Tag Archives: turnover in long-term care

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.

  

A Step Backward for Long Term Care

 

 

Yang

Last week, PHI posted the third installment of their 60 Caregiver Issues Campaign. This issue brief highlighted how the Affordable Care Act brought coverage to many caregivers who previously had no healthcare insurance and discussed how proposed changes now before congress could impact the nation’s direct care workforce.  The link to PHI’s report is at the bottom of this post.

It boils down to this: among its many provisions, the ACA included an expansion of Medicaid that benefited the working poor and thus provided healthcare coverage to caregivers who did not previously qualify because they “earned too much.” 

Here are the numbers directly from the PHI brief:

  1. From 2010 to 2014, approximately 500,000 direct care workers nationwide gained health insurance following implementation of the Affordable Care Act.
  2. The uninsured rate decreased 26 percent during the same time frame, from 28 percent to 21 percent.
  3. These coverage gains are primarily attributable to a 30 percent increase in the number of workers insured through Medicaid programs.

The repeal of the ACA threatens this coverage and many caregivers may again find themselves without the means for adequate health care. In a field where workers are at high risk for injuries resulting in musculoskeletal disorders and face the risk of serious infection every day, this lack of healthcare coverage is devastating. It not only leads to higher turnover rates that negatively impact the care of our elderly and disabled, it also reinforces the tendency to view caregivers as short-term workers, an expendable resource that can be used up, disposed of, and replaced.

We cannot properly care for the most vulnerable of our citizenry if we overlook the health and well-being of those who care for them. The two cannot be separated. In a time when the demand for caregivers has reached a crisis, reducing direct workers’ access to adequate health care is an unwise – and unhealthy – step backward.

The PHI report can be found here.

 

 

 

60 Caregiver Issues: Whose Issues Will We Hear?

 

 

Minstrel

In his recent post Yang brought our attention to PHI’s campaign to educate the public about caregiver issues, and gave us a link to their introductory video.  In that video PHI posed these questions:   

1. How can we ensure caregivers get the training they need?

2. How can we keep care affordable to families? 

3. What data is needed to help policyholders take action? 

While these are important questions, if you ask caregivers themselves why some are leaving the field and others wouldn’t think of entering it, they’ll no doubt raise a different set of issues.  At nearly every conference or webinar I attend I ask about staff-to-resident ratios and caregiver wages.  Usually there is no reply, as if I were speaking from some parallel universe and couldn’t be heard.  If there is a reply it’s on the lines of “Yes, we know.  But it’s complicated.  These things take time. You can’t expect things to change overnight.” 

Yes, there is a shortage of caregivers.  And yes, good care isn’t affordable.  In fact good care can’t be bought.  By that I mean whatever you might be paying, either for in-home care ($20/ hour? $40?) or for care in a long-term care home of some sort ($6,000-10,000/ month), the more care the person needs as health declines, the wider the gap between the person’s needs and the quality of care the person actually receives.   

Everyone is selling solutions like workshops and videos and toolkits and new business models to long-term care administrators or home healthcare systems’ owners.  Some groups are advocating on a state or even national level and some gains have been won.  But from the outcomes I’d say that a lot of the effort is wheel-spinning.  (An increase in the NYC minimum wage for home care workers to $15/hour by 2021??)   Today’s aides have rare luck if they earn $15 an hour and have a regular 40-hour work week.  An aide may have six to ten residents/patients to care for, and many of those will suffer from dementia and/or be unable to walk alone safely or even support themselves standing.  (Yes, I know I’m a broken record…)  Do you know what it’s like to try to wash, toilet, transfer these residents several times a shift, and keep them from falling the rest of the time?  (If not, go back and read CNA Edge.)  This is before we even begin to provide enrichment a la ‘person-centered care.’   

I want the whole healthcare industry – including those championing reform — to acknowledge what the biggest issues are for caregivers: our obscenely low wages and our outrageously onerous, even unsafe, working conditions.  These organizations don’t yet tackle caregivers’ most urgent needs: a living wage, safe work conditions, and a work environment that supports person entered care.  We need to ask them, What are you doing about these issues and what can we CNAs do to support you in this?  

When Malcolm X called for a change in Americans’ attitudes on race and was told that such changes (culture change, if you will) take generations, he reminded us of this: At the beginning of World War II Germany became our enemy and Russia became our ally.  But when the war ended we, America, saw Germany as our ally and Russia as our enemy.  That attitude-change didn’t take even one generation.  The healthcare industry needs an attitude adjustment.  It is not okay for long-term care operators or owners of home healthcare agencies to charge exorbitant fees to clients and return a too-small fraction of these fees as wages to their direct-care workers, while management and professional staff and consultants are handsomely compensated.  It is not okay to hire employees unless you train them in the skills they need to work with the elderly frail, starting with English language skills.  It’s not okay for the industry to tolerate poor work ethics: last-minute callouts; texting while on duty; and most of all, failure to interact with residents in a way that says to them “I love being with you.  Thank you for letting me be part of your life.” 

There are thousands of followers of CNA Edge.  As Yang exhorted us, we need to support PHI in their effort to educate the public about caregiver issues.  Let’s ensure that when they frames their 60 Issues, they don’t airbrush our issues out of the picture they’re drawing.

The Caregiver Shortage and Immigration

In reaction to the Trump administration’s recent immigration ban, Lori Porter, founder and CEO of the National Association of Health Care Assistants, pointed out a connection between the immigration issue and LTC staffing levels. In a recent Facebook post, she stated:

“A large percentage of CNAs are from the banned countries. Long Term Care is always testifying before congress for immigration to solve their staffing issue… I know nursing homes in this country who are largely staffed by those affected. Did anyone stop to think about who would care for the residents? Especially in a country who will not come out in sufficient numbers to take care of their own OLD citizens! … I have heard from nursing homes all day who will not have enough CNAs to staff their building because so many CNAs have left out of fear.”

In support of Lori Porter’s assessment, we do know two facts:  that over 50 percent of CNAs leave their jobs every year (PHI Factsheet) and over 20 percent of caregivers in the U.S. were not born in this country (Market Watch).

My concerned is about the vulnerability of caregivers coming into this country on work visas, especially if their legal status is tied to their employment. Since advocating for our elders is such a big part of what we do as caregivers, we need workers who feel secure enough to speak out within the facility and, when appropriate, in the public forum. Sometimes, we are the last line of defense for our residents and if we do not speak, no one will. Too often, incidents and issues that should be dealt with in the open are swept under the rug, mainly out of fear of some form of retaliation.

If Long Term Care is to rely on immigration to solve the caregiver shortage in this country, what kind of protections can we provide these workers so that they feel secure enough to speak out and advocate for our elders when necessary?

 

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.  

Let’s Prove Them Wrong

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Alice

    We have received some wonderful and articulate emails from a reader who posed this question:  How do we make life better NOW for those living with dementia? She went on to explain how advocacy is what drives the flow of funding and most of the funding is going towards finding a cure for Alzheimer’s disease. While vitally important, it does nothing to help those currently living with the disease in the long term care communities. Who is speaking up for them? Who us speaking up for us?

       The frustration is that here on our level, there is little meaningful conversation of such things. We are expected to show up and take what is dished out. We don’t do it for the money, they say. It’s just a “stop-gap” job. If they were smart, they would have furthered their education. Treat someone as disposable for long enough and they begin to feel disposable; begin to act disposable. Is that what we want? Disposable people caring for the most vulnerable section of our society in their hour of greatest need?

      Or maybe it’s an indication of something deeper. They treat us as disposable because on some level they feel that those within our care are disposable. They have aged out. They no longer contribute to our society. Wisdom, experience, history, dignity are not valued commodities in this fast paced world of “me first and the give me! give me! mentality. Old, sick people barely make the priority list and those of us who care for them don’t make the list at all.

      No one SAYS that of course. I have never once seen a bumper sticker that reads Old People Suck and yet the situation in which many seniors and people with disabilities are forced to live is heartbreaking. There is no other word for it. They devalue them and by doing so they devalue us. And I’ve got news for you, folks…we allow it. Hell, sometimes we encourage it by our own behavior.

      One in four seniors will suffer from elder abuse. I’m no statistician, but I would say there is a probable correlation between quality of care and treatment of the work force. One in four. The injuries caregivers suffer on the job is sky rocketing. Again, this is supposition, but I would say exhaustion due to being forced to pull double shifts or multiple jobs to barely make ends meet would contribute to this. The standards for certification is low, the wages are low, the work is difficult, and the turnover is high. Why, why, why would ANYONE choose this quagmire? Because someone has to. Because those of us in the know have a moral obligation to do everything we can to be a part of the solution. Because it’s a battle worth fighting.

         How do we make life better NOW for those living with dementia? For all of those living with a disability that requires care? I have no idea. I’m winging it. I give the best possible care to my client. I write for this blog. I notice lonely people and try to make them less lonely. That’s the only way I know to make any difference that counts. I’ll tell you this though, the most meaningful changes are going to begin with us or not at all. They think we’re disposable. Let’s prove them wrong.       

The Long Goodbye

      photo   ALICE
       I’m calling in sick. I can’t have “the talk” anymore. I just can’t. It’s ripping my heart out. After all, what are they going to do? Fire me?…These were my thoughts as I was lacing up my sneakers and getting ready for work. Even as they floated through my head, I knew the words were a hollow threat. I would not call off. I would not ruin nearly eight years of perfect attendance at work while finishing out my notice. As gut wrenchingly painful as it may be, to cave in because facing this is difficult would be like throwing the game in the last inning. THEY would win. I would lose. And far more importantly, my folks would suffer.
       You can do this, Alice. It’s the right move. After all these years, three owners and five administrators, you know that this facility is never going to change. They will never invest in competent management and because of this, you will always be stuck. Now is the time. Opportunities like this don’t fall on your lap everyday. Take it and run and start moving forward with your life. This has been my mantra, played on repeat, for the week. And it’s true. I know it is. I know that I have to get out of this particular facility. I know that I’m no longer comfortable working under questionable conditions and bosses with very questionable ethics. So, I’m moving on. My resignation letter, worded carefully to not offend so that I may visit my folks without interference from the office, is in.
       I’ve explained the situation to my residents. And explained. And explained. I’m not leaving YOU. I’m just leaving the JOB. I’ll be here to visit at least once a week. It will be different but it will be good! I’ll have time to sit and visit instead of running here and there. You will be fine…over and over again. They are scared and feel like I’m abandoning them. I know this because they tell me and that just shatters me. The average length of employment for a caregiver in this facility is six-eight months and that is being generous. The turnover is ridiculous because the wages are insultingly low and the work conditions are terrible. Because I have been there so long, this is traumatic for them and for me.
       I am letting them down. There is no getting around that. I’m making a choice that is both right and necessary but to deny that it will impact those around me would be dishonest. It is a truth that I can accept and live with, but for the moment it is incredibly difficult and painful. I really can’t discuss it without crying. This decision has turned me into a blubbering mess. I love what I do. I love many of my co-workers and I have been deeply committed to my residents. I resent having to make this choice. I am furious at the administration for not investing and paying a living wage for quality caregivers. I resent the dishonest, inept, incompetent and unethical woman in charge of coordinating care. She has not eased my residents’ stress or discussed with them the upcoming transition. She has not comforted them. She is quite honestly only concerned with how events affect her. Such apathy in this field never fails to boggle my mind.
       A few more days. That’s all I have left there. I will continue to reassure my folks that they will always be a part of my life. After so many years, they are more friends than residents and it will be nice to explore that dynamic. I know that nothing I can say will prove that to them. I will have to show them with action. And I will. Until they see me visit them, I have to accept that emotionally, they are not in a trusting place. Often, the best decisions are the most difficult to make. I know that underneath all of these deeply felt emotions that I am walking through, there is excitement at what’s to come. New opportunities will open up from this very difficult decision. For now, I have to trust the process. After all, life is change and transitions.

The Issue of Low Wages in Direct Care

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Yang

When we talk about low wages for direct care workers, it’s important not to confuse two separate issues. The first has to do with our personal satisfaction regarding the work, best summed up by the regularly repeated phrase: “It’s not about the money.” The second issue is about the impact of low wages on the quality of care and on the workers who provide it.

Many caregivers will tell you that they experience significant emotional benefits from the work. They find meaning and fulfillment in making an immediate and real difference in the lives of other people. However, personal satisfaction with the “work” doesn’t always mean contentment with the “job.” The work we find so fulfilling is only one aspect of the job, which also includes things like wages and the work environment.

For some caregivers, the emotional benefits outweigh all other considerations. They find the work so deeply meaningful that they are willing to endure the impact that low wages and difficult work environments have on their lives. It is a noble sentiment.

While the sentiment is genuine, it is also a highly personal one. Meaning is not so much found as created and how we create meaning in our lives is an intensely individual enterprise. It is not something one person can do for another; the most we can do is accept and respect another person’s sense of what brings meaning to his or her life.

It is not a contradiction to accept and even admire the notion that caregiving “is not about the money” on the one hand while condemning low wages and poor working environments on the other. The former is about the choices and perspective of individual caregivers, the latter is about a bigger picture.

Low wages is a major contributing factor to high turnover rates for direct care workers. This has a profound effect on the continuity and quality of care. In her May 5th blog post “Addressing the Difficult Issue of Money,” Paraprofessional Health Care Institute’s (PHI) National Director of Coaching & Consulting Services, Susan Misiorski, sums it up thusly:

“Low wages for direct-care workers has a trickle-down effect on the elders and people with disabilities for whom they provide care. We know that care continuity correlates strongly with care quality, but low wages encourage high turnover rates. Organizations that continually must hire — and train — new staff members likely aren’t providing the best possible care.”

Beyond quality and continuity problems, the issue of low wages has wider social implications. Since wages and benefits in long-term care are impacted by inadequate government reimbursement rates, the issue of low wages is a matter of social policy and a true reflection of the value society places upon direct care work. Misiorski tells us that 22% of direct care workers fall below the poverty line and 43% live in households that rely on some form of public benefits. The very people we depend on to provide quality care often struggle to take care of themselves and their own families. Does it really make any sense to tell workers how much you value what they do and then expect them to live near or below the poverty line?

Yes, we want workers to be properly motivated. But expecting to be compensated fairly for what you do does not equal a lack of compassion. We are all motivated by different things and genuine compassion is expressed through action, not good intentions. While we can admire the notion that “it’s not about the money,” we must reject the idea that caregivers who express concern about their wages don’t belong in the business. We lose too many good workers that way.

Another Angle on Anger

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Yang

Two recent posts on CNA Edge dealt with negative emotions: “Anger Management” by Edison Terrell and “Out of the Night” by May. While they take different approaches, these two posts share at least one very important idea: don’t allow your anger and frustration to become a problem for the people in your care.

In his post, Edison confronts his inner rage demon. The piece serves as more than a simple catharsis in the “confession is good for the soul” kind of way. As caregivers, we all have to deal with anger at one time or another – and if we’re honest, every single day. By his public confession, Edison demonstrates that it’s possible to have these feelings and still be compassionate and caring if we properly manage and process them. His post helps free us from the trap of denial and projection.

May’s post was equally introspective. But instead of a battle with her inner demons, she refuses to surrender to the negative influences of her work environment, in particular the perpetual listing of grievances by some of her coworkers. Instead, May makes a deliberate choice: “I stay despite the circumstances.” Through this simple act of will, she takes control and responsibility thus liberating her – and her residents – from the wearisome self-victimization displayed by her workmates.

Negative emotions are common in the work environment. Any time you put people together in a stressful situation there is going to be a good deal of politics and personality clashes. With egos on the line and blame to shift, some level of discord is to be expected. The same is true in any line of work. Due to the nature of our work, the stakes are higher and the emotion is amplified.

As we work to process our emotions, I think it’s useful to make a distinction between the routine frustrations of the workplace and the genuine anger engendered by problems that are endemic in long-term care. It’s difficult because the two things overlap so much. However, when we are able to separate them we elevate our awareness of something that is nothing less than a social injustice. We are not just workers; we are first hand witnesses to how the elderly and sick are directly affected by inadequate staffing levels, high turnover rates for caregivers and the poor utilization of resources due to misplaced priorities.

And here the rule applies doubly: the righteous anger we feel over this social justice should not become the residents’ problem. They are the primary victims. Don’t make them pay twice.

This brand of anger should instead be directed elsewhere.

 

Out of the night

May

When I punch in the code for the door, it feels as though I am literally punching the keypad. There’s a great deal of feeling being expressed on my exit from the building…none of it very positive.
The sad thing is, it was a good shift. Nobody died. Nobody hit me. I wasn’t overwhelmed and my workload wasn’t excessive.
But there’s a psychological stink these days, like dread and exhaustion have inhabited the walls. Maybe this place is haunted, not by ghosts of residents passed but by the negative emotions of the caregivers.

It’s hard to tell which is causing the other: are we exhausted because we dread coming to work or do we dread coming to work because we’re exhausted.
I don’t know. All I know is that I was content until I came in and now as I’m leaving I am numb. My mind is so full of echoes that I can’t hear my own voice; other people’s opinions and frustrations have filled me to the brim and I can’t find the line between what I feel and what everyone expects me to feel. Herd mentality? Peer pressure? Too many overworked aides with no relief in sight? The door clicks open and I walk out of the building. The outside air is cool, crisp. It stings my cheeks and finally my thoughts stop chasing themselves in circles and start to sort themselves out.
I was fine until shift change…if not fine, then at least coping. Then shift change happened and it seemed as though report had less to do with the residents and more to do with the situation. Did you hear so-and-so put in her notice? Well, this girl just walked out. Damn, you worked another double? How much more can we take? This place is a joke. Let me tell you girl. They don’t care.

I draw in a deep breath of the cold air and suddenly I feel like screaming in frustration…and it’s not the situation driving my agitation. It’s the gossip, the drama, the constant complaining. Isn’t it bad enough the I have to put up with the situation, the exhaustion, the dread without having it all shoved in my face every day? I’m told I am naive and gullible when I try to see “their” point of view. Every time I say “but”, I feel like I’m either going to be shouted down or glared into silence. Am I burying my head in the sand or am I resting my eyes when I don’t join the negativity train. Why, exactly, do I have to have a staring contest with the abyss?
Yes, I know things are bad–but I can’t help feeling like the constant repetition of the unfairness isn’t doing any good. There’s bringing awareness to an issue and then there’s fueling misery. It’s like some of the aides get off on working themselves and others into a state of resentment. And I haven’t got the energy to be both resentful and responsible. My poker face sucks: if I’m unhappy, I am utterly miserable and everyone knows it…everyone including my residents. And my residents deserve better than the worst version of me.
I can’t be flailing or flaccid. I won’t be. I hate reactionary people, so I’m going to have to be active in my own life.
Leave or stay. It’s not inaction or action, a choice or complacency.
I either choose to leave or choose to stay. But it’s an active choice either way. If I choose to leave, it can’t be because I’ve flown off the handle and walked out. If I stay, it can’t be because I’m paralyzed and afraid of change. I owe it to myself and my residents to do this the right way.
Exhaustion can curb many of our mental functions, it can impair judgment…all this is true and yet I do not have to surrender my willpower to it. I might be at the bottom of the ladder, but I am not helpless. I don’t have to be a victim of circumstance, bad though they are–I can still choose my way.
Leave or stay. Action, not a reaction to the grumbling of others. I don’t have to leave because other aides are and I don’t have to stay because other aides are.
My choice. What do I want to do? What is the right choice for me? Maybe the poem “Invictus” wasn’t just written for kings and presidents. Maybe CNAs can also claim a measure of their own destiny–or at least, claim the right to decide for themselves what they think and what they do with the circumstances and crap dealt us.
I arrive at my car and slowly open the door. I’m still bone-weary, but the heaviness of dread has lessened. Exhaustion I can deal with, I think. Maybe even exhaustion and the situation. But not dread. That stays here in the cold night air. It doesn’t come home with me.

I feel several ghosts lighter when I finally drive away.