The Critical Caregivers: Involved, Kind, and Competent
The Critical Caregivers—Involved, Kind, and Capable
In any facility, the official Caregivers (in Beverly’s facility they are certified CNAs/Nurse’s Aides) are the people who have the most contact with any dementia resident. These Caregivers manage the moment-to-moment activities of the residents, including bathroom, dressing them for the night and in the morning, with changes of clothing frequently during the day, moving residents to events and meals, helping them at meals. A fair guess is that 90% of a resident’s interactions, other than with each other, is between the resident and a Caregiver.
What matters for the residents interacting with Caregivers is obviously complex. But these Caregivers have power and authority since they have much control over these interactions. They can be happy and friendly—or not. The Caregivers make complex judgments about how much and in what ways residents need assistance, such as help with eating. To some degree, there surely is a “culture” of Caregivers in any institution. That culture will be managed to an extent by those who supervise, set standards and practices, etc. But the culture is there in other ways, as the Caregivers interact with and influence each other, and the “old hands” influence the new hires. What matters most to me is whether there is a strong culture of kindness, helpfulness, and calm among them. Personalities of Caregivers surely matter, but the culture has an impact on all.
From my experience, here are several kinds of cultural attitudes/behavior that were noticeable to me, both positive and negative.
There are many positive aspects to the culture. Most striking is the skill with which Caregivers respond to violence by a resident. That issue was discussed previously (Anger and Aggression blog), but here we note that Caregivers showed consistent responses to difficult situations of this kind. They remained calm and moved right into the situation without fear.
A specific example was an evening when a man entered a woman’s room and she began screaming because he was striking her in the face (discussed briefly in Anger and Aggression blog). A caregiver brought him out of the room; he then began striking the wall angrily; maybe he was still out of control and dangerous, but my intuition was that he was angry at himself for losing control and attacking someone. Who knows, but at least he did not seem to me to be threatening anyone. The nurse was panicked and ordered everyone in their room with doors locked. I got Beverly in her room but stayed out to observe and perhaps be helpful. A very small female Caregiver, who looked less than half the perpetrator’s size, walked up to him. She took his arm, and calmly said, “It is time to go to your room” and he responded with complete cooperation, so she walked off with him. An hour or so later I saw her and asked her how she managed. She said, “Oh, he has hit me before and I always say calmly, ‘Don’t do that; it isn’t nice to hit’ and he quits. He knows me well since I take care of him regularly and I just tell him to be nice.” Her statement was strikingly matter-of-fact.
And perhaps the essential ingredient in the culture of this facility is kindness and caring. These traits were consistent from all of the caregivers nearly all of the time. And the kind, caring approach generally persisted when a resident was angry with the Caregiver without adequate reason. Usually the best approach to any kind of trouble with a resident was redirection/happy lies, as discussed previously. A woman who was very upset and wanting to leave because the “children are waiting in the car” was best treated with a discussion that often required multiple happy lies to get her over being upset. “We have taken them home to Jane” (the daughter) or “Tom (her son) came and got them.” And there is very often a resident who wants to leave right now to “go home.” A common response was that “We have a nice bed in your own room and as soon as the doctor checks your blood pressure in the morning, you can go home.” In the dining room the kindness can come out with how food is delivered and requests for drinks are met.
A couple of less positive examples of “cultural practices.” One is that here were occasions when many (sometimes, it seemed all) Caregivers would be unavailable and, from reports, they had gathered in a secret place. Presumably they needed some normal social interaction and relaxation. But in the evening, as bed time approached, these disappearances were very disruptive. This process seemed to happen in spells and was corrected with administrative intervention.
Another example seems to reflect the importance of Caregivers to enforce practices that are apparently standard (maybe company policy) even when those practices might not be best for the resident. Caregivers may need to exert control over the resident. The specific example followed Beverly’s terrible fall, recuperation, and a seizure drug, as described in "Medical Troubles, Part 2." Caregivers change residents into their nighttime clothes at bedtime, an apparently required procedure. But (influenced by the seizure drug) Beverly started fighting her Caregiver over pajamas. When I was there, I would sit outside during the nighttime change. In these days, I heard troubles from her room and then went in to tell the Caregivers it was not worth a fight, and they should let her sleep in her regular clothes. This was accepted by the Caregivers as I was her husband. One night two Caregivers went together into her room at bedtime with striking deliberateness. They had obviously collaborated to prove that the “policy” could be enforced. There was a struggle with screaming from Beverly to such an extreme that it sounded as if she was being killed. I realized (correctly) that it was all about pajamas and, though mentally struggling, I decided to stay out of it. Within a very few minutes, it was all over and the two came to the door to tell me she was ready for bed. The next morning I went to the Director of Nursing to describe the incident. I told her I would not provide names, but reviewed what had happened. Then I simply said that I wanted it known that there was no reason for a physical fight over putting on pajamas, that all should know that she could sleep in regular clothes. That was completely the end of that intrusion of this “culture war” at night time.
Recognizing specific Caregivers is problematic as there are so many I could name with compliments. In order to avoid naming some of those many great Caregivers and ignoring others, I retain anonymity with pseudonyms.
William was always on duty when at work and very willing to help out for whoever needed help, unselfishly volunteering. There was always a calm and understated confidence in any assistance or intervention with difficult circumstances. And there was a steady calm reaction to those who were threatening violence
Thomas was a quiet and confident young man. He was not as experienced as many, but made up for it by paying close attention to situations. He too was especially skilled at quiet involvements, providing just as much assertion as needed.
Elaine was one who helped Beverly fairly often; she, too, had an exceptional kindness and calm. And, don’t forget, Beverly had her great skill at understanding people’s underlying feelings, even long after her rationality left. She was obviously sincere in her kind helpfulness, as Beverly knew.
And Rita was also often assigned to Beverly. She was younger than most, but had learned quickly the “culture” of kindness and calm. She was consistently available and helped out with whatever came along.
As I said, there are so many to be recognized. I have not interacted with any of them since covid restrictions, so there is much that I do not know about current people and situations.
What can we all learn from this? First, of course, is paying attention to the culture of the place for your loved one—when you are selecting a facility and during their prolonged stay. As is obvious from the above, a culture of calm kindness is very essential. And, of course, the availability and involvement of these caregivers is central; they provide the preponderance of human interaction in these facilities. And it may be helpful to ask for the Caregiver who seems to be most caring to your loved one; maybe that will be done for his or her sake.
Next, you can change what happens for your loved one. Complaints may sometimes be necessary, but should be cautiously engaged. Suggestions will always be important as well, both to the Caregivers directly and to the administrators about issues that can be adjusted. Maybe most importantly, positive support and appreciation is critical. It mattered to me to thank caregivers for whatever help (feeding, changing clothes, etc.) they provided for Beverly; how little effort that is, but it matters. And sometimes to talk to one of the central administrators about the great work of one of the Caregivers, whether in general terms or about a specific incident, such as the one discussed above. More recently it seemed important to tell the administrators that I strongly supported their taking many actions to prevent covid from coming into the facility.
Note that while these facilities are very costly for families, the Caregivers are on a low pay scale considering the responsibilities they have. At least in this facility, tipping and gifts are prohibited. So the critical element for us family caregivers is to support these paid Caregivers with thanks and involvement in supporting their good work, that is, be helpful however you can.