Tag Archives: communication in long-term care

The Language of Caregiving


Alice
Ah the tricks of the trade. The little tips that I have picked up over the years in this field have made such a big difference. I can change a brief without taking off a client’s pants in no time flat; up through one pants leg, down and around the shoe and back up again. Whether it is selling the idea of a shower to a resistant client, coaxing and encouraging a resident to eat, or redirecting a person living with Alzheimer’s, somewhere along the way these little tasks have become muscle memory, as familiar and comfortable as my favorite well worn scrub top. I was reflecting on that recently, how what was once so foreign has become second nature to me and I realized that what I did was learn a language. There may be any number of dialects, but in the end it is in one tongue.
My ultimate goal, regardless of where I may work, is to meet the needs and improve the quality of life for those in my care. That is the overarching ideal for which we caregivers strive. It’s one simple concept but it is very individualized and it’s success is based on knowing our residents and growing our understanding of what makes them tick. It is the language of empathy.
My client was having a rough day. She slept well and all her pain pills from the night before are still there, so I know her pain level was not the trouble. Her blood sugar was normal. Still, her appetite was down, and she wasn’t interested in going out. She wasn’t engaged. After a year of working with her, I knew that she would open up if I could just make her laugh. She has a fantastic sense of humor and that is one of the most effective tools to open the doors to communication with this particular client.
This resident feels safe on the porch. This resident prefers showers in the afternoon. This client loves enthusiasm. This client takes a while to open up because the woman who cared for her for five years moved and she is feeling uncertain. It’s the language of knowing, the language of patience and perseverance and consistency. Because I’ve had to learn these traits in order to do my job effectively, I find that I am more capable of applying them into my daily life off the clock. Because I want to maintain my ability to grow as a person and learn from my work, I have to honestly take stock of myself on a regular basis. The language of caregiving is universal, challenging and transcendental. The skills I have learned on the floor have impacted my life, relationships with others, and perspective deeply. I truly hope that never changes because I find it valuable beyond measure.

The Magic of Music in the Chaos of Long Term Care

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Minstrel

Being a new CNA is challenging.  Yes, in training I learned how to make a hospital bed with a mannequin in it.  To wash my hands according to procedure.  To transfer fellow trainees with a gait belt.   But now I’m in the unit, needing to transfer a dear little wheelchair-bound lady who can no longer speak and who, while petite, is a dead weight when I try to lift her.  And she is contracted.  Her arms remain tight at her side as I try to undress her.  Who is more distressed, ‘Goldie’ or me?  

Goldie, in her mid-90’s, is still a beautiful-looking woman with twinkly eyes and a smile that glows.  So as I work with her I sing “Glow little glow-worm glow and glimmer” to her.  (Are the Mills Brothers spinning in their graves?)  I’m not sure Goldie gets the words at this point, but I’m laughing as I sing and she laughs back.  She relaxes.  I open my arms wide to invite a hug and Goldie opens hers!  Now I can get her blouse off.   Mission Accomplished!  I don’t know what made me sing to Goldie that first time, except that she was such a sparkly person that being with her made me happy.   My singing is not a pretty sight.  But as one musician said to me, “They don’t care what you sound like if you love them.”    

Soon I was singing to all my residents as I did ADLs (Activities of Daily Living: bathing, dressing, toileting, eating).  Sometimes a resident would sing along.  Yes, this did mean that it took me longer than it took other aides.  One of my caregiver-mentors would say to me, “We don’t have time to talk to the residents.  We don’t have time to sing to them.”  But I persisted (quietly) and began to carry my IPOD nano and a small wireless speaker with me.  Now we had hundreds of songs, sung by the voices these residents might recognize: Frank Sinatra, Rosemary Clooney, The Mills Brothers, Judy Garland, etc. etc.  One morning as I brought residents to the dining room for breakfast I played Oh What a Beautiful Morning.  Soon the room was singing!  And smiling.  In time other aides began asking, “Do you have your music with you today?”   For one thing, I think they liked some of this old music.  And they saw that residents often became calmer and more cooperative when they felt ‘sunny.’  Music does that, connecting us to each other and to our memories.  

As my IPOD played the Marine Hymn or Anchors Aweigh, veterans walked to the dining room with new determination.  Accompanied by a waltz, a resident with unsteady legs could be coaxed to move more confidently.  Sometimes we can engage a resident with a song we know she enjoys, singing together as we walk to the toilet.  Because we’re in the midst of something pleasant, a resident might hardly notice that an ADL she usually resists is about to happen.

Some residents can no longer speak; they might no longer understand language.  The saddest reality is that some can no longer hear.  (Even then, rhythms might be felt.)  Not every musical event works every time with every resident.  Nevertheless, with many residents, music can be magical in its effect.   Music has a profound positive effect so often, that it seems crazy not to try it.  

When I am old and grey and full of sleep… (thank you Mr. Yeats), they can take my food, they can have even my books.  But I want my music.   

Experience is King

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ALICE

Hope. It is the balm that heals all the wounds that life inflicts upon humanity; that we inflict upon each other and ourselves. Hope is the driving force behind life. It is what keeps us going when we want to give up. Without it, where would we be? I was thinking about that last week, when my own chips were down; how much easier it was for me to handle the chaos of a really really bad week than it once was. All because I had hope that life would once again level out.

There was a period of my life when I had lost all hope for myself. It’s such a sick feeling, that sort of despair. It sucks the life out of you, turning the air around you into heavy shades of grey that rob you of the will to put one foot in front of the other. I wasn’t living in that phase of my life. I was existing, and barely that.

I am one of the lucky ones. I pulled through and landed on my feet. With the help and support of loved ones and ongoing effort on my part, my life has completely turned around. I was given a new perspective and renewed hope.

My biggest challenge and most painful experiences have become my greatest assets in this field. It is part of why I love it. I can in all honesty tell my folks that there is no such thing as hopeless and while life may be difficult, as long as they are breathing, it is more than worth it. They are bigger than their pain. In the world of Long Term Care, liabilities become assets; our own flaws and difficulties help us relate better to those for whom we care.

My case isn’t necessarily typical, but think about it. To whom are our residents more likely to relate? Those who sit in an office or have fewer obstacles, emotionally or financially or those of us who know what it is to struggle on a daily basis just to make ends meet?

Though it not possible to fully walk in another’s shoes, embracing the lessons we have learned by walking through our own pain can help us relate to our residents and, in doing so, help them lower their guard enough for us, as caregivers, to truly get to know them and vice versa.

To me, that is the real art in caregiving. Anyone can learn how to perform skills, but the gift of KNOWING people; of seeing past the obvious is at the heart of what we do. The best CNA’s I have worked with have all had a story, a struggle, a dynamic history that has made them especially gifted at this job.

We are given the unique opportunity to not only embrace our flaws, pain, losses, and obstacles but to put them to the best possible use, helping other human beings. What we do is real; it’s not about what looks good on paper. It’s about convincing a resident who is in great emotional pain to eat. It’s about listening when a resident is afraid or feels alone or is angry and attempting to understand the underlying cause of their pain in order to help ease it as much as we can in our capacity as caregivers. Who better to show our residents the light in the dark than those of us who are walking with them through it? So I say EMBRACE your flaws! Be grateful for the WORST of your experiences. Hold your past mistakes and the lessons you’ve learned from them close! Remember your tragedies while being mindful of the fact that you survived them. They make us more qualified to help those who are currently living through their own.

The Broken System

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Yang

On CNA Edge, we sometimes describe long-term care as a “broken system.” I’m guessing that most caregivers who have been in the business for any length of time have a general idea of what we mean by that. They nod their heads, shrug their shoulders and go back to work. It’s just the way it is.

But, really… what do we mean by “a broken system?” I think we can look at three major areas.

First, the average workload for direct care workers often makes it difficult to meet even minimum care standards. Recently, I conducted an informal poll in one of the CNA Facebook groups, asking this question: “Do you feel that your facility has enough staff working direct care to consistently meet the goals stated in the resident care plans?” About three hundred caregivers responded. Two people said “yes.” The rest gave various versions – sometimes colorful and emphatic versions – of “no.” While this was not a scientific poll in any way, it is still supportive evidence for what most caregivers take as an obvious truth.

Second, despite some efforts to integrate caregivers into the decision making process, long-term care still relies heavily on hierarchical relationships. However one wants to sugarcoat it, caregivers remain on the bottom of the pyramid. While there is nothing wrong with this traditional organizational model per se, in long-term care it fails in one significant respect: it does not address the deep communication gap that exists between those who set the parameters of care on one side and those who are expected to work within those parameters on the other. On the other side of the gap, the primary focus is on words and the manner in which words are used for professional and public consumption. On the caregiver side, it’s about action. It’s about how one interacts with a resident physically and emotionally within the context of care. The higher up you go in a hierarchy, the further those in authority are removed from that context and upward communication loses its meaning. In effect, we maintain two parallel realities with each having its own set of priorities.

Third, whether it’s a matter of maintaining a well-organized routine, fiscal constraints or legal considerations, the needs of the facility all too often trump the needs of those who live there. While large organizations are able to centralize services and provide an efficient way of utilizing resources, this comes at the price of limiting flexibility. When facilities discourage workers to proceed according to their own discretion and do not trust their ability to apply common sense and act according to the spirit of the rules rather than to their letter, the needs and desires of individual residents are often considered unreasonable or simply neglected. The purpose of a long-term care facility is to return as much as is reasonably possible to a resident’s life what disease and circumstance have taken away. In the name of efficiency, we routinely work against that purpose.

To be sure, all these areas have improved over the course of the last 30 years. We’re getting better at it, but the progress has been uneven and there is no doubt that there is still a long way to go. The question becomes, where are we going? That is, from a caregiver’s perspective what does a system that’s not broken actually look like?

I’ll give you my take on that in my post next Friday.

The Value of the CNA Voice

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Yang

There is a school of thought among some professional advocates for CNAs that says caregivers will never fully appreciate the true value of their own work until they have a better understanding of how the business of long-term care works. That, until they recognize their role in the bigger picture, caregivers will never fully grasp how they influence the larger goals of the industry and are thus left to doubt the significance of their work – and their self-worth.

While I’m not prepared to dispute any of that, I will say that in terms of utilizing resources to deliver the best care possible, the converse is far more significant: the business of long-term care can never fully come to grips with its own problems until those who establish policy and enforce standards develop a deeper awareness of what we are all about.

And it’s up to us to tell them.

Before social media, the “CNA Voice” did not have an adequate platform for independent expression. With few exceptions, CNAs were heard only through the filter of the health care hierarchy. The result was a sanitized voice, good for parroting industry buzzwords and contributing to interdisciplinary window dressing, but giving only a glimpse of how we really experience our work.

With social media, direct care workers have been given the opportunity to express themselves more openly, albeit with the caveat that you never know who is watching. The majority of these forums are administrated by caregivers and they accept a far wider range of public expression than is possible within the formal work environment.

While social media gives us a better sense of the CNA Voice, all too often it presents that voice in a fractured and superficial way. That’s just the nature of social media, which promotes interaction and response. What social media doesn’t encourage is the kind of reflection necessary to properly sort out and express that complex and often contradictory blend of thoughts and emotions that make up the inner experience of the caregiver. That is the true source of our voice – and our self-worth.

We can help long-term care understand itself by offering something precious: a dose of reality. And if there is anything that this system obsessed with image needs, it’s a steady dose of reality. Yes, there is much about the “bigger picture” that most of us don’t know. But we are aware of certain truths about long-term care in a way no one else can be. Because outside of the residents themselves, no one knows better than we do how they experience their time in long-term care. In fact, we can’t talk about our experience in a meaningful way without talking about theirs. And that is the real value of our voice.

Excuses and reasons

 

May

Every time I’ve got gloves and…other stuff…on my hands, my face starts itching.

I’ve no idea whether it’s simply that I notice the itching more when I’m unable to do anything about it, or whether it’s fate playing a cruel joke on a poor CNA. Most days, I’m inclined to suspect the latter.

I suppose that it doesn’t matter, either way. Even the persistent, annoying itch in my eyebrow is small potatoes compared to the fact that I have five minutes before I am “officially late” to the meeting (I’m “actually late” already). I try to hurry as best I can, though I’m rather thinking that a cork, rather a wipe, would be appropriate for this situation.

Eventually, there comes a time when you stop wiping and call it enough. I fasten the new brief, turn her on her side and pull the covers over her.
“I’ll be back soon, okay?” I tell her as I snap off my gloves and turn on the water to wash my hands. This resident hasn’t spoken in weeks, but I swear she doesn’t need to power of speech to express her doubts about the “soon” part. Her eyes continue to bore into my back until I leave the room.
Two minutes later, I’m quick-marching down the hall in that not technically running that I’ve perfected in my time as an aide. It’s one of the ways I got over my green-aide days, by cutting down the time it took me to get from one resident to the next without invoking my administrator’s distaste for “running around in an unprofessional manner”.

Despite my not-running, I’m one of the last to enter the meeting room. I hope for a minute that this at least means I’ll get a seat in the back of the room, but no. Seating is first come, first serve and apparently, we started in the back today. Lucky (late) May gets to sit in the first row, right in front of our special guest. And the DON and administrator, who both raise their eyebrows over my late appearance. I shrug in a half-meek, half-cheeky manner and slide into my seat.

Our guest today is a middle-aged man, dressed in an impeccable fashion. Well, impeccable if he were attending a board meeting; here, he rather sticks out. His suit fits him perfectly and nothing about him is out-of-place. Under his blazer sleeve, I see the glint of a gold watch and his brown shoes are so shiny that I can see my reflection in them. I wince.
In the sleek, expensive leather, my reflection is not flattering. My scrubs are old and faded; my shoes cheap and scuffed. I’d actually done my hair and makeup this morning, but you can’t tell now. Sweat has washed off the makeup and revealed what I was trying to hide: the pale skin and large bags under my eyes, courtesy of two doubles this week. I don’t look professional; I just look tired.
I can’t help the thought: I’d have to work a lot more doubles before I could afford a similar outfit. I try to stop the thought: I know better than to judge someone based only on appearance…but I also know that you dress for who you are trying to impress. Everything about him screams that this man is not really here for the CNAs. In this setting, his clothes do not so much impress and set him apart from us.
I glance around me and I know I’m not the only one who’s noticed. Grumbles sweep the room: there are a lot of us who hover on the poverty line, lots of single mothers working themselves ragged to provide a good life for their children, a lot of us trying to scrape enough to save for school and pay the bills.

Resentment is an ugly thing, but hard to shake…prejudice, even more so.

He clears his throat and begins to talk. I try to stop thinking. He’s here to discuss “time management and job efficiency”. Apparently, ours suck. He doesn’t say it quite like that, of course. He starts with a story about how his office is cluttered and how this ‘negatively affects’ his job performance. Somewhere along the way, he makes the connection between offices and time: how a cluttered office is like misused time. Just like we need a well-organized office to properly do our jobs, we need to manage our time.

Office? I work on the floor–closest thing I have to an office is a bathroom. I shift in my seat, stifle a yawn and think his examples are a bit odd, considering his audience. I’ve never had an office in my whole career. I’ve never had a desk, or a filing cabinet or even a chair. I do have scrub pockets, though.
He goes on at length, citing studies and tying them back to time management policies. He tells us how much room for improvement he sees for us “on the books”.
But that’s all he does: cite studies and tell us what we are doing wrong. He doesn’t give any relevant examples or any insights on how to apply these principles to the world of the floor–where residents crap a ton, tumble out of wheelchairs, slap us in the face, get confused as to we are and where they are. All he does is stand there in his fancy suit and offer us generic slogans and cookie-cutter criticisms.

Oh, crap. I forgot to lay down Mrs. T. I can see her in my mind’s eye, leaning over the right side of her wheelchair, leaning towards a tumble. How did I forget her? Oh, yes, I was dealing with the never-ending squirts. Now there’s a time management conundrum: if you only have ten minutes, do you change the soiled resident or do you lay down the fall-risk? Suddenly, I am all impatience for this meeting to be over, so I can lay down poor Mrs. T.

My attention is jerked back to the meeting by an aide behind me speaking up.
“All that is well and good,” she says drily, “but it ain’t practical. How’s it my fault that I got six people to get up and only an hour to do it in? And you want me to be doing all this other stuff in that same time? Ain’t gonna happen. If that’s mismanagement, it ain’t mine.”
“Well, you will just have to try harder,” he says. “You just need to stop thinking it can’t be done. All this can be done…I’ve been to hundreds of facilities and you’re telling me that this one is so different from all the others I’ve been to?”
Resentment flares up from all corners of the room. Come again? She made a valid point, I thought. At least valid enough to be discussed instead of being dismissed out of hand.
I’m speaking before I’ve half-made up my mind to say.
“Some days, you’re right and we do have time. But she’s also right: good quality care takes time. You can’t tell us to only provide the highest quality care–but be snappy about it. It just doesn’t work that way; especially on the days when we are short-staffed–“
“So you’re telling me that there’s nothing you can do to improve your time management?” he interrupts. “Nothing at all? You are perfect? Because this isn’t going to reflect on me; it’s your job performance that is going to be judged. And being short-staffed is just an excuse, young lady. Just an excuse to not do your best.”

I’ve got so much I want to say that they all get wedged in my throat. Of course there’s stuff I can to ‘improve my time management’. I could not sit with Mrs. W. while she cries–that’d save me ten minutes at least. I could just randomly check boxes when charting instead of accurately recording my shift–that’d be huge time saver! I could cut out the part of my day when I wash everyone’s face…I could not pee for eight, twelve, sixteen hours, whichever one I’m told to work on any given day.
A higher-up clears her throat. “I think what May means is that we do have really crazy shifts and it’s hard to focus on how else we can be doing things when we’re already so far behind. And May, he’s not trying to be mean or harsh. You’re just…tired.”
Tired?
Behind my back, I can feel the heat of resentment washing up from my coworkers. Tired? We’re all tired! And yes, exhaustion does affect our job performance. Sorry about that.
Maybe we shouldn’t be talking about time management. Maybe we should be attending a seminar on how aide fatigue affects the residents’ quality of care and what we can do about it. How we can resolve the problem, in this facility and elsewhere. But according to this expert, these are just excuses, not reasons. Complaining, not cause-and-effect.

I glance at the clock and I don’t say any of the things that are boiling inside. I need to get back to the floor and I’d be wasting my time trying to argue my point. This man is not open to listening to me and honestly, I’m not open to listening to him right now, either. Anything I say is going to get tossed in a box with the label “tired”. Funny things, labels and boxes. “Tired”, “disgruntled”, “angry”, “uneducated”: easy ways to categorize statements without sifting through the bath water to find the baby. I guess it’s easier to treat the symptoms than to cure the disease. Truth is almost always messy and multifaceted: it never fits into a neat little box.
Though, that cuts both ways. I wish this meeting had happened at some other time than during my hectic shift, some time where I had the mental energy and actual time to listen and weigh his words. I still don’t appreciate his attitude.

The last thing I hear as I leave the meeting is another higher-up talking to the special guest.
“I think a softer approach might have been appropriate. I mean, didn’t you see how tired they all are?” Her voice is quiet but hard. Displeased.
Well, they’ve noticed. No, not “they”, I remind myself as I slowly walk back to the floor…sitting still for so long in the middle of my shift has sapped my energy. The people in the offices aren’t one collective being, no more than aides are a faceless mass of cheap scrubs. At least two of the office-workers have noticed how exhausted I am, how exhausted we all are.
It’s a start.