Assisted living. It brings to mind a calm and safe environment where people who need minimal assistance with the activities of daily living can reside and flourish. It’s hardly work at all. They don’t even have lifts (in theory, anyway) and because of this, the pay is less. A calm oasis, complete with shuffle board…just like in the movie Cocoon, if you will pardon the dated reference. In my experience, the reality could not be farther than that mental image.
The state in which I live has cut so much funding for mental health that there are no longer any long term treatment options available for those living with severe mental health issues. We have a short term behavioral health center that is sort of a catch-all crisis center for a variety of disorders. Three to ten days;just enough time to get a brief taste of stability before they send them on there way until the next crisis. Those of us who bring in support groups from the outside often see the same clients come in and out again and again. Fairly often, people I would see when I was volunteering at the short-term behavioral health center ended up in the assisted living facilities where I worked.
They don’t belong here. It’s not fair to the other residents. How am I supposed to take care of her. She screamed all night long. This isn’t what assisted living is supposed to be. These are the mumbling grumblings I would hear the most. I learned early on that there is no point wasting time in the land of “supposed to be”. That is the dubious luxury of the legislators who make regulations that make no sense for a world they do not understand. Poorly enforced useless regulations at that. A facility will get dinged if a caregiver accidentally wears gloves in the hall but call bells that haven’t functioned correctly in over a year are just fine…but that’s a post for another day. My point is that as a caregiver, one of the first lessons I learned is to divorce myself from all expectations. There are no supposed to be’s.
In my experience, assisted living is sixty percent mental health, twenty percent total care and twenty percent people who need moderate assistance. Or some combination of the three. I’m not a numbers person, but I would say that’s a fairly accurate assessment. On one hall, I have had a resident who was living with the damage of long term substance abuse, another who heard voices, one in the early stages of dementia, one who spoke no English, one who was legally blind and a young man who suffered permanent damage from a catastrophic car accident. Every single case required me to use a different set of skills that I learned from the floor in order to be of maximum assistance with their activities of daily living.
Think about that. Doctors and nurses have specialities; classes and separate skill sets that enable them to work in a focused area of care. For caregivers working in assisted living, our specialty is “handling it” And I love it. It keeps my job endlessly challenging, but it is not everyone’s cup of tea. If you aren’t open minded and able to adapt to the reality of the situation rather than the expectation of what it should be it’s going to be a rough road to hoe.
My question to all who struggle with what assisted living is verses what it should be is what is the alternative? In my state, at least, there isn’t another viable option readily available. Is it ideal? No. But at least my residents living with severe mental illness have a place to live and receive their medications for both physical and mental health as prescribed. At least they have food and companionship. At least they are safe.
Some of my residents living with severe psychological challenges stay in these facilities for years and some go back and forth between the streets, the short term behavior health center, and assisted living places. I have had past residents who have left the facilities where I worked only to turn up years later at the behavioral center where I volunteer.
Last winter one of my residents living with a mental disorder died in the most tragic way imaginable. I hadn’t seen him in awhile. He was so young. Just a kid really. He slipped through every imaginable crack in the system. He left the facility where I was working at the time and later turned up in the group at the behavioral health center. That was the last time I saw him alive. I speak for every caregiver who ever worked with him when I say that there isn’t any length we wouldn’t have gone to in order to prevent his death. It’s just heartbreaking to think about. So while it may not be an ideal option and the training caregivers receive in psychological disorders is sorely lacking, those of us who adapt well to the strange and interesting world of assisted living facilities will be the first to say it certainly beats no option at all.
“I KNEW you’d be back with your stupid smile on your stupid face!”
I bit the insides of my cheeks to keep from laughing as I quietly slipped into her room to assist her to the restroom.
“Well, Alice, at least this time you were prepared.”, I thought to myself, trying hard to keep my face neutral as my resident hurled a steam of inventive and diverse insults in my direction. Thankfully, she was able to walk and talk at the same time. Physically, she did fairly well on her own but she was just unsteady enough on her feet that I didn’t feel comfortable leaving her to her own devices.
I had been warned. From name calling to throwing soiled briefs, this resident was a challenge. Maybe it’s because I had been in private care for awhile or maybe it’s because I had worked so many years at my last facility that I had a deep and loving relationship with all of those in my care, but I thought there was no way she could be that tough a case or that maybe there was a touch of dementia or mental illness involved…WRONG…SO wrong. Her mind was fine. Sharp as a tack, actually, if her comedic timing and penchant for hitting hard with the verbal blows were any indication.
“You DISGUST me. Every one of you! Women are nothing but TRAMPS nowadays”, she kept ranting through the partially closed bathroom door. I stood just outside waiting for her to finish up, still trying my damnedest to keep from laughing and maintain some semblance of professionalism in facing the wrath of…well of the meanest woman I had ever met, quite honestly.
“STILL smiling?!”, she grumbled as she shuffled toward her bed, “you ought to run away with the circus!”, she hissed. She literally HISSED at me.
“Well, I wanted to when I was a kid! But I realized that I was way too clumsy to be an acrobat and I don’t like clowns. It’s not that I’m afraid of them. I just don’t think they’re funny”…while that was all true, I was surprised to hear the words fly out of my mouth. Apparently so was she because her mouth dropped open in utter surprise. I took the opportunity to quickly cover her up with the blanket and make my escape.
The rest of the shift flew by and I felt utter relief as I pulled into the driveway in the early morning light. I went in the house, tossed the keys on the counter, made my way up the stairs and collapsed onto the bed. My boyfriend woke up and asked how my shift was. I groaned and went into great detail on how difficult and mean this one resident was. He listened to me rant for a minute and then pulled me close to him.
“You’ll find a way to reach her. You always do”. He kissed me softly on the forehead and I smiled to myself. The one thing I had forgotten, at least momentarily, was one of the biggest reasons that I am in this field: To reach people so they know they are valued and not alone. No one is born that mean. And with his reminder and his kindness, I knew that I would try again with her tomorrow. And the next day. And the next…
Unreasonable, misplaced anger, unrelenting fear, heartbreak from deeply felt emotional wounds, a lack of trust both of others and of their own capabilities, powerlessness, despair, frustration, feelings of abandonment, and utter lack of control over their own surroundings are only some of the negative emotions that those living in Long Term Care facilities face on a daily basis. My residents who struggle the most with the above mentioned feelings are usually the ones who are the least capable of clearly articulating it.
So what happens? They act out. They become verbally and on occasion, physically abusive. They often yell or become obstinate over seemingly innocent little tasks. They manipulate situations in a way that they feel best benefits their needs. They are the residents labeled “difficult”, “trouble makers”, “problems”, not just by those of us on the floor but also by those in the office.
God knows, I’m guilty of it; inwardly sighing, as I make my way to a resident who is furious at me for something over which I have no control. Or a resident who is vengeful because I’ve had to set a boundary that she doesn’t like. Some days, I wonder if all of my uphill battle folks had a meeting and decided that they would join forces in order to make a shift impossible just for their own entertainment. Those are the days that I leave work questioning both my sanity and my capabilities; the days when I think I suck at this gig and wonder why I am so determined to stick with it.
The thing is, though, when I step away for a minute, I realize that I have a level of awareness that is desperately needed in this field. I really do know that these “difficult” residents are not behaving in such a manner simply because they’re “mean”. The powers that be may know that, but in all honesty they don’t care. They can’t possibly care because their only solution appears to be medication, a problem that I will be discussing in a future post. A facilities treatment of their caregivers directly corresponds to their level of interest in their residents’ quality of care. They are not invested in us, then they are not invested in them.
SOMEONE has to be, though. Someone HAS to see beyond the behavior, which is nothing more than a symptom to the greater underlying illness. That responsibility lies on the floor. We are the witnesses and the carriers of their emotional wounds. While we are unlikely to heal them, we can step outside of ourselves and use their behaviors to learn how to better care for them, much like the pain from touching a hot stove teaches us to not touch it again.
Unreasonable, misplaced anger, unrelenting fear, heartbreak from deeply felt emotional wounds, a lack of trust both of others and of their own capabilities, powerlessness, despair, frustration, feelings of abandonment, and utter lack of control over their own surroundings…that’s a lot for any human being to have to live with. Sometimes adding “fit into my concept of acceptable behavior” on top of all that is just too much to ask of them and they can’t meet US where WE are. That’s when our empathy and understanding needs to stretch in order to better meet THEM where THEY are.
If someone calls me an “angel” one more time today, I think I’m going to puke all over their shoes. Really, I mean it. I am not a messenger of God dressed in a long white robe with wings. I am a CNA: a certified nursing assistant, a trained professional. I am a person who chose this career field. I am a wife, a mother, a daughter, a sister, a neighbor, a voter and a human being. I am not an angel.
I have a full set of emotions and thoughts that you, the family of the residents I care for, will never see or hear. You will never hear the cuss words that run silently through my brain as I discover your delirious wife smearing her feces all over her bed, the floor, herself and anything else within arm’s reach. Instead, I face the task at hand; cleaning up your wife and her room while calmly interacting with her. You will never hear me sharply respond to your mother’s cruel, untrue words concerning my work methods. Instead, I redirect the conversation in a quiet, soothing tone. You will never see the frustration I feel showing on my face when your husband refuses to walk even though he is able to do so. Instead, I continue to encourage him to keep trying. You will never notice as I slowly inhale and exhale to calm myself after your elderly father just threw his meal tray across the room because the cook accidently gave him juice instead of coffee. You will never see the tears I cry while I apply ice to my bruised cheek after your aunt, in her dementia, punched me while I changed her urine soaked clothes. You won’t know the feeling of disgust that runs through my body like an electric shock when your aged, confused uncle grabs my crotch while muttering sexually explicit phrases as I help him out of his bed and into his wheel chair. No, you family members of the residents we CNAs care for will never really know these things. You see us working and instead of respecting our professionalism you call us “angels.”
These are not the behaviors of angels; this is a professional CNA in action. We are trained, licensed and trained some more to be CNAs. We work very hard to help other people’s family members. I would much rather hear someone exclaim with pride, “She is one hell of a CNA!” than call me “an angel” any day of the week. I won’t even feel like puking because I’ll be too busy smiling.
I would like to expand on something Alice wrote in her post earlier this week. In making a distinction between “kindness” and “niceness,” Alice told us, “Sometimes, the kindest answer is no. Sometimes, setting boundaries that will upset a resident or a co-worker in the short-term but will benefit us all in the long-term is an act of kindness.”
I think part of what Alice is saying is that the tendency of LTC staff to appease a demanding resident can set a pattern of unrealistic expectations. There is nothing wrong with appeasement in and of itself, we do it all the time in both our professional and personal relationships. The problem is when we use appeasement as a quick and easy solution rather than address the underlying issue. By doing so we treat the symptom rather than the cause.
In this sense kindness is the willingness to take the time and effort to determine not only what a resident wants but also why he or she is asking. This requires a measure of patience and self-control. In the heat of the moment, it can be difficult not to react to the tone or unreasonableness of a demand. We’ve all said or heard said some version of this: “You’re not the only one that lives here.”
However, the negative tone of a resident can actually help us understand the root of the problem. Anger, impatience and frustration can indicate an underlying anxiety. Instead of reacting to surface emotions, we can focus on allaying that anxiety.
Anxiety comes from not knowing. We can better endure all kinds of mental and physical discomfort as long as we know that it’s not indefinite and that we have some control over it. For example, I can tolerate hours of being outside on a frigid winter day as long as I know I can go inside and get warm anytime I want. Take away that assurance and in ten minutes I won’t be able to stand the cold.
It’s the same with our residents. When it’s time to say “no” and set boundaries we need to engage with them in a way that reassures rather than reproaches. When we actively listen, negotiate and compromise we are communicating to the other party that they bring something to the table and that it matters. In the process, they gain a degree of control over what happens to them. And it doesn’t always have to take a lot of time. Just that opening can be enough to defuse the anxiety.
In some LTC circles, it’s fashionable to speak of this as “resident empowerment.” We should be careful not to think of this as something we bestow on them, because in reality, it rightfully belongs to them already. Our job is to facilitate it and not deny it through haste or a lack of awareness.
There is always at least one in every long-term care facility. You know, the one. No matter how many residents you are responsible for, the one sincerely believes they are the only one in the building, demanding precious minutes of your shift. The one. Mine, I secretly call the Queen. I have 25 residents on my wing yet I spend more time answering her numerous call lights than any other resident on the wing. I tried to count how many times she used the call light in one shift but when my count was up to twenty after two hours, I stopped counting before I got depressed and resentful.
The Queen cannot walk or transfer herself requiring a two person transfer with the sit to stand. She cannot see very well, even though she always seem to know what time it is, if her bedspread is too close to the floor, that her wastebasket is getting full, when her window shade is crooked and when my name tag has flipped upside down. She usually spends most of her time in her room, by choice. She does not go to the dining room choosing to eat in her room instead. It takes at least five minutes to fill out her supper slip. Sally from the movie “Harry met Sally” was a novice compared to the Queen when it comes to ordering food. The Queen does not take to waiting very well. She will not hesitate to let upper management know how much she is ignored, that the “girls” never answer her light promptly and she is the only one who has to wait all the time.
I can’t help but release a really deep sigh as I type this out and I know that I sigh deeply several times during my shift while caring for the Queen.
Yesterday the Queen was in rare royal form, throwing verbal jabs at everyone she could; “threatening” to have our jobs, complaining about supper, demanding her medications NOW and ranting about the length of time it took us to finally start getting her ready for bed. When she acts like that my best offense and defense is to keep my mouth shut. I don’t respond to her sarcastic, belittling remarks. I keep my body language as neutral as possible and do the work needed; only speaking to politely give one or two word directions to help prepare her for bed. She starts her rant over when the nurse comes in with her medications.
We’ve had a stressful week on our wing and this nurse was on the last shift of four days working double shifts. The nurse, tired and out of patience, responds to her royal tirade by firmly replying, “You are not the only resident here. We have other residents who need our time too.” ‘Oh no, oh NOOOOO!’ I silently moan to myself. I shut my eyes while crouching down to put on her night time socks and start doing deep breathing exercises knowing full well what is about to occur. And it comes, the royal Queen verbal hurricane. The nurse plays the nurse card and walks out on her mid-hurricane tirade. My partner and I still have to get her in bed. We can’t walk out. We are stuck to weather this storm. My partner starts to open her mouth to say something and I glare “NO!” at her. She snaps her mouth shut and we silently start getting the Queen into her bed.
Our silence has sucked the air out of the Queen’s hurricane. She tries a few more jabs at us (“Giving me the silent treatment, huh? Your boss will hear about this!”) and when those comments didn’t net the response she was looking for, she too became quiet. We finish tucking her in and as I approach the door, turning off the light, she calls my name. I cringe; steeling myself for what may come next.
“Yes?” I say with outer calm but inner apprehension.
“Thank you,” she replies in a soft, sincere, non-Queen-like tone. And I exhale in relief. All that transpired during the last 45 minutes evaporates like morning dew in the sunshine.
I don’t want to talk about the psychology behind her behavior. Instead, I want to share the gifts she has given to me. The Queen has taught me how to be patient when confronted with impatience. She has taught me that silence can be more powerful and calming than words. Because of her I have learned how to tune out the hurtful and sometimes cruel spoken words while tuning into the unspoken reasons behind them. She has taught me what it means to truly care for another human being unconditionally.
This fussy, demanding, insistent, bossy woman makes me a better CNA, a better person. And I can’t help but adore her.
I went to sit with Fran for a while, because she’s been unhappy lately. I don’t use words like “declining” around her, but anyone can see she’s going downhill. She knows something is wrong, but can’t put her finger on it. She’s gotten more confused the past few months, a lot weaker, and she didn’t had much self-confidence when I started here; this new development has her putting the brakes on trying at anything, even putting on a shirt. She’ll just fumble with it, groping both arms through the head hole or let it sit on top of her and look pitiful, not making any attempt until you put your foot down.
Fran’s little apartment is divided into a cozy living room/kitchen, a slightly bigger bedroom and a tiny bathroom that barely fits us and her walker. No stove, but there’s a counter and cupboards and drawers with silverware and cups, and a little fridge like you’d see in a dorm room. Coming in through the front door—always unlocked and ajar, because she fears she’ll lose her key—the kitchen is to the right, next to Fran’s electric recliner, a nightstand with a lamp and across from there are two tiny rocking chairs that somehow support my weight, though the arms pinch my girth. A subtle reminder I need to get back on a diet. Or “change my lifestyle” as chronic fat people like me tend to put it. I knocked on the door as I came in, she said she was happy to see me, which I took to mean I could have a seat. I took the chair looking directly at her.
“How you doing, Fran?” I said loudly. She isn’t hard of hearing, but speaking loudly and slowly helps her understand what you’re saying. She talks lower and slower than she used to. Takes time to ruminate on her words. I try hard not to check my watch when I’m around her. She doesn’t get a lot of talking done because we’re all rushed, almost all the time.
“I’m lonely, but I don’t know why,” Fran said finally. “People come in and out, but it’s not the same.”
“Nobody talks to you?”
“Yeah, people talk, but it’s all the same thing. They all their own way of doing things. And they creep up on me with things to do. PT. What you do—not you, but you know. The others. They want me to go watch old movies.” Fran has a perpetually sour look on her face like she was sucking on lemons before you walked in. Her skin is dry all over, no matter how much moisturizer I put on it. The flaking whiteness all over her scalp, her cheeks, and on her chin only adds to the gruesome texture of her face with her mouthed pulled back dryly in a near permanent grimace that forcibly reminds me of a skull.
“You don’t like the old movies?” I ask loudly.
“I saw them all years ago and don’t want to look at them again. That’s us. Old people. Old movies. Old things. Remembering. The sum of our parts; old, old, old; us in a nutshell.”
“Oh,” I said lamely. “I’m sorry to hear that.”
Before I could offer up an alternative, Fran verbally reached into my guts and squeezed them, twisted them. “I’m not used to being dirty,” she moaned. “I’m used to being clean all the time, but they’re not cleaning me as much as I’d like. You’re one of the only ones who does.”
I didn’t know what to say. I started to speak, to tell her she needs to tell someone about this, but she rambled on. I’ve learned sometimes it’s best to just let people talk; they don’t necessarily want advice or solutions as much as someone to grieve to.
“I don’t know what to think or where to go or how to solve anything. I used to know. This is my walker,” she said, rattling its aluminum frame. “My pouch is on it, and those are my pads. But it doesn’t feel right. It doesn’t look like my walker. I wouldn’t know it was if you didn’t give it to me. And you have to take me all the way to the bathroom if I have to go. Nothing is normal anymore. And I don’t know how to get it back to normal.
“My bottom is sore. I shouldn’t say that in front of gentlemen.”
“I know I’m gonna fall. I don’t want to fall again. It’s really bad. It’s bad when that happens. No hospitals. That’s the worst. You don’t get to live in your apartment if you go there too much. All my friends are in Independent Living and I need help with everything. That’s not normal. None of this is normal.”
If I could find words, I don’t know what they’d be. All I could think to do was validate that it’s “normal” at this stage of her life, and some people are at different levels, or some crap I was taught in orientation or class. But I’m twenty-nine. What do I know about any of that? Anything I said would come off as hollow and unhelpful as telling a dying man to cheer up, it gets better. I let the silence stretch on painfully.
Fran croaked that she was thirsty. “There’s a can of ginger ale in the fridge. Take half and we can share it,” she said.
Her fridge was barren but for a few bottles of V8. “There’s only V8 in here, Fran. I’ll have to go and get you one from the kitchen.”
“Please make sure you come back,” she whined. She had turned around in her chair to look at me, fingering the big button on her pendant, not quite pressing it. “I don’t want to be lonely.”
“I’ll be back soon,” I said, stepping out. I had a feeling it was a bad thing to say, and was rewarded for it moments later when someone else hit their pendant. Duty called, and “soon” was almost twenty minutes. I got her ginger ale in the end even though she only vaguely remembered asking for it, and she gulped it down, burping, which she remarked was very unladylike with a little laugh.
Update: Fran moved out of her apartment in assisted living to skilled about two weeks later, skipping right past personal care. Did not pass Go, did not collect her $200. This place would have taken it anyway. She died less than a week after that. I hope she was surrounded by family when it happened. I hope she wasn’t alone. No one told me or I would have been there. She was a huge pain in the final months I knew her, a physical and emotional tax more than a person, but the last few days in her company humanized her again. I’m thankful for that.
I’m sure someone would remark at how wrong it was for losing sight of her humanity. I can only shrug at it, look away. I feel exactly what you’re feeling for me, but it was never a conscious choice… No, I can’t honestly say that. I saw it coming like I’ve seen it so many times before, the moment where acquaintanceship either becomes friendship or sours slowly while you watch in a mix of anxiety and anger. Anxiety because it means a dark spot on your day, anger that swallows you up, pulls you down. Anger at the resident for being such a fuss, so much a dependent pain in the most tender part of the gluteus. The tailbone area for me, that’s the most tender area. She was a pain in my tailbone.
It’s a blind corner that you take with faith or your eyes closed tight. Every time I meet a resident like her I shut my eyes and hope for the best. Sometimes I take a hit. Sometimes I meet residents who are demanding, heavy, angry or mean. And I’d fight against it. I can’t say I did my best because I know I could’ve done a lot better. I could have smiled, forgiven them, rather than taking their meanness into me and holding onto it, hurting myself with it. I guess the more often it happened, the less I fought it, until Fran the human being with wants and needs and a personality was shrunk down to Fran the confused, shrieking harpy who depended on me for everything. Fran, My Future Back Problem. It’s hard to shake off bitterness like that after it has seeped into your skin. I still had some love for her, though, for whatever insane reason I couldn’t put my finger. Maybe because she reminded me so much of myself. A hypochondriac, dependent, whiny, pitifully scared person facing what she’d feared she would face her whole life. Trying to save her from the fear that came on at night when she was all alone—the same kind that creeps up on me when all my distractions are gone—was like saving myself. Working with her put that fear, and all the dependence, the whininess that came with it front and center. It made me take a long hard look at myself. I didn’t like what I saw.
Fran was my zen teacher, in a way, and I hated her like one, for showing me all the ways I was coming up short. I’m only realizing it now as all the confused emotion and mixed up thoughts unwind, smooth out. She was probably one of my very best teachers.
I recall the first time I heard an RN supervisor describe a resident as “demanding.” To me, the word “demanding” always carried connotations of a threatening, fist-in-palm kind of urgency. So when I walked into Freddie’s room, I was surprised to find a polite and mild mannered man. He just asked for a lot of things. It occurred to me that “demanding” means something a little different in a caregiving situation than it does elsewhere.
Freddie was young for a nursing home resident; half his caregivers were older than he was. He suffered from Huntington’s chorea, like his mother. He witnessed the disease gradually take her and he knew what was coming. And yet, if he was afraid, he didn’t show it. I wondered how I would respond if I faced the same thing.
He “demanded” a lot of our time. Frequent trips to the bathroom, assistance getting in and out bed several times a shift, fiddling with his TV and VCR remotes (this was a few years ago…) that never seemed to work right, special food requests, help making phone calls, helping him deal with the mountain of personal items he had brought with him, which only grew after he moved into the facility. Sometimes the carelessly assembled pile of stuff on his nightstand grew so high that gravity would finally take it and we would find the mess sprawled half way across the room. He was one of ten residents in his care group, but he could take up more than half his caregiver’s time. He was always either on the light or, when up, approaching his caregiver – or any staff member – with some sort of request.
Conflict was inevitable. Caregivers found it difficult to keep up with all that Freddie wanted and still meet the basic care needs of the other nine residents in the group. Some resented his requests and argued with him or just ignored him. Others tried to negotiate and set limits. The social worker spoke to him several times a week. But neither “side” actually ever adequately adjusted. There was always some issue, some trouble.
The more enlightened staff, including the social worker, looked at his behavior from a psychological perspective. He was simply acting out his fears and frustrations, grasping for some shred of control to help compensate for what his condition was taking from him. A drowning man desperately grabbing for the nearest object. And we were the nearest object.
Our RN supervisor supported her aides by explaining to the social worker that Freddie was keeping us “hostage” with his ceaseless demands. In a sense this was true. Rarely did he ask for just one thing and let you go. It was always a series of tasks, one thing leading to another. While he was mild mannered, he knew how to manipulate and once he got your attention, he wouldn’t allow you to escape politely.
In the context of a care group, where he was only one of ten people, Freddie’s demands were unreasonable. But here’s the thing: had he been on the outside, nothing he wanted would have been considered out of the ordinary by any reasonable standard. He simply refused to adjust to this environment, quietly insisting that the environment adapt to him. In this place of rigid routines and ratios, this was a cardinal sin.
They eventually moved Freddie to another unit. After a few months of struggling with the staff there, the disease reduced him beyond the ability to make requests and the issue was resolved.
These days, I think someone like Freddie would probably go into Hospice. The problem is not all “demanding” residents qualify for that service. And we are left with the same old paradigm that makes hostages out of caregivers and residents alike. To break out of it takes more than just a change of attitude, it requires more workers on the front line and a flexible approach to how they are assigned.