Category Archives: person centered enviornment

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. 

Broken System vs Personal Responsiblity

Sunflower  May

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

If there’s a story of my career in health care, it’s probably: Nothing happens the easy way, or when I have time to deal with it. Take right now, for instance.
Mr. K has a reputation for being a jokester; he loves to laugh and he loves to make others laugh. The aides are his best audience as we always appreciate a bit of levity. Unfortunately, Mr. K doesn’t so much speak as he does mumble. It’s hard to understand him…especially when he’s cracked up laughing at his own joke. I know from experience that if I keep just repeating that I can’t understand him, his joy will vanish like his independence. So, I lean down and put my face right next to his mouth, in order to catch the words of what I am assuming is a killer joke. When he repeats himself yet again, I don’t take in his words. I can’t; I’m a bit distracted.
His breath is so foul, it smells like something died in it.

I didn’t brush his teeth this morning. I haven’t brushed his teeth all week. As I gag, I ask myself “How did this happen?”

Oral care is often the last part of personal care to be done, and by the time I get to it, I’ve been in the room for fifteen minutes already and ten other call lights are going off. It seems like a quick task, so it’s easy to say “I’ll get to it in a moment,”…and then never actually find time for that moment. When you’re scrambling just to change your people, making the time to do oral care is hard. Adding another five minutes to each resident’s personal care time, when you have ten residents and you’re already running behind…yeah, that adds up quick. Sometimes it is literally a choice between brushing Mr. K’s teeth or changing Mrs. L’s brief before she soaks through her pants. In other words: when you only have ten minutes, what is the most effective way to use them? Most often, we choose the big problems to tackle, the things that have an immediate impact on our residents’ quality of life.
The other problem is that we get so used to dealing with emergencies, crunch-times and hard decisions. We get so used to cutting corners just to survive the day that we form habits around the emergencies. The little things that we had to drop during the crisis? We forget to pick them back up. We get used to not brushing teeth.

The problem of oral care is the problem of this broken system of long-term care, narrowed to razor-thin focus: too few aides taking care of too many residents. We have a system that punishes the aides who take the time to provide good care, and then punishes them again for providing mediocre care. And yet, for all that is true, Mr. K’s mouth still smells like something died in it. I am still his aide…do the flaws of the system really absolve me of my personal responsibility? Being a CNA is, in so many ways, to be forever caught in the moment of drowning: my best isn’t good enough and yet my best is always required.

I laugh, like I got the joke. “Good one, Mr. K! Tell you what, while you think of another one, I’m going to brush your teeth, ok?”

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.

A Personal Question

Sunflower May

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

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

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

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

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

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

What it’s all about

DSC00999

 

Yang

 

I’m going to post my thoughts regarding our time at the 2016 Pioneer Network Conference in more depth next week. Today, I would like to address an incident that occurred during the conference orientation on Sunday. It was a little unsettling and it affected me in a personal way.

It happened as Barry Barkan of the Live Oak Institute and one of the founders of the Pioneer Network, was closing the orientation with what he described as a “solemn ritual” that went back to the early days of the Network. In a gentle and reverent tone, he instructed the group of a hundred or so orientees to form a circle around the auditorium. As we linked hands in anticipation of a prayer or a pledge or some version of Kumbaya, Barry bowed his head for a moment, then looked up and did this:

Put your right hand in,

Put your right hand out…

Oh, that.

Let’s get something straight:

I don’t do the Hokey Pokey.

I don’t put my whole self in

I don’t put my whole self out

And I certainly do not “turn myself about.”

But I did on Sunday.

Barry Barkan, Miracle Worker, got me, a life-long anti Hokey Pokier, to perform this absurd children’s dance. And I liked it.

It wasn’t the social pressure. A good portion of the group chose not to participate and I could have easily joined the ranks of my brother and sister Hokey Pokey objectors and not have suffered any of the awkwardness of being the lone dissenter.

I did it not just because Barry is an instantly likable person …

I mean look:

Solidarity through Hokey Pokey

Solidarity through Hokey Pokey

I did it, and I liked doing it, because his approach, the buildup and the subsequent surprise (Humor 101), was utterly disarming. It allowed us to drop our social armor and just have a bit of fun.

The moment was made possible by an understanding of how we were perceiving the situation, the use of humor to lighten the mood, and the reliance on an indirect approach. Had Barry taken a direct approach and told us to get in a circle for the Hokey Pokey because it was the designated time for the Relax and Have Fun portion of the orientation, I would have indeed “put my whole self out”… of the room. As soon as I navigated the one-way traffic jam at the door.

This really is “what it’s all about.” A person centered environment means that as we approach and respond to our elders, we pick up on the cues that provide us with an awareness of how they as individuals are perceiving the situation and use this as the context for our interaction with them. An unhurried and indirect approach with a light touch creates an atmosphere of cooperation and reassures our elders that they are in control.

I didn’t have to do the Hokey Pokey. I wanted to. And I would do it again, reserving of course, my right to refuse.