Tag Archives: long-term care leadership

Well Bully for You


Corey
I wanted to write about memory care. I really did, about how it feels to come full circle and how much I love the challenge of constantly adapting but that post is going to have to wait. As much as I would LIKE to write about my new job assignment, I feel COMPELLED to tackle a different topic: bullying. On the surface, it seems a simple enough problem to discuss. Don’t be a jerk. ‘Nough said…except that as with so many other issues, bullying is a deeply rooted systemic problem that will never be solved without an open and honest examination of how and what it truly means.
Most work places have a zero tolerance policy for physical conflict. That’s a pretty low baseline. I’ve never actually met anyone who showed up for work one day and randomly started punching people, so as far as I can tell that is a cover your ass policy that does little to nothing to curb the problem. If things have gotten so bad that there has to be a no punching rule then somebody has dropped the ball somewhere.
Did you hear?…Well, First shift…If second shift…the new girl…How many conversations start like that? It catches faster than a forest fire and suddenly everyone is angry over something they heard second or third hand. Everyone gets in on the action, morale goes down, quality of care goes down, communication becomes petty and useless and I feel like I’m in fifth grade again. It’s ridiculous and I am over it.
It’s modeled behavior. Supervisors act as if they are confused as to why there is chaos on the floor. It’s baffling. Of course there is dysfunction on the floor because there’s dysfunction in the office. I have yet to work in a facility where I didn’t know exactly how the supervisors felt about each other; where I didn’t know which caregivers were favored on which shift. It’s impossible not to hear the claptrap. This along with an inconsistent application of consequences inevitably causes resentments. If management doesn’t hold themselves to a higher standard, why would they expect it from those who work under them?
It’s not just caregivers that are on the receiving end either. New supervisors come in and before they even have time to adjust, a collective snap judgement is formed by the members of management who have been there longer. Suddenly everyone from the office down is berating the new kid on the block. I have to wonder, for all the criticism regularly heaped on new people, how many senior employees have reached out their hand? How many have said, “Man, I know how tough it is to be new. I remember when I first started. I know how overwhelming it can be. If I can help you or you have any questions, just let me know”? Now THAT would be a refreshing show of true leadership. Sadly, it’s much easier to bitch about a person than it is to solve a problem.
It’s rampant in the online CNA support groups too. The helpful posts and genuine questions are often buried under posts that take unnecessary digs at other people. This co-worker is lazy. That co-worker calls out. So much of it is catty, as if one can’t feel good about themselves without putting another down. It maddening and ugly and I don’t understand the point. Unless a resident is being put in harm’s way, there are better ways to solve the day to day troubles of working with others than to engage in pettiness. Those in our care handle living with cancer, dementia, Parkinson’s, and mental illness better than some caregivers handle having to stay five minutes over or putting a trash bag in a trash can; better than some supervisors handle sharing an office. It’s a little pathetic.
The truth is, I’ve never had a problem with those from other shifts who work my hall. I do my best and respect my co-workers and in return they seem to be just fine with me. Our halls run smoother because of it and those in our care get the attention and energy that would be wasted on engaging in drama. For the most part, when I put good out I get good back and I trust my own experiences rather than the gossip that runs rampant.
Be it in the workplace or out, bullying has become an epidemic that rots the best and empowers the worst of the human experience.
It is the worst kind of groupthink and it scares me how normalized it has become in now. When did it become socially acceptable to rip another person to shreds simply for disagreeing with you. A single person behaving in such a way may hurt another’s feelings, but when it becomes groups of people tearing others down, real damage is done. It is leading us down a dangerous road at breakneck speed.
We who work in Long Term Care exist in a microcosm of the outside world. Because of this we have the ability to see the damage that collective bullying is doing on a small and intimate scale within the walls of facilities. In this world, we can do something about it. We can be helpful instead of hurtful. We can lift each other up instead of knock each other around. We can speak up, even when it’s hard, even when it is to those in charge. We can choose not to engage in toxic behavior. In doing so, we will be happier, our residents will be calmer and our co-workers will have a window into better ways of handling conflict. Maybe, just maybe, we can learn these lessons on the job and use them off the clock. We can be an example for others. After all, chaos and negativity may be contagious but so is positivity and hope. The choice is ours.

A Break before a Breakdown ; a moment to reflect


Alice
I get so tired sometimes. I want to shrink from this world that seems to subsist and thrive on anger, panic and fear. Has it always been this way and I’ve just been oblivious to the fever of it or is this some new beast fueled by everyone’s absolute certainty that they are right? The days of context and nuance seem to be gone for the moment and shades of grey no longer exist. Black or white. Right or wrong. Bottom line thinking for an end results world.
I am never very certain about very much. In my experience, that way lies madness. I have certain ethical guidelines and passions that anchor me and I try to keep my mind open to learning from others who have different points of view. Work has been vital for my sanity in this social climate where people seem to be filling some inner need by yelling at one another and coming up with shallow, half-hearted and blame-filled excuses to the deep and complex problems that our society is facing. I guess that’s easier and less satisfying than putting aside anger and wounded egos in order to come together and effectively work toward common solutions. We currently live in a world where everyone wants to be the boss but no one wants to lead.
Those of us who work in Long Term Care are no strangers to the damage such a management style causes. It’s flat out ineffective. The best supervisors are the ones who roll up their sleeves regardless of who is watching. If I only see you when state is in the building, I’m less likely to trust you around those in my care. I have more respect for an LPN who will help me calm a resident who is lashing out in fear than a career administrator with degrees on the wall who’s first solution is Ativan because she’s about to give a tour to a potential new client and wants the hall orderly. That is the difference between a leader and a boss. Because I find my own personal standards of quality care to be much higher than what is expected of us, I have no need for a boss. I learn from leaders, however, and that makes them as invaluable as they are rare.
I decided to step back from Facebook for a little while. Every other status I read is angry. Every article posted has completely different facts cherry picked to enrage or validate you depending on what side of the given position you take. They all agree that everything is the absolute worst. The only difference is who they believe is to blame…and all of that is crap. Cynical, self serving crap wrapped in a bow made of ego.
But, Alice! Aren’t you concerned about the state of affairs?! Of course I am, possibly shocked and appalled reader, but here’s the thing…this is NOWHERE NEAR as bad as it’s been. In my years in this field I’ve cared for people of color who actually lived through the civil rights era. I’ve cared for a Vietnam vet who lost his sight, and a WWII vet who lost his leg. I’ve cared for people who were children during the Great Depression and for people who lived through the Cold War. I’ve had women in my care who lived in a time when it was more socially acceptable to be an abused wife than a divorced woman. Collectively, we survived all of that. As a society, we have faced our worst behaviors and bit by bit we have grown from them; progressed step by painful step forward. I refuse to believe that this…this angry, entitled, backwards thinking reality we are all actively creating is going to stick. I have more faith in us than that.
Individuals are all more than one thing. Are my residents simply their Alzheimer’s disease? Or prostate cancer? Or schizophrenia? Are they not bigger than that? Am I not more than my political affiliation? Is it not beautiful that we are all people who bleed the same? It is a combination of different ideas and individual experiences that gives life it’s richness. When did we decide that we should only surround ourselves with those who look, think, believe and behave exactly like us? How can we possibly come up with and solutions to vastly complex issues without the benefit of diverse ideas and the freedom to dissent without fear?
So I would like to thank every single person who has ever been in my care for teaching me gratitude and perspective. Life is too short to waste on fear and anger over troubles that we create or stir up in our minds before they even occur. I would also like to thank you for living through adversity and sharing your stories so I know what courage looks like. I would like to thank my fellow caregivers who adapt to the reality on the floor rather than the one we are told to expect. We come together to make the most of what is rather than complain about what should be…ok to be fair sometimes we do both but for the most part we are about action. It is a diverse world on the floor, full of people from all walks of life with a variety of skills and reasons for being in this field. Despite what some may think, we cannot all be painted with one brush and for that I am incredibly thankful. This field has honed a strength in me that would not have developed otherwise and directed a passion for purpose toward a path where it would be put to good use. I get tired, but I’m one of the lucky ones. I get these reminders at least five nights a week. I can step back from the combative and fear filled world online and reorient myself to the world in which I live.

See No Evil, Hear No Evil … Fix No Evil

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Minstrel

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

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

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

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

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

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

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

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

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

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

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

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

The Big Picture

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Alice

  See past the disorders. See past the challenges. See past the constant reminder of our own mortality. Look beyond the dysfunction of the broken system and the day to day gripes we all face in this field. Look beyond the bad mood of that one particular resident who seems to have it in for you for no reason at all. Work around the apathetic owners of these facilities and you will learn some truths about yourself as a person through your work as a caregiver.

       We can’t fix the broken or heal the sick, but we can comfort the hurting and add a spark for another going through a day of despair. We can support and teach each other in a system that fails us in that area so often. We can reach people when we look beyond the surface. When we do not allow how we are viewed by others to define us; when we refuse to do the bare minimum in our workplaces, we set the example. We set the standard. The powers that be do not understand the nature of our work. They don’t know and many don’t care. They want the most cost efficient option and are willing to sacrifice standards of care in order to increase profit margin. I get it. They view it as a business, but they are not selling shoes and burying our collective heads in the sand is not going to work.

       Are we going to accept this? Are we going to allow those within our care to be forced to settle for apathy and neglect? Are we going to allow this system that is designed to fail convince us that we are disposable and worth very little? We have choices here. We have numbers and we have a voice. We have to stop getting stuck in the minor irritations that so often distract us from the essential truths that all caregivers share: we are the protectors. We are the comforters. We are the voice of the most vulnerable among us. That is a sacred responsibility and that doesn’t change because it goes unappreciated or noticed by others. If we embrace this, if we are motivated by this consistently, then together we have the opportunity to fight for the changes that only us and those in our care really know are needed. We need to collectively look at the big picture and then get on with the business of doing what we can to improve it. It’s in our hands.

A Failed Attempt

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Alice

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

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

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

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

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

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

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

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

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

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

A Flattened Hierarchy

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Yang

Continuing my exploration of the Green House Project, I will now turn to the second core value of the model, “Empowered Staff.” Empowered staff refers primarily to the workers who provide direct care.

The Green House term for a caregiver is “Shahbaz” (plural: Shahbazim). Shahbaz means “royal falcon” in Persian and is meant to convey a person worthy of respect, someone who is valued. The title is representative of the Green House Model’s investment in and support of the workers closest to the Elders.

The Shahbazim perform the same basic personal care duties as CNAs in a traditional long-term care setting, but along with the new title they are given a significantly expanded role which makes them responsible for the day to day management of the home. They make decisions that would normally be made by supervisors or mid-level managers. These include decisions involving scheduling, food preparation, laundry, housekeeping and care planning. They rotate the leadership roles – typically each quarter – so that each shahbaz takes a turn coordinating each of these functions.

This organizational structure is often characterized as a “flattened hierarchy.”  However, while the homes are operated by self-managed work teams, the Shahbazim do not work unsupported. They report to a “Guide,” an experienced LTC professional with extensive training in coaching skills. The Guide is responsible for providing the team with support, accountability and the resources necessary for the Shahbazim to succeed.

While it would be easy for a caregiver to simply regard the Guide as just another kind of supervisor, the core value of Empowered Staff requires the Guide to leave the day to day problem solving in the hands of the Shahbazim. A Shahbaz must be willing to receive coaching and grow into these new roles. In this sense, empowerment is not simply a matter of delegating responsibility, but it is a process that depends on the personal and professional growth and development of individual caregivers.

How and why this organizational structure works from a caregiver’s perspective will be the subject of upcoming posts.

Meet Them Where They Are

Alice

Alice

 

Alice

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.

Imagine This

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Yang

From a caregiver’s perspective, what would a long-term care system that’s not “broken” offer?

Imagine this…

Start with a 5-1 ratio. Yes, 5-1. Caregivers to residents.

Next, each resident has a private bedroom with a full bathroom. The bedroom opens to a central living area and a common dining area. There are no corridors, no nursing stations and no med carts.

There is a full kitchen with food available 24/7. The caregivers prepare the main meals – with assistance from residents who wish to help. Caregivers are encouraged eat with the residents in the common dining area. Family and friends are welcome to join.

There are no rigid routines or schedules. Residents get up when they want, eat when they want and go to bed when they want.

Caregivers serve in universal or “blended” roles. This means that along with the traditional direct care function, they are also responsible for things like housekeeping, minor maintenance and scheduling. And, of course, they will receive an additional 120 hours beyond their CNA training so that they have the necessary skills to accomplish these other duties. Residents who wish to do so will be able to assist caregivers in routine tasks such as daily housekeeping and laundry. While group activities will be available for those who care to participate, caregivers will also facilitate each resident’s pursuit of his or her individual interests.

All of this takes place in a small group home of 6-12 residents. The home can be a part of a cluster of homes offering all necessary skilled nursing and other clinical and support services. The majority of these services take place in the home, freeing both the caregivers and residents from the burden of transportation. While one RN is assigned to every two homes to meet the medical needs of residents, the RN’s job does not include supervising caregivers. Each home is run by self-managed teams. While caregivers will have the support and guidance of a manager, they make most of the day to day decisions themselves.

Most important of all, caregivers are encouraged – and are given the opportunity and support – to develop deep personal relationships with the residents. These relationships are at the heart of the entire process. Without them, the idea of “person centered care” cannot become a reality.

Of course, it’s not necessary to imagine this. For those who are familiar with the Green House Project, the description above should sound familiar. I’m sure I’ve left out some things, I’ve only recently began learning about the project. In fact, I’ve never actually visited one. However, the concept addresses so many of the problems that we have raised on CNA Edge that I think it is well worth exploring. And that’s exactly what I’ll be doing on this blog over the next several months. There is a Green House in my area and I plan on making a visit later this month and reporting what I find. I also intend on speaking with caregivers who have experience working in Green House Project homes.

From what I’ve learned thus far, my impression is that the Green House Project isn’t just about establishing an alternative to the typical skilled nursing institutional setting. It is a movement whose principles are centered on creating a genuine person centered environment and thus deinstitutionalize the institution and radically reinvent the long-term care system.

No doubt there are tremendous challenges involved in such an effort and not all of them are financial. Advocates of the project express concern over what they call “reverse creep” – a kind of backsliding into old institutional ways and habits. Ideals and principles are great things, but it’s how we put them into practice that really counts. We can work in the most perfect system, but at the end of the day it still boils down to us and how we respond on a daily basis.

For more information on the Green House Project, visit www.thegreenhouseproject.org

Protected Concerted Activity

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Yang

I’ve come across a number of posts on the CNA Facebook pages that express frustration over LTC managers not responding to caregiver concerns regarding their working conditions. If you’ve already raised an issue as an individual through the normal lines of communication within your facility and feel like you’re not being heard, there is something else you can do. It’s an option that most caregivers – and perhaps many LTC managers – are not aware of.

It’s called “Protected Concerted Activity.” This is involves a Federal labor law that protects your right to act together with other employees to improve your pay and working conditions – with or without a union.  This means you can collaborate with your coworkers and voice your concerns as a group and your employer cannot punish you for acting as a group.

According to the National Labor Relations Board website: If employees are fired, suspended, or otherwise penalized for taking part in protected group activity, the National Labor Relations Board will fight to restore what was unlawfully taken away. These rights were written into the original 1935 National Labor Relations Act and have been upheld in numerous decisions by appellate courts and by the U.S. Supreme Court.”

The law does not cover all concerted activity. Again, from the NLRB website:

“Whether or not concerted activity is protected depends on the facts of the case. If you have questions, please contact an Information Officer at your nearest NLRB Regional Office, which you can find on this page or by calling 1-866-667-NLRB. The Information Officer will focus on three questions:

Is the activity concerted?

Generally, this requires two or more employees acting together to improve wages or working conditions, but the action of a single employee may be considered concerted if he or she involves co-workers before acting, or acts on behalf of others.

Does it seek to benefit other employees?

Will the improvements sought – whether in pay, hours, safety, workload, or other terms of employment – benefit more than just the employee taking action?  Or is the action more along the lines of a personal gripe, which is not protected?

Is it carried out in a way that causes it to lose protection?

Reckless or malicious behavior, such as sabotaging equipment, threatening violence, spreading lies about a product, or revealing trade secrets, may cause concerted activity to lose its protection.”

I am not qualified to give any kind of legal advice and this post is for informational purposes only. I would urge anyone considering concerted activity to do their homework first. Check out the NRLB website www.nlrb.gov  (click on the “Rights We Protect” tab) and also speak to a NRLB Information Officer (1-866-667-NLRB).

Since our work involves residents we have to be careful not to violate their rights while we assert ours. However, there are many instances when the two overlap. In particular, I’m thinking concerted activity may be useful for issues regarding things like access to proper equipment and the availability of adequate supplies.

If you’ve already raised an issue and you feel your concerns are not being properly addressed, you may want to consider exploring your right to protected concerted activity.  Sometimes it takes a group.

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.