Category Archives: Creative approaches

Long Term Care’s “Trans” Issue

 

 

Minstrel

When the issue of CNA wages is raised, the response is never “Sorry, we don’t think you deserve better wages. We’re not going to pay you enough to live on if we can get you to work for peanuts.” No: administrators will say, “Yes, we know aides are worth more and we would love to pay higher wages. We just can’t afford to. The money isn’t there.”

Are you sure about that? Show me the money. Let us see your budget. Every organization has a budget, detailing what comes in and what goes out and where it goes. Long-term-care administrators tell us they can’t find the money to increase wages or benefits of aides. Maybe so, but we aides would like to be included in the search.

This is about transparency in money matters. If you attend conferences and webinars and read articles on how to achieve quality care in long-term-care homes, you will often hear the word ‘empowerment.’ Residents need to be empowered. Persons living with dementia need to be empowered. And direct-care workers need to be empowered—that’s what the experts say. What could be more empowering than having a say in how money is spent? Including aides in a transparent discussion of resource allotment would demonstrate trust in us, respect for us, and appreciation for the creativity we might bring to problem-solving. There may not be a wealth of money being wasted or misspent. But aides are in a unique position to see opportunities for cost savings that others might overlook. As a CNA I saw the amount of food that, at the end of every meals wasn’t in the stomachs of residents but in black plastic waste bags. I saw the wastefulness in our use of disposable items like plastic cups, paper plates and napkins. Without impacting the welfare of residents, aides might find multiple ways of cutting costs so that money might be re-directed. We might bring fresh vision to decision-making about saving and spending. Give us a chance!

Perhaps administrators protect budget secrecy out of embarrassment over the wide gap between the salaries of aides and the salaries of the executive and managers. Or out of worry that this knowledge might lead to poor morale and workplace unrest. Maybe the organization worries about privacy rights; why should anyone’s salary be public knowledge? First of all, budget transparency doesn’t mean that individuals’ salaries have to be known. (However, if it did, would this be so bad? Americans are more open about their sexual practices than about their finances! We know the salaries of the President and members of Congress and of the CEO’s of publicly-traded corporations. It is a tool of accountability.) There are ways to protect information about individual salaries (as the federal government does for federal civil servants) while making information available about salary ranges, the percentage of the budget spent on various classes of jobs, etc. This privacy issue is an excuse, a ploy to halt discussion before it starts. It’s not a justification for saying no to transparency.

Aides aren’t children. We’re capable of understanding issues, of being reasonable. We can understand that some positions merit higher wages than others and that some employees will deserve to earn more than others. We can be patient about wage increases. But we shouldn’t be shunted off to the side when budgets are discussed, as if we were just another piece of mechanical equipment in the workplace. We need to breach this wall that seems to create a ‘them’ and an ‘us,’ the intelligent responsible people on one side and lower class workers on the other. We are all part of the care community; we all want to improve it. One way to do this is to make budgets more transparent. If we want to retain employees and attract new job seekers, salaries and working conditions must become more appealing. I suspect that money might be found to do this, if budgets were transparent to all stakeholders.

We hear a lot about the need for culture change in long-term care. Budget transparency is a culture change issue that we don’t hear about yet. Let’s hear a call for transparency from the leaders of the culture change movement. Let’s hear it now!

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.

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.

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

A Wide Movement

May

As I talk about CNA Edge more, there’s a question that keeps coming up: for whom am I writing? What is my target audience?

Whenever I’m asked, my initial reaction is always: “My audience is whoever reads it”.
But that’s a vague answer at best, and no answer at worst. There are some who tell me I should focus more on reaching policy-makers and people in positions of power. And I can follow their line of thinking and I agree with their points: there is a divide between direct care workers and those at the top. That divide hurts our residents, often badly. So yes, I would love to reach more policy-makers.
But not at the expense of also my reaching my fellow CNAs. To put it another way, I do not want to be the sole spokesperson for CNAs to policy-makers and administrators. 

Policies can change. Rules and regulations can be changed with administrations, and then swept away with the next changing wind of politics. I am not dismissing the importance of good policies and those who work so hard to affect change for long-term care. We need people fighting for good policies, and for responsible leadership. We also need people fighting to change the way CNAs think about themselves, to throw off the label of “nothing but an ass-wiper”. If I can do that, then I am not alone. One or even three CNAs speaking up can be ignored. We could even be silenced. How about one hundred CNAs? Or three hundred? How about a thousand, or a million?
That starts by letting CNAs everywhere know that they are not alone. Sometimes I think the worst affect of this broken system is that it makes people who work so closely with others feel utterly alone. We, who have the power to deeply impact the lives of our resident, are often made to feel helpless by all that we cannot change. We feel alone, helpless and burnt out. Silence and sullenness can and do follow.
But together and aloud…what can’t we achieve?
I do not ever want to talk over the heads of my fellow caregivers. I refuse to fall into the trap of thinking that I am somehow more than they are, or that they are something less than me. If I am intelligent, compassionate and eloquent, that does not make me unique among caregivers. Actually, I’d argue that makes me about average. If I stand out, it’s only because I speak out.

What we need now is change, both on a personal level and on a larger cultural one. Compassion, common sense, communication and critical thinking have got to be infused into this broken system. We have to have people dedicated to change on every rung of the ladder…including the one belonging to CNAs.
Just like a democracy cannot function without the active participation of ordinary citizens, neither can our long-term care system function without a principled and vocal base of direct care workers. CNAs who are willing and able to speak up for themselves and their residents.

Nursing-home-made

Sunflower May

In compliance with HIPAA, all resident names and identifying details have been altered or removed. 

It’s funny, how a person’s possessions can tell us so much about them. Most new residents come in with very little: just the clothes they wore in the hospital and maybe a small bag. Then, their families either start bringing in loads of stuff…or they don’t. I have seen rooms so crammed full of personal mementoes that it’s hard to care for the resident; so many clothes in the closet that the door won’t shut and every surface covered with knick-knacks.
I have also seen rooms bare weeks after the resident moved in, the only proof of occupation being the person in the bed. Only a few clothes, no knick-knacks…no decorations or pictures.

Mrs. L seems to be one of the latter category. After a week, she still only has the one bag that she had clutched so tightly on the first day, plus a couple outfits. They’re nice, but the kind of nice that has been worn for years and years. Her family comes often, but they seem more stressed each time and their visits get progressively shorter.
There’s always a learning curve, some time required to start feeling comfortable in the new environment…but Mrs. L doesn’t appear to be adjusting at all. She won’t leave the room, she hardly eats and from what I can tell, she seems to spend most of her days screaming into her phone and crying. I decide I can’t kept walking past such agony. We don’t know each other very well, but that’s about to change.
“Hey, can I sit down?” I ask, walking into her room and gesturing to the empty chair (provided by the facility) that sits by her bedside. She shrugs and I take that as permission. Good Lord, but it feels wonderful to get off my feet.
“I’m May, if I haven’t introduced myself before,” I add…although I’ve introduced every day this week. “Do you need anything?”
She shakes her head. I’m trying to decide between asking another question and telling a story about myself when she suddenly starts talking.
“You can’t help, nobody can help. Can you make me better? Can you tell the insurance company not to be assholes? Can you give my family a fortune so they won’t have to sell my house to afford ‘getting me the help I need’? Can you buy back everything of mine they had to sell, so I don’t have to look at bare walls while I wait to die?”

I can’t. I can’t wave a magic wand and sort out the economy, endow her with the money she needs to have a good life even though she is now elderly and disabled.
The only magic I have at my disposal are my imagination and my hands. I stay for a few minutes, now holding her hand as she cries yet again, then I slide off the chair and leave the room.
It only takes a few words in the right ears. When I come back, I’m not alone and we aren’t empty-handed.
We disperse over the room, laying out our various offerings. The Laundry department brought up clothes that have been donated to the nursing (usually by families of resident who have passed away in our care); Activities gave several left-over decorations from the various Arts-and-Crafts over the years. Nursing gathered personal care items from the supply room and arranged them in her drawers. Staff from every department drew pictures and scribbled down nursing-home-made Get Well cards…but the best bit came from a fellow resident. She heard of my cheering-up campaign and told me to pick out the prettiest flowers from the bouquet she got for her birthday and give them to that “poor lady”.

Small acts of kindness in Long-Term Care are not whistling in the dark. With each act of compassion, we light a candle. True, it will take a lot more candles than I can personally light to lift the shadow of greed from our broken system…but that’s the funny thing about kindness. Even when it’s not enough to turn the tide, change the culture or right the wrongs of this world––it is still appreciated and it can still mean the world to that one person.

My hope is that, one day, we will have more to give than what we can scrape up. I hope that one day, compassion will be considered along with costs, that questions of ethics will be given equal standing with questions of economics. 

Break Interrupted

Sunflower  May

In compliance with HIPAA, all resident names and identifying details have been altered or removed to protect patient privacy. 

“I need a break!”
With these words, I sweep into the room, startling the occupants.
“So,” says Mrs. R, “go to your break room.”
“Can’t, they’ve already looked in there for me,” I sigh as I drop down on Mrs. R’s bed…it’s the one farthest from the door and it’s the empty one. For good measure, I pull the privacy curtain down to the foot of the bed and arrange my legs so that you can’t see tell-tale nursing shoes from the door. I don’t dare close the door: I wouldn’t be able to listen for call-lights and nothing screams “CNA in here!” louder than a closed door.
Mrs. E, the resident in the first bed, rolls back over and goes back to sleep. She’s always resting her eyes; meal times are her favorite nap times of all. Mrs. R, sitting up in her wheelchair, turns away from the window to look at me…apparently, I’m more interesting than the birds outside. “What do you mean, they looked in the break room for you?” she asks. “It is the law that you have two ten-minute breaks and, knowing you, you probably haven’t taken them already. Tell them to go away.”
I just stare at her. “How do you know that?”
“I listen,” she replies, a bit smugly. “You would have to be completely deaf not to learn every detail of the working conditions here. Someone is always complaining.”
“Um…sorry. I try not to complain in front of you guys––”
“Quit changing the subject. Why don’t you just tell them to go away and leave you alone on your break?”
“Because then they just say ‘Oh, when you’re done’. It’s not one of those things worth kicking up a fuss over. I’m sure if I went and complained to the DON, there’d be an in-service for everyone to sign…and nothing would change. Everyone would continue to interrupt my breaks for the stupidest crap.”
I sound bitter, I realize. The thing is, being fetched out of the break room during one of my few breathers never fails to irritate me. I only take my ten minute breaks when I’m about to snap, but today there is no escaping the madness. The straw that broke the camel’s back was when my nurse stormed into the break room right after I’d gone in, to tell me to get back out on the hall because “there are too many call lights for one person to keep up with”. I think she meant “one CNA” because she has said before that she is “above aide work” and I’ve never once seen her answer a call light.
The next chance I had to take a breather, I decided the break room was not a safe place to take it––so here I am, seeking refuge from the demands of my residents in the company of my residents. Funny how things work, sometimes.

Mrs. R looks at me steadily for a minute while I swing my feet. “That nurse today is lazy,” she declares. “Next time, tell the person interrupting your break to go to hell.”
“Mrs. R!”
“Or, better still, tell them to take care of the crap themselves.”
“Do you really want the nurse you call ‘lazy-ass’ to be the one taking you to the bathroom?” I grin.
“Yes. Then I could fart in her face.”
It’s a good three minutes before I catch my breath enough to answer. Mrs. E grumbles about the noise and tries to burrow deeper into the covers.
“Oh, Mrs. R, never change,” I tell her, still giggling.
“I’m sure I’ll change a bit when I die,” she says. “Can you cuss in Heaven?”
I shrug. “I don’t know, Mrs. R. But I’ve got to get back work now. Thank you for the refreshing break!”
“No, you don’t,” she replies. “You have four more minutes. Sit your ass back down and tell me about what’s going on in your life. Then, you can take me to the toilet. I promise not to fart in your face.”

Selling lemons and changing briefs

Sunflower May

 

This is crazy.

It’s one of those times when nothing I do works. This woman is not going to let me change her brief.
I’ve already left the room and come back three times: the re-approach technique isn’t working. She may not remember who she is or where she is, but when it comes to how many times I’ve been in her room…good Lord, but this woman has a fantastic memory!
I place her hand on the opposite bed-rail and try to roll her over again.
“No! No! No!” she screams, letting go of the bed-rail and pushing against me with all of her frail but frightened might. “Oh, stop, please stop! Mother!”
And now she’s crying again.
My feet hurt. My head hurts. It’s been a long day: this shift just will not end and this woman just will not be changed.
“Please, Mrs. E,” I beg her again, “just roll to the right–just a little bit! One roll. One roll, that’s all I need! I can get this brief out from underneath of you and put the new one in just one roll. And, um, maybe the sheets too. Possibly. Please?”
Mrs. E just buries her face in her hands and cries harder. There’s a certain smell when a brief has been left on too long, when it is soaked beyond capacity to absorb anymore: I catch that scent now, wafting up at me every time she moves. There’s a brown ring on the pad too, further evidence of her refusal to let anybody change her all shift.
I’ve stood here for fifteen minutes, alternately pleading, begging, reasoning, ordering and bribing: nothing is working. She’s not my resident. I could just walk away, tell my newbie coworker that “Yep, she’s refusing care all right, can’t do anything with her”.
Or I could go get help and we could change her in spite of her refusals. This is one of the blurry lines between right to refuse and being mentally incompetent.
I groan and lean against the bed rail. I’m too tired for ethical quandaries right now. I’ve been working for fifteen hours now and I’m dead tired. I swear I can feel my patience wearing thin, like the belt in a car about to snap and bring the whole engine to a crashing halt. In this case, my ability to be a caregiver is what’s in danger…I want to scream, cry, run away and make this woman let me take care of her.
Instead of doing any of those wonderfully tempting things, I move the bed-rail closest to me and, taking care to land on the clean sheets, collapse beside her on the bed.
It feels good to sit down, to not be on my feet. I feel like all my bones have turned to liquid within me and all my muscles have turned to jello.
Mrs. E jumps slightly and hiccups, my sudden movement startling her out of her tears. I stare back at her, blinking away my own tears. The silence holds for a long, long moment.
“You see this thing,” she says suddenly, catching ahold of the call-light and swing it around in a lazy little arc that brings it close to my face. “I told my father, I said, I don’t know what you want me to do with this…thing. It’s just stupid, is all and I said, well, I said I’m not doing it. And he said, well, what am I supposed to do with it? What am I supposed to do with thing, huh? What’s it for?” She holds it out for me.
On a sudden inspiration, I lean forward. “Hello?” I say into it, pitching my voice as though it were being filtered through a microphone.
For the space of three heartbeats, Mrs. E just stares at me. Then she throws her back and laughs, great big chuckles that shake the whole bed. “You’re a nut!” she gasps out, shaking her head.
“That’s me,” I agree, “the biggest nut you’ve ever seen. A cracked nut, too.”
“A cracked nut,” she repeats. “You’re silly.” But she’s smiling now and not crying.
“I am so silly that I want to get this pad out from underneath you,” I continue. “Do you think you could roll for me so I can get it out?”
“No,” she says firmly. “I’m not doing that.”
Damn.
“Why?”
“Because I’m not. My father said, now he said, we’ve got to sell these lemons and I said, now who wants to buy lemons? That’s just stupid. But he, he wanted to sell them and I thought, he’s nuts. He’s crazy.”
“He sounds crazy,” I say, wondering how the hell we got to selling lemons. “Hey, how many lemons do we have to sell?”
“Lots and lots.”
“Tell you what, I think I can sell your lemons for you–there’s a baker who wants to trade me lemons for cookies…she’s, um, making lemon meringue pie or something. But I need your help with something, ok? My wallet fell under your sheets and I need to get it out or my father is going to be very upset with me.”
“We can’t have that,” Mrs. E says, shaking her head in solidarity with me over unreasonable fathers who expect us to sell lemons and not lose wallets in other people’s sheets. Then, without warning, she grips the bed-rail tightly in her left hand, braces her right hand on my thigh and lifts her bottom off the bed.
There are times to provide meticulous peri-care and times to hurry it the hell up. This most certainly falls into the latter category. Her bottom is hardly in the air for twenty seconds, but I somehow manage to whisk out the old brief and pad and replace them with a clean set. It’s hardly the best brief placement I’ve ever done, but at least it’s not saturated with six hours of urine.
“Did you say cookies?” Mrs. E asks as her bottom thumps back on the bed.
“Sure did,” I smile at her, “but first, can you give me a hug?”
“Oh, honey,” she laughs, but she rolls towards me and crushes me against her. “You’re so silly,” she tells me.
“Guilty as charged,” I gasp, using my free hand to wiggle the brief into a better position.

It’s serious work we do, as CNAs, but sometimes serious just doesn’t get the job done.
We cannot always bring our confused residents back into what we call the “real world” so must be willing to lay aside our pride and look silly for a good cause. I have often found that a person’s sense of humor is the very last thing to go.

Small Gestures Go A Long Way

Sunflower  May

This would so much easier if there were tears, screaming or something. Hell, at this point I’d take a nightmare and violent confusion. I know how to soothe nightmares. I’m good at chasing the monsters away.
I’m not good at this.
I don’t know how to make this better, this lingering listlessness, the utter lack of energy and interest. It’s not like I’ve never seen this before: depression is wide-spread in the nursing homes. Depression is a hard thing to treat, harder still to manage in the time-crunch of Long-Term Care…the CNAs quite literally do not have the time or emotional energy to coax every one of our residents out of the deadened state of despair every time they fall into it. The sad truth is, when a resident refuses to get out of bed, that’s one less person you have to try to get back into bed later. It’s easy to let slide. It is, after all, the resident’s right to refuse. You can’t make them get up and coaxing takes time. Sometimes a lot of time. You say “I’ll get them next time,” and the next time things are so hectic that you don’t even remember your whispered promise. Eventually, you realize that you’ve let your depressed resident stay in bed for the tenth shift running…but by now it’s a habit, both for you and the resident.
I’ve seen it a hundred times, and I’ve had to turn away, had to prioritize my other residents who really wanted to get up and interact with the world over the one who continually refuses to leave their room…the one who just wants to sleep.
Not this time. I can’t make Mrs. N get up, but I can’t just leave her to wallow in her own regrets and despair.

“I’m not leaving you like this,” I say suddenly. “I’m not giving up on you, okay? I really don’t care if you appreciate it or not. I’m not giving up on you. Ok, then think, May. What helps alleviate depression?”
Sunlight.
I rush to the window and twitch the curtains open. Light floods the room, chasing away the shadows and warming the air. A thousand dust-motes swirl in the golden beams. Well, I feel better, at least…strange how quickly the sunshine can work on human physiology. Mrs. N stirs and mutters. One eye opens, just a tiny sliver and then it’s squeezed shut with a force that only a person can only manage when they’re awake.
Well, that’s sunlight. I can’t think of anything else to do and as much as I like to shut the door and say “I’m not leaving her alone,” I can’t abandon my other residents. Also, if I push too hard, I could unravel any progress I’ve made.
I lean over her and squeeze her limp hand. “I’ll be back,” I tell her.
It’s a busy day (as per normal), so it isn’t until a couple of hours later that I’m able to slip back into Mrs. N’s room to check on her. She’s still laying motionless in her bed, but she’s oriented to the window and her eyes are open. She’s staring out at the green grass, the trees and the flowers. As I watch, a tear slips down her face.
What’s it like for her? She knows that even if she musters the energy to get up, even if she goes outside, she can’t do anything help. She can’t run across the grass, she can’t reach up and touch the trees. She can’t pick the flowers.
Flowers.
I rush from the room, down the hall and out the front door. Thank God for landscaping, because I don’t have to search very long to find what I was looking for.
I head back inside, back to the room that remains gloomy, in spite of the warm sunlight still pouring through the window.
“Here,” I say loudly, ignoring the way she slams her eyes closed and pretends to sleep. I set the handful of flowers I picked down on her bedside. “These are for you.”
She’s so startled that she drops the act mid-snore. I hear a call-light go off down the hall and I reluctantly turn to leave.
“Hey, little girl.”
I turn back. Mrs. N is clutching all of my flowers in her hands.
“Bring me some more tomorrow?”
“Oh, you bet,” I agree softly.

Those of us with whole bodies and sound minds, I think we often forget to appreciate the simple things. Things like opening the curtains to let in light, going outside for a walk when we feel blue. The natural world is bound up tightly in our psyche…replaced by the sterile environment of a hospital-like nursing home, is it any wonder that depression abounds in nursing homes? We can’t give our residents back everything they’ve lost: their mobility, their independence, their careers and loved ones.
By contrast, it’s a simple thing to bring a bit of nature to those who cannot go out to nature…to open a curtain, hang up pictures of landscapes, take them outside for five minutes turn on the Nature Channel, or bring a handful of flowers to a depressed resident who won’t leave her room. But simple doesn’t mean insignificant and small gestures often mean the world to someone who has learned the hard way not to take anything for granted.

There is something about nature that speaks to our primal nature, that has the ability to soothe us even after we lose our words or our will. There’s something about natural light that makes us feel at home, something about flowers that delights us. These primal instincts are a caregiver’s best friend, if you learn how to harness them.