Tag Archives: direct care worker

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.

  

There’s Nothing Like a Good Dog

DSC00999

 

 

Yang

As I begin the HS care routine, my thoughts wander to home, to Jenny and the girls. I always get a little tug of homesickness around this time in the shift. The girls are picking out their bedtime stories right now, each gets to choose one book and they pick one together.  They’ll gather around the bed of our youngest – along with our little Australian Shepard, Kip – and Jenny will read to them. Then, she’ll tuck them in, kiss them good night, and they’ll drift away with Wynken, Blynken and Nod. Not being there is the hardest part of being here.

Tonight, it’s worse than usual because I’ve been pulled to a unit that I’m not familiar with and I’m the outsider. I don’t know the staff well and I know nothing about the residents in my group, save for the information on my “cheat sheet” and what the other caregivers have time to tell me. For the rest I have to depend on what I can glean from the residents themselves.

Ziggy can’t help me much in that regard. He has a pleasant demeanor and he follows simple cues, but he doesn’t respond to all of my questions and when he does respond it’s with a nod or one word answer.  And he seems reluctant to maintain eye contact.

In the dietary column, the cheat sheet states that Ziggy is a “feeder,” an uncomfortably crude way of saying that he can’t eat without total assistance. But the information is accurate, as I discovered at supper time. He loves to eat – that isn’t on the cheat sheet – I couldn’t get his dinner on the spoon fast enough for him. He polished off his tray in ten minutes and accepted a second dessert when one of the regular caregivers offered. For caregivers, there is something satisfying about a resident who likes to eat. And I could tell from the regular caregivers’ interaction with him that he is just about everybody’s favorite. That isn’t on the cheat sheet either.

There is a lot about Ziggy that isn’t on the cheat sheet. You can’t tell a story in box.

He nods as I explain that I’m going to help him on to his bed, but he says nothing. Under the “transfer” column of the cheat sheet, he is listed as 1HH, meaning one human help. He is as tall as I am and not thin, but if the sheet is up to date, he should be able to bear weight and I should be able to get him into his bed without having to ask the other caregivers for help.

I position his Geri chair parallel to his bed, about midway between the head and foot. This leaves room for me to help him stand and pivot 90 degrees, then ease him into a sitting position on the edge of the bed. The next step is to use the edge of the bed as a fulcrum and help him swing his legs into the bed, effectively creating another 90 degree pivot. If all goes to plan, his head will end up straight on the pillow.

I pause after getting him on the bed. I always like to take a moment when a resident is sitting on the edge of bed, whether it’s in the process of getting out or going in.  Just to let him get his bearings after the change of position. Sometimes I’ll sit on the bed with him – for just a moment or two – steadying him if necessary.  

As I’m sitting next to Ziggy, my attention is drawn to two photos tacked to his personal poster board hanging on the wall over his night stand. Other than the Activity Department’s weekly newsletter, the photos are the only items on the board.  In most of the residents’ rooms these poster boards are covered with various personal items such as photos, greeting cards, notes, and assorted decorations. For our residents, these items sometimes serve as tangible, but slender connections to the lives they had before they came here. For us, they provide tiny shreds of evidence of who they are as people.

One of the pictures is an 8×10 of a gorgeous pure bred German Shepard standing in someone’s front yard. A smaller photo shows a much younger Ziggy kneeling next to the Shepard with his him arm draped across the dog’s back. Both photos are faded, dog-eared, and peppered with a dozen thumb-tack holes along the top edges.

From my spot on the bed, the larger photo is within arm’s reach. I lean over, remove it from the board, and hold it up in front of Ziggy.

“He’s beautiful, Ziggy.”

Ziggy reaches for the photo and I hand it to him. He studies it and nods. “Chummy is a good dog.”

Okay, present tense then. I’ll follow his lead and we’ll stay there. “Yes, he looks like a great dog.”

He nods again. “Chummy is a good, good dog.”

“Are you best buddies?”

“Yeah. He’s my dog.”

He still hasn’t taken his eyes off the photo.

 “Do you play with him?”

“Yes… he plays.”

 “There’s nothing like a good dog. I have one too.”

He looks at me, eyebrows slightly raised.

“Here, I’ll show you a picture of her.” I lean back and retrieve my wallet from my front pants pocket. I slip a small photo of Kip from its protective plastic sleeve. The picture shows Kip with all four legs off the ground, snatching a tennis ball in mid-air.

Ziggy is impressed. “He’s a good dog!”

“Yes, she is,” I agree, but I stand firm on the gender. “She loves to play fetch. We play until I get too tired to throw the ball. I always get tired way before she does.”

Ziggy chuckles, he’s familiar with that story.  I hand the photo to Ziggy. He’s still holding the picture of Chummy in his other hand and looks from one photo to the other, apparently comparing the two dogs.

“Ziggy, do you suppose Chummy is more expensive to feed than Kip?”

He grins, “Oh yes, Chummy eats a lot.”

“Kip loves to hunt.  One time she ran away and came home with the leg of a deer. And rabbits don’t dare to come in our yard anymore. Does Chummy hunt too?”

“Oh, no, no. Chummy doesn’t hunt.” He hands me Kip’s picture and returns his gaze to his Shepard. “Chummy is a good dog.”

“Do want to hear a secret about Kip, Ziggy?”

He looks back at me. “Yes… what is it?”

“My wife let’s her sleep in our bed.”

Ziggy shakes his head. “Chummy sleeps in his own bed.”

“I know, we’re not supposed to let her on our bed. But we do anyway.” I put my hand on his shoulder and say, “At least there is one thing that we both know…”

He looks at me again, “What?”

“… There’s nothing like a good dog.”

He smiles and nods. “Yes, Chummy is a good, good dog.”

I proceed with his HS care and wonder if Ziggy will dream about Chummy tonight. I hope so.

I also wonder what other connections we could make if I had more time and knew more about who Ziggy is.

Caregiver versus Caregiver

DSC00999

 

 

Yang

For a CNA, working with other caregivers you can trust and depend upon can make a bad shift tolerable and a good shift even better. In an environment where workers often feel like they’re under siege,  maintaining a positive relationship with the people you work with can take the edge off the worst aspects of the job and can provide a sense of security and comradery. It is not unusual for caregivers who work with one another for an extended period of time to develop close personal relationships, sometimes lasting a lifetime.

But it’s not always that way. Right?

You don’t have to work direct care very long to realize that caregivers do not always get along.  A brief survey of caregiver related social media will support this. One of the most common rants in the CNA Facebook groups is about other coworkers. These describe fellow workers as “lazy, whiners, cliquish, back-stabbers, know-it-alls, butt-kissers, bullies, wimps, rude, inconsiderate, uncooperative, mean,” and – of course – “judgmental.”

To be sure, social media rants tend to be motivated by the emotion of the moment and they only tell one side of the story. Also, some of the discord among caregivers can be attributed to the ordinary conflict that occurs in any workplace. There are politics in every organization and at every level. Personalities clash, agendas conflict and sometimes people with good intentions simply don’t agree.

And yet, there just seems to be something about the nature of Long Term Care that makes worker on worker conflict especially prevalent – and harmful. Almost as if it’s woven into the very fabric of the system itself.

I’ve often thought that the LTC brand of coworker friction was a product of the nature of our work. Since we work hands-on with residents, almost everything we – or don’t do – has a direct impact on the well-being of another human being. The moral element is immediate and powerful and when someone implies that you’re not doing your job, it doesn’t just mean they’re calling you a bad worker; they are also saying something about you as a person. Even the slightest hint of criticism can be taken as a personal attack. On the other hand, LTC management is often disconnected from the day to day realities of caregivers and workers in genuine need of correction do not always receive it. The injustice and unresolved resentment grind on people daily and sooner or later, there’s going to be trouble.

However, there may be much more to caregiver vs. caregiver conflict than hyper-defensive workers and disengaged management.  I recently received a request from a reader who asked if we could do a post on “horizontal violence.” Not being entirely certain what that phrase means, I did a little research. What I found was pretty interesting and may provide some additional insight to why caregivers don’t always get along.  In my next post, I’ll give a brief summary of horizontal violence and how I think it applies to the LTC workplace.

The Power of Caregivers

DSC00999

 

 

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.

“They Love Their Overtime”

DSC00999

 

Yang

My former place of employment has been in the local news lately. This always gets my attention. Normally, I tune into these reports not so much because I’m interested in keeping up with what’s going on at the place – I have better ways of doing that – but more to see what the local media got wrong.

However, the most recent series of reports is highlighting a very real problem involving staffing shortages. According to yesterday’s report, the agency responsible for keeping the facility staffed with direct care workers has admitted to not meeting their minimal contractual obligations. In other words, the place is working short all of the time. And we all know what that does to the quality of care.

The acting CEO at the facility says they make up for shortages by having caregivers work overtime, either voluntarily or through mandating. He pointed out that this is not unusual in Long Term Care, falling into the old LTC industry trap of comparing itself to itself. All the other kids are doing it, so it must be okay. He did admit that it can be hard on caregivers to work double shifts.

But then he went on to say this: “Some people love to work double shifts… People want to have that extra overtime.”

Yes, they want the overtime, Mr. Acting CEO. But not because they love it. They do it because they have to. Because the pay is so poor to begin with that they either have to pick up extra hours or work a second job just to make ends meet.

It wasn’t always this way at my old place. There was a time when it was staffed by unionized direct care workers who made a living wage and had decent benefits. And this provided the facility with a stable, dedicated work force. That’s gone now.

I remember hearing someone in our business office complaining about the caregivers being paid too far above “market standards.” Today, they simply work people into exhaustion. Expendable workers – yes I think that pretty much matches the current market standard.

Something Worth Exploring

DSC00999

 

Yang

Yesterday, I had the opportunity to visit a local Green House home as part of a six-hour workshop concerning the Green House Project. I’m still processing everything I saw and heard, so this is going to be a very short post. However, I do want to say a few things about my first impression.

First, from a caregiver’s perspective, this is well worth exploring. It’s pretty amazing in fact. In essence, what the Green House Project does is create places where a high level of skilled nursing is done in not just a “home-like” environment, but in an actual home. The kind that anyone would recognize as a home and not a “home for elderly” or a “home for the disabled” or any other qualification you could add. Just a home. How this is done and why we would want to do it – again from a caregiver’s perspective – is going to be the main subject of my posts on this blog for the next few months.

Second, the Green House Project is truly revolutionary.  This is not just Wouldn’t-It-Be-Nice talk about “culture change” or “new paradigms” by people with lots of letters next to their names. It is, in fact, “culture changed.” It is both a physical and philosophical transformation in how we approach the entire long-term care process.

Third, on CNA Edge we talk a lot about the significance of the caregiver-resident relationship.  In my last post, I said that what caregivers want more than anything is to “reach” all of the people in their care. While my natural skepticism prohibits me from becoming a full-fledged Green House Project advocate without taking a closer look, as I listened and watched yesterday, the voice in the back of my mind kept saying “They finally figured it out – this is what we’ve been wanting for so long…”

We’ll see. One of the things I’ll be doing in the coming months is seeking out caregivers who have had experience working in Green House homes and getting a better feel for it from the direct care perspective.

Scapegoats

Alice

Alice

 

Alice

“THIS IS BULLSHIT!, I heard someone shout from the back of the bus. Man! I heard that over Nine inch Nails that I had blasting full volume through my earbuds. THAT guy is seriously ticked off. I knew what the trouble was. On a day where the temperatures were close to 100 degrees, several of our city buses had broken down. The one I was currently riding in was unable to go over 20 MPH.

I had very nearly passed out while waiting almost two hours for a bus to show up, so I understood the frustration the man was feeling. It was his REACTION to the frustration that left me baffled. He continued to curse, eventually focusing his fury on the driver and it wasn’t long before other riders were joining in on what I can only describe as bullying. Suddenly, I felt a flash of white hot anger course through me.

“HEY! Do you think this is FUN for her? Do you think that she broke the bus herself? Maybe just for shits and giggles she jacked some wires? She is doing the best she can in an impossible situation so BACK OFF!”

My heart was pounding at the ferocity of my reaction. Calm down, Alice. You’re hot and exhausted and not thinking clearly. Still, the small but vocal passengers piped down and the look of gratitude and relief in the bus driver’s eyes was unmistakable. What had provoked such a vocal and immediate reaction? At first, I thought it was simply my gut level aversion to bullying in ANY situation. Upon later reflection however, I realized that it went deeper than that. I RELATED to that bus driver in that moment.

As a direct care workers, we know EXACTLY how it feels to be held accountable by family members, office staff, even our own residents for situations that are beyond our control. We are the faces they see every day and we make good enough scapegoats.

It’s a counterproductive mentality that is easy in the short term but inevitably causes complications, as we are so busy trying to appease people about situations over which we have little power, that we sometimes neglect those situations to which we can actually contribute and actively offer solutions. Again, it goes back to the difference of what the reality is verses what it appears to be.

For me, one of the greatest blessings derived from being a direct care worker is that the lessons that I learn on the job, I often have the opportunity to apply to my life outside of work and vice versa. My encounter on the bus reminded me how very important it is to step outside of our own little worlds, our own little circle of irritants and personal frustrations in order to see clearly. Otherwise, we run the risk of remaining stuck in that futile cycle of blaming or being blamed. As for the bus driver, well, I hope that in that rough moment in what had to be a terrible day, she felt just a little less desperate and alone. After all, being the scapegoat can be terribly lonely business.

Kindness Doesn’t Cost a Thing

photo

 

Alice

         Some shifts, caregiving is like juggling while doing acrobatics on a tightrope through a flaming hoop suspended over a pool of hungry sharks. It requires mental and physical dexterity, finely honed observation skills, the ability to multi-task, set boundaries, and meet needs all while maintaining balance and sanity in completely insane scenarios.

       It’s a tap-dance. The office people have expectations and yet do not provide us the means with which to meet them. Our residents can be very difficult to please. Frustrated with their own situation, the can lash out with anger at the faces they are most used to seeing…ours. Sometimes our OWN frustrations and lack of communication can have us at each other’s throat. On a tough day, it is inevitable that something will be missed.

        I’ve learned to be ok with that…alright, that’s not EXACTLY true, but I’ve learned to accept it. We are human, after all, and no one ever died because I forgot to change a bedspread with a drop of coffee on the bottom or I ran out of time and had to postpone a shave until the next day. I’ve learned to accept that nothing is ever going to be done perfectly in the conditions in which I work. I tend to worry about those small lapses more than my residents do.

       What I try NEVER to forget, however the shift may be going, is that kindness is a skeleton key. Doors that have been slammed closed because of fear and broken trust will open slowly if kindness is applied with consistency. It sounds so trite in its simplicity but it really isn’t.

       To my way of thinking, there is a difference between NICENESS and KINDNESS. Niceness involves plastering a smile on your face; it’s a people-pleasing skill that enables us to be “yes” people. It involves more sweetness and duplicity than it does any depth of thought. Kindness is a different story. 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.  Sometimes, it’s simply noticing that someone is “off” and taking the time to let them know you care. Being present, actively listening and responding with honesty, stepping up when needed with no thought of reward, taking a minute to address an issue during a time when you are calm rather than exploding when you are angry are all varieties of kindness. It’s a thoughtful ability that requires practice and introspection and, when applied correctly, it can teach us the art of knowing when to calm the waters and when to rock the boat.

     For me, this is the most important skill. I have seen it pull both residents and co-workers through when morale was low and patience was as short as the staffing.  A genuine smile and a well-timed joke can lighten the darkest of moods. You never know what another person is going through. You never know who you can reach. Kindness doesn’t cost a thing, but I have found that it pays dividends.

The Value of the CNA Voice

DSC00999

 

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.

Fran is Lonely

buddha

 

 

Edison Terrell

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.