn’t time for both.
Sometimes I swear it’s like high school in here.

Boundaries

buddha

 

Edison Terrell

It’s all hypothetical right now, but my grandfather was diagnosed with Alzheimer’s a year ago and it’s progressed sharply since then, prompting the “home health talk.” He’s there enough to know something is seriously wrong, that he needs help with basic things he could do before this, but he won’t allow for help from outsiders. My mom asked me today without verbalizing it, would I be willing to step in when the time comes? 

Normally, my answer would be no. I have boundaries and I think it’s important to have boundaries. This isn’t the first time it’s come up, but things are different now. There are a whole new set of issues to deal with back home; on top of those and her meager job and keeping her family afloat she’s trying to keep her father’s head above water at her own expense. Now my mother is drowning, and here I am, a veritable lifeguard who’s choosing to stay on shore and see how it plays out because I don’t like getting wet. 

It’s selfish, right, to do nothing when you’re capable of doing something? Isn’t that someone’s definition of evil? But I’ve got a family now, living with my in-laws. I was hundreds of miles apart from my fiancée, now wife, for years and we’re just starting to make up for all the lost time. I also have clients here who need me, and whose families depend on me. And to be completely honest I never really liked my grandfather. He was a bore when I was growing up, and had a quick temper with nothing but a fixed smiley veneer over it. He’s different now, I’ll grant you that. The Alzheimer’s took more than just his memory. In a way he’s a proper grandfather now, just one that doesn’t remember your name. 

I don’t feel much for the man or his wife, except discomfort. I can barely muster up the effort to call him Nonno. That word is a grenade loaded with implications and a deafening reminder that for all our culture’s emphasis on family they did everything for their sons and nothing for their daughter except make life difficult at every turn, impose their will on her, and when they had her, neglected her love and adoration. They’ve done so little to deserve respect and even less to deserve anyone’s help at this time, least of all from the same person they neglected and abused, publicly humiliated on a regular basis. 

It’s so easy for me to say Healthcare professionals shouldn’t be affected by what a person has done in the past but only deal with them as they are now in a time of need. The words rise to my lips now but they’ve last all their meaning. There’s only the stark reality of my situation: I can act or I can let this play out.

To call in or not to call in…

May

Some days I swear clocks are the worst kind of liars. They sit there, calm and inanimate, as the hands spin or the numbers shift, but the time they tell never seems to be consistent. Minutes pass so quickly when I’m trying to get all my people up for a meal; they meander slowly when I’m working a double and can’t wait to get off.
Time only seems to fly when it’s inconvenient.

I’m too tired for this crap, I think…or should that be I’m too tired from this crap? Either one works. I’m clearly succumbing to some form of madness, laying here in bed cursing at my clock. Or maybe the fever has gone to my brain.
Why should it be this difficult? Why is this issue, to call in or not to call in, such a sore one? I’ve reached for my phone half a dozen times now…only to put it down each time. The words are there: “I’m sorry, I’m sick, I’m not coming in,” but I can’t quite bring myself to actually make the call.
I didn’t chose to be sick and if my actions are any indication, I don’t want to call in. I also don’t want to work while I feel like crap.
I’m still awake, so I’ll just analyze the crap out of my feelings. Who knows, maybe I’ll either come to a decision or bore myself to sleep. Why am I having such trouble calling in, even though it is justified? It’s not just me with this issue…I recently read an article (I can’t for the life of me remember where) about nurses and aides not taking their sick days. I’ve seen it in the field too…just few days ago, I asked an obviously sick coworker why she hadn’t called in. Her answer was painfully familiar: “I couldn’t do that to the rest of you. Or my residents.”
I’ve seen this issue from both sides. I’ve been resentful, having to work short because someone called in. I’ve been resentful, working sick so my coworkers wouldn’t work short. I’ve powered through shifts, counting the minutes until I got off and praying for the strength to stay upright. The problem is, I know I can do it again.
But should I? Is it right or fair? And fair for whom? It’s not in the residents’ best interest if I work when I’m feeling like crap…but it’s also not in their best interest if I call in every time I don’t feel 100%. Like many aides, I want to take care of others first. It feels…so selfish to say “Sorry, can’t do it”. And there’s pride, too. Pride can do wonders for your motivation and judgement of your limits.
There’s got to be a line. And I have to start taking care of myself too. I can’t give from emptiness.
Okay, a line. I can work when I’m not feeling good, but not if I’m sick. Not all illnesses come with a high fever. I can’t remember facility policy all that well…Whatever definition I come up with, I’m pretty sure “I think I’m dying and I can’t breathe because there’s an old man snoring in my lungs” counts as sick.
I resolutely roll over in bed and make the call. I make myself stay on the line until I hear someone answer.
“Hi, it’s May–”
“My God, you sound awful!”
“I’m sick–”
“You don’t say! Want me to put you down for a call in? Right, get some rest and feel better.”
As I hang up, I can only think one thing: I seriously overthought this one!

Role Reversal

photo

 

Alice

“Stop it.” she said, as I adjusted her enormous purple pillow beside her in her wheelchair, making sure she could maneuver her unaffected hand enough to play Word Whomp on her tablet.

“Stop what?” I asked without looking up.

“WORRYING. You’re going to give yourself an ulcer.”  I have cared for this particular resident for more than three years now. I was the first caregiver she met when she arrived at our facility and we became fast friends. Funny, incredibly intelligent, stubborn, and sometimes impatient, she is one of the most remarkable people I have ever had the pleasure to know…she could also read me like a book.

“I’m not worrying,” I said with more certainty than I felt.

“You are so. You always get a wrinkle between your eyebrows and chew on your bottom lip. Spill it,” she said without looking up from her game. Sigh. No time. I had seven more showers to finish, call bells were going off and it was almost time for breakfast. Besides, it wasn’t her job to cheer me up. It was my job to care for her.

“I’ve got to go. I’ll be back to check on you in a little while,” I said as I headed out the door.       “Fine. But you’ll be spending your lunch break with me. You either come back in here or I will find you and ‘accidentally’ run over your foot with my wheelchair.”…she’d done that once before in a fit of anger. I’d always suspected that it wasn’t exactly by mistake, little devil that she could be sometimes.

The morning melted into the early afternoon, blurring by as showers melded into beds that needed to be changed. Between snack time, intervening a feud between residents, and redirecting another one of my folks with a propensity for thievery, I didn’t catch a breath until nearly one o’clock. I decided to take my lunch while the sea was calm.

As I headed down the hall after I clocked out, I felt a nudge on the heel of my left sneaker. I turned around in surprise to see my friend in her power wheelchair. She really is hell on wheels in that thing. I’m lucky I only got nudged.

“Let’s go,” she demanded. There was no room for argument. This was my own fault. About a year ago, I made the mistake of telling her that I consider her and the other residents my boss. In my book, everyone else, including administration, was secondary. It went straight to her head.

“Fine. It’s peaceful in your room and I can still hear the hallway if there’s an emergency.” I perched on the end of her bed as she raised her chair up, elevated her feet and looked at me with a raised eyebrow.

“It’s NOTHING! Honestly. It’s no big deal.” She said nothing. Damn it. She KNEW I was uncomfortable with long awkward silences. Before I knew it, almost as if my mouth had a mind of its own, I found myself pouring my heart out to her; openly discussing my fear that my poor choices in my past would always define me, my frustration that I would never be able to move beyond my current level of effectiveness. I expressed my deep longing to do more to make life better for them and my sincere gratitude that life brought me to this place. My feelings of loneliness and the feeling that I’m always just a little off. A little weird. To my horror, I felt tears on my face. This was no good! I was breaking my own professional boundaries! This was a BIG no-no in the books!

After a moment, she cocked her head in my direction and said, “Well…you ARE a little weird. You are one of the few people I’ve ever met who didn’t see my wheelchair first. From the first day we met, you never assumed I was mentally slow because of how I talk. THAT’S WEIRD! That’s gloriously, wonderfully weird. So yes. You are a weirdo. It’s one of my favorite things about you. Look. I’m a college graduate. I’m an artist. I used to paint before my hand got too bad. Even sold a painting or two. I’ve been to Hawaii before. I am sure as hell bigger than Cerebral Palsy. And YOU are bigger than your mistakes. Hell, we all have a story.”

I took a deep breath and realized, right or wrong, I felt much better after our conversation.

Before I left to clock back in, I gave her a hug and apologized for unloading on her. She looked at me thoughtfully. “No apology necessary. Maybe a thank you for offering such profound wisdom free of charge…Besides, it’s nice to be reminded that I can still be useful,” she said wistfully.

I thought about that for a moment; how I would feel in her shoes. Smart as a whip and capable of much more than most people realized, but minimized to someone who constantly needs care despite the fact that she has so much to offer others. I would go crazy. It’s such a vital part of life to feel useful and of service. I realized then that while setting boundaries is a necessary part of our job, it is just as important to know when to lower our guard and let our residents in. Take away the roles and the walls and we are all just people. She reminded me that life isn’t about the hand we are dealt. It’s about how we play the cards. I gave her a hug before I left her room.

“Thank you for talking me out of my meltdown… And stop running over people with your wheelchair. There are better, albeit less effective, ways to get your points across.”

I sometimes wonder who is taking care of whom.

It’s How You Say It

DSC00999

 

Yang

I would like to expand on something Alice wrote in her post earlier this week. In making a distinction between “kindness” and “niceness,” Alice told us, “Sometimes, the kindest answer is no. Sometimes, setting boundaries that will upset a resident or a co-worker in the short-term but will benefit us all in the long-term is an act of kindness.”

I think part of what Alice is saying is that the tendency of LTC staff to appease a demanding resident can set a pattern of unrealistic expectations. There is nothing wrong with appeasement in and of itself, we do it all the time in both our professional and personal relationships. The problem is when we use appeasement as a quick and easy solution rather than address the underlying issue. By doing so we treat the symptom rather than the cause.

In this sense kindness is the willingness to take the time and effort to determine not only what a resident wants but also why he or she is asking. This requires a measure of patience and self-control. In the heat of the moment, it can be difficult not to react to the tone or unreasonableness of a demand. We’ve all said or heard said some version of this: “You’re not the only one that lives here.”

However, the negative tone of a resident can actually help us understand the root of the problem. Anger, impatience and frustration can indicate an underlying anxiety. Instead of reacting to surface emotions, we can focus on allaying that anxiety.

Anxiety comes from not knowing. We can better endure all kinds of mental and physical discomfort as long as we know that it’s not indefinite and that we have some control over it. For example, I can tolerate hours of being outside on a frigid winter day as long as I know I can go inside and get warm anytime I want. Take away that assurance and in ten minutes I won’t be able to stand the cold.

It’s the same with our residents. When it’s time to say “no” and set boundaries we need to engage with them in a way that reassures rather than reproaches. When we actively listen, negotiate and compromise we are communicating to the other party that they bring something to the table and that it matters. In the process, they gain a degree of control over what happens to them. And it doesn’t always have to take a lot of time. Just that opening can be enough to defuse the anxiety.

In some LTC circles, it’s fashionable to speak of this as “resident empowerment.” We should be careful not to think of this as something we bestow on them, because in reality, it rightfully belongs to them already. Our job is to facilitate it and not deny it through haste or a lack of awareness.

 

 

Hostages

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Yang

I recall the first time I heard an RN supervisor describe a resident as “demanding.” To me, the word “demanding” always carried connotations of a threatening, fist-in-palm kind of urgency. So when I walked into Freddie’s room, I was surprised to find a polite and mild mannered man. He just asked for a lot of things. It occurred to me that “demanding” means something a little different in a caregiving situation than it does elsewhere.

Freddie was young for a nursing home resident; half his caregivers were older than he was. He suffered from Huntington’s chorea, like his mother. He witnessed the disease gradually take her and he knew what was coming. And yet, if he was afraid, he didn’t show it. I wondered how I would respond if I faced the same thing.

He “demanded” a lot of our time. Frequent trips to the bathroom, assistance getting in and out bed several times a shift, fiddling with his TV and VCR remotes (this was a few years ago…) that never seemed to work right, special food requests, help making phone calls, helping him deal with the mountain of personal items he had brought with him, which only grew after he moved into the facility. Sometimes the carelessly assembled pile of stuff on his nightstand grew so high that gravity would finally take it and we would find the mess sprawled half way across the room. He was one of ten residents in his care group, but he could take up more than half his caregiver’s time. He was always either on the light or, when up, approaching his caregiver – or any staff member – with some sort of request.

Conflict was inevitable. Caregivers found it difficult to keep up with all that Freddie wanted and still meet the basic care needs of the other nine residents in the group. Some resented his requests and argued with him or just ignored him. Others tried to negotiate and set limits. The social worker spoke to him several times a week. But neither “side” actually ever adequately adjusted. There was always some issue, some trouble.

The more enlightened staff, including the social worker, looked at his behavior from a psychological perspective. He was simply acting out his fears and frustrations, grasping for some shred of control to help compensate for what his condition was taking from him. A drowning man desperately grabbing for the nearest object. And we were the nearest object.

Our RN supervisor supported her aides by explaining to the social worker that Freddie was keeping us “hostage” with his ceaseless demands. In a sense this was true. Rarely did he ask for just one thing and let you go. It was always a series of tasks, one thing leading to another. While he was mild mannered, he knew how to manipulate and once he got your attention, he wouldn’t allow you to escape politely.

In the context of a care group, where he was only one of ten people, Freddie’s demands were unreasonable. But here’s the thing: had he been on the outside, nothing he wanted would have been considered out of the ordinary by any reasonable standard. He simply refused to adjust to this environment, quietly insisting that the environment adapt to him. In this place of rigid routines and ratios, this was a cardinal sin.

They eventually moved Freddie to another unit. After a few months of struggling with the staff there, the disease reduced him beyond the ability to make requests and the issue was resolved.

These days, I think someone like Freddie would probably go into Hospice. The problem is not all “demanding” residents qualify for that service. And we are left with the same old paradigm that makes hostages out of caregivers and residents alike. To break out of it takes more than just a change of attitude, it requires more workers on the front line and a flexible approach to how they are assigned.