Category Archives: Green House Project

More on the Green House Model of Long Term Care

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Minstrel 

In a series of posts in 2015, CNA Edge offered a caregiver’s perspective of the Green House Project, an innovative alternative model for Long Term Care. In today’s post, caregiver and guest contributor Minstrel gives her take on the Green House Project after a visit to one of the homes.

Yang has written previously on the Green House Project.  Recently I also visited a Green House Project complex.  Today these embody the most promising ways of caring for those needing long-term skilled nursing care.  It’s a tremendous care model.  I do have several reservations.

First, this model depends on having a majority of residents with substantial nest eggs.  (At one home in New Jersey, I’m told this is about $350,000.)

Second, while Green House homes do pay their Shahbazim more than what they were previously earning, they are still not earning a living wage, and some work a second job to supplement income.  One of the Green House Project’s three philosophical underpinnings is staff empowerment.  Doesn’t staff empowerment need to include their economic empowerment?  I asked this question at a GHP seminar but didn’t get a satisfactory response.

Third, as aging impacts physical and mental health, some elders will develop dementia and some will need two-person assists for transfers. We may find that even a two-to ten ratio won’t sustain the quality of care as care needs increase.  The current staffing ratios, which seem ideal, may not be adequate.  Down the line there is likely to be a need for more staff at greater cost to the home; or, if staff isn’t increased to meet the greater needs, a diminution in care.

It’s hard to imagine how this model could be affordable on a large scale — and Dr. Bill’s vision is enormous — without a changed allocation of national resources.  In 2014 the US GDP was over $17 trillion. Green House nursing homes are an economic possibility, just not a political possibility yet.  Thus the current model of LTC homes seems likely to survive.  But the culture of care — for residents of LTC homes and also for their caregivers — must and can be improved radically.  This belief is at the heart of CNA Edge’s mission.

It’s About Who They Are

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Yang

The third and final Green House Project core value I’ll be dealing with is meaningful life.  I think this is really the essence of the Green House movement. It says that “good care” isn’t enough and that we can’t truly address the humanity and dignity of those who reside in LTC without awareness of what it is that makes their lives worth living – to them, as individuals. It’s not just about what they need, it’s about who they are.

The basic premise behind meaningful life is that in some respects the last stages of life are really no different than any other stage. We don’t stop growing and developing just because we hit a certain age or suffer from some debilitating physical or mental condition. Whatever our life circumstances, stagnation is unnatural and harmful to both body and spirit.  People in their 70’s, 80’s and 90’s can still have their dreams. Sometimes we just have to work harder to see it. And harder still to facilitate it.

But what does this mean from a caregiver’s perspective? I often hear caregivers say that the hardest part of the job is losing residents to whom they’ve become attached. While I’ve also experienced that kind of loss, the most difficult part for me had more to do with what was going on with certain residents while they were still very much with us. It’s not easy to describe the blend of emotions I felt after providing routine care to a favorite resident – hygiene, dressing, transferring, grooming and finally wheeling him down to the day room – and then having to turn and step away, leaving him there in front of the TV, waiting for his next meal as if getting a few spoonful’s of pureed meat and vegetables was the point of all of this and the pinnacle of his daily existence could be found in his dessert pudding. And I had no choice but to leave him there and move on because there were nine other people waiting for me. We did this day in and day out.

In those moments when I had to turn and walk away, I experienced more than just that sense of emptiness. I also felt guilty and angry and frustrated because I wanted to do more. I really believed we could do better than this. Yes, the facility provided activities and encouraged him to participate and this was better than nothing. But none of it was really about him. It was more about meeting some requirement imposed from the outside or impressing the never-ending train of oh-so important visitors. It was really about what the institution needed – and quite honestly, in this regard, he was just part of the window dressing.

What a person finds meaningful – what to him makes his life worth living – is intensely individual. It varies widely from person to person and can significantly change with time and circumstance. And it is not something we can choose for another person.

What we can do is know that person so well that we are able to engage him and help him experience what he does find meaningful. And no one has more opportunity to know a resident on this level than his caregiver. This is even more so when dealing with people who suffer from some degree of cognitive impairment or inability to express themselves in the usual ways. The caregiver-resident relationship provides a context that allows communication that might otherwise be overlooked.

The genius of the Green House Model is that it recognizes the potential of this deeper awareness and enables caregivers to act on their profound desire “to do more.” 

One Reason Why the Green House Movement Can Grow

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Yang

Before moving on to the third core value of the Green House Project, meaningful life, I would like to address one key question regarding staff empowerment. Currently, only a tiny fraction of residents in Long Term Care in the United States live in Green House Homes. Something under 2000 nationwide, but it’s growing. If the Green House movement ever grew to the point where it became a major alternative to traditional institutional care, would there be enough direct care workers with the right blend of personal and professional qualities to meet the demand? Or is the potential shahbaz candidate a rare breed drawn from an elite group of exceptional caregivers, high in motivation and ability, but too small in numbers?

There is much about the feasibility of the Green House Model that I am not qualified to answer. I know very little about the financial aspects and I don’t have the administrative experience or education to speak to the problems involved in organizing and sustaining something like a Green House Home. But what I do know and what I am qualified to address is the caregiver issue. And my answer to the question of whether or not there would be enough direct care workers with what it takes to meet the demands of a large scale Green House movement is an emphatic “yes.”

Yes, they are out there. I’ve worked with them. I know them. I know that many strive to maintain high standards of care while practicing a deep and genuine brand of compassion that endures despite difficult circumstances. And while they are acutely aware that the system they work under is deeply flawed, they are no less motivated by a sense of pride in their work and by the strong personal connection they have with their residents. These are caregivers who refuse to define themselves by the environment in which they work.

This breed of caregiver is all over social media. There, as in the work place, they find like-minded caregivers and create bonds of mutual support and understanding. Whether onsite or online, good caregivers are drawn to one another. And as we witness this larger community of caregivers begin to take shape and develop a sense of itself, we can see an independent grassroots ethos form, expressed in a thousand different ways, but with a common theme: “As a CNA, I know I am underpaid, not appreciated like I should be and worn out. But I also know that under my care, I will do whatever it takes to make sure you will have the best life possible.” While the words are simple, the commitment behind them is profound. And it is the essence of what it means to be a shahbaz. 

Of course, there are administrators and LTC professionals who don’t see it that way. There are those who would look at the unique labor requirements of the Green House Model and tell you – at least in private – “It wouldn’t work here – we just don’t have that kind of people.”

I think this lack of faith in the average caregiver extends from the fact that the skeptics are judging caregivers from the outside and in an environment that limits them. Heavy workloads, rules and regulations that do not make sense at the caregiver level and a hierarchical system that stifles initiative masks a powerful underlying and largely untapped potential. Even well intentioned administrators often lack the awareness of what caregivers actually do and are capable of doing. You have to descend into the trenches and become a part of it to really see it and understand it.

I have little doubt that with proper support and training, most caregivers would thrive in an environment of staff empowerment. If the Green House Project fails to become a large scale movement, it won’t be because the right kind of people aren’t available.

Staff Empowerment and Caregiver Relationships in the Green House Model

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Yang

I think one of the things that make the Green House Model viable from a caregiver’s perspective is that it incorporates many of the positive things that direct care workers in traditional institutional settings already do – or would like to do – and then formalizes and enhances them in a supportive environment. For example, that “deep knowing” of elders so vital to the Green House Model also exists in traditional settings. However, in places where caregiver workloads are too heavy, that level of awareness can’t happen consistently – even with the best of efforts – and some residents are going to fall through the cracks.

This is also applies to how workers relate to one another. Anyone who has been in the business for any length of time will tell you that friction among direct care staff is a staple of the institutional work environment. At its worst, it is exhibited in things like petty rivalries, cliquish behavior and bullying. Some of this behavior borders on the juvenile and the atmosphere on a nursing home unit can sometimes feel more like a middle school cafeteria than a home for the elderly. A quick check of the CNA Facebook pages will confirm this. Frustrated managers will often respond by saying something along the lines of “Why can’t you just act like adults – aren’t we all here for the residents?” apparently oblivious to the fact that having to remind workers of something so patently obvious is an indication that the problems go deeper and require a better solution than simply telling people to “grow up.”

On the other hand, it’s not unusual for direct care workers to create strong and positive relationships with one another and cooperate in ways that benefit their residents. Even in the worst work environments, caregivers often form very close bonds that resemble family ties and can even last a lifetime. Sometimes these are bonds are formed because of poor work environments, as a matter of mutual self-preservation. These relationships develop spontaneously, more a result of the nature of the work and the individual personalities of caregivers than from any systematic institutional initiative. And the value of these relationships often go unrecognized. Indeed, according to the conventional wisdom of many managers and caregivers “We are here to take care of the residents, not to make friends.” As if creating heathy personal connections with your coworkers is somehow inconsistent with good care.

By empowering staff, the Green House Model depends upon self-managed teams of workers to deal with the day to day issues of the home. In this model, strong interpersonal relationships among caregivers is a critical element. As part of their extended training, shahbazim receive instruction in interpersonal skills. This provides them with the tools that enable them to defuse personality clashes and focus their energies on resolving common problems. In the process, the natural bond that forms between caregivers is nurtured and can grow into a strong and effective professional relationship.

Furthermore, prior to the opening of a Green House Home, direct care staff go through a team building process that enable workers to develop positive relationships. In this way, caregivers become familiar with one another, learn to trust each other and a cooperative foundation is established even before the real work begins. As new workers are hired, they are brought into an environment that is open and supportive. The self-managed team has the supportive aspects of a clique, but without the exclusion. In a Green House Home, everyone belongs to the clique.

The shahbazim I talked to characterized their work relationships as “like a family.” I have no doubt that this is precisely what the creators of the model intended.

Staff Empowerment and Problem Solving

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Yang

In this post I will address how the Green House Project’s core value of staff empowerment creates a work environment that better utilizes the ability and motivation of direct care staff to solve problems. Please bear with me as I take a bit of an indirect route…

One of my favorite games in elementary school was “Telephone.” In Telephone, one person whispers a message to another, which is passed through a line of people until the last player announces the message to the entire group. The original message is inevitably changed in some significant way, often absurdly. There were those of us who took advantage of the anonymity and helped the process along by purposely changing keys words. Thus “Miss Austin says that London Bridges will be falling down at 2 p.m. next Tuesday” became “Miss Austin says her big britches will be falling down with b.m. today” much to the delight of her entire 4th grade class. But the lesson remained the same.

The object of the lesson was to teach us the impact of gossip and rumors. You simply shouldn’t believe something just because someone says it (an idea that seems to have lost ground with the advent and popularity of social media). And perhaps it was also meant to teach us the value of clear and precise communication.

I remember actually playing a version of Telephone during an inservice training class. Again, the focus was on gossip and rumors, but also to demonstrate the importance of written communication and to help explain why health care in general seems obsessed with documentation. Of course, this part of the lesson didn’t say much about the fact that written communication can distort the truth as well, indeed more powerfully and often more by design than by misunderstanding. We were left to surmise that part of it ourselves.

There is something else that happens to both verbal and written communication as it is passed down the line. Not only can the literal meaning be altered, the significance of the message can change. In other words, the message is often most important to the person who initiated it and it can lose a measure of importance with every link in the communication chain it passes through.

I experienced this both as caregiver, and later as a storekeeper responsible for keeping a 730 bed facility and its 300 busy nurses supplied and happy. As a caregiver, I learned that it was often quicker and more efficient to bypass the official line of communication – that is, through my supervisor – and go straight to the person who could help me solve the problem. Plugged toilet in Room 237? I knew the extension of the maintenance person responsible for plumbing issues and I knew he would come up to the unit ASAP if I asked because we had a good working relationship and he knew I wouldn’t expect him to drop what he was doing unless it was really important. And it was really important, because Mr. Verlander absolutely refused to use any toilet except the one in his room and would rather risk defecating in his pants then sit on an unfamiliar commode. And the clock was ticking.

Normally, I would inform my supervisor of the problem who would then instruct the unit secretary to create a work order that would be sent to a maintenance supervisor who then delivered the work order to the plumber’s desk. While the literal meaning of the problem – a plugged toilet – doesn’t change, with each step the immediacy and significance of the problem fades and thus the motivation to address it promptly diminishes as well. While no one wished for Mr. Verlander to crap his pants and understood it as – in the parlance of moderately over-educated professionals – a “negative outcome,” it had the greatest meaning first to Mr. Verlander and then to me. My supervisor, the unit secretary and the maintenance supervisor may or may not have been present and able to respond quickly – they weren’t always where I wanted them to be. And besides, they all had their own problems that no doubt had higher priority to them.

As a storekeeper, I got to experience being at the other end of the service chain. Every day I would get requests for nursing supplies from caregivers who chose to contact me directly rather than go through their supervisors. While I completely understood their reason for doing so, it did create a few problems for me, like the phone constantly ringing and a bit of flak from the people in my own department who insisted that I was subverting the requisition process by responding to requests from “just caregivers.”

But I knew something about these workers. That is, the ones who pestered me the most were also the best caregivers. I knew this because I had worked on the nursing units with them, some for several years. I was well aware of the kind work they did, how they treated the residents and how important they were to their residents. They were willing to do whatever they needed to do to get the job done, even if it meant breaking some rules and going outside the facility’s official procedures. Bad caregivers tend to hide behind the rules and use them as an excuse not to act.

I should also note that while I knew these caregivers well and trusted their judgement, they also knew me well and thus felt comfortable coming directly to me. In a sense, this relationship empowered them, albeit unofficially.

Recently, I sat down with a small group of shahbazim from a local Green House Project home. When one of them used an example of dealing with a broken bed to illustrate how problem solving differs in a Green House verses a traditional institutional setting, I knew exactly what she was talking about. No one could understand better than her the particular difficulties the broken bed created for one of her elders and thus she was the one most motivated to get the problem resolved as quickly as possible. Not having to go through any chain of command or requisition process, she made the appropriate call herself and was able to state the urgency of the situation directly to the individual that could help her solve the problem. In one person, she represented the authority, the responsibility and the motivation to resolve the problem in a way that benefited the elder most. And make no mistake, such problems are routine in a long-term care setting.

Given the appropriate tools and support, no one is more capable of creating a “positive outcome” for a resident than a motivated caregiver.

A Culture of Empowerment

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Yang

In my last post, I listed the structural elements that enable the Green House Project’s core value of empowered staff to become a reality. In this post, I will begin to tackle the less easily defined dynamics of empowerment.

Whenever we talk about staff empowerment, we need to keep in mind the reason behind it. While the title “shahbaz” denotes respect for the caregiver, it is actually the elders that are being empowered. The Green House model simply recognizes that in order for elders to be empowered, those closest to them and know them best must have the means to facilitate that empowerment.

Obviously, caregivers in traditional institutional settings play a critical role in how a resident experiences life in in long-term care. Both the nature of the work and the manner in which caregivers engage residents guarantee that central role. For many long-term care residents, the quality of their relationships with their caregivers determines the quality of their lives.

However, when it comes to actual power – the ability to make day to day decisions that most directly impact residents and the accountability for those decisions – the traditional model provides the caregiver with a distorted version of power, created more by default than by design. While caregivers report to a unit supervisor, much of their daily routine is conducted without the direct involvement of that supervisor. The nature of the long-term care business demands that a manager’s time and attention be occupied by matters not directly related to the details of daily care. Simply put, a supervisor has limited awareness of what goes on down the halls and in the rooms.

In this vacuum, individual caregivers are compelled to make decisions regarding the use of limited resources – time, especially. How they prioritize these choices is often influenced by an informal, but powerful subculture in which the caregivers with the strongest personalities sent the standards. Sometimes, this actually works well and supervisors even learn to rely on these caregivers to help manage the unit. But all too often, it leads to mistrust and petty bickering among caregivers. The relationship between caregivers and managers is commonly characterized by conflict over authority, self-promotion, stonewalling and manipulation. Good work is not rewarded and poor work is left uncorrected. This is not the kind of “power” that contributes to a meaningful life for residents on a consistent basis.

By providing the Shahbazim with real decision making power, the Green House Model formalizes and expands the caregiver subculture. In doing so, it changes the dynamics of the relationship both among caregivers themselves and between caregivers and the individual charged with holding them accountable, the Guide. Leaders will still emerge within the group, but everyone is expected to grow into leadership roles. Along with the guide and clinical staff, the strongest and most experienced shahbazim are charged with coaching newer staff members into those roles.

Furthermore, the Shahbazim are held accountable in a way that caregivers in a traditional setting are not. While caregivers are always responsible for their individual actions, the ultimate responsibility for what happens on an institutional unit falls on the licensed supervisor. In the Green House Model, the caregivers assume that responsibility. The team is self-managed and while there can be a degree of flexibility in some matters, they have a vested interest in following their own rules and developing a cooperative work environment.

While the Guide expects and encourages the Shahbazim to make decisions, he or she is much more aware and involved with the day to day details of the home than a traditional manager. Not only does this allow the Guide to be effective in the coaching and support roles, it leaves less room for the kind of finger pointing and lack of transparency so prevalent in traditional settings. Issues are more likely to be dealt with directly and in the open. Again, this is aided by the small size of the home compared to large institutional nursing units.

In my next post, I would like to talk about how an empowered staff’s approach to problem solving differs from the approach taken in a traditional institutional setting.

How the Green House Model Makes Staff Empowerment Possible

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Yang

In my last post, I began looking at the second core value of the Green House Project: empowered staff. This features an organizational structure that “flattens” the traditional hierarchy and leaves the responsibility for day to day decisions in the home to direct care staff (shahbazim). How and why the Green House model makes this organizational structure viable from a caregiver’s perspective will be the subject of my next two or three posts.

There are three tangible and interrelated ways in which the Green House model makes it possible for the Shahbazim to perform this expanded role. First, as previously noted, the shahbaz to elder ratio is 5-1. In most LTC settings that ratio is much higher, sometimes 10-1 or more on the day shift and higher on the evening and night shifts. The higher ratios guarantee that a caregiver in a traditional setting is going to be overwhelmed with basic daily care concerns and is not a position to take on the additional burden of assuming responsibility for matters not directly related to care. The 5-1 ratio allows a shahbaz the flexibility to effectively deal with these additional responsibilities.

Second, along with the CNA requirement, shahbazim receive an additional 128 hours of training specifically related to their expanded role. This includes instruction in safe food handling, culinary skills, first aid, basic home maintenance and management skills. Shahbazim also receive instruction in dementia care, critical thinking, communication, teamwork and policies and procedures. The shahbaz builds on this foundation of knowledge and develops professionally through a combination of practical experience, coaching and peer networking. There is an expectation that with proper support, caregivers can and will grow into the expanded role.

Third, Green House homes are limited to 10-12 elders. The small scale significantly changes the nature of the problems and decisions faced by the Shahbazim as opposed to what managers deal with in large institutions. For example, nutrition in a traditional institutional setting involves a whole range of problems such as large scale procurement, storage, inventory control and staff management, not to mention the difficulties involved in preparing and delivering large volumes of food. While preparing meals for a home of 10-12 people is not a small job, the problems revolve more around individual preferences and are thus more similar to what a shahbaz experiences in his or her own home.

While we can point to these more tangible factors that make staff empowerment possible, the dynamics that really make the whole thing work are a little harder to define. But I’ll give it a shot in my next post.

A Flattened Hierarchy

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Yang

Continuing my exploration of the Green House Project, I will now turn to the second core value of the model, “Empowered Staff.” Empowered staff refers primarily to the workers who provide direct care.

The Green House term for a caregiver is “Shahbaz” (plural: Shahbazim). Shahbaz means “royal falcon” in Persian and is meant to convey a person worthy of respect, someone who is valued. The title is representative of the Green House Model’s investment in and support of the workers closest to the Elders.

The Shahbazim perform the same basic personal care duties as CNAs in a traditional long-term care setting, but along with the new title they are given a significantly expanded role which makes them responsible for the day to day management of the home. They make decisions that would normally be made by supervisors or mid-level managers. These include decisions involving scheduling, food preparation, laundry, housekeeping and care planning. They rotate the leadership roles – typically each quarter – so that each shahbaz takes a turn coordinating each of these functions.

This organizational structure is often characterized as a “flattened hierarchy.”  However, while the homes are operated by self-managed work teams, the Shahbazim do not work unsupported. They report to a “Guide,” an experienced LTC professional with extensive training in coaching skills. The Guide is responsible for providing the team with support, accountability and the resources necessary for the Shahbazim to succeed.

While it would be easy for a caregiver to simply regard the Guide as just another kind of supervisor, the core value of Empowered Staff requires the Guide to leave the day to day problem solving in the hands of the Shahbazim. A Shahbaz must be willing to receive coaching and grow into these new roles. In this sense, empowerment is not simply a matter of delegating responsibility, but it is a process that depends on the personal and professional growth and development of individual caregivers.

How and why this organizational structure works from a caregiver’s perspective will be the subject of upcoming posts.

The Core Values of the Green House Project

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Yang

Last week, I promised an outline of the core values of the Green House Project. There are three of them. Straight from the brochure, they are:

Meaningful Life

“Individual needs are met because each person is deeply known and valued as creative, resourceful and whole. Everyday tasks, such as personal care, bathing and mealtime, are seen as opportunities to support elder autonomy, decision making and meaningful engagement.”

Empowered Staff

“Direct-care staff functions within self-managed work teams to provide day-to-day care and act as managers of the home. They partner with nurses and other clinical team members and report to a Guide, who is responsible for providing the team with the support, accountability and resources necessary for success in their role. This model returns power to elders and those who are close to them.”

Real Home

“The physical environment of each Green House home is designed to transform the institutional nursing facility into a small, residential environment that is home to 10 to 12 elders. Each person who lives in a Green House home has a private bedroom and full bathroom with a shower. Elders share meals prepared in the full kitchen in the home, at a common table. The homes fit in the surrounding community.”

And that’s it. While the language used in expressing these values is important, the real challenge is putting them into practice and sustaining them on a day to day basis. In my current exploration of the Green House Model, I have heard of instances of Green House Homes “not working.” While this depends on upon one’s definition of “not working,” my guess is that it has something to with practical problems causing administrators and staff to stray from these core values.

We’ve already shared a good example of the Real Home core value in practice (see At Home With the Green House Project) . The only thing I would like to add is that the purpose behind this physical environment can be defeated by staff reverting to institutional-like habits and patterns of behavior (see An Institutional Mindset). You can build the house exactly right, but to sustain the culture and avoid “reverse creep” requires administrators and staff who are totally committed to the core values and philosophy of the Green House Model.

In my next post, I would like to take a closer look at the Empowered Staff core value and the people who ultimately make the model become reality: the caregiver – or in the Green House vernacular, the Shahbaz.

An Institutional Mindset

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Yang

In my last post, I shared my initial impression of the physical aspects of the Green House Project based on a workshop group tour of a local Green House Home. While the design of the home is a key element in the Green House “revolution,” it is only one piece of the puzzle. There is also a set of core values and a philosophy behind the Green House approach. For a Green House Project home to succeed, staff and administrators must totally embrace these values. In future posts, I’ll outline what these values are, explore what they mean from the caregiver’s perspective and talk about the philosophy that makes the Green House model truly revolutionary. In this post, I would like to share a simple personal epiphany.

Embracing the Green House core values means shedding the institutional mindset that comes from working in a traditional long-term care setting for any length of time. During the workshop, I noted a kind of “born again” theme running through the presentations. One speaker actually used the phrase “in my former life in long-term care,” more than once. I got the sense that in order to accept the principles of the Green House model and practice them effectively, one must first go through a process of internal psychological change. My epiphany: as much as the Green House model appeals to me, I have not gone through that process and as a caregiver, I am still very much a product of my institutional work culture.

The institutional environment is task orientated. For a caregiver, this means going full steam through the shift, efficiently organizing your activity so that you can get as much done as possible in the time you’ve been given. That is how a good worker responds to heavy workloads. It is a necessary approach, because the alternative is allow the sheer volume of tasks to overwhelm you and ultimately you simply leave things undone. When it comes to residents, “things undone” is actually another way of saying “neglect.”

But residents aren’t “tasks” or “things to be done,” and to approach them this way is another form of neglect. So within this flurry of activity, a good caregiver will seek to engage residents on an emotional level. The posts on CNA Edge deal with this aspect of caregiving almost every single week. I’ve always thought of the Art of Caregiving involved the ability to go full tilt until the point of physical and emotional contact with the resident, then decelerate as if time was standing still. But the art is imperfect and we don’t always make that shift.

For a caregiver, shedding the institutional mindset means to liberate yourself from that anxious “gotta get it done” mentality with which we have been conditioned. There are tasks to perform in a Green House Home, but the work environment is such that they are performed within the context of the emotional and social relationship with the Elder and not the other way around. In other words, there is no reason to “decelerate,” because you don’t “accelerate” in the first place.

I think that with the proper support and appropriate training, most good caregivers would be both capable and highly motivated to make this psychological adjustment. But if the change is to be real and sustained, one must first be aware of his or her starting point.

For me, such a psychological shift would require me to reshape my definition of The Art of Caregiving. Perhaps the first step has been taken with my growing awareness of how much the institutional influence is still with me.