Tag Archives: caregiver workloads

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.

  

60 Caregiver Issues: Whose Issues Will We Hear?

 

 

Minstrel

In his recent post Yang brought our attention to PHI’s campaign to educate the public about caregiver issues, and gave us a link to their introductory video.  In that video PHI posed these questions:   

1. How can we ensure caregivers get the training they need?

2. How can we keep care affordable to families? 

3. What data is needed to help policyholders take action? 

While these are important questions, if you ask caregivers themselves why some are leaving the field and others wouldn’t think of entering it, they’ll no doubt raise a different set of issues.  At nearly every conference or webinar I attend I ask about staff-to-resident ratios and caregiver wages.  Usually there is no reply, as if I were speaking from some parallel universe and couldn’t be heard.  If there is a reply it’s on the lines of “Yes, we know.  But it’s complicated.  These things take time. You can’t expect things to change overnight.” 

Yes, there is a shortage of caregivers.  And yes, good care isn’t affordable.  In fact good care can’t be bought.  By that I mean whatever you might be paying, either for in-home care ($20/ hour? $40?) or for care in a long-term care home of some sort ($6,000-10,000/ month), the more care the person needs as health declines, the wider the gap between the person’s needs and the quality of care the person actually receives.   

Everyone is selling solutions like workshops and videos and toolkits and new business models to long-term care administrators or home healthcare systems’ owners.  Some groups are advocating on a state or even national level and some gains have been won.  But from the outcomes I’d say that a lot of the effort is wheel-spinning.  (An increase in the NYC minimum wage for home care workers to $15/hour by 2021??)   Today’s aides have rare luck if they earn $15 an hour and have a regular 40-hour work week.  An aide may have six to ten residents/patients to care for, and many of those will suffer from dementia and/or be unable to walk alone safely or even support themselves standing.  (Yes, I know I’m a broken record…)  Do you know what it’s like to try to wash, toilet, transfer these residents several times a shift, and keep them from falling the rest of the time?  (If not, go back and read CNA Edge.)  This is before we even begin to provide enrichment a la ‘person-centered care.’   

I want the whole healthcare industry – including those championing reform — to acknowledge what the biggest issues are for caregivers: our obscenely low wages and our outrageously onerous, even unsafe, working conditions.  These organizations don’t yet tackle caregivers’ most urgent needs: a living wage, safe work conditions, and a work environment that supports person entered care.  We need to ask them, What are you doing about these issues and what can we CNAs do to support you in this?  

When Malcolm X called for a change in Americans’ attitudes on race and was told that such changes (culture change, if you will) take generations, he reminded us of this: At the beginning of World War II Germany became our enemy and Russia became our ally.  But when the war ended we, America, saw Germany as our ally and Russia as our enemy.  That attitude-change didn’t take even one generation.  The healthcare industry needs an attitude adjustment.  It is not okay for long-term care operators or owners of home healthcare agencies to charge exorbitant fees to clients and return a too-small fraction of these fees as wages to their direct-care workers, while management and professional staff and consultants are handsomely compensated.  It is not okay to hire employees unless you train them in the skills they need to work with the elderly frail, starting with English language skills.  It’s not okay for the industry to tolerate poor work ethics: last-minute callouts; texting while on duty; and most of all, failure to interact with residents in a way that says to them “I love being with you.  Thank you for letting me be part of your life.” 

There are thousands of followers of CNA Edge.  As Yang exhorted us, we need to support PHI in their effort to educate the public about caregiver issues.  Let’s ensure that when they frames their 60 Issues, they don’t airbrush our issues out of the picture they’re drawing.

A Day in the Life

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Alice
Ughhhhh. Five more minutes. Five more minutes. FIVE MOOOORE MINNNUTES! I think to myself as my fifth and final alarm blares, jarring me from my sleep. I look at the clock. Sigh. No more minutes. I was pushing it as it was. Three minute shower time. I throw on clothes after kind of sort of drying off and simultaneously brush my teeth, hunt a missing shoe, and grab my keys. Catching a glimpse in the mirror, I smile wryly. Good enough, I guess. I kiss my love goodbye and off I go.
Thirteen miles to empty. It’s going to have to do. I’ll make it on time but only if the bridge isn’t up. Don’t be up. Don’t be up. Don’t be up! Traffic isn’t backed up. Always a good sign. Ahhh! I breathe a sigh of relief as I see the cars flowing smoothly over the bridge. I’m going to make it.
I pull into my client’s driveway with three minutes to spare.
“Help me have patience. Help me do some good. Help me maintain my sanity”. It is my little ritual. I send that prayer out to the universe at the beginning of every shift.
I let myself in the house and start the coffee. My client is still sleeping pretty soundly, so I put out some chicken to defrost for dinner, prepare her morning meds, set up her glucometer and put the gas fireplace on low to knock out the chill in the room.
“HEY GAL!”, her husband yells down from upstairs. I make sure she’s still asleep before I go to the staircase. He forgets sometimes that he hired me as his wife’s caregiver and often monopolizes my time. Still, he means well and I don’t have the heart to tell him. I think he sometimes just wants a captive audience.
After ten minutes of listening about his knee pain, bunions,”damned liberals”, and a list of chores he expects me to do (honestly, I’m not sure how cleaning HIS bathroom became part of my job duties), I am able to make a graceful (graceful-ish) exit.
My client and her husband live in a beautiful house on the beach. It’s huge, divided into two separate living quarters, almost like separate apartments. Most of the time, when he is home, he is downstairs with my client. The upstairs is mainly for when he goes to bed. He is active and loves to be out and about, so until one or so, my client and I have the house to ourselves.
I head into her room to start the day’s routine. First, I open the blinds. Then I check to see if she took any of the three pain pills that are left by her bedside. If all three are there, we’re in for a good day. If all three are gone, it’s going to be a rough one. There are two. Could go either way. I massage her legs to get the blood flowing, apply lotion and her leg brace. The transfer from bed to chair goes smoothly and we are off to the bathroom.
We call it the bat-cave. A good chunk of our time is spent in there. I think, in part, because it is a comfort zone for her. She has a routine and deviating from it causes her unease. In the mornings, we wash her face, she takes her AM meds. She says she keeps pharmacies in business. I check her blood sugar. She handles it like a champ. 137. Not too shabby.
Dark cherry Chobani yogurt, oatmeal, half a cup of coffee with one Splenda and a dash of cream, cranberry juice over crushed ice in a tall glass. NEVER a plastic cup, which would be easier for her to manage. I’m not sure the reasoning behind that but I aim to please. Breakfast is served. I pour myself a cup of coffee, sit down beside her and we do some morning readings from her daily meditation book.
She takes her time at breakfast. It can last anywhere from one-two hours, depending on how she feels. I don’t rush her. I’m grateful that I don’t have to hurry her along. It’s one of the job perks of private care and she told me once that she hated it when people put pressure on her to speed up.
Time is a funny thing in that house, simultaneously crawling and flying, depending on the moment. Take the shower transfer, for example. I am not one to throw the word hate around. Usually, I think it’s an embellishment of mild annoyance, so you can believe me when I say that I HATE that transfer. On the BEST of days, I feel it’s a risky maneuver. The handrails are all in weird places. It’s a tiny space. It requires my client to take a step that’s about three inches and then walk backwards. To get out, she has to let go of one rail, reach her arm out and grab one outside the shower, lean forward, and step down on her good leg as I assist her on her affected side. It is the stuff of nightmares for an over-protective caregiver.
As I am independently contracted, I don’t have an agency to set work boundaries and that is not a strength of mine. Still, after nearly a year with this family, I have learned to draw a few lines in the sand…not many, but a few. It’s all about progress, right? So, back to the shower. Now, that was a conundrum. My client loves the shower. It’s every bit as much of a joy for her as it is an anxiety attack for me. I actually get her much cleaner using a Sitz bath and scrubbing her down on the shower chair than I do in that tiny shower. Still, perception is fact in this gig and a shower feels better. What’s a girl to do? Finally, an opportunity arose to address it. My client was having a tough day. Her pain level was high and her mobility wasn’t good. Still, she insisted that she could handle the shower. She asks for so little that I didn’t have the heart to tell her my misgivings. She got into the shower fairly easily. Getting out was an entirely different beast. It took over an hour and a half. We tried a variety of ways to exit that tiny tiled tomb. By the time we got out out, I was sweaty and exhausted, she was sweaty and exhausted, we were both sore and completely out of breath. It was a dumb move on my part. Though it was well intentioned, she could easily have fallen and that would have been on me and my stupid Wonder Woman complex.
Still, it opened the door to solving that problem. From calamity came opportunity!
“You know, after all that effort, you ended up messier than you were before the shower! What do you think about doing a full shower every other day so it’s not quite as hard on you?” She looked dubious at first.
“I can do a more thorough job if we wash in the bigger space. Plus, it will give you the chance to soak your feet! And the time we would spend transferring out of the shower we can spend on hair and make up! Turn those days into in-home spa treatments!”…AH-HA! Those were the magic words! I saw her eyes light up and it has been far less of a problem ever since. She still gets the full showers on her good days and on her challenging days, she gets to be spoiled like a princess, complete with a foot massage.
Today is hair washing day, so that means a full shower. I push her into the bat cave and maneuver her as close as I can to the treacherous step. The transfer goes smoothly, much to our relief and I slowly release my breath as she settles onto her chair. Now, hair washing seems simple enough. It certainly was when I worked in the facility. It’s a little different here. There are steps. And timers. And products. And then hair appliances. My client and I move seamlessly through the process. Such a difference from when I first started! I got the products confused and had no idea what “confixer” was. I still don’t, really. I call it hair cement. And wasn’t adept at curling or teasing or spraying hair. Personally, a good day is when I can find my brush. I am much more concerned with my client’s hair and appearance than my own. See, it matters to her and she thought for many years that she had to let it go. That’s also one of my favorite perks in private care. I can help her hold onto who she is underneath her disability in ways that those who aren’t in the field often overlook. I have the time to make that a priority.
12:30. We successfully made it through the shower and hair. Nine hours left in my shift. Next is her beauty regimen. I set up a variety of lotions and powders and push her close enough to reach. This process takes around an hour and she likes to do it for herself. While she’s beautifying herself, I chop potatoes to boil and mash later. I marinate the chicken and wash up the breakfast dishes. I peek in the bat cave to make sure she’s doing all right. After getting the thumbs up, I load up the laundry, run it upstairs and toss it in the wash, collect the upstairs garbage ( and the man has like twenty five tiny waste baskets filled with nothing but tissues and scary political pamphlets) and it’s back downstairs just in time to hear his truck pull up into his garage.
“The Bear’s here!”, I call out to my client. It’s our nickname for him; a nickname he likes a little too much if you ask me. Goes straight to his head.
“Hey Gal! Make me a sandwich!”, he says before going on a long rant about whatever crap he heard on conservative talk radio. Ok. I’ll make you a sandwich. But ONLY because I’m not doing anything else right this second. Not because I suck at setting work boundaries!… I think that, but I don’t say it. Light mayo. Light mustard. Two slices of cheese. One piece of Carolina Pride boiled ham Nuke it for 15 seconds. That’s the only way he will eat it. The ratio of cheese to ham is of utmost importance. He’s like the picky eater, frustrating kid I never had. All that aside, I have a fondness for him. Almost a protectiveness. He is unaware how he comes off sometimes. Besides, I had to fix my client’s lunch too and when he’s happy, she’s happy.
As he is eating his sandwich, I dress her in her favorite purple shirt and black pants, she picks out her jewelry and I push her to the table for her lunch; turkey on rye. Every day. She doesn’t like to switch it up.
I set up her afternoon meds as her hubby continues to rant. Something about Obamacare and guns. I try to keep my face neutral and decide it’s a good time to switch the clothes to the drier. Or escape. It’s a matter of perspective.
After lunch, she brushes her teeth. This is also a very specific routine. I’ll spare you the details but it takes about forty minutes. By this time it’s 3:30. I settle her into her lounge chair and turn on the Waltons.
Then it’s back to the kitchen. Wash up the lunch dishes, put the potatoes on to boil, pre-heat the oven. Run upstairs and grab the clothes from the drier and drop them in her bedroom to be folded later. Pop the chicken in the oven, turn off the potatoes and take my client to the bathroom.
“You know, Alice, when my daughter was a teenager she wanted me to buy her a KISS album for her birthday. I didn’t mind it. I didn’t tell her but it was catchy.” …my client will surprise me on a regular basis, but this takes it to a new level. I can’t stop laughing as I transfer her back to her lounge chair. It’s 5:15. I have to turn on the porch lights. Her husband is very particular about what time they come on. OK! I’ll turn on the porch lights at exactly 5:15, even though you are perfectly capable of doing so. But ONLY because I’m not doing something this second and not because I’m lousy at setting work boundaries!…I think but don’t say.
Dinner, chocolate ice cream since her sugar was good, then back to the bat cave for her teeth brushing routine, PJ’s, night time meds. I transfer her into bed, massage lotion into her legs, put on her nighttime fuzzy socks, and arrange her pillows so she’s comfortable. It’s 8:30. I make certain she can reach her pain meds, water and tissues and then I collapse in the chair beside her bed and pull Little Women from her book shelf. We’re on page 284. This book is flying by! I read to her until she falls asleep and then quietly slip out of her room. I gather my purse and keys, grab the trash and call out good bye to her husband.
“Goodnight, Gal! Thanks for all you do. Don’t know what we’d do without ya!”
As I lock the door behind me and pull the trash bin to the curb, I realize that I am exhausted…but it’s a good kind of exhaustion. The kind that comes from feeling like a job is well done.

“I’m Just Doin’ My Job”

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Minstrel

One of my all-time favorite movie lines was spoken by Paul Newman in Cool Hand Luke.  Luke, the non-conforming prisoner in a tough southern prison, refuses to accept the prison’s status quo.  His conduct is a cascade of rebelliousness, until finally the warden orders Luke to “the box.”  The box is a small tin-roofed building, the size of an outhouse, under the blazing sun in the middle of the hot, dry prison yard.  After Luke spends twenty-four punishing hours in the box, the guard releases him.  As he does he says, “Sorry Luke, I’m just doin’ my job.  Ya got to appreciate that.”  Luke replies,  “Nah, callin’ it your job don’t make it right, Boss.”   

Calling it our job doesn’t make things right.  Among the most pernicious problems in long-termcare homes is staffing shortages.  With a census of 25 to 35 residents or patients needing skilled nursing and/or dementia care, there might be only three to five aides scheduled to work a shift.  (Then there are the last-minute call-outs).  If the aide is lucky, very lucky, she may have only five or six persons to care for.  The more frequent reality is having seven to ten persons needing care.  Remember that cacophony of call bells that May wrote about?  Blame it on short-staffing.  And the resident pleading for you to take her to the toilet?  Oops, it’s already too late…  The resident teetering perilously as we rush to prevent a fall? … And the time you lifted a non-ambulatory person by yourself because there was no one around to help?  What about those wheelchair bound residents who haven’t been taken out to feel the fresh air in weeks?  The hits just keep on comin’.   And we keep right on keepin’ on, because it’s our job; right?   

No, it isn’t.  We simply can’t do our jobs as CNAs adequately when we’re so understaffed.  What most determines the quality of care is the staff-to-resident ratios (‘duh’).  I challenge anyone to find an aide who disagrees with this.   Yes, staff need to be trained in good care practices.  Yes, we need to have certain supplies available (soap, towels, functioning hospital beds, appealing food, etc.).  But the key to quality care, to person-centered care is PERSONS.  Staff.  

We continue to work in short-staffed conditions we know violate our residents’ right to good care.  (See medicare.gov for a description of rights of persons in nursing homes.)  If we ‘complain’ to management about short staffing (and that’s how it’s viewed, as a petty complaint), we’re told sweetly that the staffing levels meet the state requirements.  And that’s probably true, because industry lobbyists have made sure that state regulators don’t burden the long-term-care industry with costly staffing requirements.

We complain about these deplorable conditions all the time.  As CNAs we’re mandated reporters of abuse.  (I guess we’d better not think about that one too much!)  But we tolerate abuse that residents endure as a result of understaffing.  Abuse isn’t just about physical or sexual assault.  It’s also about neglect and emotional abuse.  If I neglect a call bell for so long that a resident is left to soil himself and remain in his soiled condition for hours, that is abuse.  If I say to a resident who asks to be taken to the toilet, “Janie, I just put a clean Depends on you; I can’t get you back into the Hoyer lift and take you to the toilet, you have a diaper on, you can use that,” that is abuse.  Abuse is ridiculing a resident who cries for her mother all afternoon; scolding a resident who spills her drink all over the floor; ignoring the call bell of a resident who constantly asks to be taken to the toilet minutes after the last toilet trip, because we know she ‘doesn’t really have to go.’  Well, she needs something and it’s our job as aides to find out what.  “But I don’t have time for all that.  I have seven other residents to get to.  I’m just doin’ my job.”  

So what can we do?  Unlike the workers of the 1920’s and ’30’s, we can’t go on strike to win better working conditions.  We’re caring for the sick and the frail, not assembling cars.  But if we can’t leave the floor for a sit-down strike, we can use our cell phones as weapons in the revolution for better care.  Call your county or state abuse hotline every time aides have more than six residents to care for on a shift.  (And don’t count the LPN or Medication Aide in your ratio if she isn’t providing care, even if management does.)  The state regulators aren’t always thrilled to receive reports of abuse because they are short-staffed too, and don’t have the means to investigate all complaints properly.  They don’t always to a good job, for the same reasons we don’t always: because they’re understaffed and a little intimidated by their bosses.  

Revolution isn’t about violence and nastiness. (Remember Gandhi and Mandela and Rosa Parks.)  It’s about patient persistence and never giving up as long as change is needed.  It means taking that first step.  Maybe our first step will be a phone call.  

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 Power of Caregivers

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Yang

In her December 2 post on CNA Edge “Quality of Life is a Precious Gift, Alice distilled the true meaning of a caregiver’s work into one fundamental principle: “Improving the quality of life for those around us.” While the idea may seem obvious, how we go about living up to it is anything but easy, given the typical long term care work environment.

We all know the list. It’s an environment where caregivers are overworked and underpaid, overwhelmed and undersupported. It’s an environment that features disconnected management and rules that make little sense at the caregiver’s level. It’s an environment where mistrust and dissension among staff is common.  It’s an environment that breeds cynicism and futility.

While we can’t ignore the negative aspects our work environment, how we respond to them is entirely up to us. Even in the worst of circumstances, we can always do something to improve how our elders experience their time with us. In fact, doing so is a kind of moral imperative – something that we know by reason is the right thing to do and a far more powerful and consistent motivator for ethical behavior than the directives and admonishments issued by those above us in the LTC hierarchy.

Alice’s “simple idea” is more than just about doing the right thing. It provides us with a standard of behavior that we can cling to amidst the chaos. Or as Alice put it:

“For me, realizing that truth has brought me great peace. It simplifies it. I don’t have to fix, save, diagnose, manipulate, or perpetuate any negativity. My job is to make life as positive as possible and to preserve the dignity as much as possible for those in my care.”

By persistently returning to that simple idea, we make a conscious choice to liberate ourselves from the drift into despair.

May makes a similar point in her post “Soap and Thought”:

“Sometimes it’s too much, being a CNA. There’s too much stress, too much everything until I think I just can’t take it anymore. Days when I want to tear out my hair; shifts when I want to leave and not come back. The problem, I’ve come to realize, is that the bad things are the big things; the skyscraper problems that draw our eyes and threaten our strength. The good things, well, they’re quiet, understated. Things like washing my hands with a resident that is special to me.”

We need these “quiet, understated” moments. And do so our residents. These moments are as significant as the bigger issues that plague us. In some sense, they are more real. 

The common thread between these two posts is that despite the difficulties, we are not powerless. For Alice, it’s a simple idea. For May, it’s a simple act. As we proceed through our daily routines, we may not be able to directly address the larger problems, but we do have the ability to alter our immediate environment. And our immediate work environment is a big part of our residents’ living environment. In that we find our true source of power.

None of this is to suggest that direct care workers will never play a major role in making fundamental change in the Long Term Care system. In fact, it really can’t be done without us. But to play that role effectively, we must never stray too far from what really gives us our strength.  I’ll explore that idea in my next post.

We Need More Caregivers

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Yang

Well, they’re at it again. Nursing home operators and advocates for quality nursing home care are bickering over nursing home regulations and how much regulation is enough. This time they’re facing off in Kentucky. The operators and their supporters claim the current regulatory environment in Kentucky invites “toxic litigation” and that the funds used in such settlements and other fines could be better used to improve care and reduce costs. The quality advocates and their supporters say that’s nonsense and that regulations and penalties are put in place to provide an incentive to put resident care above the bottom line.

This is an old battle. It’s been going on since the 60’s when Medicare and Medicaid came along and nursing home operators discovered how much money there was to be had in the LTC business. Long Term Care facilities were not as closely regulated as they are today and the resulting “hell hole” horror stories gave nursing homes a bad name. Then OBRA came along in the late 80’s and conditions seemed to have generally and gradually improved since.

While OBRA was landmark legislation, the above is an oversimplified version of events and it took much more than government oversight to put Long Term Care on the right path. It took – and still takes – many different people from many different directions to make Long Term Care work and evolve. And sometimes those people coming from different directions clash.

From a caregiver’s perspective, these two adversarial camps, the operators-administrators-managers and the regulators-advocates-surveyors, can be seen as one big group. As a group, they collectively create and enforce the standards and policies under which we work. However, by the time all of this gets to us, what they’ve come with often doesn’t make much sense.

Oh, the particulars are good. It always about making some improvement in our residents’ lives. No one is going to argue for bringing back vest restraints or argue against resident privacy rights. We all accept that regulatory oversight and the policies that result from it are both necessary and well-intentioned.

What doesn’t make sense from a caregiver’s perspective is that the additional duties created by these regulations and policies are rarely accompanied by a corresponding increase in direct care staffing levels. We are simply told to do more with what we have. When I started in 1977 my resident group included 12 residents on second shift and 10 on first. While some places have improved on this, that ratio is still pretty much the standard. And due to difficulties in keeping facilities properly staffed on a day to day basis, the reality is often worse.

Not too long ago, I conducted an informal Facebook poll of direct care workers regarding care plans. My question: “Do you feel that your workload is light enough to enable you to consistently meet the care plan goals of all the residents assigned to you?” The overwhelming response was “No,” often expressed forcefully – and sometimes, colorfully. Out of 303 caregivers, only four answered yes.

It reminds me of that classic definition of “a mess”: A mess is trying to fit ten pounds of manure into a five pound bag. When you simply pile on more work but fail to provide more direct care workers to do it, you’re going to have some kind of mess.

Dear Operators-Administrators-Managers-Regulators-Advocates-Surveyors and assorted LTC professionals: we simply cannot do what you ask with what you’ve given us. Believe us, we want to do everything you ask of us – and much, much more. Perhaps you could find a way to work together and help us out a bit here?

Leap of Faith

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Alice

You know you have to take this leap, Alice. You KNOW you do, not only for your financial responsibilities but also for your mental and emotional well-being. Sigh. I knew this. And I was excited about the opportunity that practically landed in my lap. Excited, yes. But scared and sad too. After nearly eight years of working with my folks, I am taking another job. Instead of taking care of more than twenty people, I will be caring for one. I’m so accustomed to running and routine that this is a big change for me.

         My ability to get to know and connect with my residents is where my strength lies. I look forward to actually having the time to spend one on one with someone; to get to know her on a deeper dimension than the facilities can provide due to time constraints. I’m excited to put into use much of the training that was a lost cause working in a facility that was often short-staffed. I can actually use music therapy and appropriate forms of redirection. Together, this client and I can plan our day; I can actively encourage her to engage in the development of a routine that suits her rather than trying to get her to follow one that is easiest for me.

       It is a wholly unexplored area of long term care for me and I think there is much that I can learn from the experience. It will be trial and error as we get to know one another and I adjust to the different pace. That is actually a benefit though. This will be a new adventure for us both.

       Ah, but I am not overstating it when I say that it breaks my heart to leave my folks. I know logically that they will be ok. I also know that I’m not actually LEAVING them. The facility is only four miles away and I’m already making plans for fun visits. It will just be a new dynamic to our relationship. We will meet as friends rather than caregiver/residents.

     My difficulty stems from love, but also from my reluctance to let go. My reluctance to trust such a broken and flawed system to care for them properly. It’s MY issue, not theirs. It is true that I need to take this leap. To deny that would be a disservice to myself. It is equally true that taking this position affects more than just myself. To deny that would be a disservice to my residents whom I’ve formed such close bonds with these past several years.

       Change is the one constant in life and I’ve been walking through my fair share of it lately. Though most of these changes have been very positive, it is my nature to cling tightly to the familiar. There is no room for growth in holding on to fear.  Letting go is never easy, but that doesn’t mean it’s not the right move and I look forward to exploring and sharing this new chapter with all of you. I believe this period of one on one caregiving will hone my abilities and help me become more well-rounded, both of which I will be able to use for future endeavors in the world of Long Term Care.

Wonder Woman

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Alice

Taken for granted. THAT’S what I’ve been feeling. I’d been trying to put my finger on what exactly has been causing this nagging malaise for a few days now.

It’s nice to be able to finally put a name to it, though it’s not a feeling that I like admitting. It feels so very self-serving. Poor me. I work so hard for so little. People don’t understand the nature of our work. Blah blah blah blah. That is not who I am. That’s not who I WANT to be.

How can I feel SORRY for myself when I’m surrounded by people living with sometimes unimaginable hardships? Who LIVE in the environment that I can leave at the end of my shifts? How can I feel such exasperation, frustration and occasionally even anger towards my residents who I really do love very much? How can I hate and love what I do in such equal measures? Is such a juxtaposition of emotions normal? Is it the facility? Is it me? What’s going ON here?

It took some time for me to work it out, but I did find my answer. My facility is toxic. It is all excuses and no accountability. It is impossible situations piled on top of undertrained staff. It is equal parts challenging, which I love, and frustrating, which I don’t love. This is not new. This is how it’s always been. I’ve learned to compartmentalize very effectively, but every so often the doors will open and all of a sudden, I’m feeling everything at once. So far, thanks to the hectic pace of first shift, those fall apart moments happen off the clock; they happen in the quiet of my own apartment (or on break in a linen closet) when I’m alone with no one depending on me.

I’ve been in the same facility for seven years. The bonds I’ve formed with my residents have been an incredible gift in my life. It is through working with them that I’ve learned to trust, not only others, but also myself. They have taught me how to value the moment, to not take life for granted, to look beyond the obvious. They have greatly enriched my life, and I will always be grateful for that.

They are WONDERFUL people; that doesn’t mean that they are EASY people.

“alice. Alice. ALICE. ALLLICCEEEE!!!!”…all day every day. The down side to having been in the same facility for so long is that they are used to me. In a world where faces change as fast as underwear, mine is the familiar one. Twenty-eight residents, a brand new trainee and a call out. Alice can handle it. Before I even hit the clock, Ms.___throws up a massive lake of stewed beef and peaches. I got it! Nobody panic! Mr.___ doesn’t like his feet to touch the floor. Ms.___ is claustrophobic. Ms.___ isolates when she’s feeling depressed. Mr.__ lashes out in anger when he’s scared…hundreds of pieces of knowledge that are now like muscle memory for me. What residents need boundaries and what residents need coddling. So I run. All day every day, from resident to resident, task to task determined to do whatever needs doing…but that’s not fair. It’s not fair to my residents, my co-workers or to myself.

I learned all I know by working consistently with my folks. What I NEED to do, instead of running whenever a co-worker says they are calling for me, is to encourage her to try for herself and encourage the residents to allow her to do her work. Otherwise I am enabling all of us, myself included. Make no mistake, there is a part of me that has become as dependent on filling the role of “Wonder Woman” as they are at putting me in it.

The inner need to “fix” impossible situations is an old song and dance for me, as if somehow solving a problem guarantees that I wasn’t the cause of it. It is an issue of mine that I am working through, but MAN does it fit in well within the world of Long Term Care.

The truth of it is this: it is not my job to be the solution to every problem, inside of work or out. It is setting myself up for failure and OF COURSE it leads to feelings of being taken for granted. I have choices. I could leave and find another job. I CHOOSE to stay, at least for now. That means I have to gain a measure of acceptance about the facility as a whole while doing my best to improve my corner of it. I don’t want to be Wonder Woman. Take away the magic lasso and invisible plane and she is just a regular person dealing with issues of co-dependency.