I'm studying intro to psych on my own as one of the pre-reqs I'll need for nursing school, and read this paragraph today:
"Impaired memory, particularly for very recent events, typically is one of the first symptoms to appear. Poor judgment, language problems, and disorientation may appear [...] and episodes of distress because they feel confused. Their behavior may become uninhibited, they may lose the ability to perform familiar tasks, and they may experience significant physical decline in addition to cognitive impairments. [...] being a caregiver for a spouse or one's elderly parent who has developed dementia often is a stressful and psychologically painful experience. Over half of the people diagnosed with senile dementia show combinations of depression, anxiety, agitation, paranoid reactions, and disordered thinking that may resemble schizophrenia. Ultimately, they may not even be able to walk, talk, or recognize close friends or family members."
Sigh.
Betty has had us think of all the terms we can in class for bowel movement and urination, so that we'll recognize when patients or residents are telling us they need to go. Hospitals and long-term care facilities should actually have a copy, on each floor, of a notebook that catalogs all such terms. This is necessary in part because of the loss of inhibitions that accompanies Alzheimer's, in particular: people who had been gentle and discreet before its onset can become potty-mouths.
She told us about a 3-level Alzheimer's facility nearby, where the least-impaired, sweet, mildly forgetful Mrs. Smiths are on the first floor, and hostile and foul-mouthed residents occupy the second, and the third is for residents who mostly can't do anything for themselves any more. They're all on their way to the 3rd floor eventually--there's no cure, and they all go through the emotional, physical, and mental decline. Our job, she says, is to respond to even unkindness in a therapeutic manner. To figure out how to find connection and fulfillment in meeting the needs of even the most difficult residents. And to know our own limits, and ask our nursing supervisor occasionally to transfer to a less emotionally trying section of a facility if such a spot is available. I wonder, especially in light of Hazel's comments, whether such a transfer is realistically possible in most workplaces. It seems incredibly trying to respond to aggression gently. But I've learned to do it with my daughter, because I have a different set of expectations about what a 2-year-old is capable of and "means" by her actions. She is not yet herself. I suppose I can try to adjust my expectations consciously when I work with people who are no longer themselves.
Betty has occasionally calmed a distraught patient by putting a pile of clean washcloths on her overbed table and asking her to help fold them. I find this poignant; I suppose such a task can ground a woman who has spent a lifetime doing laundry for others, and who is now feeling lost and helpless. Betty says "it'll take her an hour." She is a no-nonsense instructor, but her tone of voice as she relates these things to us, imitating herself in such situations with vulnerable and confused patients or residents, is incredibly kind and non-patronizing.
She emphasizes that in a healthcare situation, as healthcare providers we are _always_ in a position of power, and patients/residents are vulnerable, and often perceive themselves to be, so they can be fearful of us as well, that we might withhold care, and let them suffer. Funny--I'm guessing most NACs don't have good enough health care insurance to afford the kind of care they themselves provide to others, but I suppose it is true that the balance of power between the p/r or the NAC is in the NAC's "favor," for the little that is worth. :/
Sunday, May 31, 2009
Friday, May 29, 2009
Healthcare Fails & Jobsite Reconnoitring
Betty has told us some disturbing war stories, some on specific events, others on things that tend to happen.
In the tends-to category, the day she showed us how to clean and care for dentures, she told us to be really conscientious about them (she actually said to "be ever-so-careful"), because they are expensive, warp easily, and along with hearing aids, are the number one item to fall into the bed and be sent out with the laundry. Eek.
There was a point in her career where she worked for an agency that would farm her out to cover staffing shortages at various facilities for 16-18 hour shifts. She said she saw some really unacceptable, unhealthy, unsafe stuff going on at the different places she'd go to about once a month. During one of her shifts it took her _2 hours_ to wash a female resident's hair because of how gnarled it had become from neglect.
She advocates answering call bells quickly. She says she's seen it happen lots, and there's nothing sadder than getting to a room in a longterm care facility to a resident who's broken down in tears, saying "I put the call light on, but no one came, and the doctor just prescribed me this new laxative, and I tried to hold it and just couldn't"--and the person has messed him/herself. It's a first-order health risk, since urine and feces damage the skin, especially the fragile, non-elastic skin of elderly people, and it's also such a blow to a person's self-esteem. How can you have any dignity or sense of self-worth when you're unable to avoid going on yourself?
Several weeks ago a student ask how we should go about finding a job, or deciding where to work. I must confess I'm not currently looking, even though I intend, rather abstractly, to find a job for this summer after I'm certified. Anyway, Betty said what she's done for hospitals is dress normally, go to the cafe, drink a cup of coffee, and pay attention to how long call lights stay on at the nurses' station and listen to how and if people talk about patients. She also said that if anyone stops to see what you're up to, tell them honestly, and if s/he is a nurse or NAC, take the opportunity to ask them what they think about their job, what they like best about their place of work, etc. Clever, and I wouldn't have thought of it. Isn't it great in life that we can learn from others and don't have to reinvent the wheel? I'm not sure, however, how such recon would play out, if it could, at a long-term care facility.
In the tends-to category, the day she showed us how to clean and care for dentures, she told us to be really conscientious about them (she actually said to "be ever-so-careful"), because they are expensive, warp easily, and along with hearing aids, are the number one item to fall into the bed and be sent out with the laundry. Eek.
There was a point in her career where she worked for an agency that would farm her out to cover staffing shortages at various facilities for 16-18 hour shifts. She said she saw some really unacceptable, unhealthy, unsafe stuff going on at the different places she'd go to about once a month. During one of her shifts it took her _2 hours_ to wash a female resident's hair because of how gnarled it had become from neglect.
She advocates answering call bells quickly. She says she's seen it happen lots, and there's nothing sadder than getting to a room in a longterm care facility to a resident who's broken down in tears, saying "I put the call light on, but no one came, and the doctor just prescribed me this new laxative, and I tried to hold it and just couldn't"--and the person has messed him/herself. It's a first-order health risk, since urine and feces damage the skin, especially the fragile, non-elastic skin of elderly people, and it's also such a blow to a person's self-esteem. How can you have any dignity or sense of self-worth when you're unable to avoid going on yourself?
Several weeks ago a student ask how we should go about finding a job, or deciding where to work. I must confess I'm not currently looking, even though I intend, rather abstractly, to find a job for this summer after I'm certified. Anyway, Betty said what she's done for hospitals is dress normally, go to the cafe, drink a cup of coffee, and pay attention to how long call lights stay on at the nurses' station and listen to how and if people talk about patients. She also said that if anyone stops to see what you're up to, tell them honestly, and if s/he is a nurse or NAC, take the opportunity to ask them what they think about their job, what they like best about their place of work, etc. Clever, and I wouldn't have thought of it. Isn't it great in life that we can learn from others and don't have to reinvent the wheel? I'm not sure, however, how such recon would play out, if it could, at a long-term care facility.
Thursday, May 21, 2009
Clinic
I have really enjoyed, and felt intimidated by, learning skills that require me to use my hands, not just my head. We've had to make an occupied bed, clean dentures, take blood pressure (that's so hard!), and we're way behind. There are a total of 24 skills we have to know for the practical part of the NAC exam, and they all have lots of steps. The actual book the state publishes that supposedly contains all the information is dreadful. A given skill will contain some number of steps, but their division is arbitrary--some are separated, some chunked, some skipped--and their directives are often unclear. Step 4 says, in useful, clear, commands, "Raise the side rail on the working side and move to the other side of the bed." Step 5 will say, "Patient is covered with clean top sheet, bath sheet and/or soiled top sheet has been removed." When? Before which step? Doing what before or after? The book is full of these. And we've just finished our 3rd week of class, next week has a holiday, so we have only 8 more classes in which to learn to do all these skills. Eep!
Our lab is old, and full of old, no-longer-standard equipment. Betty grumbles about it and it's pretty funny to hear her. We have about 10 beds in the lab, and at least 4 of them have side-rails that extend the length of the bed. Nowadays, no healthcare facilities have these, since leaving them both up is a form of physical restraint, which, like chemical restraint, only occurs under physicians' orders, and only when it is considered a way of protecting a patient (not staff) from harm, if no other methods work. Facilities now have beds with 4 side-rails, two at the top half of the bed, two at the bottom half, and only one half is left up at a time.
We practice skills like feeding or making an occupied bed in 3's: one do-er, one patient/resident, and someone to read the misleading and infuriating steps out of the NAC book. Therefore, the 4 or 5 fragile and expensive mannekins in the lab are in our way, we have to stack them on top of each other, where they lie, foley catheters askew and limbs partially detached, looking ghoulish and abused. The first day Judy saw us do it, she commented that it looked like Auschwitz. Incidentally, for this purpose we use one of the over-long-side-rails beds one of the now-verboten rails of which is permanently and unhelpfully stuck in the up position.
Unlike in the classroom, where there are books and a lecturer involved, I feel hapless in clinic, which is good, because it is humbling and means I'm not a "seminar pariah"--each of us is useless at some things, skilled at others, and all of us, even Betty, don't perform skills in exactly the same order as they're written in the pamphlet. And all of us need extra help figuring out how to measure blood pressure. Betty is taking extra time this week and next to do FORTY-FIVE MINUTE tutorials with every pair of students in our class willing to take the time to do that with her. That is a _lot_ of extra hours for her. She's really, really, dedicated. And often impatient with me, and I don't even mind, which is funny.
Our lab is old, and full of old, no-longer-standard equipment. Betty grumbles about it and it's pretty funny to hear her. We have about 10 beds in the lab, and at least 4 of them have side-rails that extend the length of the bed. Nowadays, no healthcare facilities have these, since leaving them both up is a form of physical restraint, which, like chemical restraint, only occurs under physicians' orders, and only when it is considered a way of protecting a patient (not staff) from harm, if no other methods work. Facilities now have beds with 4 side-rails, two at the top half of the bed, two at the bottom half, and only one half is left up at a time.
We practice skills like feeding or making an occupied bed in 3's: one do-er, one patient/resident, and someone to read the misleading and infuriating steps out of the NAC book. Therefore, the 4 or 5 fragile and expensive mannekins in the lab are in our way, we have to stack them on top of each other, where they lie, foley catheters askew and limbs partially detached, looking ghoulish and abused. The first day Judy saw us do it, she commented that it looked like Auschwitz. Incidentally, for this purpose we use one of the over-long-side-rails beds one of the now-verboten rails of which is permanently and unhelpfully stuck in the up position.
Unlike in the classroom, where there are books and a lecturer involved, I feel hapless in clinic, which is good, because it is humbling and means I'm not a "seminar pariah"--each of us is useless at some things, skilled at others, and all of us, even Betty, don't perform skills in exactly the same order as they're written in the pamphlet. And all of us need extra help figuring out how to measure blood pressure. Betty is taking extra time this week and next to do FORTY-FIVE MINUTE tutorials with every pair of students in our class willing to take the time to do that with her. That is a _lot_ of extra hours for her. She's really, really, dedicated. And often impatient with me, and I don't even mind, which is funny.
They hear you
Betty says to be aware of what we're saying to and around patients and residents, and to never say anything we wouldn't want re-broadcasted over a loudspeaker. Unconscious, partially conscious, "asleep," heavily drugged, whatever, they might, and often do, hear you. Betty's mom underwent highly invasive back surgery years ago, and the last thing she heard as she went under was the surgeon saying to a resident, "the bigger the cut, the more you can charge." Yikes! Betty went on to say it's not just a matter of avoiding saying the wrong things around patients, but that we should also try to talk to them kindly and conversationally, even the unconscious ones. "Hi, Mr. Smith. It's a beautiful day today. It's around 12 o'clock noon, May 21st, the sun is shining. I went on a vacation last week to the ocean. The water was so lovely... You know, talk to them as if they were your signifant other, or your parent, or child."
At this point a student asked, "How do we avoid getting attached to patients?" "You don't," said Betty. "I have held many people as they've passed on. I've had people cry in my arms when their spouse passed on. You're allowed to have emotional connection with your patients, it's how you display it that determines whether it's appropriate. Are you gonna pass by someone in the hallway who's sobbing against a wall without asking them what's wrong?" She said if you present a robot-like mask to the people you're serving, you're doing that to protect yourself, not for them. And our job isn't about our convenience, it's about our patients' and residents' well-being.
This seems like a job where one has the opportunity to do really good work and make a difference for people who are vulnerable. I hope it will help me to cultivate my better angels, kinda the opposite of how, I think, had I become a lawyer, I would've become successful by strengthening my worse qualities.
At this point a student asked, "How do we avoid getting attached to patients?" "You don't," said Betty. "I have held many people as they've passed on. I've had people cry in my arms when their spouse passed on. You're allowed to have emotional connection with your patients, it's how you display it that determines whether it's appropriate. Are you gonna pass by someone in the hallway who's sobbing against a wall without asking them what's wrong?" She said if you present a robot-like mask to the people you're serving, you're doing that to protect yourself, not for them. And our job isn't about our convenience, it's about our patients' and residents' well-being.
This seems like a job where one has the opportunity to do really good work and make a difference for people who are vulnerable. I hope it will help me to cultivate my better angels, kinda the opposite of how, I think, had I become a lawyer, I would've become successful by strengthening my worse qualities.
Thursday, May 14, 2009
Disaster preparedness
Betty's husband used to be in the military, now he works at the local airport, I'm not sure in which capacity. Yesterday we discussed disasters, since NACs are expected to know the disaster preparedness plan at the facilities where they work and know what is expected of them should one occur. (Maybe a NACs job would to be to get on the phone and call the next shift's RNs and NACs in early.) Betty asked the class for examples of disasters, so people said "earthquakes, volcanoes, terrorist attacks..." Betty said, "and we live close to an airport." I wasn't sure where she was going with this. Like, a plane drops out of the sky onto the city and causes a disaster? She told us that each local hospital has a command center with a red phone manned 24/7. I'm not sure if the phone's color was a figure of speech. One of the hospitals works as an uber-command-center for the rest of them, so that in case of an emergency, it can quickly be determined which hospitals have how many beds, how many can be made available in X amount of time, how many operating rooms can be up and running quickly... I asked if the need to use this system had ever arisen here. "All the time." "Why don't we hear about it on the news?"
So then she told a story. Back in her 20s, she'd run away from home (clearly that was all resolved later--the first day of class she mentioned caring for her Daddy when he was dying). She was living at the YWCA in Memphis and didn't have a car or 2 pennies to rub together, so she walked to the local AT&T office (then Southern Bell) without any identifying papers whatsoever, and got a job as a long-distance operator--headset, cords, plugs, the works. If the person next to her was missing, she'd scoot her chair in-between their two stations and work two switchboards. (At this point in Betty's story, Judy piped up that she'd done the same job back in the day, as well.) Betty worked a split shift: 10am-2pm, 10pm-2am. So she'd walk along Beale Street between work and the YWCA multiple times a day. One day she went into work and after a while, the whole switchboard lit up. She thought it was on fire at first. No one could get through to anyone. She finally found out that Martin Luther King had been assassinated. After working for what felt like days and was likely 18 hours, she walked home in a daze, and said it was like a war zone outside. When she got back to the YWCA she went up onto the roof where the other women were gathered, because from that vantage point, they could see the Lorraine Motel, and the window of what had been MLK's room. Police were milling about. Anyway, Betty's convinced that, as awful as it was that MLK was killed, the panic and chaos that followed his death compounded the tragedy, with people's reactions making things worse.
So, she said, bringing it back to our local airport, stuff happens here all the time, and it's dealt with efficiently and safely, and it never shows up on the news, because that wouldn't be helpful or productive, since people's reactions would make things worse. I find that thought creepy. Like what? Airplane crashes we're not hearing about? I'd love to figure out what's not making it to the news that's of enough concern to make multiple hospitals coordinate bed and operating-room availability.
So then she told a story. Back in her 20s, she'd run away from home (clearly that was all resolved later--the first day of class she mentioned caring for her Daddy when he was dying). She was living at the YWCA in Memphis and didn't have a car or 2 pennies to rub together, so she walked to the local AT&T office (then Southern Bell) without any identifying papers whatsoever, and got a job as a long-distance operator--headset, cords, plugs, the works. If the person next to her was missing, she'd scoot her chair in-between their two stations and work two switchboards. (At this point in Betty's story, Judy piped up that she'd done the same job back in the day, as well.) Betty worked a split shift: 10am-2pm, 10pm-2am. So she'd walk along Beale Street between work and the YWCA multiple times a day. One day she went into work and after a while, the whole switchboard lit up. She thought it was on fire at first. No one could get through to anyone. She finally found out that Martin Luther King had been assassinated. After working for what felt like days and was likely 18 hours, she walked home in a daze, and said it was like a war zone outside. When she got back to the YWCA she went up onto the roof where the other women were gathered, because from that vantage point, they could see the Lorraine Motel, and the window of what had been MLK's room. Police were milling about. Anyway, Betty's convinced that, as awful as it was that MLK was killed, the panic and chaos that followed his death compounded the tragedy, with people's reactions making things worse.
So, she said, bringing it back to our local airport, stuff happens here all the time, and it's dealt with efficiently and safely, and it never shows up on the news, because that wouldn't be helpful or productive, since people's reactions would make things worse. I find that thought creepy. Like what? Airplane crashes we're not hearing about? I'd love to figure out what's not making it to the news that's of enough concern to make multiple hospitals coordinate bed and operating-room availability.
Privileged
I am changing careers at age 35 with an almost 2-year-old, having just embarked on what will be, at best, 4 years of training before I'm earning real wages. This would not be possible without my husband's deep pockets and near-infinite patience with me (to be sure, on a global level; on a day-to-day basis he's actually human and snips at me when I'm out of line).
This Nursing Assistant certification program is complicated: it began with First Aid certification (two 5-hour night classes), then we took CPR and HIV/AIDs & Bloodborne Pathogens certification courses, each about 8-hour Saturdays. Then there are twenty 2.5 hour classes, and finally 80 hours of clinic in June. One woman who doesn't look much older than me had to bring her (astoundingly well-behaved ) 4-year-old grandson to one of these classes for 5 hours. My husband watched our daughter during the Saturday classes, and my housemates and he dealt with the other irregular class times. We have (and can afford) good, reliable childcare during the days.
There was another woman, let's call her Nikita, who managed to attend all of those irregular classes. On the first day of normal NAC class, when we were told to leave our cellphones off during class, she protested that she has a two-year old with sickle cell, and that she needs to be reachable by phone were something to happen. Betty and her co-instructor "Judy," (who's there specifically to help all the ESL students), agreed that perhaps she could leave her phone on vibrate, and dash out of class to answer it. Nikita hasn't come back to class since about day three. I assume that childcare issues are the reason.
Our economy sucks and so many people are trapped. I listen to Planet Money (http://www.npr.org/blogs/money/) regularly, and keep hearing about people in Detroit who've worked in the automotive industry their whole lives, are losing their jobs, so have mortgages they can't pay, and houses they can't sell, because property values there have dropped at a more dizzying rate there than elsewhere. Who wants to move to a sinking ship?
I, on the other hand, am changing careers mostly because I want to feel like my life is meaningful. Yeah, the economy's this bad, and I get to play around at the top level of Maslow's hierarchy, right? How fair is that? (There's a little more to my decision, but I'll save that for another post.) I think most of the people in my NAC class are there to bump up the amount they're getting paid to provide home care, or in the hopes of getting a decent wage at all--this for me is just a step to learn a little about the field in which I hope to advance further.
And it's not cheap! The course is a little over $900, scrubs, shoes, stethoscope, other random equipment, books, transportation, add up to another $500 or so. I hope and assume a lot of the other students have financial aid for this, but still. I wonder if Nikita will be able to get any of her money back.
This Nursing Assistant certification program is complicated: it began with First Aid certification (two 5-hour night classes), then we took CPR and HIV/AIDs & Bloodborne Pathogens certification courses, each about 8-hour Saturdays. Then there are twenty 2.5 hour classes, and finally 80 hours of clinic in June. One woman who doesn't look much older than me had to bring her (astoundingly well-behaved ) 4-year-old grandson to one of these classes for 5 hours. My husband watched our daughter during the Saturday classes, and my housemates and he dealt with the other irregular class times. We have (and can afford) good, reliable childcare during the days.
There was another woman, let's call her Nikita, who managed to attend all of those irregular classes. On the first day of normal NAC class, when we were told to leave our cellphones off during class, she protested that she has a two-year old with sickle cell, and that she needs to be reachable by phone were something to happen. Betty and her co-instructor "Judy," (who's there specifically to help all the ESL students), agreed that perhaps she could leave her phone on vibrate, and dash out of class to answer it. Nikita hasn't come back to class since about day three. I assume that childcare issues are the reason.
Our economy sucks and so many people are trapped. I listen to Planet Money (http://www.npr.org/blogs/money/) regularly, and keep hearing about people in Detroit who've worked in the automotive industry their whole lives, are losing their jobs, so have mortgages they can't pay, and houses they can't sell, because property values there have dropped at a more dizzying rate there than elsewhere. Who wants to move to a sinking ship?
I, on the other hand, am changing careers mostly because I want to feel like my life is meaningful. Yeah, the economy's this bad, and I get to play around at the top level of Maslow's hierarchy, right? How fair is that? (There's a little more to my decision, but I'll save that for another post.) I think most of the people in my NAC class are there to bump up the amount they're getting paid to provide home care, or in the hopes of getting a decent wage at all--this for me is just a step to learn a little about the field in which I hope to advance further.
And it's not cheap! The course is a little over $900, scrubs, shoes, stethoscope, other random equipment, books, transportation, add up to another $500 or so. I hope and assume a lot of the other students have financial aid for this, but still. I wonder if Nikita will be able to get any of her money back.
Wednesday, May 13, 2009
Communication and interaction in caregiving
Betty talks a lot about communication. There's a specific chapter in our book, _Essentials for Nursing Assistants_, on communication, in which one labels pictures with "message," "receiver," and "sender," accompanied by workbook questions so simple I realized I was overthinking their answers (example: which of the following is an example of communication? (a) giving a gift (b) driving to a friend's house (c) saying something to someone). Betty brings it up all the time, and, I am glad to report, in much more thought-provoking ways.
We talk a lot about Standard Precautions, which are certain procedures you follow in healthcare in which you basically treat every patient/resident (henceforth P/R) as though he or she could be carrying HIV or Hep. That is, gloves if you come in contact with certain bodily fluids, mask + protective eyewear if possibility of splashes, washing hands before and after doing anything with a patient/resident in his/her room... (You do specific precautions if someone has, say, TB, which is airborne, or measles.)
So some student logically asked whether we shouldn't just wear masks all the time. Betty said "No. If you put on gloves to take someone's blood pressure, or come in with a mask on to change sheets they've soiled, what message are you sending?" She went on to explain that it'll freak out a P/R as to how serious their condition is in the first case, and in the second, you humiliate them, because you're sending the message that you don't want to be in that room doing that task. "Learn how to breathe through your mouth or put a little vicks vaporub under your nose." Everything she tells us is centered around the safety and comfort of the care-recipient, and I'm certainly realizing that NACs spend more time with P/Rs than anyone else and likely affect the P/R's quality of life the most. Maybe not in hospitals. But this is certainly the case in longterm care facilities.
Our book mentions Maslow's hierarchy of human needs: a triangle the base of which is physiological needs (food, elimination, sleep), over which is safety, then love, then self-esteem, and finally, self-actualization, and gives examples of what NACs can do to meet each level of need a P/R has. While the ways in which NACs would meet physiological needs are obvious, Betty continually points out ways we're affecting the P/R's self-esteem. We'll likely be caring for the elderly, that is, folks who've spent their lives doing for themselves and others and are now forced to be helped and depend on others.
The main way we can accomplish this, she says, is to give the P/R choices whenever it is possible to do so without jeopardizing their care. "Mrs. Smith, we need to get you a bath so you can be clean and dry, but if that's not convenient right now, would you like me to come back at 9 am, or around 1 after you've had lunch?" She says this works wonders. It is also the main principle behind "Love and Logic," a parenting style my housemate's mother introduced us to, the goal of which is not explicitly to build self-esteem, but rather, to teach children how to make decisions and live with their consequences. The situation in a care facility is obviously different. The trick with L&L with kids is that if kids make a "bad" decision, their parents don't rescue them from the consequences. So it can't work exactly the same with Mrs. Smith--a NAC can't simply not perform care a P/R balks at. The L&L side effect I've enjoyed as a parent is how it calms me down to think through how to present a potential conflict as a choice, and I'm guessing that'll be invaluable on the job, as well.
Most of the things Betty has told us about communication I've "learned" at some point or another, but I hope to internalize it all, because it seems like I'd be a better friend, wife, and family member, as well as employee and co-worker, were I to make a habit of all of this stuff: get down on the person's level--sit, if you can; listen; make actual real eye contact and don't turn away when talking or "listening;" never, ever interrupt (I'm terrible about that); and with the elderly, especially, use a low tone of voice, since this could make the difference for them "between isolation and engagement." We also learned a little bit about resolving conflict in the workplace: ask to speak to the person, in private (eek! scary! but so useful.), be willing to hear stuff you don't want to, talk only about the specific event--don't generalize or psychoanalyze or try to make observations about somebody else's behavior patterns, be willing to agree to disagree, if necessary... I wish I'd learned some of that stuff before going to grad school and stepping on toes and later hiding from those whose toes I'd inadvertently stepped on. Ugh. This stuff is _not_ instinctive for most of us, I think--wish someone had explicitly taught it to me. Never too late, right? :/
We talk a lot about Standard Precautions, which are certain procedures you follow in healthcare in which you basically treat every patient/resident (henceforth P/R) as though he or she could be carrying HIV or Hep. That is, gloves if you come in contact with certain bodily fluids, mask + protective eyewear if possibility of splashes, washing hands before and after doing anything with a patient/resident in his/her room... (You do specific precautions if someone has, say, TB, which is airborne, or measles.)
So some student logically asked whether we shouldn't just wear masks all the time. Betty said "No. If you put on gloves to take someone's blood pressure, or come in with a mask on to change sheets they've soiled, what message are you sending?" She went on to explain that it'll freak out a P/R as to how serious their condition is in the first case, and in the second, you humiliate them, because you're sending the message that you don't want to be in that room doing that task. "Learn how to breathe through your mouth or put a little vicks vaporub under your nose." Everything she tells us is centered around the safety and comfort of the care-recipient, and I'm certainly realizing that NACs spend more time with P/Rs than anyone else and likely affect the P/R's quality of life the most. Maybe not in hospitals. But this is certainly the case in longterm care facilities.
Our book mentions Maslow's hierarchy of human needs: a triangle the base of which is physiological needs (food, elimination, sleep), over which is safety, then love, then self-esteem, and finally, self-actualization, and gives examples of what NACs can do to meet each level of need a P/R has. While the ways in which NACs would meet physiological needs are obvious, Betty continually points out ways we're affecting the P/R's self-esteem. We'll likely be caring for the elderly, that is, folks who've spent their lives doing for themselves and others and are now forced to be helped and depend on others.
The main way we can accomplish this, she says, is to give the P/R choices whenever it is possible to do so without jeopardizing their care. "Mrs. Smith, we need to get you a bath so you can be clean and dry, but if that's not convenient right now, would you like me to come back at 9 am, or around 1 after you've had lunch?" She says this works wonders. It is also the main principle behind "Love and Logic," a parenting style my housemate's mother introduced us to, the goal of which is not explicitly to build self-esteem, but rather, to teach children how to make decisions and live with their consequences. The situation in a care facility is obviously different. The trick with L&L with kids is that if kids make a "bad" decision, their parents don't rescue them from the consequences. So it can't work exactly the same with Mrs. Smith--a NAC can't simply not perform care a P/R balks at. The L&L side effect I've enjoyed as a parent is how it calms me down to think through how to present a potential conflict as a choice, and I'm guessing that'll be invaluable on the job, as well.
Most of the things Betty has told us about communication I've "learned" at some point or another, but I hope to internalize it all, because it seems like I'd be a better friend, wife, and family member, as well as employee and co-worker, were I to make a habit of all of this stuff: get down on the person's level--sit, if you can; listen; make actual real eye contact and don't turn away when talking or "listening;" never, ever interrupt (I'm terrible about that); and with the elderly, especially, use a low tone of voice, since this could make the difference for them "between isolation and engagement." We also learned a little bit about resolving conflict in the workplace: ask to speak to the person, in private (eek! scary! but so useful.), be willing to hear stuff you don't want to, talk only about the specific event--don't generalize or psychoanalyze or try to make observations about somebody else's behavior patterns, be willing to agree to disagree, if necessary... I wish I'd learned some of that stuff before going to grad school and stepping on toes and later hiding from those whose toes I'd inadvertently stepped on. Ugh. This stuff is _not_ instinctive for most of us, I think--wish someone had explicitly taught it to me. Never too late, right? :/
Tuesday, May 12, 2009
Why my teacher is great
My instructor, let's call her Betty, is southern and in her late 50's or early 60's, I'd wager. I first spoke with her when I took an all-day CPR course as this whole NAC class got into gear. I ran into her in the bathroom as I was leaving, and she told me "you know what, with all this MRSA (Methicillin resistant Staphylococcus aureus) and other stuff around, you should just open the bathroom door with your back." I love her accent--it reminds me of a certain kind of southerner I really miss. She sounds like my maternal grandmother, and she has a fantastic laugh. The first day of our actual class she got kinda defensive about a crappy powerpoint thing going on, but she wisely abandoned it altogether and went back to lecturing, and she's great. She's been a nurse since 1974, when she was thrilled to be getting a little over $5/hour. She's been a hospital nurse and a nurse in longterm care facilities, and prefers hospitals because they're faster-paced.
We've had 6 class meetings (all about 2.5 hours long) so far, and at least three times she's brought up the phenomenon of hospitals being obliged to provide care to people in the E.R., and mentioned a few hospitals who have to subsidize 40% of what they do, because it's free, with the other 60% of what they do, which of course makes the costs of the 60% that much more. She said people get sent home sooner and sicker than they used to because of something called DRGs, diagnostic-related groupings, started by Medicare, that determine how much will be spent on a patient's care based on the original diagnosis that put them in the hospital. Sort of makes sense, seems like it might cut down on abuses of piling up procedures to make money. But instead, it sounds like it just forces MDs to send patients home that shouldn't be. A student asked about that, and Betty said that the doctors "are good people, they don't want to do it, they're just trapped by the system." At this point, I raised my hand and asked whether there are organizations for nurses who have opinions on how the healthcare system should work, and do they practice advocacy... she looked at me and said "I teach." True. But it seems like approaching the problems from the wrong direction, so I said "what about policy"? She didn't really answer me the second time. I'll push harder later. :)
I did find out after class today that she's had cancer 4 times; she said she's living on borrowed time.
We've had 6 class meetings (all about 2.5 hours long) so far, and at least three times she's brought up the phenomenon of hospitals being obliged to provide care to people in the E.R., and mentioned a few hospitals who have to subsidize 40% of what they do, because it's free, with the other 60% of what they do, which of course makes the costs of the 60% that much more. She said people get sent home sooner and sicker than they used to because of something called DRGs, diagnostic-related groupings, started by Medicare, that determine how much will be spent on a patient's care based on the original diagnosis that put them in the hospital. Sort of makes sense, seems like it might cut down on abuses of piling up procedures to make money. But instead, it sounds like it just forces MDs to send patients home that shouldn't be. A student asked about that, and Betty said that the doctors "are good people, they don't want to do it, they're just trapped by the system." At this point, I raised my hand and asked whether there are organizations for nurses who have opinions on how the healthcare system should work, and do they practice advocacy... she looked at me and said "I teach." True. But it seems like approaching the problems from the wrong direction, so I said "what about policy"? She didn't really answer me the second time. I'll push harder later. :)
I did find out after class today that she's had cancer 4 times; she said she's living on borrowed time.
Thursday, May 7, 2009
Nursing Assistant Certification course
For years I've been reading about healthcare from a top-down perspective as a pseudo-intellectual devourer of articles in Mother Jones, the Atlantic, Harper's, etc. I've formed many opinions about our country's crappy healthcare system, its failures in getting care to the people who most need it, the pattern of people avoiding seeing a doctor till they have to get to the emergency room since E.R.s are not allowed to turn away patients. I'm a big-pharm hating, single-payer-healthcare-system loving typical liberal you'd meet at a party who's read just enough and has just enough personal and anecdotal experience with the healthcare system to have opinions, but not enough, really, to justify promoting them to others to the degree that I do.
So when I decided to become a nurse and went to an open house at the MSN (Master's of Science in Nursing) program I hope, eventually, to attend, and they advised those of us without HC experience to get our Nursing Assistant Certification (NAC) and get some experience in the field before applying, I didn't realize how strange it would feel for me with my surplus of education and dilettantish knowledge of the field to be put into a place where I was taught how healthcare works from the bottom up. I'm taking the class at a local community college, many of my classmates are young, a lot speak English as a second (or third) language, so a lot of the things I'm learning are introductions to concepts such as how a hospital is set up, or what are pathogens, what is the NAC allowed to do, what can the nurse do, what may doctors do...
Because of the number of non-native speakers of English in my class, some concepts get repeated a lot, because they are expressed in an idiomatic way or they are "hard" words. Chain of Command was one of these. It was said in a way that makes me think of A.A. Milne capitalization, and repeated enough that I kept thinking of The Wire, specifically of Lt. Daniels frowning while upbraiding McNulty. I am concerned that my tendency to speak out about what I think will get me into trouble doing this job. As a case in point, I took an all-day course on HIV/AIDS and bloodborne pathogens last weekend as part of this whole certification, and in order to leave, we had to take a multiple-choice test and score 80% on it. I took the test, a few of the questions were poorly worded, so I circled an answer and wrote a comment as to why I chose the one I did, to make it clear I'd understood the material. The instructor graded my test, then told me, I'm sure to be helpful, that if I wanted to do the nursing program at her community college, I needed to "get out of the habit" of writing comments on tests, since it looks like I'm "arguing" with the questions, and it's just "not good." I've been a teacher for 10 years and have probably written over 100 tests by now--it's hard to do it well, and I appreciate student comments, since the point of tests is to make sure students have learned what you wanted them to. Huh.
Since I've told folks I want to be a nurse, most have been encouraging, and have named character/personality traits I have that will make me a good nurse. I'm looking at this drastic career change as an opportunity to be required to change things about myself I need to change: (1) I need to learn to keep my mouth shut. (2) I need to slow down my speech--I'll likely be caring for elderly patients, especially as a NAC, and if they can't understand me, that'll only increase their sense of isolation. (3) I need to move more slowly and carefully, and not multitask as much. (4) I need to get over my desire to make sure others know that I "already knew that," whatever it may be. Like, decouple the ego from the intellect. And, (5) one thing this will require from me that I'm not willing to admit should change is the oomph in my stomach I feel about waste and non-re-use. Preventing the spread of pathogens requires using all kinds of disposable equipment and double-bagging and not (gasp! ouch! ooomph!) that "perfectly good" whatever. That will be hard for me.
So when I decided to become a nurse and went to an open house at the MSN (Master's of Science in Nursing) program I hope, eventually, to attend, and they advised those of us without HC experience to get our Nursing Assistant Certification (NAC) and get some experience in the field before applying, I didn't realize how strange it would feel for me with my surplus of education and dilettantish knowledge of the field to be put into a place where I was taught how healthcare works from the bottom up. I'm taking the class at a local community college, many of my classmates are young, a lot speak English as a second (or third) language, so a lot of the things I'm learning are introductions to concepts such as how a hospital is set up, or what are pathogens, what is the NAC allowed to do, what can the nurse do, what may doctors do...
Because of the number of non-native speakers of English in my class, some concepts get repeated a lot, because they are expressed in an idiomatic way or they are "hard" words. Chain of Command was one of these. It was said in a way that makes me think of A.A. Milne capitalization, and repeated enough that I kept thinking of The Wire, specifically of Lt. Daniels frowning while upbraiding McNulty. I am concerned that my tendency to speak out about what I think will get me into trouble doing this job. As a case in point, I took an all-day course on HIV/AIDS and bloodborne pathogens last weekend as part of this whole certification, and in order to leave, we had to take a multiple-choice test and score 80% on it. I took the test, a few of the questions were poorly worded, so I circled an answer and wrote a comment as to why I chose the one I did, to make it clear I'd understood the material. The instructor graded my test, then told me, I'm sure to be helpful, that if I wanted to do the nursing program at her community college, I needed to "get out of the habit" of writing comments on tests, since it looks like I'm "arguing" with the questions, and it's just "not good." I've been a teacher for 10 years and have probably written over 100 tests by now--it's hard to do it well, and I appreciate student comments, since the point of tests is to make sure students have learned what you wanted them to. Huh.
Since I've told folks I want to be a nurse, most have been encouraging, and have named character/personality traits I have that will make me a good nurse. I'm looking at this drastic career change as an opportunity to be required to change things about myself I need to change: (1) I need to learn to keep my mouth shut. (2) I need to slow down my speech--I'll likely be caring for elderly patients, especially as a NAC, and if they can't understand me, that'll only increase their sense of isolation. (3) I need to move more slowly and carefully, and not multitask as much. (4) I need to get over my desire to make sure others know that I "already knew that," whatever it may be. Like, decouple the ego from the intellect. And, (5) one thing this will require from me that I'm not willing to admit should change is the oomph in my stomach I feel about waste and non-re-use. Preventing the spread of pathogens requires using all kinds of disposable equipment and double-bagging and not (gasp! ouch! ooomph!) that "perfectly good" whatever. That will be hard for me.
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