Tag Archives: bad management in long-term care

A Not so Obvious Picture at the Grand Rapids Home for Veterans

Bob Goddard

In early August, a disturbing news story broke about the Grand Rapids Home for Veterans, my old workplace.  After an investigation by the State of Michigan’s Attorney General’s office, eleven former employees – all direct care workers – were charged with falsifying medical records. The caregivers charted that they had checked on members (the Veterans Home refers to the residents living there as members) while surveillance video shows that these checks were not done. In Michigan, falsifying medical records by a health care provider is a felony, punishable by up to four years in prison and a fine of up to $5000.

The investigation followed a scathing February 2016 report by the Michigan Auditor General. According to that report, the home failed to properly investigate allegations of abuse and neglect, took too long to fill prescriptions and operated with inadequate staffing levels. Both the Attorney General’s investigation and the audit came almost three years after the State privatized the entire direct care workforce at the home, thus replacing a dedicated, stable direct care workforce with contract workers from a demonstrably unreliable agency, J2S.

The eleven workers charged by Attorney General’s office were employed by J2S. That company was replaced by two other contract agencies last year after J2S repeatedly fell short of adequately staffing the facility.

As we have come to expect in media coverage of anything related to long term care, the local media treatment of this story displayed a superficial understanding of how a long term care facility operates and relied on sensational wording to make the story more compelling. In the process, the reporting presented a misleading picture of how caregivers go about their work. While reporters expressed outrage over the quality of care at the home, they seemed clueless regarding what it takes to make good care happen. I think it would be useful to correct this and offer a different perspective.

In one report following the announcement of the felony charges against the caregivers, a local TV reporter assured viewers that the Attorney General’s investigation “paints a pretty obvious picture of the situation” and concluded that bringing the charges does two things: “it holds people accountable for what they did,” and second, “I can guarantee you tonight at the home for veterans they’re going to be doing their member checks.”

The assumption in that last statement is that fear is a necessary and effective motivator in providing good care. This is a common fallacy among observers unfamiliar with the nature and practice of caregiving. You cannot get genuine compassion and caring from fear.

Yes, as our visibly self-satisfied watchdog reporter suggested, I’m guessing “those member checks” were indeed “being done tonight,” but as I will explain below, that form of diligence has little do with the actual quality of care at the home.

The media reports and statements from the Attorney General gave the impression that these hourly checks were at the heart of what caregivers do. They are not. In fact, the hourly checks are superimposed over normal care routines. In a typical institutional setting, each caregiver is assigned a group, usually ten or more residents depending on the shift, unit and facility, and is charged with completing a whole series tasks including assisting with the residents’ personal hygiene, bathing, grooming, dressing, toileting, bowel care, skin care, turning positioning, transferring, ambulating, transport, serving meals and feeding patients, offering fresh water and snacks, take vital signs, make beds, keep the residents’ room clean, answer calls lights and respond to requests, record intake and output information, observe and report changes in residents’ physical and mental condition. And of course, document these activities via flowsheets and other similar forms. The location sheet is one of these forms.

It’s important to understand that given the direct care staffing levels in a typical long term care facility, and this certainly includes the Grand Rapids Home for Veterans, assigned caregiver workloads are rarely possible to complete – not to the standards set forth by regulators, facility policy, and customary nursing practices, let alone family and public expectations.  This means caregivers are constantly engaged in a form of care triage, made necessary because no one above them in the Long Term Care hierarchy, including policy makers and legislators, seem able to provide the resources necessary to do the job according to standards. Either they lack adequate awareness of the problem or are simply not willing to make the hard choices. By default, this is left to the direct care worker.

Given the inadequacies of the system, the best a caregiver can do is to arrange these various tasks in some order that makes the most sense for everyone in the group, taking into account the unit’s mealtimes and other facility routines. While a good caregiver tries to plan ahead, working with human beings means that unexpected needs routinely arise and no can anticipate everything.  Each shift becomes a unique time puzzle that the caregiver must solve if the residents are going to receive the best care he or she can provide. But the puzzle is dynamic, the “pieces” change according to the immediate needs and expectations of residents, coworkers and management. The caregiver must continually adapt his or her time organization to ever changing circumstances and priorities. In essence, the caregiver spends the shift involved in perpetual problem solving with ethical implications.

At the Veteran’s Home, the check sheets are kept behind the nurses station while the majority of care is conducted in the members’ bedrooms and bathing areas. So, to properly document the checks consistently in a timely manner requires this absurdity: the already overwhelmed direct care worker must pause care and walk away from the members for whom she is providing care for the purpose of putting her initials on a sheet of paper that indicates she knows the location of the members she was just with. This may provide the facility with documentary evidence and meet an institutional need, but it does not necessarily address the needs of the members.

If we are truly concerned about the quality of care for our veterans, the real question is not whether or not the checks were properly documented, but what the caregivers were actually doing when they indicated they made the checks. Were they in the shower room with a member or making sure an unsteady member wasn’t tumbling off a commode or perhaps transporting a member to a therapy appointment? Were they in the middle of assisting a member with his meal or helping a coworker transfer a 350 pound man from his bed to his wheelchair? Were they responding to a member’s urgent request for help? Were they redirecting a confused member for the tenth time in the last five minutes? Were they assisting another caregiver who was trying to manage a combative member? Were they comforting a member who was experiencing some kind emotional turmoil? Were they on their way to nurses’ station to get the location checks clipboard when they noticed a call light? Were they with a sick member, maybe dealing with copious amounts of diarrhea or vomit? Were they cleaning up a spill that presented a fall hazard? Were they speaking with the family of a member regarding their loved ones’ care and status? Were they holding a dying member in their arms? Or perhaps they were engaged in a member’s post-mortem care.

I will leave it to the Attorney General and media reporters to decide to which of these activities caregivers ought to interrupt so that they might properly document the checks – and presumably stay out of prison.

Let’s be clear, if the workers were sitting behind the desk or off the unit or otherwise not engaged with the members when these checks were supposed to be made, then our sympathy and support for them evaporates. Not because they didn’t make the checks properly, but because they weren’t with the members and on task. Even in bad work environments, caregivers are ethically and morally obligated to the use the time and resources that they do have to do the best they can for the residents.

Of course, it could be argued that the hourly checks provide a more systematic way of accounting for the members’ location and condition. Regular checks ensure that no one gets forgotten.  It seems obvious, right?

However, when you start to look at how caregivers actually gather information and keep tabs on the members in their group, the hourly checks take secondary importance. Caregivers are routinely provided with a “cheat sheet,” a one or two page list of all the members in their assigned group. The cheat sheet includes basic care information for each member. The caregivers carry these sheets with them and will refer to them throughout the shift. Even caregivers who are familiar with the members in their group will often use the cheat sheet as an aid to help organize their time and, of course, to help make sure no one is forgotten.

Given the real needs of the members, the fact that the checks are hourly is completely arbitrary. The reality is that some members don’t need to be checked that often and some leave the grounds for long periods – as is their right, it’s a home not a prison. Other members may need to be checked even more frequently depending on their particular physical and mental status.  A lot can happen in 59 minutes and the hourly checks can no way guarantee the safety and well-being of all members. The best way to keep members safe and their immediate needs met is to have well informed, well supported, on-task caregivers. And by well-informed, we mean caregivers who are thoroughly familiar with the members – not just with their current medical status, but who they are as individuals, their daily needs, preferences, and habits.

By threatening caregivers with prison sentences and the like, we can make them jump through hoops and give the appearance that good care is being done, but we should wonder what is actually being missed while they’re putting on this show for us. As our watchdog reporter implied, fear will elicit a sure response. But with fear, the issue becomes not about the real quality of your work and how those in your care are experiencing it, it’s about how you think it’s being perceived by those who can punish you. Under siege, our actions are informed not by our sense of right and wrong nor even by common sense, but by the assessments and attitudes of those who are judging us. When those assessments and attitudes are based on faulty perceptions – which is often the case in long term care and certainly the case here – our priorities become skewed and we add yet another obstacle to good care.

Fear won’t take caregivers into the places where genuine compassion and caring will go. As a motivator, it’s a weak and insufficient substitute for the truly powerful motivations that result in the best care possible. On the other side of those closed doors and privacy curtains where caregivers engage members and actual care takes place, you really want people who are inspired by the better angels of their nature.

The quality of care in any long term care facility is directly tied to the facility’s investment in the caregivers who provide it. Paying direct care workers good wages with decent benefits not only helps attract and retain workers, but it also gives them the means to adequately provide for themselves and their families. Many caregivers have no choice but to work a lot of overtime or find second jobs just to make ends meet. The work itself is physically and emotionally demanding, and when you add the stress of double shifts and long hours, the result is a caregiver workforce perpetually on the edge burnout. You can’t get the best possible care on a consistent basis from workers who are physically exhausted and emotionally drained.

It should be no mystery why J2S had such difficulty staffing the place and why even now one of the current contract agencies continues to have problems. The shortage of caregivers has become a nation-wide crisis and annual turnover rates for direct care workers typically run between fifty and sixty percent. Prior to the State’s privatization of the direct care workers, the Grand Rapids Home for Veterans was immune to this crisis.

The cost of losing that stable direct care workforce cannot be overestimated. Caregivers who are unfamiliar with the members in their care groups cannot possibly provide the same level of care as those who have had long standing relationships. But we continue to routinely throw these workers into chaotic situations and expect them to perform a high level. Usually they feel fortunate just to get through the shift with no major disasters. Or investigations.

While a sense of duty and a good work ethic are necessary in providing adequate care, there is no substitute for the personal relationship that develops between the caregiver and resident. This bond is the single most powerful motivator in providing excellent care. In environments where these relationships are encouraged to develop and flourish, workers become more caregivers, they become advocates.

If the caregiver has a moral obligation to do the best for his or her residents despite difficult circumstances, then those above us in the hierarchy and those on the outside who seek to influence the activity of caregivers have an equally compelling moral obligation to understand the consequences of that influence. This requires a basic awareness of the real challenges faced by caregivers and insight into what really motivates them. From what I’ve seen, both the Attorney General and the local watchdog reporters have failed to demonstrate that awareness and insight.

  

My Old Work Partner

 

Bob Goddard

For a caregiver, there is nothing like a good hall partner to make the shift go right. Reliable coworkers that you get along with can help you maintain your sanity even on the most challenging days. They can make the difference between looking forward to coming into work or dreading it. During my 25 years as a caregiver in the veterans’ home, I had many such hall partners. One that stands out for me is my old buddy Russ.

While we worked well together, Russ and I had completely different personalities. Russ was loud, gregarious, and not afraid to speak his mind – to anyone. He was a big guy, with long hair and sported more than a few tattoos and body piercings. I was always more reserved, careful with my words, and more deliberate in my actions. And I was far more conventional in my appearance. However, he did talk me into getting a couple of small tattoos, one of which he did himself as a budding tattoo artist.

On the unit we complemented each other well. We were each assigned permanent groups, but we knew each other’s residents as well as we knew our own. When one of us had the day off, we knew the other would be watching out for our respective residents. “Take care of my boys tomorrow,” Russ would remind me before a day off.

We also knew each other’s routine and work habits. Russ was always around when I needed help. I always pretty much knew where he was and I didn’t have to spend a lot of time running around the unit looking for someone to spot me on a Hoyer lift or assist with a two-person transfer. And I did the same for him. I just kind of knew when to show up in one of his rooms. In fact, Russ referred to this as my “Jedi Wall Trick,” this uncanny ability to suddenly, but quietly appear – as if I walked out of the wall. It actually kind of freaked him out a little; he would grin and shake his head, and ask me to stop doing that.

We each took different approaches to our residents. Russ was more forward, sometimes a little too forward, and I would have to steer some of his interactions in a more appropriate direction. The same level of familiarity with certain residents in a care situation might not be as acceptable in a more public setting. At the same time, Russ had a knack of bringing residents out their shell and could reach them in ways that didn’t come natural to me. He showed me that being authentic, especially when laced with humor can help break down social barriers and actually strengthen the bond between resident and caregiver.

Due to the nature of the beast, caregivers in an institutional setting often have to work with a looming sense of turmoil and even fear. We may like the work and enjoy our residents, but sometimes we’re not so crazy about our place of employment nor the system under which we work. In this kind of atmosphere, we learn to rely on each other to keep it real. And more than anything, Russ helped to keep it real.

In my next post, I’ll talk about my current work partner.  She’s a few feet shorter and a couple hundred pounds lighter than Russ, but just as valued.

It will be okay

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Rose 

It seems like every other word out of my mouth tonight was an apology.  “I’m sorry I forgot your towels.”  “I’m sorry I forgot your coffee.”  “I’m sorry it took me so long.”  “I’m sorry, but it looks like I won’t be able to do your shower tonight.”  After two years of this, I finally felt like I was starting to get the hang of things.  But this particular hall was so busy that some things just slipped through the cracks.

              Every time I feel like I’ve finally got things figured out, it seems like the universe drops a load of crazy in my lap.  Or in this case, a week of crazy.  They just filled this rehab unit up after having it closed for a few weeks due to low census, and it seems like they managed to find every demanding, picky, or needy person in town and drop them on us all at once.  Everyone who works this unit knows that it’s crazy.  We’re struggling to get the bare minimum done, and it’s starting to show.  We’ve been asking for more help for days, but it’s not going to happen.

              It’s been a while since I’ve had an assignment this busy, and it was a rough day.  I forgot Mr. A’s towels and Mrs. B’s coffee.  Mr. C’s wife and daughter were sitting in the hall just before dinner, watching me run my legs off and making sympathetic comments about how I needed more help.  Mrs. D waited over two hours for me to be able to put her to bed, and I never did get the chance to give Mrs. E her shower.  As I’m driving home, I find myself running through the day in my head, trying to pinpoint what I could have done better.

              I want to tell them that I’m busy.  That there are too many people.  That I need more help.  But I try to avoid excuses, because they don’t really change anything.  For better or for worse, this is what I’m stuck with, so I’ll figure it out.

              In the end, Mr. A and Mrs. B got their towels and coffee.  Mr. C’s family went home and I was finally able to take care of him without someone breathing down my neck.  Mrs. D got into bed, and I told Mrs. E that maybe she can request a shower tomorrow or the day after if the staff has time.  The orientee from the other hall came over to help me for the last hour, and I finally got everyone into bed.  The charting wasn’t finished, and I clocked out late, but that’s okay.  It happens.  I’ll get to try again next time.

              The truth of the medical field is that it’s hard.  Some days it feels like I’ve been put through the wringer and dropped on a sinking ship with a teaspoon to bail myself out.  I can either sink or learn to swim very quickly.  But in the end, it’s worth it.  Because when I walk into a room, they smile.  They ask how my weekend off was, or how my classes are going.  I celebrate with them when they graduate from the wheelchair to the walker.  I give them a hug goodnight and tell them I’ll see them tomorrow.

              They need me.  It’s terrifying to realize that these people are totally dependent on me to care for them.  It’s a million times more terrifying for them.  There will be good days and bad days, but I’ll figure it out, because I have to.  It will still feel like things are falling down around me, but I’ll learn to be calmer and deal with it.

              When I first started as an aide, it was hard for me to accept the fact that I can’t do everything.  That some days I was only able to get the minimum done.  I thought that I was failing, and or that there was something I was doing wrong.  But eventually I realized that everyone else was in the same boat, and that we were all just doing our best within a tough system.  I learned to cope by focusing on the good parts of my day, not the bad.

              And there were good parts today.  I was able to share a joke with Mrs. F as I readjusted her pillows and gave her something to drink.  Mr. C told me that I must like my job because I’m always smiling.  I was able to teach the new girl a few tricks she didn’t know.  Several people asked me when I would be back.  If they want me back, I must be doing all right.  I’m driving home listening to a good CD, and I have the weekend off before my classes start.

              So I’ll go home, go to bed, and come back next week to start all over.  It will be crazy, and I’ll probably mess up a few times.  But I’ll survive in the end, and I’ll find a way to make someone smile.  Just as I told Mr. C, I really do like my job.  And it will be okay. 

See No Evil, Hear No Evil … Fix No Evil

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Minstrel

As aging impacts physical and cognitive health, many of us will eventually live in long-term care homes.  Thanks to poor standards of care, most people dread this prospect.  To improve care, experts advocate a person-centered model of care as an alternative to the traditional medical model.  Moving from one care model to the other calls for culture change.  Last year I visited the website of a leading culture change organization for information on their annual conference.  It was discouraging to see that among their many events, none included one of the critical elements of culture change, CNAs: our workloads, wages, and caregiving standards.  Hour after hour, day in and day out, CNAs are key caregivers.  Without us, there can be no culture change.  Yet CNAs aren’t heard.  Here is one CNA voice.

I first became familiar with LTC homes when a family member needed care.  I explored many places to find him a good home, then visited him frequently.  Since then I’ve worked in LTC homes and gone into others as a hospice volunteer.  When my uncle moved to a memory care home, I saw the aides who cared for him as angels: they did for my uncle and the other residents what we family members no longer could.  They did this with magical skill and saintly kindness.  And for wages that were obscenely sub-standard.  I was enormously grateful to them.  But in these years of being in and out of long-term care homes, this is what I’ve also seen: aides who sit talking to each other or texting while residents sleep in front of TVs or sit staring into space, alone.  I’ve seen a resident fall because an aide was busy texting.  Aides spend mealtimes noisily socializing with each other instead of engaging with residents, most of whom (at least in memory units) need some level of assistance.  Some aides announce, by their behavior, “Once she’s bathed and dressed and in the dining room, once he’s fed and toileted: once the ADLs are completed, it’s my time.”  Sometimes instead of interacting with residents, aides simply take time apart to rest.  It’s not that aides are intentionally mean or abusive.  And comradery among aides isn’t a perk; it’s essential.  But on every shift there are failures in attentiveness to residents, failures to engage them in an enriching way, lost opportunities for Creating Moments of Joy, as Jolene Brackey has written. 

Some will object, “Not in OUR facility!  We have awesome aides who go out of their way every day to make life better for residents.”  Yes, aides are often inspirationally caring.  But too frequently the quotidian reality is lackluster care, not the person-centered care promised.  Tellingly, the administrators who dispute this picture are often conspicuous for their absence from the daily fray.

Here’s something else I see: thanks to abysmal wages, many aides work two jobs.  Where I live, starting wages are $9 to $12 an hour.  Self-employed aides can earn more, but have no benefits.  Full-time aides are sometimes scheduled to work only 32 hours a week, to avoid overtime when an aide is asked to work a double shift to cover for someone who calls out at the last minute.  Many aides have children at home to care for.  By the time the aide starts his or her shift, which typically involves caring for six to ten residents, she is already tired in body and spirit.  How can this aide bring to work the physical and emotional energy needed to care for the chronically ill, the elderly frail, the cognitively impaired?  Is this what you want for your parent or spouse, or yourself?

How to improve care?  Administrators provide innovative training programs.  Workshops offer state-of-the-art information and creative care ideas.  Two questions not examined:  1. How do we get aides to buy into culture change and embrace person-centered care, once the trainer leaves?    2. Where do we find the money to increase staffing and pay direct-care workers a living wage, one that honors the physical and emotional demands they meet every day?  

Culture change seems focused primarily on training of direct-care workers and renovations to the physical environment.  A more effective approach might come from a change in what we expect of leadership.  Once upon a time, ‘Management-by-Walking-Around’ was the mantra.  An effective manager was expected to circulate on the factory or office floor, paying attention.  Not spying on employees, not micro-managing, but noticing things.  Sensing conflicts and stresses before these undermine performance.  Offering feedback when needed.  In care homes, how often do you see someone on hand whose role is to encourage, compliment, coach or critique?  To see that necessary supplies are on hand.  To offer an on-the-spot performance suggestion, transforming a moment of poor care into an opportunity to reinforce good care skills, per Teepa Snow’s  coaching model.  And at times, with a chronic slacker, to go down the road of discipline.  How much do managers engage with direct-care workers? 

Today’s code word for good care is engagement: aides need to engage with residents.  If administrators aren’t modeling this by meaningful interactions with direct-care workers, will aides believe that engagement is to be the ethos in their workplace?

We can’t improve what we don’t see.  If administrators don’t see the problems, it might be because they are buried in ‘CYA’ paperwork, medication management, marketing efforts, and time-stealing meetings.  Sometimes their offices are in some distant realm of the facility.  Culture-changing organizations might hire a clerk for paperwork and scheduling, freeing the front-line manager for a more constructive presence among staff.  Give this manager a mandate to convert ‘person-centered care’ from a slogan to a fact.   

Can LTC homes provide person-centered care, without the personnel?  Staffing levels are egregiously low.  They may meet states’ woeful requirements but we all know they are inadequate to ensure patient safety, let alone the person-centered care everyone espouses.   Inadequate staffing also leads to on-the-job injuries and CNA burnout.  Are any of the culture-change conferences addressing these issues?  Are leaders lobbying for better staffing and better wages for their CNAs?

Ah, wages!   One is tempted to wonder whether managers tolerate poor performance out of guilt or shame for what they pay their aides.  Even compassionate professionals don’t want to mention the issue of wages in public.  It may seem too daunting and discouraging a challenge—and an embarrassment.  Compensation levels reflect the fact that the job doesn’t require high-level academic or technical credentials.  But aides shouldn’t be thought of as unskilled.  Our skills lie in meeting the global needs of residents who are sometimes completely dependent on us.  A good aide needs to excel in kindness, patience, gentleness, flexibility, effective time management, communications creativity, appreciation for the diverse ethnic, racial, religious, cultural backgrounds of those in our care.  We care for residents regardless of their illnesses or diseases.  We don’t need to describe here the physical tasks we perform, sometimes difficult, often unpleasant.  When the person has dementia, the challenges are doubled, tripled.  We’re accountable to employers, to families, and to our residents.  Not everyone is up to the job.  Wages should reflect the importance of this work and the competencies it requires.  We need a mindset conversion among executives who still think it’s acceptable to sustain their LTC organizations by reliance on a bare-boned staff of underpaid workers who need public assistance to supplement their wages.  Care homes charge their CNAs to respect the dignity of residents.  What about respect for the dignity of CNAs, starting with a living wage?

“Where will we get the money to raise wages and increase staffing?” ask horrified LTC operators. The question is valid.  However, it begs the further question: How much are you spending now, and for what?  Until there is budget transparency (another piece of culture change), the industry’s position that these proposals aren’t affordable, isn’t credible or convincing.  Their question should be not the end of the discussion, but the beginning.  Reviewing the content of culture-change workshops, we don’t see these issues on agendas.  No one wants to touch staffing or wage issues.  Could it be that the profit motive plays too big a part in the culture of some LTC organizations? 

This isn’t rocket science: Be as zealous about improving supervision, staffing, and wages as you are about upgrading the chandeliers and countertops and holding conferences.  Put your assets where you claim your values are.  (Make your budget transparent!)  Invite CNAs to be co-leaders in culture change.  Then we might see culture change that leads to transformed care, transformed lives.  

The Long Goodbye

      photo   ALICE
       I’m calling in sick. I can’t have “the talk” anymore. I just can’t. It’s ripping my heart out. After all, what are they going to do? Fire me?…These were my thoughts as I was lacing up my sneakers and getting ready for work. Even as they floated through my head, I knew the words were a hollow threat. I would not call off. I would not ruin nearly eight years of perfect attendance at work while finishing out my notice. As gut wrenchingly painful as it may be, to cave in because facing this is difficult would be like throwing the game in the last inning. THEY would win. I would lose. And far more importantly, my folks would suffer.
       You can do this, Alice. It’s the right move. After all these years, three owners and five administrators, you know that this facility is never going to change. They will never invest in competent management and because of this, you will always be stuck. Now is the time. Opportunities like this don’t fall on your lap everyday. Take it and run and start moving forward with your life. This has been my mantra, played on repeat, for the week. And it’s true. I know it is. I know that I have to get out of this particular facility. I know that I’m no longer comfortable working under questionable conditions and bosses with very questionable ethics. So, I’m moving on. My resignation letter, worded carefully to not offend so that I may visit my folks without interference from the office, is in.
       I’ve explained the situation to my residents. And explained. And explained. I’m not leaving YOU. I’m just leaving the JOB. I’ll be here to visit at least once a week. It will be different but it will be good! I’ll have time to sit and visit instead of running here and there. You will be fine…over and over again. They are scared and feel like I’m abandoning them. I know this because they tell me and that just shatters me. The average length of employment for a caregiver in this facility is six-eight months and that is being generous. The turnover is ridiculous because the wages are insultingly low and the work conditions are terrible. Because I have been there so long, this is traumatic for them and for me.
       I am letting them down. There is no getting around that. I’m making a choice that is both right and necessary but to deny that it will impact those around me would be dishonest. It is a truth that I can accept and live with, but for the moment it is incredibly difficult and painful. I really can’t discuss it without crying. This decision has turned me into a blubbering mess. I love what I do. I love many of my co-workers and I have been deeply committed to my residents. I resent having to make this choice. I am furious at the administration for not investing and paying a living wage for quality caregivers. I resent the dishonest, inept, incompetent and unethical woman in charge of coordinating care. She has not eased my residents’ stress or discussed with them the upcoming transition. She has not comforted them. She is quite honestly only concerned with how events affect her. Such apathy in this field never fails to boggle my mind.
       A few more days. That’s all I have left there. I will continue to reassure my folks that they will always be a part of my life. After so many years, they are more friends than residents and it will be nice to explore that dynamic. I know that nothing I can say will prove that to them. I will have to show them with action. And I will. Until they see me visit them, I have to accept that emotionally, they are not in a trusting place. Often, the best decisions are the most difficult to make. I know that underneath all of these deeply felt emotions that I am walking through, there is excitement at what’s to come. New opportunities will open up from this very difficult decision. For now, I have to trust the process. After all, life is change and transitions.

A Failed Attempt

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Alice

    I had planned to write a piece from the point of view of the administrators; what it must be like to walk in their shoes. Such pieces help me connect on a deeper level with others. I sat down at my keyboard and closed my eyes for a moment, trying to imagine the chaos and stress that my bosses must feel in order for it to translate into such dysfunction on the floor. But nothing came. All that kept popping in my head was that the call bell system didn’t work. How does that slip through the cracks? HOW DOES THAT SLIP THROUGH THE CRACKS? What’s worst is that I told the owner of the facility that it was on the fritz a year ago.

       Ok, Alice. Try again. Deep breath. Think about all the paperwork and pressure to keep up the census. Think about all the complaints they must hear from both residents and staff. Think about how they have to fix specific situations in order to meet state regulations…but…census IS up and staff is poorly paid and badly scheduled. Honestly, every month they put out three to five schedules! And most of the situations they have to fix could have easily been prevented had they listened to those of us on the floor in the first place. Had they not placated the residents with empty promises and then dismissed their concerns.

       Ok. This is going nowhere. Think of this as a business. It’s not a nonprofit. People have a right to earn a living…except I know how much my folks pay each month to live in this place. And I know how much Medicaid and Medicare cover. And I know that the combination of disorders is not healthy. And I know my residents living with severe mental illness are not getting the kind of care they need. And I know the “house” doctor pops up every two weeks supposedly visiting eight-twelve residents in under thirty minutes; and after several YEARS, still can’t remember their names. I know that they shuffle around my folks with no warning and no thought to the impact such changes have on the people…

       That’s when I realized that this was an exercise in futility. I was too angry. I AM too angry. They deserve better. The sheer courage it takes to live with such debilitating challenges should give them a pass at a decent quality of life. They deserve better than the best I can give in these circumstances, better than the system provides and certainly better than the passing acknowledgment that they happen to live where the administrators work. As if my residents are in the way in their own home.

         It’s not MALICE that drives administrators. It’s apathy. Greed. Maybe fear of losing their own jobs. Its ignorance and they lack both the willingness and the interest in learning from anyone other than their peers. The trouble is that their peers are also in the office, far away from the reality on the floor.

       THEY aren’t the ones in the in-services learning more about mental health. They aren’t the ones being taught about the importance of consistency and how to successfully redirect certain behaviors without robbing a person’s dignity. They aren’t out there every day learning folks through trial and error. They are not solution oriented problem solvers. At least not in my facility. They are surface level friendly, but the times I’ve tried to discuss the real, underlying issues, they completely closed ranks and shut down.

       They are not interested in open communication. They are not interested in supply shortages or unreasonable workloads. They don’t bother themselves with how things truly are, only with how they appear to be. They dismiss us and in doing so they dismiss the people for whom we care.

         I admit that it isn’t my incredible boundary setting skills that make me good at my job. I am unable to detach enough from my residents and my own experiences to objectively see through the eyes of my administrators. What I do see clearly is the end result of bad decisions and poor leadership. Could I do it better? Who can say. I do know that the one thing I wouldn’t be is apathetic. Because I started out as a caregiver; because I am by nature a caregiver, I believe I would have a very different bottom line.

         I mentioned earlier that I’m angry. That is true enough but anger is a surface feeling. It masks deeper emotions that are more difficult for us to face. Feelings like disgust and heartbreak over the idea that we, as a society, take little issue with “warehousing” our sick and elderly. Our ability to simply embrace this “out of sight, out of mind” mentality with fellow human beings, dismissing people who have lived and experienced more in their lifetime than most could imagine rather than embracing and learning from them. I also fear that reality, because like it or not, we are all on the road to that same destination. The day will come when the line between “them” and “us” will no longer exist.

       I don’t need to walk in the administrator’s shoes. I would rather use them as an example of how I do not want to be, regardless of where I may land. I know and feel all of these truths. They feed my commitment. No matter what path my life may take, I will not stop advocating for those living in these facilities. I will not stop shining a light of their truths and on ours. I will tell our stories. If we give our all every single day in an attempt to change their lives for the better, maybe nothing will come of it. But if we DON’T try; if we just accept the status quo, then DEFINITELY nothing will come of it. These people are more than worth the effort. They are more than just residents. They are my friends.

A Different Kind of Career Path

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Alice

Two glorious days off! IN A ROW! It had been over a month and a half since I’d had that luxury and I was counting down the minutes on Friday. I planned to have a creative, productive, friend filled weekend and intended to enjoy every moment of it. I gave myself a strict “no work talk” rule and actually managed to stick with it. I drew, wrote, went to a movie, rested, caught up with friends and volunteered. As much fun as I had, by Sunday night I knew I was ready to return to the hustle and bustle of the floor.

         The idea of “career people” used to conjure up images of high powered entrepreneurs, doctors, nurses or lawyers rushing to and from important meetings; people very dedicated to their careers, sometimes to their own detriment. It never occurred to me that the term could apply every bit as much to those of us scraping by on an hourly wage in broken down facilities in a broken down system and yet, here I am, just as much of a career woman as those with advanced degrees.

       Let’s look at the facts: I’m single, without children. When I’m not at work I’m writing about work, or attempting ways to improve work. I’m incredibly dedicated to my residents and have the lofty long-term goal of doing whatever I can for as long as I can to greatly improve the system in which they are forced to live from the bottom up. That is the very definition of a career woman.

         The SYSTEM may think we are disposable, our pay, bosses, and the ethic of those who have been so burned out that they can no longer care the way they should may reinforce that idea, but it isn’t true. Ask the residents who they count on, who they trust, who knows them the best, who SEES them, and their answer will be us; the caregivers. We cannot allow anything else to dictate our self-worth or the value in what we do. I wish I could burn into the heart of every caregiver the knowledge that they are uniquely gifted and desperately needed in the lives of those who have so little. Our skills are different, not less. We are not diet nurses. We are not “ass wipers”. We are the frontline.

     I will learn and forget countless bits of knowledge as I go through my life. I don’t know if I will always be a caregiver, but I do know that whatever path I may end up on in the future will be richly informed by the career that I hold right now. As I punched in early Monday morning, I was met with smiles from my residents and fellow workers on the floor. I missed them while I was gone and though I don’t know what my future may bring, in that moment I felt like I was coming home.

Two Open Letters

Alice

Alice

 

Alice

 

To Potential new hires,

I want you to be responsible for the care, protection and quality of life for a hall full of people with a wide variety of physical and mental illnesses. Make sure they are clean and dry, supervise their gait, and make certain that their oxygen tanks are full and on the appropriate setting. If they have a doctor’s order for TED hose, please make sure they are on in a timely manner.

Because these folks are unwell, they are occasionally combative. We will offer no help to you in these matters, other than suggesting that you get another aid to help, if you can find one. Often, you won’t be able to because we have a bare staff. We are also desperate for help, so many of the people we DO hire are unable to lift and are squeamish about body fluids, so they will not be much help to you. We hope that you are not like that, but if you are, eh. You get what you pay for. Someone will pick up the slack. Someone always does.

We can’t promise that we’ll remember to tell you if your hall partner called out or your shift relief will be late. We are very important and busy people. You can’t expect us to value your time and effort enough to interrupt our own.

You will be covered in any number of body fluids, we will often run short of supplies and expect you to figure it out. As a matter of fact, we pretty much expect you to handle any situation with little or no input from us. Oh! We will make rules and change them without telling you and we will apply them with inconsistency, as we see fit. This applies to both you and the residents. There will be no raises. No benefits and no rewards for doing an excellent job. But there will also be very few consequences for doing terrible job. Life’s a balance. We’ll pay you 9.00 an hour. What do you say?

Sincerely,

Management

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To Potential new hires,

This job is tough. It is not for everyone. It will break you into a million pieces and teach you how to put yourself back together in ways you never thought possible, if you allow it.

There are facilities with kind, involved supportive management who offer substantial training and ample rewards for good work ethic. There are facilities with relatively calm residents who are not living with severe mental illness. This is not one of them, a fact that over time I have grown to appreciate, oddly enough. When there is no one willing to solve problems, it motivates you to first understand the problem and then figure out how to solve it yourself.

I have learned more about life, love, courage, vulnerability and perseverance than I could have in any other facility. I have explored, hand in hand with my residents, the subculture in which they live. I’ve learned to trust and be trusted. I’ve learned how to speak my truth, and more importantly, to speak theirs.

None of this will pay my bills, and there are times that I am resentful at the lack of pay, and basic lack of respect for what we do; a job that matters deeply to me is dismissed by those who should know better. I don’t wallow in that though, because I believe that WE can change that. If enough of us refuse to allow our pay rate to dictate our level of care, if we use the systems flaws and mismanagement to teach us how to problem solve and lead ourselves rather than embitter us enough to lose our empathy, then we really can make a difference. I believe this in my heart of hearts and truly hope that you will be a part of the solution. It’s easy to be a light in the day. My facility needs lights in the dark.

Sincerely,

Your fellow Caregiver

My Plea

Alice

Alice

        I am tired. I am tired and heartsick, frustrated, disillusioned and losing patience. I know that many of us work in a subpar facilities within a broken system. I understand that we make less money than pretty much any other field. I GET that, in our facility at least, there have been no raises and having worked there for the better part of seven years, I can almost guarantee that there will be none forthcoming. This is the reality of it and nothing I say or do can change it in the short-term. I feel your frustration because it is my own.

       Having acknowledged that, it needs to be said that there is a level of accountability that we, as caregivers, need to meet despite the above mentioned conditions. In this, we are failing and in our collective inability to elevate ourselves above these pitfalls, we inevitably shortchange both our residents and each other.
        Lately, the level of cattiness, finger pointing, laziness bred from apathy, and passive aggressive tendencies have played havoc with my morale and because of that, I find myself becoming impatient with some of my co-workers. I don’t want to spilt my focus between resident care and conflict on the floor; conflict over nothing. I simply do not have the energy to deal with both.
       I know that I can be overzealous, overprotective of my residents, and perhaps I have higher expectations of my co-workers than I should, but don’t we owe them our best? Don’t we owe that to each other? Don’t we owe that to ourselves?
          If I didn’t believe we could do better, I wouldn’t find it so maddening. I expect very little out of the administration because they neither know nor really care about the world on the floor. Oh, they care if it smells, or if it looks neat enough for prospective clients, but other than that, they care only that it’s quiet. They want the residents quiet and the workers quiet. But the residents psychological, physical and emotional well-being? It’s not on the forefront of their minds. Neither is ours, for that matter. 
        That will never change if we continue to feed into their stereotypical view of us. Often enough, we give them the very excuses they use to not offer us decent pay or recognition for the work that we do. Call outs, tardiness, poor work ethic, constant conflict all contribute to their preconceived notion that we are disposable. And where is there room for our residents in the midst of all that chaos?
       The bottom line of it is that our residents, our sick, elderly, vulnerable residents deserve better care than 8-9 dollars an hour can provide. We cannot allow our pathetic excuse for wages to dictate how we work. We have a choice here. We can let the negative toxic work environment dictate our attitude and personal ethics, or we can face each day with a clear, stubborn and consistent determination to do our very best regardless of what goes on around us. We can be strong enough to not be defined by the broken system in which we work and by doing so, we will slowly but surely affect change. Robert Kennedy once said that “Few will have the greatness to bend history itself; but each of us can work to change a small portion of events, and in the total; of all those acts will be written the history of this generation.” …I wholeheartedly believe that. The first step towards being a part of the solution is to not be a part of the problem.

The Unspoken Rant

Alice

Alice

“I thought this would be a productive conversation. I really did.”, I said to myself as I sat across the desk from the fifth administrator that I’ve worked for in seven years. Rookie mistake. I should have known better.
I asked to speak to her because  there is a distinct lack of communication between the office and the floor. What little interaction we have comes in the form of snappy demands, as if we are incapable of comprehending sentences containing words with more than two syllables. It is seriously affecting morale and when morale goes down, so does quality of care.
I wanted to tell her that when a person in authority such as a resident care coordinator speaks negatively of staff members in front of their peers, it breeds dissent. I had hoped to explain that there has never been “light duty” in our facility because there IS no light duty. We don’t have enough staff to allow for such luxuries. The rule has always been that you can come back when a doctor signs off on it. Otherwise, you have one caregiver doing the work of two, while the other is getting paid to sit down and watch. It’s different than in the bigger facilities, where perhaps they have areas that don’t involve lifting, running and transfers. I wanted to point out that this naturally causes resentment for those of us who end up carrying the load when it happens every other week.
I had hoped to discuss the incredible frustration I feel when the powers that be freak out over someone forgetting to put away a package of briefs but don’t blink an eye when every single month, a resident runs out of his colostomy supplies, leaving the staff on the floor scrambling for solutions with no help from the office, or only having small or extra large gloves, or not being informed that we would need to work over until after our shift ends.
I wanted to tell her that the woman who does our inservices is passionate and full of fantastic information and ideas that we aren’t being given the opportunity to utilize.  I had hoped to explain that the uneven application of consequences suck the motivation out of caregivers who feel like the end results are the same regardless of whether or not they give their best.
I thought she should know that it was a bad idea to put a resident who has maintained sobriety after a number of years of being drunk and violent in the same room as an active alcoholic who sneaks in bottles of Canadian Mist any chance he gets, or a resident living with severe mental illness in a room with a resident who doesn’t speak a word of English.
I though she should know that it’s both dismissive and unfair to paint all the caregivers in the facility with one brush; as if we aren’t individuals, each with our own work ethic and points of view.
We choose to stay there, whatever our reasons, knowing that there will be no raises, no bonuses, very little leadership, hell, the shower room doesn’t even have a dip in the floor. The water just pools around so we have to work in wet sneakers. Still, we STAY. Despite the fact that it’s the lowest paying facility in this town, our folks deserve the best possible care and we deserve open and two-sided communication that would benefit everyone; to be talked WITH rather than talked AT.
I WANTED to tell her all of that, but after about two minutes of discussing the need for better communication, I realized I would be wasting my breath.
“I would LOVE to just have to give someone a shower. You have NO idea what it’s like for us in the office!”, she snapped. I sighed, as I left the office, strangling on all that was left unsaid. She’s right. I don’t know what it’s like in the office, but if she thinks that showering people is the basis of what we do, she has no idea what it is to be caregiver and very little interest in learning anything that would make life run more smoothly for all involved. I will never understand why people in authority continually fail to grasp the simple notion that an ounce of prevention is worth a pound of cure.