Posts Tagged ‘Culture Change’

Working Thanksgiving

November 26, 2011

Nursing homes never close.   Weekends and holidays are included in the work schedule.  The most popular holidays to have off are Christmas and Thanksgiving.  New Year’s Day is special to those who party the night before.

I worked Thanksgiving last year. It was my turn. We planned our meal at home around my absence. I was annoyed. Holidays are family time and I hate missing my routine, watching the Macy’s Thanksgiving Day Parade in my flannel pajamas and fuzzy slippers, spending most of the day in the kitchen, basting the turkey, mixing batter for pumpkin bars, smacking the boys’ hands as they dip a finger for a taste, peeling ten pounds of potatoes, listening to Johnny Mathis croon Christmas tunes, and later, after the feast and dishes, football games.  Next year, I thought with a sigh.

Oh well, I reasoned, go in early, leave early, dinner with in-laws by four o’clock, help with dishes at their house, and finally football at home. The day won’t be a total wash, but not what I love.  I hit the time clock by the nursing home kitchen door at seven twenty-six, making Thanksgiving a work day.

The halls were quiet, not like a usual nine to five day.  I got the daily newsletter printed and delivered. As I visited room to room, my elder friends greeted me with “Happy Thanksgiving, It’s so nice to see you here today.”  

Most every room’s television displayed marching bands, floats with popular singers, and giant helium balloons coming around the corner onto Sixth Avenue from Broadway in New York City.  Mary and I watched  Kermit the Frog wave to the crowd. Down the hall and around the corner Olive and I laughed at Ronald McDonald as he looked to be running to catch up to his fellow helium-filled buddies.  I sat on Earl’s bed while we watched a marching band move into formations while keeping tune. Earl kept time with his right foot tapping on the linoleum floor tile.

I dropped by the kitchen to see how the holiday dinner was coming along.  Three, golden brown twenty pound turkeys lay side by side in baking pans, Raymond, the chef, kept an eye on the candied yams, green bean casserole, oyster dressing, and glazed carrots.  He was chopping cranberries for the relish and had a pot boiling on the stove for ‘real’ mashed potatoes. Yeast rolls rose in the warming tray and gravy bubbled in a pot.  Twenty-five homemade pies cooled on the rack. In my thirty years, I’d never seen such a feast. I smiled with anticipation for the elders and went back upstairs to transcribe the list of “things we’re thankful for” residents had turned in the week before.

Robert, the maintenance assistant walked into the Activity Room for his break, and put on a pot of coffee.  He was working Thanksgiving day too. As the smell of brewed coffee filled the room, Robert pulled up Tractor.com on the computer and drooled over several John Deere four-wheel drive machines with enclosed cabs.  Robert’s a farmer at heart, keeping up with a small cattle farm single-handedly in addition to his forty hour work week at the nursing home. 

The elders love Robert.  They’ve adopted him as their son.  His daily rounds include a tool box filled with wrenches, hammers,  hugs, cups of coffee,  and often, just five minutes of time to listen to stories. 

“What are you doing at noon?” I asked him.

“I don’t know, probably checking the tags on fire extinguishers, why?”

“Can you carve the turkeys in the dining room?”

“Sure,” he said. “Where’s the knife?”

We searched the cabinets and finally came up with a fairly large, straight edged knife.

“Can’t cut hot butter with this thing,” Robert said, running his thumb across the dull edge. “Let me go find a file.”  Suddenly, he was in his element, finding an implement he could sharpen, like a blade on his hay mowing machine.

Robert and I met upstairs at 12:00 sharp. There are sixteen tables in the dining room. Sixty-four people, dressed in their finest, bowed their heads as Nannie gave thanks.  “We gather today to count our many blessings,” she said. “Thank you Lord for everyone here, for the hands that prepared this meal, and for another year of life. Please help us remember to appreciate each day we are given and to love those around us. Amen.”

Robert carved, and the rest of the staff members served the feast.

The large, flat screen television over the fireplace is perfect for football. Dallas and New Orleans faced off and old men stared intently at the action. One shook his fist at an Umpire’s call. Several cheered when their team scored, and a few on the losing side cursed. It was just like home, only with wheelchairs.

I brought the craft materials into the dining room where several ladies helped me glue the Thanksgiving quotes onto a tri-fold poster board. Earlier in the week, each elder had been given a strip of paper. “Think about what you’re thankful for,“  I said.  We’ll post them on Thanksgiving day for everyone to read.”

“I’m thankful for my health.” –Albert

“My children.” –Jim

“The staff here.” –Mary

“Science Club” –Sonny

“To have won the battle against Cancer.”—Hazel

“Friends” –Anne

“I wasn’t born a woman.” –Robert

“Having enough food to eat, and a roof over my head.” –Patty

We unfolded strip after strip of paper, transcribed with so many blessings in shaky handwriting, by nursing home residents who still felt thankful.

“You write one,” Constance said to me.

I took one of the strips and wrote in bold letters:

Spending Thanksgiving Day with my Friends here.

The Importance of Apples

November 20, 2011

Margaret-Dawn Thacker

Usually, when corporate executives visit the nursing home, the experience raises everyone’s blood pressure. Their expectations seem so unrealistic. After all, they sit in some office somewhere and make policy. We are busy taking care of basic needs and attempting to add a little light into old, frail lives.

This week, the biggest of the corporate folks arrived in force. The company has re-organized due to cuts in the Medicare program. The new directors are moving across country, visiting all the homes, offering assistance, best practices they’ve seen on their travels. They’re asking us questions. They’re encouraging us to share our best practices with them. They’re listening.  Our blood pressure has leveled off, maybe even decreased.

Prior to their visit, sometime over the weekend, someone dropped off a bushel of apples from a local orchard. They were on my doorstep at work Monday morning. I was excited. Here was an unlimited variety of meaningful activity for my elders, a week’s worth of fun, pies, apple butter, applesauce, dried apples, sliced raw apples, juice running off whiskered chins, wrinkled hands peeling, shared recipes, stories of orchards, harvests, and senses enhanced by cinnamon, nutmeg, allspice and real butter.

“You cannot use those apples,” someone said. “They haven’t been FDA approved.”

Something stopped me from getting rid of them. I left the basket of apples on the counter. When staff asked about them, I said I had a plan for them. I wasn’t sure what it was yet, but I knew there was one.

The corporate wheels rolled into the parking lot at varying times on Tuesday afternoon.  They converged in the conference room as our staff whispered, and wondered, and wrung their hands in anticipation. The surface of the place shined, the halls smelled of aerosol orange essence.

There were a whole lot of us, so we met in the activity room. It’s the place where residents feel most at home. There’s a green Formica-top kitchen table with chrome legs, a distressed white-washed kitchen cabinet housing mixing bowls, spices, a flour sifter, a Rumford baking powder cookbook and a china tea set.  Against one wall, a wooden workbench sits under a pegboard with tools attached, a hammer, wrench, oil can, spark plug, fan belt, garden hose sprayer, carpenter’s level and a screwdriver. The piano sits against the other wall with music books. Spider plants and terrariums enjoy the sun from stands in front of the windows. A couch, love seat, and glider rocker sit in a group encouraging rest or reading of the books and magazines on the shelves. It’s a place I’d want to go to find refuge if I lived in the nursing home.

 The VP had us sit in a circle. He introduced himself and asked each of us to do the same and tell everyone how long we’ve worked here. There are five of us who have been working here over thirty years. We are considered the elders of the staff. The VP was in awe of our longevity. He shouldn’t have been. It’s what we do, it’s who we are. These elders are our hearts.

When the meeting disbanded, when we understood the goal, the company director of dining services walked over to my basket of apples.

“You planning some apple activities this week?” she asked.

“I was,” I said.

“And you changed your mind?” she asked.

“They’re not FDA approved,” I said.

“Let’s see,” she said taking one from the basket, washing it thoroughly with soap and water and biting into it. “Seem like perfectly good Granny Smith apples to me, great for cooking and eating. They’d make wonderful pies. Just wash them well,” she said, turning toward the door.

Celia and I peeled a colander full of the crisp green apples this afternoon. She had her own knife, the one she keeps locked in my desk drawer. We tried to outdo each other in making the longest spiral of peel. She beat me hands down. I cored and sliced the juicy quarters into one-eighth inch slivers.

Betty gave up her mother’s apple pie recipe. It took very little coaxing and brought a warm smile to her face.

Robert, a former chef, explained the difference between nutmeg and cinnamon and how much to sprinkle over the pie because Betty’s mother didn’t measure, she just sprinkled.

Elise, whose fingers don’t work like they used to, sugared the apples, and Tessa fussed over the crust.

Ethel tasted the fruit, extolling its tartness and declared it “a good cookin’ apple.”

Laura, who has difficulty finding the words for her sentences, read each step of the recipe with her glasses perched on the end of her nose.

And Sonny, who’d never baked anything in his life, measured out the butter because he didn’t think it was fair to eat a piece of the pie if he didn’t do something to help.

With the oven preheated to 350, two apple pies slid inside and onto its metal rack. We waited the hour of baking, telling more stories of pies from the past, of other mother’s recipes, of days in kitchens from years ago. The scent of cinnamon and nutmeg, butter and sugar filled the room and drifted out into the hallway. Staff members drifted back to us to see what smelled so good. They wanted us to start a bakery. They complimented the group on a job well done.

The only thing better than warm apple pie topped with vanilla ice cream is the feeling of accomplishment in making the pastries from scratch. If you don’t believe it, just ask Celia, Betty, Robert, Elise, Tessa, Ethel, Laura and Sonny.

Build a Green House, They Will Come

January 11, 2010

Our community needs a Green House. Not one for gardening, but one for growing the lives and minds of frail, dependent, elders. One that promotes cultivation of people in a warm environment. Currently, too many of our seniors with physical and cognitive challenges are planted in cold warehouses.

Two of my grandparents died in nursing homes. They had no choice. My grandfather had a massive stroke, lost the use of one whole side of his body, his speech, and his ability to control bladder and bowel.  Days spent in a wheelchair, dribbling food and drink from the corner of his mouth, trying to speak with his eyes alone, made my grandfather the saddest person in my life.  I visited and tried to bring a little light back into his existence, but failed in my attempts. I always left him, crying. A lifetime of fly fishing for trout, growing Beefsteak tomatoes in his garden and building homes from the ground up, only played as old movies in his head.  No one in the nursing home talked to him about his life; no one knew; no one cared to know.

My Grandmother lost her mind to dementia.  She didn’t recognize me.  Looking through me, she mumbled words that made no sense to either of us.  She dressed in backward layers and searched for home.  In her day, she raised five children, cooked meals that fed not only her own family, but others in the neighborhood who were hungry.  She pieced quilts to keep those she loved warm, and braided my long hair while telling me stories of her childhood.  To the staff in the nursing home, she was a wrinkled body that had to be fed, bathed, and chased down the hallway because she wandered, looking for purpose.

When my great-grandparents were elderly and unable to live alone, they spent six week intervals with each of their nine children. When the elders visited, they helped as much as they could with cooking, cleaning, watching the children, doing yard work and small repair jobs around the house.  When they were no longer able to be of assistance in a physical way, they used their knowledge to share recipes and gardening hints. They rested in rocking chairs, and at the end, took to the bed until it was time to ‘go home.’  Family gathered at the bedside, caring for basic needs and listening to last stories. When God and others before them called, this generation was sent to the next life surrounded by love.  Nursing homes didn’t exist.

In the 1960’s family units began to change. Women worked outside the home and children no longer lived in close proximity to their parents.  Something had to be done with Mom and Dad when age took their bodies or minds.  As elders became unsafe in their own homes—leaving pots on the stove, wandering winter streets at night with no shoes, forgetting to eat—families, children, and communities, needed a ’safe’ place.  There was no model.

The early architects of nursing homes looked to the hospital as their model.  Semi-private rooms, long halls, starched staff, polished tile, stainless steel, and shiny linoleum suddenly became ‘home.’  Kitchens were placed far away from living quarters. No one’s mouth watered from the smell of baking biscuits. Laundry swished and swirled in industrial machines and came delivered in folded stacks, with a scent of Clorox. Baths, meals, therapy, activities and laxatives came on a set schedule. For the sake of safety, doors locked, walking discontinued, bodies with weak legs were tied down and when voices rebelled, chemicals in the form of antipsychotic pills hushed them. In caring for elders, quality of life was sacrificed. Staff ‘cared’ the life right out of the wisest ones.

During a visit to the ‘home,’ visitors met with scenes of drooped heads, drooling mouths, calls for “help” and “bring me a pair of scissors to cut this strap.”  Bingo was the only activity that promised a surprise ending in a long and tedious day. Elders didn’t have a say in their care. Their feelings and knowledge were ignored.  They suffered alone in a building filled with people rushing about, or vegetating.

Laws in 1987 tried to regulate care, bringing rights to nursing home residents. It’s a sad commentary on a society that has to pass laws to protect its eldest citizens.  Each of us has these civil liberties—we are born with them, but because of rampant abuse and neglect, Congress passed a ‘Nursing Home Bill of Rights.’  Included in this mandate were the following rights:

  • to be treated with respect and dignity;
  • to receive care, treatment, medicines, and services in compliance with laws;
  • to be free from mental and physical abuse, restraints;
  • to open and read one’s own mail, have access to a telephone, and writing materials;
  • to manage financial affairs;
  • to enjoy privacy in one’s own room,  with a spouse and for the couple to share a room;
  • not to be expected to work for room and board;
  • to have personal belongings.

We, as youthful humans, take for granted and expect these rights. We become outraged if these freedoms are yanked from us.  In 1987, fundamental human rights had to be spelled out and enforced in nursing homes. Legislators developed a three inch thick ream of rules to regulate care facility practice. Nursing homes became the second most regulated industry in the United States behind nuclear power plants. Twenty two years later, there is change, but not nearly enough.

The medical model still exists.  Nursing home residents continue to suffer from loneliness, helplessness and boredom.  Institutions are large and every room, every hallway, looks the same.  Breakfast sits on the plate in a yellow mound. Lunch and dinner are ground into unrecognizable meats and vegetables. Sliced bread is the only piece of normalcy on the plate. There are few spontaneous activities, while choices are limited.

Elders are no longer tied down or given  pills to shut them up, but body alarms have taken the place of restraints.  If someone chooses to rise from a wheelchair and their legs refuse to hold them up, a screeching alarm alerts staff.  In most cases, the noise startles the elder into moving too quickly, and they sprawl on the floor anyway.  As soon as most residents arrive, they are presented with wheelchairs.  The halls in the building are long and the walk to the dining room for meals is quite a hike for arthritic bones. Loss of mobility comes quickly. Loss of self comes even faster. A person’s diagnosis becomes his name, his disability, a nickname, his frustration, and a staff member’s annoyance.

~~~

“There’s a new admission in 208, he’s a fractured hip, a feeder, and a screamer at night.”

~~~

Not all facilities are warehouses for broken, old people.  A reform movement called ‘Culture Change’ is making some progress.   It’s slow in coming, but all needed change seems to crawl when it should sprint. The main principle of culture change is person centered care.  Individuals in these homes are encouraged to thrive in a community environment, not decline. ‘Home’ becomes the operative word, not the residence that each person remembers, but closer than the institutions that exist today.

A social model replaces the medical one. Each resident’s room reflects her personality. Family photographs and artwork recognizable to the individual decorate the walls. Familiar furniture, a favorite chair, a vanity with a dresser set, and a four poster bed with a soft mattress make life more livable.  Memory books, with cards and notes from children and grandchildren, stories from the past, and love letters from a spouse provide comfort. Residents choose when they wake, when they want to rest, what foods they wish to eat, and when they bathe.  Staff members have consistent assignments—they learn the history, interests, likes and dislikes of the elders in their care.  More importantly, the elders recognize their caregivers and relationships develop. Nursing assistants begin to understand that care is not the physical act of bathing and dressing, cleaning and making beds. Care is about the individual, and helping to make her life worth living.

“Clara helps me get dressed for the day, then we can sit and talk a few minutes about the red bird couple visiting my bird feeder this morning,” says Joan, a recipient of culture change care.

Unfortunately, the rules that came in the 1980’s, designed to protect and care for elders, have discouraged a rapid jump into culture change.  Administrators and Healthcare companies are fearful of the new direction. Regulations are strictly enforced and severe monetary penalties are imposed for noncompliance. ‘Infection control’, limits family style dining, homemade foods brought in by the community, and the adoption of pets.  Medical care and treatment still supersedes a resident’s right to eat and drink what he enjoys, or have a peaceful night’s sleep without being awakened for turning, positioning, and care needs.

~~~

“I’m 96 years old. Sure I have diabetes, but I’d rather die from the sugar in a Hershey Bar than die from wanting one,” says Earl, a three year resident in a care facility.

~~~

Staff are so concerned with documenting care , that they don’t have the time to deliver it in a way that makes the resident feel like an individual.

“If services are not documented, they did not occur.” This statement comes directly from a State inspector.

“Get it done, write it down,  that’s what I have to do in eight hours with a caseload of ten residents,” says an overworked C N A. This rushed approach leaves the elder feeling like a piece of furniture to be dusted or a wilted plant needing water.

A forerunner of the Culture Change movement is The Eden Alternative.  It’s a small not-for-profit organization which is turning eldercare on its gray head.  This organization embraces the belief that aging is a stage of development and a person can continue to grow well into the age of elder-hood.  The Eden Alternative has developed new models for housing those in our society who are frail and dependent on others for care.  These communities are called ‘Green Houses’. They promote growth in their inhabitants.  When an alternative Green House is built, instead of an institutional design with long foreboding hallways, smaller, residential housing units are organized.  Each unit houses no more than ten private bedrooms with private baths.  The rooms have doors that open to a short hall or a great room. Each house has its own kitchen, dining room, laundry, front porch, mailbox, backyard with grass, bird feeders, a cat or a dog, and a garden.  There are upwards of fifteen units in a Green House community. Each house has ten elders, and a family of care staff.  Residents can assist as they are able with meal preparation, cleaning, laundry, gardening, pet care—all activities they would normally participate in at home. Recreational pastimes, calendared events, interests and hobbies are pursued with passion or not, depending upon the likes of each individual. Elders feel needed, valued and activities are meaningful. Each house is run separately from the others.  Each small community within the larger, is autonomous.

Where are the nurses?  Where are the administrators, social workers, business office personnel, maintenance workers, housekeepers, and dietitians?  This innovative living concept does away with some positions. Those that are necessary, are housed in a separate unit within the confines of the community. Care staff in the Green Houses are cross trained to provide personal care. Staff cook, clean, assist with activities, budget household expenses and shop for needs.  There is one ‘Administrative Building’, which houses offices and the nursing staff.  Nurses travel from house to house like home health workers. They come at a specific time, provide medications and treatments, then leave. The housekeeper comes once or twice a week for deep cleaning, and the bed and bath linens are taken to a separate building for washing. They are delivered back to the house when clean, reminding elders of the old time laundry services.  Personal laundry is washed, dried, folded, and ironed in each house with the assistance of the residents.  The elders rule their homes. They plan meals, celebrations, spur of the moment ice cream making, trips to the store, or poker nights.

Green Houses in existence have waiting lists. The concept is innovative and studies show that elders thrive in these communities.  Costs are lower, staffing needs are less, and quality time between elders and caregivers increases. With the Baby Boomer population reaching retirement age, society needs a new and better way to care for those who will be unable to care for themselves in the near future.

In a prime example, the City of Charlottesville prides itself on being a mecca for retirees.  Cultural, educational, medical and community based services for seniors abound in this city.  Yet, when a certificate of need is granted for an eldercare facility, an old medical model nursing home is built.  Isn’t it time that we, as an innovative community, take the reigns in the Culture Change movement.  Shouldn’t we set the example of improved quality of life for our frail elders?  Shouldn’t we make the difference before we are placed in a medical model facility and wish we had done something about care when we had the ability?