More Related Content
Similar to Caring: The Heart of CNA Practice
Similar to Caring: The Heart of CNA Practice (8)
Recently uploaded
Recently uploaded (20)
Caring: The Heart of CNA Practice
- 1. Caring: The Heart of CNA Practice
- 2. “Lots of times people think that nursing is just about caring, but caring comes from knowledge of science. We are science based.” Porter and Chester Institute in Connecticut 2
- 3. Caring: The Heart of CNA Practice • Depending on the Kindness of Strangers 3
- 4. “Who is here for me?” 4
- 5. •“Whoever you are, I have always depended on the kindness of strangers.” •Blanche Dubois 5
- 6. Mum, 2002 6
- 7. 7
- 8. 8
- 9. 9
- 10. “Yes, we are supposed to treat the patients with compassion and dignity. I think they use more the[word] respect and to be attentive to their needs and wishes. They try, but they don't do a unit on it. … I think if you treat them how you would your own parents or want yourself to be treated, then you know what to do. ” 10
- 11. Residents' Rights Residents’ Rights while Living in a Nursing Home The rights of nursing home residents are codified in both federal and state statutes with the intent of further protecting each resident’s civil, religious, and human rights while they reside in a nursing facility. To be treated with *consideration, *respect, *and full recognition of personal dignity. 11
- 12. • Compassion is the wish for another being to be free from suffering…. 12
- 13. Matthew 7:12, Luke 6:31,Lev. 19:18 and 20 other the world religions Therefore all things whatsoever ye would that men should do to you, do ye even so to them: for this is the law and the prophets." Matthew 7:12, King James Version. 13
- 14. • Tenzin Gyatso: The Compassionate Life • Usually when we are concerned about a close friend, we call this compassion, but it too is usually attachment… 14
- 15. 15
- 16. • True compassion is not just an emotional response but a firm commitment founded on reason. Because of this firm foundation, a truly compassionate attitude toward others doesn’t change even if they behave negatively. 21 16
- 17. “You should expect that the person be kept as well as possible, well fed and hydrated, protected from obvious risks, and clean and comfortable.” 278-9 17
- 18. • …the nature of for-profit businesses. No matter how caring their brochures may make them seem, they are businesses run by administrators beholden to the bottom line, a reality that can result in long-and short-term strategies not in a patient’s best interest… 10 18
- 19. • Get paid and don’t get caught. 19
- 20. 20
- 21. Wheelchair AND alarms… 21
- 22. 22
- 23. 23
- 24. “The company will see that as a red flag.” 24
- 26. 26
- 27. Five Star Quality Care … an experience that is positive, stimulating and filled with dignity… emotional comfort... committed to the highest standards … 27
- 28. Compassion: not a static state, not a destination to be reached, not a subject that can be taught. 28
- 29. Compassion: a way of being in a relationship, a way of acting and interacting 29
- 30. Tony’s Wāt Problem. 30
- 31. Tony’s Wāt Problem. A stroke landed Tony in his nursing home and in a wheelchair. He can’t walk and there is evidence of dementia, too. He lives in Wisconsin and believes he can see the Rocky Mountains from his west window. Sometimes he is confused about what floor he is on, but usually he’s cheerful and sociable. He wanders, via wheelchair, throughout the facility, stopping to speak to whoever smiles at him and says, “Hi, Tony.” An aide has taken the handles of his wheelchair and moved him to the hallway of a wing he doesn’t live on. He asks, “Where are we going?” 31
- 32. She says, “Your weight,” as she stops his wheelchair and sees that the scale has been removed. Annoyed, she releases the wheelchair, steps around Tony, turns left and disappears into the shower room where lifts and other equipment are stored. Uncertain about where he is, where she went and what she said, Tony says, “What?” She speaks loudly from inside the shower room, “Weight!”H e, hearing wait, responds, “Wait for what?” 32
- 33. Louder, now, assuming he can’t hear or isn’t trying to, she barks, “Weight! Weight!” So Tony says, “Okay,” and he sits there cooperatively waiting until she comes out of the shower room with the scale that she’s had to search for and takes his weight. Relieved now because he finally understands, he smiles at her. She thinks his smile means he’s enjoyed being querulous with her, so she doesn’t smile back. Now Tony is more confused. 33
- 34. …the desire to relieve suffering. 34
- 36. “You’re just like me. My memory is bad, too.” 36
- 37. Milwaukee Journal/Sentinel “She didn’t want me and my friend saying [anything] in Spanish because it was a bother to patients and the other employees,” Lopez said. 37
- 38. James Ryan, a U.S. Equal Opportunity Commission spokesman said, “We don’t consider customer preference as any kind of justification for any kind of discriminatory behavior.” Requiring employees to speak only English violates federal law… 38
- 39. An attorney for St. John’s argued that Lopez’s charge should be dismissed. “It was a matter of providing dignity and respect to the residents…by speaking a language that residents do not understand…a staff member may make a resident feel uncomfortable in his or her home.” 39
- 40. 40
- 41. “There is always a choice about the way we do our work, even if there is not a choice about the work itself.” 41
- 42. • “And be present, fully present.” 42
- 43. Being fully present… 43
- 44. “The night nurse is so kind.” 44
- 45. Residents' Rights Residents’ Rights while Living in a Nursing Home The rights of nursing home residents are codified in both federal and state statutes with the intent of further protecting each resident’s civil, religious, and human rights while they reside in a nursing facility. *Always knock before entering a room… *Wait for a response. *Knock even when the door is open… *Privacy should always be ensured. 45
- 46. 46
- 47. “What a fun bunch!” 47
- 48. “That’s hard to tell…” 48
- 49. • “The three-five minutes I chose to deal with Jessie rather than answer that call light were three-five minutes I could have been assisting Sally, three-five minutes that may have prevented her fall, three-five minutes I wasn’t there.” 49
- 50. Compassionate CNAs • Choose and agree to be there with the resident in a relationship. • Relieve pain and provide comfort where that is possible. 50
- 51. The Heart of CNA Practice • Being fully there. 51
- 52. • Access to CNAs while they’re still in training. 52
- 53. …at the core of every single one of the world religions is the virtue of compassion, which does not mean "pity"; its Latin root means to feel with the other. Karen Armstong 53
- 54. • The quality of mercy is not strain’d, • It droppeth as the gentle rain from heaven • Upon the place beneath. It’s twice blest; • It blesseth him that gives and him that takes. • The Merchant of Venice 54
- 55. • Being fully there… 55
- 56. Those ten residents 56
- 57. • Caring: The Heart of CNA Practice 57
- 58. Caring: The Heart of CNA Practice Depending on the Kindness of Strangers by Caroline Court 2009 58
- 59. References Armstrong, Karen. The Great Transformation: The Beginning of Our Religious Traditions. Anchor Publishing, 2007. Armstrong, Karen. A History of God: The 4,000-Year Quest of Judaism, Christianity and Islam. New York: Random House, 1993. Court, Caroline. Mum, Alzheimer’s and Me: Staying Alive. Mequon, WI: Caritas Communications, 2007. Gyatso, Tenzin (the 14th Dalai Lama). The Compassionate Life. Boston: Wisdom Publications, 2001. Hart, Sura and Victoria Kindle Hodson. The Compassionate Classroom: Relationship Based Teaching and Learning. Encinitas, CA: Puddle Dancer Press, 2004. Lundkin, Stephen C. Ph.D., Harry Paul and John Christianson. Fish!: A Remarkable Way to Boost Morale and Improve Results. New York: Hyperion, 2004. Mace, Nancy L. M.A. and Peter V. Rabins, M.D., M.P.H. The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life. Baltimore: John Hopkins University Press, fourth edition, 2006. Moore, Marianne. Complete Poems. New York: Penguin Books, 1991. Shakespeare, William. The Merchant of Venice. New York: Washington Press, 1992. Steele, Dennis R. and Edward C. Watters III, M.D. Danger Zone: Unlock the Secrets of Nursing Home Medical Records and Protect Your Loved One. Severna Park, Maryland: Members of the Family LLC, 2003. Williams, Tennessee. A Streetcar Named Desire. New York: New Directions Publishing Corporation, 2004.
Editor's Notes
- I’m glad to see caring as the theme of your retreat. I was a little worried about caring going away when I was browsing nursing school web sites in preparation for this presentation. I found a web site for Porter and Chester Institute in Connecticut, a technical college with a nursing program It had a little video on the site. Slide
- A nurse appears and says, “Lots of times people think nursing is just about caring, but caring comes from knowledge of science. We are science based.” Call me old fashioned, what’s wrong with nursing that’s caring based, informed by science, but still mainly about compassionate care? Nurses have patients; scientists have “subjects.” If I’m headed for a hospital or a long term care facility, give me the caring -based staff. I may have to depend upon the kindness of strangers. Nursing skills minus caring sounds like surgery without anesthesia. I won’t want to be studied; I’ll want to be cared for. Slide.
- I see the nurses in Arizona have it that way. A retreat for CNA teachers that puts caring at the heart of CNA practice. I like being where the sun shines and caring is king, so thanks for having me. I’ve subtitled this presentation Depending on the Kindness of Strangers because it defines the relationship between residents, especially those with dementia, and their CNAs. Slide.
- When I took my mother to her nursing home, I explained to her that the staff, the aides, nurses, doctor, etc. would take care of her. She was frightened by all of it. She said, “But who is here for me?... You mean you’re going to leave me here…ALONE?” Because, to her, they were all strangers. Many residents must feel that way, especially those with dementia. Slide.
- Maybe some of you recall an old classic of American theater, also a movie: A Streetcar Named Desire. The character Blanche Dubois is horrified when men in white coats come to take her away. One suggests “the jacket,” but a compassionate doctor speaks kindly to Blanche; she relaxes and takes his arm as he leads her away. She says, “Whoever you are, I have always depended on the kindness of strangers.” Scene 11 She’s kind of a pathetic, tragic figure and her predicament isn’t unlike real characters who find themselves being cared for by people who are strangers to them. This character in Tennessee Williams play is the namesake of my Blanche Dubois in Mum, Alzheimer’s and Me: Staying Alive. My Blanche in real life was a roommate my mother had for four years. Like Blanche of the play, my Blanche relied, after her institutionalization, upon the nursing home staff, primarily its CNAs, for her care. So did my mother, the Joan of my book. Slide.
- My mother entered a nursing home in May of 2002. But I’m going to fast forward a few years to 2007. That’s where my book ended, so this is post book. She had just been moved to a room on another floor, another wing, deemed more appropriate for her advancing confusion and dementia. As usual, I liked to introduce myself to her caregivers. Slide- black or blank
- I stood in the doorway to her room and scanned the hallway. To my left, (use gestures) a few rooms away, a resident lay on a bed that had been rolled into the hallway and she appeared to be praying, maybe with a rosary, a quiet but plaintive, “Oh, Mary, mother of God, oh Mary, mother of God…, help me, help me” repeatedly. About four rooms beyond her, at the end of the dining room, a nurse sat at the nurse’s station and appeared to be having a telephone conversation. In the other direction, at the end of the hallway, three CNAs, a man and two young women, stood near the meds cart. I walked toward them, introduced myself and asked which one was my mother’s aide. One said, “Me. What does she need?” I explained she didn’t need anything; I just like to know her caregivers and have them know me. Meanwhile, the rosary lady’s lament had increased in volume and speed. She was really crying out now, “Help me, help me, help me…Oh, Mary Mother of God…,” etc.
- I’m going to interrupt this story for a minute to show you this cartoon . The cartoon is sympathetic to the nurse. (Read it: My patient’s family has been pretty stressed out. I think I’ll pass by the waiting room to let them know I’m back from break…Can you believe she has the nerve to take a break while grandpa is in there suffering! And she was smiling, too.) There is a little exaggeration here, but family of residents do get this way. I’ve felt like that. It’s fear and frustration, fear that staff is too used to seeing suffering to be sensitive to it and frustration over being powerless to help the loved one. Those powerful emotions make otherwise reasonable people shift into a fight or flight mode. Some families take flight. Those are the families of residents who get no visitors. Their families have fled. Others have family advocates that stay. Sometimes their expectations for care are not in sync with the care that’s being delivered. Then you have an adversarial relationship like the cartoon demonstrates. Now let’s get back to that story.
- I asked the aides, who were not near the rosary lady, what was wrong. One said, “She’s in pain.” That was disturbing; there was the specter of my mother being in her place one day, so I asked, “Can’t you do anything for her?” “We can’t. She’s already had her pain medication.” “Maybe it’s worn off? Could she have more?” “We can’t give her any more. The nurse on duty has to call the doctor for orders, but it’s a pool nurse and we don’t know what she’s going to do.” The woman continued to wail; I thought how heartbreaking for all the residents within earshot to listen to unanswered calls for help. “Is the woman maybe out of her head and not really in pain?” I hoped and asked. One of the CNAs said, “No, you can talk to her and she can tell you exactly where it hurts.” This picture seemed all wrong to me. I expected caring in the form of action, some sort of compassionate behavior, maybe someone sitting with the woman, trying to comfort her, holding her hand, something. These CNAs could report suffering to the RN on duty, but they were powerless to prescribe pharmaceutical pain relief. If that’s the way the system works, I asked myself, what is compassionate care in CNA practice? And what is a CNA doing when she is being compassionate? What I mean is, what are practical applications, the observable behaviors that come out of all those great but abstract concepts: compassion, respect, dignity, etc. I’m not sure that every CNA could answer that question. I asked one who is a caring CNA what she recalls of her training regarding caring and compassion. Slide.
- She said, “Yes, we are supposed to treat patents with compassion and dignity. I think they use the word respect and to be attentive to the needs and wishes. They try, but they don’t do a unit on it… I think if you treat them how you would your own parents or want yourself to be treated, then you know what to do. So she didn’t recall the word compassion or caring being used but the words respect, dignity…like the exhortations I saw posted on the walls of my mother’s home. Here’s an example.
- Read slide: To be treated with consideration, respect, and full recognition of personal dignity. The expectations of residents’ families are high when they see these high ideals. I like them. I’m not sure how they translate into action for CNAs. I don’t see the words caring or compassion there either. I still think there’s something more tangible that is at the heart of CNA caring, at least from the perspective of the family of a resident. I’m going to try to get at that in this presentation. I like this Buddhist philosophy of compassion and I’m not Buddhist. I just like the clarity of this definition: Slide.
- Compassion is the wish for another being to be free from suffering… Is wishing someone free of suffering compassion enough to satisfy the family placing a dementia afflicted nursing home resident? The family naturally wants the freedom from suffering not just the wish for it. My husband , like the CNA acquaintance I talked to said, what you want is a CNA to care for your mother the way you would. The CNA said that she tries to treat them as she would treat her own family or want to be treated herself. That sounds like the golden rule, the compassion of the Matthew 7:12. Slide.
- And the golden rule idea that my CNA acquaintance paraphrased. Who would argue with that. It’s the cornerstone of 21 of the world’s religions. But families have attachments to each other, familial attachment. I had an attachment to my mother that I wouldn’t expect a CNA to have. I loved her and I liked her. She was my mother and my friend. I know compassion and attachment aren’t synonymous. If a CNA had a strong familial attachment to each of her 10-13 residents, some of them in pain, some of them dying, how could she survive emotionally? Slide.
- The author The Compassionate Life…puts it this way: Usually when we are concerned about a close friend, we call this compassion, but it too is usually attachment..20-2 It doesn’t seem realistic to expect CNAs to feel as though all of the residents in their care are their friends. CNAs are in a relationship with their residents but it’s not friendship. For one thing, we choose our friends, and if we decide not to be friends anymore, we can end the relationship. But this author…. believes compassion without attachment is possible…and so do I. Slide
- I have seen some residents who I think are lonely or angry at their families for abandoning them or just plain mad about something take out their frustrations on CNAs. One lady made a fist and punched the CNA pushing her wheelchair. I asked the resident what she did that for and she smiled. I saw a tray flying out of a resident’s room, its target-a CNA. The patient was mad because her CNA wasn’t getting in there fast enough. Those behaviors would end a friendship. Slide
- “True compassion is not just an emotional response but a firm commitment founded on reason. Because of this firm foundation, a truly compassionate attitude toward others doesn’t change even if they behave negatively.” Maybe compassionate care, as it applies to CNA practice, has more to do with something that’s been thought out, rather than felt? So even if a CNA hasn’t been treated well by a resident, she can still provide care? Hold on to that thought. Among other books I’ve read about dementia and Alzheimer’s, one old standard is The 36-Hour Day. Slide.
- “You should expect that the person be kept as well as possible, well fed and hydrated, protected from obvious risks, and clean and comfortable.” It sounds like what I expect when I take my dog to the kennel, that he’ll be fed, given his meds, water, etc. The bar seems set rather low. It doesn’t say to expect compassion. But of course I do expect compassion for my mother. For the dog, too. Also perplexing are some rather ugly realities of our profit-driven long-term health care systems. The values reflected in company policies can give CNAs mixed messages about the premium placed on compassionate care. After my mother had been in the nursing home for five years, I saw this next book recommended on a Department of Aging web site- for people with a loved one in a nursing home. I would not have believed what it said if I hadn’t already spent so much time at a nursing home. Slide.
- Slide of cover of The Danger Zone “…the nature of for-profit businesses. No matter how caring their brochures may make them seem, they are businesses run by administrators beholden to the bottom line, a reality that can result in long-and short-term strategies not in a patient’s best interest…10 The author who is a doctor and whose mother had Alzheimer’s insists the for-profit nursing home credo consists of two items: Slide.
- Get paid and don’t get caught. ”Insurance carriers and government regulators assume that everything not documented in writing hasn’t been done. Remember the first two tenets of the nursing home credo: get paid and don’t get caught…Each group is trying to maximize its own reimbursement while at the same time creating an audit-proof chart…11 Seems cynical. Where’s compassion? Let me tell you another story. Here’s the experience of nursing staff at my mother's nursing home. Slide.
- A man on my mother’s wing suffered from dementia. He had a bed alarm so staff would know when he was up and about. The alarm was very loud and could not be turned off unless staff entered the room, and prompt response to bed alarms was not an expedience that I observed. So there would be a lot of noise in that room. A new admission was assigned the same room, to occupy the other bed. He was suffering from a number of conditions including post-traumatic stress syndrome. The nursing staff were concerned when they learned of this admission. Of course, the arrangement, the grating bed alarm at all hours and post traumatic stress, didn’t work out. The decision to put the men together was an administrative directive. It filled the empty bed, so it was cost effective, but it was not compassion driven; it was bottom line, profit driven. And the people who had to pick up the pieces of this rather mean decision were the CNAs who had to care for the two men. They did not get a lesson in compassion from “the company.” Slide.
- This is one of my own experiences: Following a hospitalization, my mother was given a wheelchair. Because she would likely fall if she got up from the chair, an alarm was attached. The nursing supervisor thought an alarm on her wheelchair and close monitoring was appropriate care. But I didn’t see close monitoring when I visited her the day she returned from the hospital. I was sitting with her in the dining room that afternoon when I heard a chair alarm go off on her wing. No aides were in the hallway, but there were three in the dining room, clustered around a table, talking with one another. No one responded to the alarm. I think no one even heard it. I followed the sound right into my mother’s room. Slide.
- A male resident had wheeled himself in, climbed out of his wheelchair and was sitting on the toilet in her bathroom. His alarm was still blaring. I approached the aides then and told them an alarm had gone off and there was man in my mother’s bathroom. One aide said, “Oh, that’s Vincent; he’s mine,” and she left the group to attend Vincent, who had not fallen but easily could have. Slide blank or black.
- Because of that disturbing scene and the likelihood that my mother would have a fall, I felt very uncomfortable leaving that day. Not only was Vincent not monitored closely; his alarm failed to alarm anyone. What would happen to my mother? I decided to speak to an administrator and the director of social services. The nurse/administrator had been at some of my mother’s care meetings. I’m not sure what her official title was but she was somewhere between the director of nursing and the CEO. She’s the one who would remind me about “the company.” The nurse administrator would say, Slide
- “… the company will see that as a red flag.” She was acting as an agent of “the company.” In previous meetings, I didn’t always get a sense that she was representing my mother’s best interests. Anyway, I had to talk to somebody. I explained what I had observed of the three aides, and the administrator was defensive. When I told her they had not responded to the alarm, she said… Slide
- The director of social services looked at her, then at me, then at her, then echoed, “Yes, that happens.” Slide to blank or black.
- If someone at or near the top of nursing home bureaucracy looks at an incident involving staff and alarms like this one and says, “That happens,” you must suspect that compassion for nursing home residents doesn’t trickle down from the top. It doesn’t trickle down, because maybe upstairs is an empty vessel? Compassion, not to mention competence, is not being modeled or expected. Even though the company may talk the talk about caring- you can see that in their brochures- Slide.
- Note the high minded language, positive, stimulating, dignity, comfort, committed to the highest standards. I believe compassion that we mean- the kind that is the heart of CNA practice -can unravel if CNAs are expected to look at the corporate model of the for- profit, long -term healthcare industry for inspiration. Somehow the inspiration has to come in with CNAs themselves. How is that possible? Stay with me…An interesting book, especially for teachers, is The Compassionate Classroom. Slide. Compassion is defined this way: Slide.
- Compassion is not a static state, not a destination to be reached, not a subject to be taught. Slide.
- Compassion is a way of being in a relationship, a way of acting and interacting. Let’s look at a few CNA scenarios to see these ideas in action. Slide.
- This happened just outside my mother’s room. I knew Tony long before he came to the home. His family and mine are related. This happened just exactly as you see it here. Slide.
- The title contains the phonetic spelling of homonyms, w e i g h t and w a i t. A stroke landed Tony in his nursing home and in a wheelchair. He can’t walk and there is evidence of dementia, too. He lives in Wisconsin and believes he can see the Rocky Mountains from his west window. Sometimes he is confused about what floor his in on, but usually he’s cheerful and sociable. He wanders, via wheelchair, throughout the facility, stopping to speak to whoever smiles at him and says, “Hi, Tony.” An aide has taken the handles of his wheelchair and moved him to the hallway of a wing he doesn’t live on. He asks, “Where are we going?” Slide.
- She says, “Your weight,” as she stops his wheelchair and sees that the scale has been removed. Annoyed, she release the wheelchair, steps around Tony, turns left and disappears into the shower room where lifts and other equipment are stored. Uncertain about where he is, where she went and what she said, Tony says, “What?” She speaks loudly from inside the shower room, “Weight!” He, hearing wait , responds, “Wait for what?” Slide.
- Louder, now, assuming he can’t hear or isn’t trying to, she barks, “Weight! Weight!” So Tony says, “Okay,” and he sits there cooperatively waiting until she comes out of the shower room with the scale that she’s had to search for and takes his weight. Relieved now because he finally understands, he smiles at her. She thinks his smile means he’s enjoyed being querulous with her, so she doesn’t smile back. Now Tony is more confused. There’s no abuse here, certainly none intentional. And there is some interacting going on, but it’s not right. It isn’t a compassionate scene. Remember … Slide
- Compassion: the Desire to Relieve Suffering.The suffering of dementia can’t be relieved if confusion isn’t recognized as a kind of suffering. Maybe you’re familiar with the television ad for the antidepression drug Cymbalta . A very sad looking woman appears on the screen and then a narrator says… Slide.
- Depression hurts. Well, so do shame, humiliation, embarrassment, anxiety, insecurity, fear, loneliness, alienation…Those hurt at least as much as a headache, and for a headache we get aspirin. Staff used to say to my mother, “Do you remember…? or “Don’t you remember…?” But one CNA seeing my mother’s embarrassment over not remembering something and empathizing with the alienation she must have been feeling said…Slide.
- “You’re just like me. My memory is bad, too.” My mother’s face lit up. She was just like somebody instead of different from everybody, so that moment must have made her feel rather normal. The CNA was spot-on, in tune with the resident. And that was a compassionate gesture, geared toward relieving suffering. Now, in contrast to that, here’s an interesting scenario. It’s from a newspaper article in The Milwaukee Journal Sentinel regarding a Milwaukee long-term healthcare facility this past year. A CNA’s supervisor insisted a CNA named Lopez speak English only in front of nursing home residents for whom English was the spoken language. The CNA later initiated a federal discrimination law suit over the matter. I have taken key statements from the article for brevity. Slide. ……………………………………
- “She didn’t want me and my friend saying [anything] in Spanish because it was a bother to patients and other employees,” Lopez said. Slide.
- James Ryan, a U.S. Equal Opportunity Commission spokesman said, “We don’t consider customer preference as any kind of justification for any kind of discriminatory behavior.” Requiring employees to speak only English violates federal law… Where in either of these, from the CNA, from the Equal Opportunity Commission, is compassion for the residents? People make jokes about attorneys…(How do you know an attorney is lying? His lips are moving.) but this one is no joke. Slide.
- An attorney for St. John’s argued that Lopez’s charge should be dismissed. “It was a matter of providing dignity and respect to residents…by speaking a language that residents do not understand…a staff member may make a resident feel uncomfortable in his or her home.” Wanting to hear English being spoken is not a matter of personal preference for confused residents. They need to have a sense of security where they live and from those who are there to provide care. If a CNA switches to another language while she is on the job, then she has switched off her residents; she is no longer with the residents. Which leads me to this last component of compassion as it pertains to CNAs and the heart of their practice. There was more to this story than what initially appeared in the newspaper. I think the CNA who wanted to speak Spanish was burning out, maybe looking for a way out, through a lawsuit. CNA turnover is very high, too, about 100% a year at my mother’s home. There’s a little 100 -page book , the principles of which make compassion in the workplace more likely. Slide.
- The principles practiced by Seattle’s Pike Place Fish Market apply to anyone in any sector of any organization. You may know of this book from previous seminars or you may have seen it featured on 60 minutes. Slide.
- “There is always a choice about the way we do our work, even if there is not a choice about the work itself.” And Ms. Lopez made her choice. But so did her supervisor. Only one made a compassionate choice. The authors of Fish emphasize four points; I’m skipping ahead to the fourth, the last one, because it’s the big one… Slide.
- It is…Being there. And this is compassion as it applies to CNA practice from the point of view of family, I believe. It’s a commitment, an agreement. It’s not just punching in. It’s being there, being fully present, and in tune with the resident. Slide.
- Every one knows who they are, the compassionate CNAs. There is Gwen (the model for the character Joy in my book because that’s what she was- a joy) who told me she learns each resident. She learned that my mother’s morning anxiety could be relieved with a cup of decaf coffee. My mother used to walk to the vending machine and buy coffee, 7-10 times a day, until she forgot there was a vending machine and by that time she was walking with a walker and couldn’t have managed the hot cups of coffee herself anyway. So Gwen made a pot of coffee each morning and brought my mother a cup whenever she seemed distressed. Slide.
- I used to encourage my mother to write things down that she wanted to tell me or to remember. She seldom did. But once she wrote, “The night nurse is so kind.” I came at night to seek out this nurse and find out what she was doing. .. What she was doing was noting my mother’s evening disorientation. My mother would block the entrance to her room, by parking herself in the door way. When her roommate tried to enter, she refused to budge, insisting this was her room. The CNA didn’t try to reason with my mother. She’d ask her if she’d like an ice cream. My mother would say, “Oh, do you think you could get me some?” The CNA kept single-serving sized containers for her in a refrigerator. Once the ice cream was in her hands, my mother forgot about her claim to the room. This is another CNA who learned the resident and was present in the resident’s moment. And then there is the man, the CNA from Ethiopia, who would actually knock on the door before he entered the room. Here is what families of residents see posted in the hallways of the nursing home. So this is what families expect to see, although I didn’t see it much. Slide.
- Always knock before entering a room. Wait for a response. Knock even when the door is open. Privacy should always be ensured. Slide.
- I was often present when Gutama’s shift started and what made him unique among his peers was his entrance. After he knocked on the door first and then came in, he’d stand in front of my mother so she could see him and then he’d greet her by name. Next, he would say, “I am Gutuma and I am a nurse.” Now that is important if the resident thinks she is a 36-year-old woman with her sexuality intact. She can see he’s a man, but she may not understand that he’s a nurse. Once when my mother was in the hospital after an episode suspected as having been a small stroke, she emerged from the emergency room in very good spirits, said of the staff that they were a fun bunch. Slide.
- My husband and I were with her and I introduced her to him since she sometimes did not remember him. Near the end of our visit, he said, “Well, I’ll be going now. It’s 9:30, past my bedtime.” She grinned and winked, sort of a you betcha --Sarah Palin- come-on wink and grin and said as seductively as a woman who’s 80 but thinks she’s 30 can, “Oh, you don’t have to tell me about your bedtime.” I don’t know who she was thinking he was, certainly not her son-in-law, or what she was thinking her relationship to him was. My point is these moments can be funny and harmless and sometimes you just have to laugh, but on other occasions, they can be frightening to the patient as well. Slide.
- A man breeching what she perceives to be the privacy of her room could be threatening if the female resident doesn’t understand who the male is, if all she understands is that she is alone in the room and she is a woman. Then there is fear and insecurity. That’s pain. But Gutuma would add, “ I’m going to take care of you this evening,” followed by a smile and, “Is that okay?” She never said no. Gutuma would repeat this introduction every time he came in because of his awareness that she would not remember him from day to day or hour to hour. He did not expect her to remember. Compare that to another CNA who entered the room and asked my mother, “What time do you want to go to bed?” Seems like a reasonable question except people with Alzheimer’s don’t get time and sometimes they think they’re going home. So my mother was confused and to cover her embarrassment, more pain, said, “That’s hard to tell.” Dementia is difficult to deal with, no doubt. I would call it incredibly challenging work, requiring special training. My mother’s short term memory was so profound, I could ask her if she would like to watch Casablanca and she would look at me and say, “My mind is blank. I don’t know what you just asked me.” But, in spite of the challenges, there are CNAs who do maintain a healthful presence in the lives of their residents with Alzheimer’s and other dementias. They practice an awareness that I think makes compassionate care possible. The character Cate that I created for my book is a compassionate CNA. Her not being fully present during what might have been a harmless moment of inattentiveness seriously hurt her daughter, led to the end of her marriage, and damaged her self-esteem. Later, she saw the absence of being there again in her CNA practice, when she took her eye off the ball for just a few minutes. Slide.
- “The three-five minutes I chose to deal with Jessie rather than answer that call light were three-five minutes I could have been assisting Sally, three-five minutes that may have prevented her fall, three-five minutes I wasn’t there.” I think being present is a huge component in compassionate care. Slide.
- This is what I’ve observed compassionate CNAs doing: They choose and agree to be there with the resident in a relationship and they relieve pain, psychological or physical, and provide comfort where that is possible. They are not the ones who enter a resident’s room, close the door, sit down in a resident's chair, take out a cell phone and call their boyfriends for a chat while the resident lies in her bed and waits for her care to begin. The caring ones don’t want to cause the resident any unnecessary discomfort, including psychological discomforts like fear and insecurity. The compassionate CNAs don’t check out until they punch out. Slide.
- Reduced to its simplest terms, compassionate care which is at the heart of CNA practice, from my point of view, is being fully there. You as teachers of CNAs can’t fix the whole health care industry or that for-profit model of health care that has created some obstacles. But you do have one thing that the corporate world of nursing homes and its CEOs don’t have. Slide.
- Access to CNAs while they’re still in training. Expecting CNAs to make compassion the heart of their practice is not expecting them to do more work, just more compassionate work. The CNA who told my mother, “You’re just like me. I have a bad memory, too,” had not added more to her workload by committing a compassionate act. The act did not deplete her resources. In fact, I imagine, it energized her. She must have felt very good when she saw my mother’s reaction. Clearly, my mother felt good. It was an example of what the poet Marianne Moore would call the giving heart gathering, too.
- A contemporary and popular theologian and writer of comparative religions, Karen Armstrong, reminds us that “at the core of every single one of the world religions is the virtue of compassion, which does not mean “pity”; the Latin root means “to feel with the other.” Armstrong points out that all religions teach compassion and her conclusion is that compassion makes us happy. I’m not going to start singing Kum-ba-ya or anything, but I agree. Look what the great bard Shakespeare, no Buddhist monk or Catholic nun, had to say. Substitute compassion for mercy and you have the same sentiment. Slide.
- “The quality of mercy is not stain’d. It droppeth as the gentle rain from heaven Upon the place beneath. It is twice blest; It blesseth him that gives and him that takes.” So you’re not asking CNAs to work harder, you’re asking them to feel the sun on both sides of the face. You’re tapping into their integrity, the higher part of themselves. Let’s say one of you persuades one CNA candidate that compassion is the heart of her practice, no matter what she sees going on in the nursing home to the contrary, and by that compassion you mean … Slide.
- Being fully there. Not just punching in, but being fully there in the resident’s moment, and you mean choosing that attitude as you go through your day… if one of you convinces one CNA to make that agreement, then at least ten nursing home residents will get more compassionate care. Slide.
- One of them could have been my mother. One of them could be yours one day. Ten nursing home residents getting more compassionate care is not nothing; it is something. And if it happens, I’ll call it progress.
- What if two of you reach two of them or if five of you reach ten of them? We’re talking big numbers and lots of compassionate care. Thank you for trying to do that, for having a retreat theme of such importance and for inviting me here.