Tuesday, June 3, 2014

The Fantasy and Reality of Assisted Living

This movie portrays residents in assisted living accurately.
          First, let me say that this is not a criticism of the company I work for. Rather, they are mere observations of things I didn't expect to see.
          Remember how I was gushing about getting this job after experiencing a 2 hour preview (http://aboutlifeandrunning.blogspot.com/2014/05/an-easter-present-or-bust.html)? Well, there were certain things I wasn't shown during that preview. Can one call it a bait and switch? Having finished 3 shifts of orientation (or shadowing as they call it) and a couple of weeks being given my own assignments while working the evening and overnight shifts, the reality of what really goes on in assisted living as opposed to what's presented and advertised in public and what I learned through the online "university", is setting in. And the difference is glaring. No, not in the care of residents. That remains top notch as far as I can see. After all, their families are paying an inordinate amount of money for that care. The ideal and model of the company is highly admirable and every day my perception is that the caregivers strive to achieve that ideal despite the compensation not being proportionate to the amount of work they do. I guess that's the kind of salary you should expect when just about anybody can walk off the street, come in, apply, and be hired as long as you are able to verbalize or show compassion for frail senior citizens.
          Some of the things I learned during computer orientation: Beer and wine can be served to the residents just like home. The culture of the company and their approach to compassionate care for seniors. A lot of the lessons touched on dementia because they have a dedicated "neighborhood" for those residents. We are not supposed to say a resident is incontinent but use a more positive "needs continence care". And some residents who need help feeding, normally called "feeders" in a hospital or nursing home, should be called 'residents who need assistance in feeding". All part of the aim to preserve dignity because regardless of their condition, they are still individuals with the same wants and needs as shown by Maslow's hierarchy of needs, even though they may not be able to verbalize them anymore. The computer orientation emphasized that regardless of what department you work for and/or what kind of care you are providing, everything goes back to the Principles of Service, and that all team members are caregivers.
          After seeing what was portrayed on the computer, I was excited to get started in this new job and apprehensive at the same time because I was the NKOTB (new kid on the block). After just a couple of days, I realized that I would have to deconstruct my previous training and learned reactions in psych units, because the approach in taking care of residents is much different from what I've been doing for the past 3 decades. Different techniques are required to redirect behaviors that in psych units would normally warrant psychotropic medications. For example, both sundowners syndrome, agitation, and echolalia were dealt with medications in psych units. And in psych, there has not been too much family involvement, while in assisted living, the designated caregiver is in direct communications thus having more interactions with the families who are very involved with their loved ones.
          During the 2 hour preview with a lead caregiver, and before accepting the job offer, this is what I observed with the residents I followed, which is the FANTASY part: they were all able to bear weight on their legs and stand up, needed little direction to change their clothes, were able to brush their teeth and comb their hair when given a toothbrush and comb, were able to walk to the dining room for breakfast, and still had some mental orientation left (to time, place, and person). That created a false impression that all residents were like this, fairly easy to take care of, and probably didn't need too much supervision. Another thing they didn't show was a separate "neighborhood"  at the end of one hallway that had a smaller number of residents with much worse mental and physical deterioration. They are what we call in hospitals as requiring total care. And this is where REALITY starts. I didn't find this out until I started my orientation on the overnight shift. I was surprised to see Hoyer lifts, hospital beds without side rails, cushions on the floor beside the beds in case a resident falls off, and lots and lots of continence care and feeding. I found out about the contractures and decubitus ulcers later. When I started "shadowing" or unit orientation, what I saw during the preview suddenly looked different even in the main dementia (it's called memory care) neighborhood. No, not the behaviors of persons with dementia, I expected that, but rather how much more physical care they required. This included assisting them with showers, continence care, clothes changes, ambulation, protection from falling off beds by using wedges and body pillows, use of chux (bed pads), and diapers (we have to call them briefs, pull ups, or wraparounds) and doing laundry 24 hours a day. The evening shift also served dinner, cleaned up, and did dishes. Another thing that was unexpected was the extraordinary amount of housekeeping especially on the overnight shift. After doing continence checks at the start of the shift, we had to give the dining/kitchen area a thorough cleaning - disinfect tables and chairs, clean fridge inside and outside, set tables for breakfast, wash clothes, kitchen linen, and aprons, pick up the trash in all areas, and prepare coffee for the next day. I already touched on those in this blog entry: http://aboutlifeandrunning.blogspot.com/2014/05/my-new-duties-responsibilities-in.html . I have a similar list for the evening shift which I have to update and have not yet posted. I found out from another caregiver ad on the internet that this is called the Universal Worker Model. So in short, the work is very, very physical, and because I move a lot when I'm on shift, I actually am losing weight. Might I add that the work is almost non-stop for 7.5 hours other than a lunch break and two 10 minute short breaks? Having finished all my orientation, I had to deal with reality - having my own residents to take care of. And despite one evening shift and two overnight shifts of orientation, I still felt unprepared to work independently. The lessened flexibility of my brain as I get older may partially have something to do with that.

          The difficulty I'm currently having while I'm new is this: since the residents don't wear wrist I.D. bands, I'm finding it hard to connect the name with the face, the type of care he or she needs, and how the residents prefer to be helped since what may work for one may not work for another. Or even what worked yesterday for a certain resident, may not work again today or maybe even a few minutes later. I look at the assignment sheet, add my own notes based on what I ask the other caregivers, or read the Individualized Service Plan (treatment plan). Another difficulty I'm having is locating the belongings of a resident in his or her room - where is the underwear, the blouse, the nightgown, the toothbrush, denture cup, continence care products, etc.? So I'm fumbling that too and it takes me longer than the regular staff to do it. Heck, I can barely find my own stuff at home much less doing it for 8 to 14 residents whom I don't know yet!
          As time goes on and if I can adjust my brain, then I believe I'm going to like it there. I'm just getting unnecessarily anxious due to the fear of failure. I have to give myself a chance to do the job, maybe fail in some aspects as long it doesn't harm the residents, then learn from them.  I hope my co-workers will be patient and understanding because they may have gone through a similar experience when they were just starting out. I too can do this eventually and hopefully sooner than later! To my co-workers, please don't hesitate to ask me if I already did this or that, or tell me what else needs to be done if you notice I haven't done it. That way, I can learn from you. Because even though I tried to take copious notes about what to do and how to do it, what I interpreted as what you said may differ to what you meant. So please bear with me and thank you in advance.
          Which leads me to the questions: why are there so many caregiver agencies? Are more seniors preferring to stay at home and just have a companion (basically an hourly paid housekeeper)? Is it a very lucrative business? Is home care the new nursing home? Or maybe these businesses have been there all along and I was just not aware of them? Perhaps it's just a cheaper version of a CHHA (certified home health aide) without the certification so they can be paid lesser.

Other random thoughts on this topic:
·         *They call shift report a handover and it's only between 2 lead care managers (CM). Other than the lead CM's who work 8 hour shifts, the rest work 7.5 hours. Which begs me to question why management is giving people a hard time when they clock out more than 5 minutes after their shifts? After all, they don't get paid overtime until it's over 8 hours for the shift.
·        * Are the unsuspecting workers being given the old bait and switch based on the glaring difference between the preview and the reality? What's the difference between an RCFE (residential care for the elderly)and a SNF (skilled nursing facilty/nursing home)? Perhaps it's the ability to pay exorbitant fees out of pocket for rent and caregivers vs. paying with personal assets and governmental assistance for nurses and nurse's aides. But you get excellent care given by underpaid caregivers.
·         *The fantasy and the harsh reality - I truly admire and have absolute respect for people who do this for a living, me excluded because I'm still learning and have to achieve even an iota of their skills. I'm afraid my co-workers are going to say "he's not good at this job, he did a bait and switch on us too based on his resume". And by the way, a similar job in the Philippines, you might be called a maid or house servant. Maybe 8 months of unemployment has made me soft.
·         *If there is one thing I'm getting out of this job, it's that I'm learning to smile more, being more compassionate with residents because that would be me in a few years, and more appreciative of what the caregivers do.
·        * The residents of assisted living and I (well, mostly me) were singing along while watching The Sound of Music before dinner one afternoon, and despite their dementia, they were enjoying it. Too bad I had to leave the TV room to set the tables in the dining room. That movie is shown several times a week by the way because they like it so much.The interactions with the residents I enjoy, the showers and diaper changes, not so much.
·         *When we were signing our hire papers, we were reminded by human resources that stealing is a basis for termination. I asked her if that included stealing someone's heart (more specifically, the resident's hearts). She said I can steal those as much as I want.
·        * Maybe, just maybe, if euthanasia is an option when I get to the stage where some of the residents are in, that's a decision that could be made. In short, when I get to that condition, please off me if that's my wish.
·         *The work is hard but the food looks and tastes great, and we are allowed to eat with the residents at their table. Although there is so much wasted because the leftovers are just thrown away.
·         *On my birthday, 6 of the 7 residents I was taking care of at the area behind closed doors gave me special presents when my night shift ended, but it was not of the pleasant kind, and came in all shapes, sizes, and textures. The first initial of this present is a B, and the second initial is an M. Yes, it was a BIG MESS!
·         *And yes, I do love the pets where I work (^.^)

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