Category Archives: Minstrel

A Numbers Game: Resident Acuity and Staffing – Part Three

 

 

Minstrel

We cannot provide person-centered care without the personnel.  My previous comment, Part Two, presented a list of symptoms that arise from dementia.  These symptoms are the constant companions of those living with more advanced dementia, and their care partners.  The symptoms create behavioral challenges we CNAs must and want to respond effectively, so our residents can feel secure, content, at home.  

We have our list of dementia symptoms.  But wait—there’s more.  Let’s look concretely at the workday of a LTC direct-care worker.  Aides work an 8-hour shift, with one-half hour mandatory meal break.  (In some places they are also entitled to or permitted to have a second 15-minute break.)  The first and last ten or so minutes of a shift are spent getting and giving shift updates to the previous or next shift of aides.  Aides will also need one or two bathroom breaks during a shift.  Thus an aide has about 7 hours (420 minutes) left for care tasks.  This scenario doesn’t take into account the moments an aide might need for a calming ‘time-out,’ for a few minutes of helpful conversation with another aide or a supervisor, for an important phone call from home, for time spent walking from one task to another or one resident to another.   And it doesn’t allow for other encounters we expect aides to have with residents, creating ‘moments of joy.’ 

Aides will customarily be responsible for the care of six to ten residents on a shift that has plus or minus 420 minutes of usable work time.  (And would you believe the number of residents might be higher?)  If you do the math, you see that aides may have 42 to 70 minutes for each resident.  Seventy minutes to help a person exhibiting symptoms of dementia with toileting, washing (on certain days showering), grooming, dressing or undressing, moving to the dining room, eating, returning to the day room, using the toilet during the day.  And these are just the essential ADLs.   

Other tasks aides are responsible for during a shift: 

  • for safety purposes, keep alert to where each resident is;
  • distribute drinks to prevent hydration;
  • serve snacks;
  • check toileting needs and assist residents with this as needed;
  • help with transfers (from bed to wheelchair, wheelchair to lounge chair, lounge chair to wheelchair, wheelchair to toilet and back several times in a day, wheelchair to bed) for those residents who cannot transfer themselves;
  • help other aides with two-person-assist transfers;
  • answer resident questions throughout the shift (“When can I eat?” “Where is my mother?” “When will my son be here?”  “I’m cold, where is my jacket?” “Don’t I have a doctor’s appointment today?”) ; 
  • in between ADLs engage with residents through conversation, music, activities;
  • accompany residents to other areas of the building as needed for medical care, hairdressing appointments, other events.

In some LTC communities aides are also responsible for making beds, doing laundry and putting it away, or other housekeeping duties.  Throughout the day there are spills to clean up, phones to answer, paperwork to be done, questions from visitors.  If an aide is tired from working a second job, or a double shift, this will slow the aide down.  If an aide has a bad back that day, or sore knees, or is pregnant, these things will also mean the aide has a lower energy level or slower response time.  All these factors take a toll.  If some aide should call out at the last minute and the shift is short-staffed, this further impacts care.   Even if forty or fifty or seventy minutes of care per resident were sufficient—and really, it’s not—at the current staffing levels in most LTC homes, residents don’t get even this.  I challenge administrators to refute this with data.  

Is it really acceptable to pare staff levels so thin that we impair not only the quality of care but the safety of residents and aides alike?  Is it acceptable that the owners of long-term care homes are sustaining their organizations by controlling their costs with sub-par staffing levels?  Those responsible for setting care and staffing standards should feel responsible for doing something about the unacceptably low staffing requirements they’ve established and tolerated, thanks to lobbying efforts of the long-term care industry.  (Shame on you, CMS.)  The rest of us should hold them accountable.  Families and direct-care workers and anyone who is an advocate for those living in long-term care communities:  Unite!  Lobby!  Write, email, text, twitter.  Demand that your care home managers and your state legislators see what is before their eyes.  For added clout, partner with organizations that advocate for better long-term care.  To any CNAs up for a little non-violent guerrilla warfare: sneak a copy of these comments to a few trusted family members of residents.  Ask them to bring the staffing issue up at a Family Council meeting.  Send a copy anonymously to your Administrator.  

Owners, operators, executives and regulators of LTC homes will say that we don’t need more staff, we need more or better training.  Our CNAs need to work ‘smarter.’  And there is something to this, we do need to look at work assignments and patterns and at aides’ understanding of how to interact with persons with symptoms of dementia, etc.  But tell me how all this will change the fact that an aide may, on a good day under ideal conditions, have 70 minutes to give a resident.  (A resident who may be paying $5000 to $8000 a month for memory care.)  

This isn’t a game.  Would we let a dog lie in a kennel and give that animal only seventy minutes of direct attention a day?  Long-term care homes don’t care for dogs, they care for human beings.  Tell me please, how can we sit still and stay quiet about this appalling reality, one minute longer? 

A Number’s Game: Resident Acuity and Staffing – Part Two

 

 

 

Minstrel 

This is about person-centered care. To repeat: We cannot provide person-centered care without the personnel! CNAs, do the administrators of the LTC homes you work get this? Do they really comprehend what your work day is like? Do they appreciate how much time it takes for you just to assist with ADLs, when a person is showing symptoms of dementia? Do the state regulators? Or are they ‘cognitively impaired’ when it comes to understanding life on a memory care unit. As my uncle used to say when his dementia advanced: “Donna, I hear you but I don’t understand what you’re saying.” Administrators may see things, but do they really understand? A Resident Acuity Assessment tool might help them understand.

A Resident Acuity Assessment tool is a descriptive list of the symptoms of dementia. This list isn’t comprehensive; it can’t be. We’ve all heard this: “If you’ve seen one case of dementia, you’ve seen…one case of dementia.” Everyone is different; each care partner may observe a new symptom. This list isn’t meant to be discouraging for those who, thanks to the support they have, may not show severe symptoms. The better care a person has, the more a person diagnosed with dementia can retain functionality, with fewer and less severe behavioral symptoms. But insofar as residents of LTC homes do experience serious consequences of dementia, those who regulate care homes need to appreciate their needs and regulate accordingly with regard to staffing.

Here is what I think a Resident Acuity Assessment tool might look like.* If you are a CNA working in a memory-care community, or a home care aide, or someone caring for a family member at home, these symptoms of dementia are familiar to you. I’m not sure they’re as familiar as they need to be to those who set long-term care standards. If they were, we would have better staffing.

Part Three, the next chapter in my mission to lobby for better aide-to-resident staffing ratios, will mention other factors that need to be taken into account by administrators and regulators.

RESIDENT ACUITY ASSESSMENT

Key: N = Never = 0      S = Sometimes = 1        F = Frequently = 2        A = Always = 3

** under 60: low to moderate acuity;   61 to 100: moderate to high acuity; over 100: very high acuity.

RESIDENT _________________________ Date Assessed _______ by ________________

*There may already be such a tool, a better one, that I haven’t found. (The tests used to diagnose dementia serve a different purpose.)

 

 

 

 

 

 

 

 

A Numbers Game: Resident Acuity and Staffing – Part One

 

 

Minstrel

This is a story of staffing, substandard staffing in memory care homes. It’s an attempt to offer evidence of what life is like in a memory care home and to document why staffing guidelines are missing the mark, are ignoring the ramifications of residents’ symptoms and CNAs’ workloads. In memory care, the gold standard of care is ‘person-centered care.’ But we cannot provide person-centered care without the personnel! In a hospital setting, administrators use something called a Patient Classification System to plan care. This is a method for determining how serious the medical condition of a patient is, what level of care the patient needs, and how many nurses they must have on duty to ensure that patients get the care they need. The severity of a patient’s medical condition and needs is known as acuity. In long-term care homes this notion of patient or resident acuity doesn’t seem to have the same imperative that it does in hospitals. It should.

We hardly use the term ‘nursing home’ nowadays, it’s almost politically incorrect. We speak of long-term care ‘homes.’ It’s to the credit of the nursing home industry and consumers of that industry that if our loved elders become too frail to remain at home, people want to make their final residence more homelike. Not an institutional, hospital-like environment—with all the sterility and standardization and disregard for individuality that the word ’hospital’ ironically implies. And so we move our family members to long-term care homes: skilled nursing facilities, assisted living communities, or personal care homes. Still, residents of these homes, whatever we call them, are there because of declining health. They need care. Maybe not the kind of care that calls for physicians, medical specialists, hi-tech equipment and RNs to be on hand on a daily basis. But they do need attention paid to their declining physical and/or cognitive health.

The area of long-term care I’m involved in is dementia care. I challenge everyone reading this page to name one memory-care home that has the staffing it needs to ensure a high level of person-centered care for every resident on every shift, every day. Not perfect care; just consistent high-quality care. (And if you know of such a place, please let us all know about it. I’m signing up for their waiting list!) Long term care homes simply don’t have the staff they need. CMS and state regulators don’t set specific standards that could ensure better care. The sad standards they do establish don’t come with penalties that encourage compliance.

I first became interested in this kind of tool while working in a memory support home. When we CNAs asked for more staff, the Administrator would respond, “Document that you need more help.” I began putting charts together to demonstrate the time CNAs actually had to do ADLs. One reason legislators don’t pay more attention to staffing levels is that they just don’t understand what the symptoms of more serious dementia are and how these symptoms impact aides’ workload throughout the day. A Resident Acuity Assessment tool could, I believe, help us educate administrators, families and legislators about the staffing we need. In Part Two I’ll present one suggestion for a Resident Acuity tool, hoping that other CNAs will find ways to improve it. Use your own tool to persuade your employers and regulators to require improved staffing of memory care homes.

60 Caregiver Issues: Whose Issues Will We Hear?

 

 

Minstrel

In his recent post Yang brought our attention to PHI’s campaign to educate the public about caregiver issues, and gave us a link to their introductory video.  In that video PHI posed these questions:   

1. How can we ensure caregivers get the training they need?

2. How can we keep care affordable to families? 

3. What data is needed to help policyholders take action? 

While these are important questions, if you ask caregivers themselves why some are leaving the field and others wouldn’t think of entering it, they’ll no doubt raise a different set of issues.  At nearly every conference or webinar I attend I ask about staff-to-resident ratios and caregiver wages.  Usually there is no reply, as if I were speaking from some parallel universe and couldn’t be heard.  If there is a reply it’s on the lines of “Yes, we know.  But it’s complicated.  These things take time. You can’t expect things to change overnight.” 

Yes, there is a shortage of caregivers.  And yes, good care isn’t affordable.  In fact good care can’t be bought.  By that I mean whatever you might be paying, either for in-home care ($20/ hour? $40?) or for care in a long-term care home of some sort ($6,000-10,000/ month), the more care the person needs as health declines, the wider the gap between the person’s needs and the quality of care the person actually receives.   

Everyone is selling solutions like workshops and videos and toolkits and new business models to long-term care administrators or home healthcare systems’ owners.  Some groups are advocating on a state or even national level and some gains have been won.  But from the outcomes I’d say that a lot of the effort is wheel-spinning.  (An increase in the NYC minimum wage for home care workers to $15/hour by 2021??)   Today’s aides have rare luck if they earn $15 an hour and have a regular 40-hour work week.  An aide may have six to ten residents/patients to care for, and many of those will suffer from dementia and/or be unable to walk alone safely or even support themselves standing.  (Yes, I know I’m a broken record…)  Do you know what it’s like to try to wash, toilet, transfer these residents several times a shift, and keep them from falling the rest of the time?  (If not, go back and read CNA Edge.)  This is before we even begin to provide enrichment a la ‘person-centered care.’   

I want the whole healthcare industry – including those championing reform — to acknowledge what the biggest issues are for caregivers: our obscenely low wages and our outrageously onerous, even unsafe, working conditions.  These organizations don’t yet tackle caregivers’ most urgent needs: a living wage, safe work conditions, and a work environment that supports person entered care.  We need to ask them, What are you doing about these issues and what can we CNAs do to support you in this?  

When Malcolm X called for a change in Americans’ attitudes on race and was told that such changes (culture change, if you will) take generations, he reminded us of this: At the beginning of World War II Germany became our enemy and Russia became our ally.  But when the war ended we, America, saw Germany as our ally and Russia as our enemy.  That attitude-change didn’t take even one generation.  The healthcare industry needs an attitude adjustment.  It is not okay for long-term care operators or owners of home healthcare agencies to charge exorbitant fees to clients and return a too-small fraction of these fees as wages to their direct-care workers, while management and professional staff and consultants are handsomely compensated.  It is not okay to hire employees unless you train them in the skills they need to work with the elderly frail, starting with English language skills.  It’s not okay for the industry to tolerate poor work ethics: last-minute callouts; texting while on duty; and most of all, failure to interact with residents in a way that says to them “I love being with you.  Thank you for letting me be part of your life.” 

There are thousands of followers of CNA Edge.  As Yang exhorted us, we need to support PHI in their effort to educate the public about caregiver issues.  Let’s ensure that when they frames their 60 Issues, they don’t airbrush our issues out of the picture they’re drawing.

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.

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.

“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.  

Cueing for Caring

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Minstrel

I volunteer in a long-term care home which serves, among others, those with dementia.  The aides in this home have had dementia training and the care level is already exceptional.  I think this is because management expects the aides to…well, to care — not just to ‘provide care,’ and because management models this value.  Still, the nursing supervisor wanted a performance boost.  Training.  

Aides benefit from understanding dementia and from exposure to the best ideas on dementia care.  But what’s most important about staff education is that their new knowledge lead to new workplace habits.  Training that doesn’t result in improved care is about ‘CYA’ compliance for CMS, not about caring.  How do we ensure that training actually improves how we do our jobs?  How do we transfer the training lessons from the training site to the workplace?  As a reinforcement tool, cueing is used very effectively in memory support homes which adopt Montessori methods.  Are there some short-and-sweet (and fun) cueing tools we might use to reinforce training? 

If there were just a few practices that would transform care, I believe it’s those illustrated in the poster below.  These are tried-and-true best-care practices from experts like Teepa Snow and Naomi Feil.  Let’s try turning these ideas into cues to use where we work: nurses’ stations, employee lounges, food prep areas, in the laundry, at the time clock.  Hanging icons separately in the halls—for example, the little cheerleader—may remind us all to encourage and praise residents’ efforts.  We’d be surrounded by encouraging reminders.  Cues keep us mindful of the kind of environment that is most beneficial for all residents, especially those with dementia.  

Along with cueing, another way to reinforce training lessons is the use of rewards of some kind.   The next step is to develop a rewards program for aides who go the extra mile to use these ‘care commandments.’  This is trickier but surely warranted for aides working to create an environment that says, “We Love Our Residents.”

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Comfort and Joy

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Minstrel

At the end of my first year of work as a CNA, when it came time for my job evaluation, I was asked what my job goals were.  I wrote, my goal as a CNA was for my residents to go to sleep smiling.  Whatever the rest of the day might have been like, bedtime belonged to me.  I wanted each resident to fall asleep feeling loved.  As we did the bedtime ADLs I played lullabies on my IPod.  I hoped that some positive feeling would stay with them through the night.  

How horrible it must be for a person’s last experience of the day to be one of distress because someone rushed them, tugged at them impatiently, scolded them to hurry.  Didn’t smile.  Didn’t speak to them by name, maybe hardly made eye contact. Didn’t wish the resident goodnight as they left the room.  (Didn’t kiss them goodnight!)  Dementia can be a world of isolation, confusion, fear. 

Confusion and fear, or love and joy: which will be my residents’ last companions of the day?  We all know what kind of aides we want to be.  But we let ourselves be pushed by ‘the system’ into being the kind of aides we ourselves don’t like.  Don’t!  Giving even just an extra two minutes to each resident, what a difference we might make at the end of their day.  

There must be joy!  For the sake of our residents.  And for the sake of our own joy-seeking souls.

The Magic of Music in the Chaos of Long Term Care

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Minstrel

Being a new CNA is challenging.  Yes, in training I learned how to make a hospital bed with a mannequin in it.  To wash my hands according to procedure.  To transfer fellow trainees with a gait belt.   But now I’m in the unit, needing to transfer a dear little wheelchair-bound lady who can no longer speak and who, while petite, is a dead weight when I try to lift her.  And she is contracted.  Her arms remain tight at her side as I try to undress her.  Who is more distressed, ‘Goldie’ or me?  

Goldie, in her mid-90’s, is still a beautiful-looking woman with twinkly eyes and a smile that glows.  So as I work with her I sing “Glow little glow-worm glow and glimmer” to her.  (Are the Mills Brothers spinning in their graves?)  I’m not sure Goldie gets the words at this point, but I’m laughing as I sing and she laughs back.  She relaxes.  I open my arms wide to invite a hug and Goldie opens hers!  Now I can get her blouse off.   Mission Accomplished!  I don’t know what made me sing to Goldie that first time, except that she was such a sparkly person that being with her made me happy.   My singing is not a pretty sight.  But as one musician said to me, “They don’t care what you sound like if you love them.”    

Soon I was singing to all my residents as I did ADLs (Activities of Daily Living: bathing, dressing, toileting, eating).  Sometimes a resident would sing along.  Yes, this did mean that it took me longer than it took other aides.  One of my caregiver-mentors would say to me, “We don’t have time to talk to the residents.  We don’t have time to sing to them.”  But I persisted (quietly) and began to carry my IPOD nano and a small wireless speaker with me.  Now we had hundreds of songs, sung by the voices these residents might recognize: Frank Sinatra, Rosemary Clooney, The Mills Brothers, Judy Garland, etc. etc.  One morning as I brought residents to the dining room for breakfast I played Oh What a Beautiful Morning.  Soon the room was singing!  And smiling.  In time other aides began asking, “Do you have your music with you today?”   For one thing, I think they liked some of this old music.  And they saw that residents often became calmer and more cooperative when they felt ‘sunny.’  Music does that, connecting us to each other and to our memories.  

As my IPOD played the Marine Hymn or Anchors Aweigh, veterans walked to the dining room with new determination.  Accompanied by a waltz, a resident with unsteady legs could be coaxed to move more confidently.  Sometimes we can engage a resident with a song we know she enjoys, singing together as we walk to the toilet.  Because we’re in the midst of something pleasant, a resident might hardly notice that an ADL she usually resists is about to happen.

Some residents can no longer speak; they might no longer understand language.  The saddest reality is that some can no longer hear.  (Even then, rhythms might be felt.)  Not every musical event works every time with every resident.  Nevertheless, with many residents, music can be magical in its effect.   Music has a profound positive effect so often, that it seems crazy not to try it.  

When I am old and grey and full of sleep… (thank you Mr. Yeats), they can take my food, they can have even my books.  But I want my music.