Category Archives: Creative approaches

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.

Who’s the One with Dementia?

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Minstrel

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

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

Person with Dementia: “No.”

Caregiver: “C’mon, time for bed.”

PwD: “No.”

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

PwD: “No, I’m not.”

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

PwD:  “No!  I’m not going.”

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

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

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

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

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

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

The 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.

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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The Wheelchair Test


May    Sunflower

 

The first time I went job-hunting as a CNA, I didn’t have a clue what I was doing. But that was then and now? Now I at least have a clue. Two years experience has at least given me that.

“Hello, this is _____ Healthcare, ____ speaking. How may I help you?”
So far, so good. The woman’s voice is pleasant and friendly and she doesn’t sound like she ready to rip somebody’s head off.
“Hello, my name is May and I was wondering if you could tell me what your base pay is for CNAs? Um, on first shift?”
There’s a small silence on the other end of the line, then the other woman says, “Give me just a second and I’ll find out for you. Are you looking for a job?”
“Yes,” I respond, still marveling at my decision. It’s been a long time coming, but it still doesn’t feel real. This isn’t an “I’m so fed up I’m reminding myself I have options” kind of call, such as I’ve pulled in the past…no this is the genuine article. I’m leaving. On some level, it feels like a betrayal to feel so relieved.
The receptionist’s voice cuts across my thoughts, pulling me back to the present. The figure she names is decent, slightly below average national pay, but more than my current pay…especially since my current pay includes shift differential! Hello savings account, you might not remember me! I force myself to calm down. The other place I called offered similar pay and a crap-ton of stutters and excuses instead of an answer to the next question on my script. Speaking of…
“And can you tell me what your resident-to-aide ratios are?”
The other woman laughs. “At the risk of repeating myself, give me a second to check.”
This time, the pause is longer. I can’t help but spring to my feet and start pacing the room. My thoughts pound out in rhythm to my steps: please, please, please. For years now, I’ve heard the same mantra thrown at me, “If you leave, you’ll never find as good a place as this.” At first it was reassuring. Then it was annoying and now I’m praying that it’s not true. I don’t want to have to decide between the money it will take to have a good life and ratios that allow me to take pride in my work. Please, please, please.
“Well, our staffing person is not answering the phone, but I just talked to one of the CNAs and she said she’s got eight people today, if that helps.”
“That’s very helpful, thank you,” I reply, trying and failing to keep my glee out of my voice. “Just one more question: are you hiring?”

It’s dangerous to accept a job sight- unseen, so I continue to check my rising excitement until I actually walk through the doors of the facility the next day. To my surprise, the receptionist recognizes me from our phone conversation as soon as I ask for an application. She’s seems as friendly in person as she did on the phone. That’s good.
As I fill out the application, I take time to look around me. It’s not quite as opulent as my current place, but there’s a friendly functionality at work. There’s also no odor that I can detect, no harsh scent of ammonia and urine. I can see aides moving quickly on the halls and some nod at me or wave. They look busy, but not hassled. A few residents are lined up by a nearby nurse’s station and I examine them closely. Men and women both are neatly shaved and groomed, there are no food stains on their faces and they all appear engaged with their surroundings. Quite a few of them are looking at me quite as intently as I’m looking at them. I hand in my application, wondering if I’m about to become their caregiver.
The receptionist asks me if I want to schedule my first interview for today, warning that it might be a bit of a wait. I say yes. I want to get this ball rolling, get this transition over with.
As I wait, I do the last thing on my list. It’s not something I’ve pulled off the Internet or asked other aides about, unlike everything else on my list or script. This is something I came up with on my own, a pattern I’ve noticed in my own experience. I like everything else I’ve seen and I almost don’t want to look. But as I wait, I walk up to a resident and start talking to them. Our conversation is mostly an exchange of names, but it gets me close enough to the wheelchair that nobody looks at me like I’m crazy when I squat down to put myself more or less on eye-level with the resident in the wheelchair. Nobody even notices when I duck my head down for a quick look at the underside of the wheelchair.

See, when you’re short-staffed or overwhelmed, somethings slip through the cracks–things like washing wheelchairs, for example. As an aide, I’m…not exactly okay with this, but I understand it. You can only do as much as you can, and when you’re running late on time and short on energy, primary care comes first. Better to make sure your people are clean than to make sure the wheelchair looks nice.
We’ve all had those shifts. Everyone, no matter how good the facility, has had that kind of day, and a good facility can rally. If one shift slips, the others can still catch up around it. The wheelchair gets washed the next go-round and all’s well.
But if that facility is in crisis mode and has been for a while, if every single shift is short…there’s no catching up. That wheelchair goes unwashed shift after shift, week after week. There’s a big difference between a bad day once in a while and a string of bad days; I’ve learned to tell the difference in the state of the wheelchairs.
And this one is mostly clean. There’s a bit of grime and dust on it, but it’s only a single layer. There aren’t layers upon layers of bad days coating the underside of the wheelchair.
Okay, I can work with that. I don’t expect perfection, but I’ve come from a place that’s been in crisis mode for almost a year and I can’t take it anymore. I’ve learned too many bad habits, too many shortcuts and there’s a bitterness in the air I just can’t breathe anymore. I need a clean break, a new place to make a stand…and I think I’ve found it here.

Alice in Wonderland

The thoughts flit through my mind at a dizzying pace, a kaleidoscope of colors and frenzied impressions that dance around the idea of what could be and what already is. We are in New Orleans. The Big Easy. A city that has no shortage of whimsy and magic in its own right but to be here to present to the world our writing? To be given a platform in which we can shout our truths in the hopes of reaching others on our path to deep, meaningful and lasting change?…that’s surreal.
It wasn’t an accident that I chose “Alice” for my pseudonym. As a child, Alice in Wonderland was my least favorite fairytale. It made no sense. I much preferred Robin Hood. Now THAT was a story I could sink my teeth into. So, it came as a quite a surprise to me that after a great amount of life experience, I awoke one day in my mid thirties only to realize that my LIFE was wonderland and I am indeed Alice.
Call it fate, providence or synchronicity, I never believed it was an accident that I crossed paths with Yang and May. The odds of meeting two like minded caregivers across the country with such an amazing talent for writing and dedication to expressing truth and impacting change would be slim in any case, but the fact that we have worked together fluidly for two years without meeting one another until this week? The fact that our different styles and voices flow together in a way that is harmonious rather than clashing? The odds of us being offered such an opportunity by the Pioneer Network to speak out and reach others? No. That is more than coincidental.
Sir Arthur Conan Doyle said that if you eliminate the impossible, whatever remains, however improbable, must be the truth. The truth, as I see it, is this: We are on a path that is uniquely suited to us. We have not only the opportunity but the obligation to follow through to wherever this journey may lead and in doing so, we will impact the lives of the most vulnerable among us for the better. We will impact our OWN lives for the better and what we learn on the way will forever enrich us in ways that we cannot imagine. This I know to be true.
Lasting change may not happen on my timeframe but it does happen. I cannot properly express how grateful I am to the Pioneer Network, everyone involved and all who attended, for seeing in us the message that fits so perfectly with their vision or Yang and May for being such a vital part of my life or how much hope our collaboration has brought me these past two years. I only know that the three of us will continue to speak our truths, shouting it when necessary and as much as we can, be the voice for those locked in this deeply flawed system. We will never give up. Of that, I am absolutely certain.
As I sit outside, watching this whimsical city in all its wonders, I feel bittersweet about leaving in the morning. This conference has been the biggest and most fulfilling achievement of my life and it’s sad that it’s almost over. But in my heart of hearts I know it is but the first step of a journey that is sure to be a thousand miles and I am so excited to be a part of whatever comes next. In the meantime, we will continue to write and remind you, our readers…our friends, that each and every one of you matter and each and every one of you can and do make a difference. So don’t ever let the world convince you otherwise. Shine on, my friends!