In all my years in this field I have never had a person in my care who did not respond better when approached consistently with kindness. Never, not one single time. My most resistant residents have been more willing to be an active participant in their own care when they didn’t feel invisible. My most confused residents had less anxiety clouding their minds when I have been able to coax a laugh from them. Kindness doesn’t cost a thing. It takes no more time to be kind than it does to be resentful and impatient and it takes far less energy.
“You’re going to spoil them”.
“Now they’re going to expect that from everyone.”
“Don’t get that one going. She’ll talk your ear off if you let her”…To which I politely smile and go about doing my job exactly as I see fit. Treating my folks the way I’d want to be treated is not “spoiling” them. It’s being good at my job. I give my best effort regardless of what it causes other people to expect. Quite frankly, I don’t care if that raises the bar or not. My work ethic does not include doing less for those in my care so they don’t expect it from other workers. And I don’t mind having my ear talked off. Why should my night owls feel lonely? If they want to talk and I’m not in the middle of a task, I have no problem listening.
The idea that the people in our care are tasks to be minimized and tackled begrudgingly has to be changed. Not every caregiver treats the job with such apathy; not even most, but there are more than enough that do. Rightly or wrongly, the majority of hard working and dedicated caregivers are stigmatized by the behavior of those who are not right for this field.
We are the frontline of Long Term Care. We are the faces most seen. When something goes wrong, we are the easiest to blame. People see the bad behavior of the caregiver and not the broken system that spawned it.
There is grace, value and purpose in this field. We are needed and trusted by those in our care. There is something sacred about that. If the system has beaten you down to the point of resenting those in your care and basic human kindness is too much to ask, then maybe it’s time to consider another field. As workers we don’t like to feel disposable or invisible so why would we treat our residents as little more than a burden? We can do better. We HAVE to do better…any lasting change that matters will begin with those of us who work the floors. We are the closest to the residents and we have a deeper understanding of the world through their eyes. All improvement begins from within, though, and before we change the system we have to change our attitude toward those who live within it.
In my last post I talked about the value of good work partners. For a caregiver employed in LTC, working with a good crew can make even the most difficult situations tolerable. A healthy and happy work environment isn’t really sustainable without making some effort to maintain a positive working relationship with your fellow caregivers.
In this job, you really do have to take care of the people around you. This includes an awareness of your coworkers’ needs and circumstances. Yes, we are there for the residents, but when we neglect or mistreat our work mates, we are poisoning our own work environment and this will inevitably impact the people who live there. I’ve known some aides that had some great qualities as caregivers, but couldn’t keep their mouths shut when it came to what they perceived as the inadequacies of other workers. Rather than simply dismiss fellow caregivers as unworthy of the work, how much more effective it would have been had they offered their assistance without judgement when they saw a need and perhaps through their actions provide a better example of how to approach the job.
In my current daily routine with Claire, I am blessed with a great work partner: my 4 ½ year-old granddaughter, Aubrey. From a caregiver’s perspective, Aubrey would be considered a part of my “case load.” Indeed, she does demand considerable time and attention – and she can be quite a distraction for Claire. But she also assists me in ways both big and small. In fact, when it comes to Claire’s care and training, she can do some things much better that I can.
Like my old work partner Russ at the Veterans’ Home, Aubrey is very familiar with our care routines and habits, and she knows when to jump in and help. Most of the time, she’ll do this without direction from me. If I’m involved in some task away from Claire and she gets fussy, Aubrey is right there to give her sister a pacifier or entertain her with a toy until I’m able to focus on Claire again.
Whenever I’m engaged in an activity with Claire, I always make sure that Aubrey has the opportunity to participate if she chooses. Just as Russ and I complemented each other with our differing approaches to our residents, Aubrey adds a quality to the activity that I am unable to provide. Claire simply has more fun and stays engaged longer if Aubrey joins us.
Of course, I often have to redirect to keep both girls on task, but I try to do this by example and not through verbal correction. Sometimes the structure of the activity breaks down entirely, overwhelmed by sisterly chaos and mirth. That’s okay, at that point, we just move on to something else.
When Aubrey chooses to occupy herself in parallel play, she can still be extremely helpful. In our effort to correct Claire’s dominant tendency to arch her back as a means of mobility, we do a lot of floor work in which we try to keep her focus forward. Sometimes this is simply a matter of sitting her on the floor, placing her favorite toys in front of her, and having her reach for them. If Aubrey is playing nearby, I always try to orient Claire toward her sister with the toys in between. To Claire, Aubrey is the most fascinating thing in the world and she’s more motivated to sustain her forward focus when her sister is in front of her.
Like any work partnership, this is a two-way street. One of Aubrey’s favorite activities is taking care of her babies. When I’m busy with Claire, Aubrey is busy with her “group.” This consists of one or usually several “Baby Alive” dolls, most of which are capable of some bodily function.
Aubrey takes her care activities very seriously and I am obligated to pay proper respect to her efforts and assist her when necessary. Sometimes this means I have to stop what I’m doing with Claire to help Aubrey put some article of clothing on one of the dolls or take a turn feeding one of them or perhaps help search for some microscopic toy part of critical importance. Other times, it can mean turning off the music and tip-toeing around the house, because it’s nap time for her babies.
Here, I was rightfully chastised for taking a photo that happened to show in the background her changing her baby (“You DON”T do that!). I duly apologized for the indiscretion:
Clearly, it would be a mistake for me to dismiss Aubrey’s play concerns as frivolous. If I want her cooperation with what I do with Claire, then she should be able to depend on me to do the same for her group – whatever that may consist of from day to day. That is what good work partners do.
There is something else going on here. Aubrey will often use her babies to imitate my activities with Claire. She’s learning by watching and doing, developing skills that will serve her for a lifetime. In a very real sense, I’m training her as much as I’m training Claire. And while Aubrey does not yet grasp the meaning of Claire’s ACC, she is already learning some valuable lessons on how to treat it. As both girls grow, Aubrey will have more influence on her sister’s development than any of us.
In a couple months, I will be losing my valued work partner. Having recently graduated from preschool, Aubrey will be attending full-day kindergarten this fall. While this will leave me more time to work with Claire, I’m really going to miss my little work partner.
Yoga pants. YOGA pants? Poor staffing, supply shortages, low wages, a world full of people who see a disability instead of a person, a world full of people who treat the elderly as if they were disposable, a broken system and a national elder abuse average of one in four but no. She’d rather put an embargo on Yoga pants. Stop muttering to yourself, Alice. You’re alone in your apartment ranting like a lunatic at something you read online. Take a breath.
It was nothing, really; an innocuous comment on one of the support sites that got me going. The poster commented about a facility that contracts out to her agency that allows their employees to wear yoga pants. She thought it was inappropriate. That was it. So why did slowly work me into a tizzy? Why did it nag at me like a hole in my sock?
There is a smug superiority in some of the comments I read that concerns me. If you don’t like yoga pants, work at a facility that doesn’t allow them. Why pull others down in order to boost yourself up? And it happens often. First shift blames second. Hospitals are better than facilities. Home care has higher standards. This caregiver has tattoos and is unprofessional. We pull each other apart over nonsense when in reality, we are ALL running around and sticking our thumbs into the leaky dam as the water comes crashing around us!
Don’t misunderstand me. I think the fact that we have online groups is great. Many of the questions are insightful and uplifting and funny and it’s wonderful to have sites full of people you’ve never met who all speak the same language. Long term care is a bizarre world and as caregivers we see it through different eyes and relate on a different level. Maybe it’s because I believe in the best of us. Maybe it’s because I know we are better than the powers that be treat us. Maybe it’s because I expect more from us, but for whatever reason, I was really bothered by that comment and could not shake it…but then Yang pointed something out to me. Maybe people resort to that sort of destructive behavior because they feel so powerless over everything else. That stopped me in my tracks.
Let me assure all of you that we are not powerless unless we allow ourselves to be. We have choices! We can advocate in so many ways, big and small. We can be kind to the new co-worker. We can speak our truth to our employers. We can volunteer or start a support group, or write for a blog, or join the Alzheimer’s association. Most importantly, with our united actions, we can start a much needed conversation about changes that need to be made in the system from our own perspective as well as those for whom we care.
It’s not that we are “entitled” to a living wage. It’s that we’ve EARNED it. We have earned the right to safe work places and proper supplies. We have earned the right to be treated with respect and we have earned the right to be heard. We will never get to the real issues if we allow ourselves to stay stuck in a mindset where another person’s pants choice is of grave concern. Margaret Mead said never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has. Isn’t it time to get started
In my last post, I suggested that there may be something about the Long Term Care work environment that makes conflict among caregivers almost inevitable. Some – or perhaps even most – of the behaviors associated with this conflict could be described as “horizontal violence.”
Horizontal violence is a form of hostile and aggressive behavior exhibited by individuals or groups toward others within the same peer group. It is usually not a physical kind of violence, but relies more on emotional and social pressure. It includes a wide range of negative behaviors, both overt and covert. Examples include such things as direct verbal abuse, belittling gestures, threats, intimidation, gossip, “humorous” put-downs, sarcastic comments, social exclusion, nitpicking, ignoring legitimate concerns, withholding support, and slurs based on race, ethnicity, religion, physical appearance, gender or sexual orientation. In a word: bullying.
The thing that makes horizontal violence “a thing” is not a big list of nasty behaviors. These can happen anywhere and for a lot of different reasons. Horizontal violence is a phenomenon that occurs within oppressed groups. That is, groups of people who do not feel as though they have the means to adequately address the most significant problems and issues associated with their group. Some respond to this sense of powerlessness by becoming submissive and exhibiting learned helplessness. Others respond by adopting feelings and attitudes of superiority over others within their group. In a sense, both are coping mechanisms, characterized by inappropriate and self-defeating behaviors.
If a sense of powerlessness is at the heart of what it means to be an oppressed group, than direct care workers certainly qualify. Overworked, underpaid, and unsupported, LTC caregivers generally do not believe that they have the means to independently create the kind of fundamental change that would address these issues in a meaningful way. You either accept “that’s just the way it is” and learn to do what you can with what you have – or you leave.
At the bottom of the LTC hierarchy, the caregiver brand of horizontal violence plays out in one of two ways. The first way is the classic division of Older Workers vs. Newer Workers. This divide is typical in nursing in general and most of the literature I’ve come across regarding horizontal violence has to do with career RNs, but it applies just as well to nursing assistants.
New workers enter the field with a set of expectations of what caregiving is all about and are soon disillusioned by the reality of what they witness on the units. If they are unable to adapt to “the way things really are,” the more experienced caregivers have ways of putting them in their place. Newer workers are regarded as both naïve and judgmental – and perhaps even threatening – because they base their impressions of experienced workers on unrealistic expectations. They often become victims of horizontal violence, not fully comprehending why they are being mistreated.
The second situation is created by the absence of adequate and appropriate involvement of management in the typical LTC work environment. The formal rules and standards are enforced inconsistently, sometimes capriciously, depending more on personality and circumstance, such as inspections or any other time the facility is under public scrutiny. Good workers go unnoticed and poor workers go uncorrected.
By default, caregivers are left to fill the vacuum and develop their own norms and standards. These can be very different from facility to facility and even from unit to unit within the same facility. To one degree or another, they are informally enforced by the strongest personalities among the established caregivers. In the best circumstances these norms and standards are communicated through example and positive leadership, but often they are enforced by various forms of horizontal violence.
Caregivers frustrated by their inability to formally address the larger problems of the Long Term Care workplace find an outlet by dominating their coworkers. Others simply acquiesce, doing their best to keep to themselves as they struggle to find a balance between the official standards, pressure from their workgroup, and their own sense of right and wrong.
In my next post, I will share my take on how we as caregivers should approach the problem of horizontal violence in the LTC workplace.
For more information on horizontal violence:
I think one of the things that make the Green House Model viable from a caregiver’s perspective is that it incorporates many of the positive things that direct care workers in traditional institutional settings already do – or would like to do – and then formalizes and enhances them in a supportive environment. For example, that “deep knowing” of elders so vital to the Green House Model also exists in traditional settings. However, in places where caregiver workloads are too heavy, that level of awareness can’t happen consistently – even with the best of efforts – and some residents are going to fall through the cracks.
This is also applies to how workers relate to one another. Anyone who has been in the business for any length of time will tell you that friction among direct care staff is a staple of the institutional work environment. At its worst, it is exhibited in things like petty rivalries, cliquish behavior and bullying. Some of this behavior borders on the juvenile and the atmosphere on a nursing home unit can sometimes feel more like a middle school cafeteria than a home for the elderly. A quick check of the CNA Facebook pages will confirm this. Frustrated managers will often respond by saying something along the lines of “Why can’t you just act like adults – aren’t we all here for the residents?” apparently oblivious to the fact that having to remind workers of something so patently obvious is an indication that the problems go deeper and require a better solution than simply telling people to “grow up.”
On the other hand, it’s not unusual for direct care workers to create strong and positive relationships with one another and cooperate in ways that benefit their residents. Even in the worst work environments, caregivers often form very close bonds that resemble family ties and can even last a lifetime. Sometimes these are bonds are formed because of poor work environments, as a matter of mutual self-preservation. These relationships develop spontaneously, more a result of the nature of the work and the individual personalities of caregivers than from any systematic institutional initiative. And the value of these relationships often go unrecognized. Indeed, according to the conventional wisdom of many managers and caregivers “We are here to take care of the residents, not to make friends.” As if creating heathy personal connections with your coworkers is somehow inconsistent with good care.
By empowering staff, the Green House Model depends upon self-managed teams of workers to deal with the day to day issues of the home. In this model, strong interpersonal relationships among caregivers is a critical element. As part of their extended training, shahbazim receive instruction in interpersonal skills. This provides them with the tools that enable them to defuse personality clashes and focus their energies on resolving common problems. In the process, the natural bond that forms between caregivers is nurtured and can grow into a strong and effective professional relationship.
Furthermore, prior to the opening of a Green House Home, direct care staff go through a team building process that enable workers to develop positive relationships. In this way, caregivers become familiar with one another, learn to trust each other and a cooperative foundation is established even before the real work begins. As new workers are hired, they are brought into an environment that is open and supportive. The self-managed team has the supportive aspects of a clique, but without the exclusion. In a Green House Home, everyone belongs to the clique.
The shahbazim I talked to characterized their work relationships as “like a family.” I have no doubt that this is precisely what the creators of the model intended.
In my last post, I listed the structural elements that enable the Green House Project’s core value of empowered staff to become a reality. In this post, I will begin to tackle the less easily defined dynamics of empowerment.
Whenever we talk about staff empowerment, we need to keep in mind the reason behind it. While the title “shahbaz” denotes respect for the caregiver, it is actually the elders that are being empowered. The Green House model simply recognizes that in order for elders to be empowered, those closest to them and know them best must have the means to facilitate that empowerment.
Obviously, caregivers in traditional institutional settings play a critical role in how a resident experiences life in in long-term care. Both the nature of the work and the manner in which caregivers engage residents guarantee that central role. For many long-term care residents, the quality of their relationships with their caregivers determines the quality of their lives.
However, when it comes to actual power – the ability to make day to day decisions that most directly impact residents and the accountability for those decisions – the traditional model provides the caregiver with a distorted version of power, created more by default than by design. While caregivers report to a unit supervisor, much of their daily routine is conducted without the direct involvement of that supervisor. The nature of the long-term care business demands that a manager’s time and attention be occupied by matters not directly related to the details of daily care. Simply put, a supervisor has limited awareness of what goes on down the halls and in the rooms.
In this vacuum, individual caregivers are compelled to make decisions regarding the use of limited resources – time, especially. How they prioritize these choices is often influenced by an informal, but powerful subculture in which the caregivers with the strongest personalities sent the standards. Sometimes, this actually works well and supervisors even learn to rely on these caregivers to help manage the unit. But all too often, it leads to mistrust and petty bickering among caregivers. The relationship between caregivers and managers is commonly characterized by conflict over authority, self-promotion, stonewalling and manipulation. Good work is not rewarded and poor work is left uncorrected. This is not the kind of “power” that contributes to a meaningful life for residents on a consistent basis.
By providing the Shahbazim with real decision making power, the Green House Model formalizes and expands the caregiver subculture. In doing so, it changes the dynamics of the relationship both among caregivers themselves and between caregivers and the individual charged with holding them accountable, the Guide. Leaders will still emerge within the group, but everyone is expected to grow into leadership roles. Along with the guide and clinical staff, the strongest and most experienced shahbazim are charged with coaching newer staff members into those roles.
Furthermore, the Shahbazim are held accountable in a way that caregivers in a traditional setting are not. While caregivers are always responsible for their individual actions, the ultimate responsibility for what happens on an institutional unit falls on the licensed supervisor. In the Green House Model, the caregivers assume that responsibility. The team is self-managed and while there can be a degree of flexibility in some matters, they have a vested interest in following their own rules and developing a cooperative work environment.
While the Guide expects and encourages the Shahbazim to make decisions, he or she is much more aware and involved with the day to day details of the home than a traditional manager. Not only does this allow the Guide to be effective in the coaching and support roles, it leaves less room for the kind of finger pointing and lack of transparency so prevalent in traditional settings. Issues are more likely to be dealt with directly and in the open. Again, this is aided by the small size of the home compared to large institutional nursing units.
In my next post, I would like to talk about how an empowered staff’s approach to problem solving differs from the approach taken in a traditional institutional setting.
I am tired. I am tired and heartsick, frustrated, disillusioned and losing patience. I know that many of us work in a subpar facilities within a broken system. I understand that we make less money than pretty much any other field. I GET that, in our facility at least, there have been no raises and having worked there for the better part of seven years, I can almost guarantee that there will be none forthcoming. This is the reality of it and nothing I say or do can change it in the short-term. I feel your frustration because it is my own.
Having acknowledged that, it needs to be said that there is a level of accountability that we, as caregivers, need to meet despite the above mentioned conditions. In this, we are failing and in our collective inability to elevate ourselves above these pitfalls, we inevitably shortchange both our residents and each other.
Lately, the level of cattiness, finger pointing, laziness bred from apathy, and passive aggressive tendencies have played havoc with my morale and because of that, I find myself becoming impatient with some of my co-workers. I don’t want to spilt my focus between resident care and conflict on the floor; conflict over nothing. I simply do not have the energy to deal with both.
I know that I can be overzealous, overprotective of my residents, and perhaps I have higher expectations of my co-workers than I should, but don’t we owe them our best? Don’t we owe that to each other? Don’t we owe that to ourselves?
If I didn’t believe we could do better, I wouldn’t find it so maddening. I expect very little out of the administration because they neither know nor really care about the world on the floor. Oh, they care if it smells, or if it looks neat enough for prospective clients, but other than that, they care only that it’s quiet. They want the residents quiet and the workers quiet. But the residents psychological, physical and emotional well-being? It’s not on the forefront of their minds. Neither is ours, for that matter.
That will never change if we continue to feed into their stereotypical view of us. Often enough, we give them the very excuses they use to not offer us decent pay or recognition for the work that we do. Call outs, tardiness, poor work ethic, constant conflict all contribute to their preconceived notion that we are disposable. And where is there room for our residents in the midst of all that chaos?
The bottom line of it is that our residents, our sick, elderly, vulnerable residents deserve better care than 8-9 dollars an hour can provide. We cannot allow our pathetic excuse for wages to dictate how we work. We have a choice here. We can let the negative toxic work environment dictate our attitude and personal ethics, or we can face each day with a clear, stubborn and consistent determination to do our very best regardless of what goes on around us. We can be strong enough to not be defined by the broken system in which we work and by doing so, we will slowly but surely affect change. Robert Kennedy once said that “Few will have the greatness to bend history itself; but each of us can work to change a small portion of events, and in the total; of all those acts will be written the history of this generation.” …I wholeheartedly believe that. The first step towards being a part of the solution is to not be a part of the problem.
Often, I have heard it said that CNA’s “eat their young.” For some, it stems from burnout due to understaffing and high turnover. For others, it is that all of their patience is saved for the residents. Maybe, it is simply because it’s a tough field. Keep up, or move out of my way. I can understand the reasons, but I do not consider them excuses for poor behavior. There is a difference between being honest and being cruel.
There is a dark part of the human nature that thrives on kicking people when they’re down. I see it on the news, on Facebook, on videos of others’ misfortune that go viral and I recognize it for what it is; that ugly pimple on society’s face that is born out of collective fear and insecurity; that need to feel superior to another human being in order to feel ok about oneself. It’s a temporary, false sense of confidence and by its very nature, it is destructive. It also has no basis in reality and holds no truth.
This cliquish mentality that holds us back, prevents us from compromise and promises to keep us in a futile battle of the egos, has been prevalent in almost every environment in which I’ve worked, but nowhere have I seen it have such a divisive, disruptive and dangerous affect than in the world of long term care.
Third shifters are lazy. Second shifters all call out. First shift are all whiners. Medication Aids don’t listen. The office doesn’t care. The administrator is useless. The activity director is lame. Did you hear what she said?! Did you see what she did?!..Where, in all of our self-righteous finger pointing, is the solution? Where is their room for our residents? It’s toxic and contagious; a virus of negativity.
Make no mistake, I sometimes find myself thinking along those same lines. I GET the inclination. It stems from fear and frustration; a subconscious need to believe that, whatever the issue, it’s another person’s fault. It’s a way to avoid accountability. I feel awful when I allow myself to be dragged into the abyss because I know that with that awareness comes responsibility.
The truth is, NOBODY is right if EVERYBODY is wrong. The truth is, we are powerless over everyone but ourselves. Our choices. The truth is we are in the business of lifting people up rather than bringing them down. In order to do that, sometimes you have to defy gravity and rise above the chaos. If enough of us consistently try to help our fellow co-worker, whatever their department, rather than rip them to shreds, then maybe we can set an example and create a new, more cohesive, happier environment. Happier workers mean happier residents.