You can look at nursing homes (NH) in two ways. The first approach takes a bird's-eye view and surveys the LTC landscape. Here you soon notice the pall that hangs over nursing homes: The menacing cloud that surrounds them on the outside, and a besieged sense that prevails within their walls. The outside world holds nursing homes in low esteem. No one looks forward to a nursing home as one's last home. Some elders resist going to a nursing home and think of suicide, some actively attempt it, some passively achieve it. Consumer advocates bemoan the conditions in nursing homes, regulators fence in caregiving with ever tighter rules, and trial lawyers presume liability when a nursing home falls short of perfect compliance.
“Exemplars in LTC” is scheduled to appear periodically in Long-Term Living. Its purpose is to recognize and celebrate the commitment of the tireless caregivers in long-term care (LTC). We will, in particular, train our spotlight on those who lacked resources, not imagination, to devise simple answers to stubborn challenges. We'll salute the exemplars who without fanfare and amidst stifling conditions, pioneer a surer path to quality. Each column will present one or two such innovators whose creations are likely to inspire, educate, and motivate many.
We encourage your feedback. Share with us the exemplars and exemplary innovations that may have caught your attention. We're looking for the unsung exemplars, not the big well-known programs, or just “best practices”-an elastic label often applied to a range of amorphous practices. We seek to inform and edify, not to market or to promote. Three key words will guide us: commitment, imagination, and innovation, in LTC generally, and in nursing homes and LTC communities in particular.
I note two areas rich in exemplars in LTC.
Humanize dying, death, and grieving. Residents, families, and caregivers support each other as they grieve and bid farewell to one departed.
Involve certified nursing assistants (CNAs) in care-planning; early alert and response to preclinical symptoms. Residents and families reinforce and reward CNAs for person-centered acts and attitudes.
Use state-of-the-art technology to reduce paperwork; lessen caregiver burden; increase resident comfort, dignity, and well-being.
Managers: Those who turn workers into devoted caregivers
Create supportive work environments-caregivers are set up for success; play a role in product selection, waste reduction, planning the budget; their work role complements and doesn't conflict with demands of personal life.
Make “mission and values” drive everyday care activities, orientation, in-services, evaluation.
These outside pressures exact a toll within the NHs. One nursing home administrator (NHA) laments (this and the following quotes are drawn from my research notes): “This is the only industry where the mandate ‘assure’ means that we have to provide high-quality nursing care with no error, 365/24/7, for a reimbursement of Motel 6; where you are penalized for what occurred months ago; and where you get no credit for making the correction.” Directors of nursing (DONs) concur: “MDS encourages an amoral hypocrisy. MDS requires we use RNs to chase paperwork and to create nonworking care plans for the floor nurse who has no time to read 60 care plans that contain eight to nine problem areas.” More than 40% of administrators and DONs, disheartened, will walk through the exit door this year. More than 70% of CNAs, demoralized, will follow their Pied Piper out that door.
The second approach focuses on the microdynamics of daily life in an NH. An ethnography of the complex give-and-take between residents, caregivers, and families will reveal, even in a mediocre NH, the reservoir from which spring genuine caring, bonds of friendship, and unexpected levels of satisfaction and commitment.
What satisfies CNAs, DONs, and NHAs has little to do with pay; it has everything to do with the relationships they forge. One NHA echoes many others: “I love working with the elderly. Its reward cannot be measured in dollars. If I could live without money, I would give myself completely to them…the pleasure of caring for one of the greatest generations that has ever lived!” DONs agree: “Seeing the progress residents make, watching staff develop professionally! Nothing is more gratifying than the feeble ‘Thank you, honey,’ the touch of a frail hand, or the heartwarming smiles I am blessed with every day.”
Such commendable altruism inside NH walls is hidden from the public eye, although it is amply documented by researchers. Around the nation, half of all NH residents and their families say they would recommend their home to others as “good,” and an additional one in three would recommend it as “excellent.” CNA commitment is masked by their deceptive high turnover. Much of the CNA turnover occurs via the revolving door at the fringes of a solid core of stable caregivers who stay on and ensure continuity of care and relationships. In an NH, typically 70% of CNAs have tenure of more than a year, 15% have served there for five to 10 years, and another 15% for more than 10 years. For many a CNA, caregiving is not merely a job, it is almost a calling. Long-term care attracts an uncommon worker.
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