"Getting to know you": the staff's key to success.

Throughout the enabling legislation of OBRA '87, and indeed, woven into the very fabric of the regulations, is the need to promote and safeguard residents' autonomy, independence and privacy. In the nursing home, certified nursing assistants (CNAs) have first-line responsibility for this. In this article, I will focus on the critical relationship of the CNA and the resident and provide examples involving some of the residents we have cared (and are caring) for. A long-term care facility that is successful in meeting resident autonomy and privacy needs is one whose management team recognizes the need to develop a system "wherein all the people involved in the care-giving process are interrelated and everyone affects the outcome of the organization's efforts."[1] The administrator must develop a philosophy and mirror an attitude that stresses a commitment on the part of all staff members to reach out to the residents entrusted to their care, by recognizing the unique individuality and worth of each resident as a human being.

Not long ago, the terrible loneliness, frustration and sense of total dependence, either on one's caregiver or on institutional timetables of "rules and regulations," were described, in a heart-wrenching and straightforward manner, by Mrs. Anna Mae Halgrin Seaver[2] in a Newsweek Magazine article entitled "My World Now: Life in a Nursing Home, From the Inside". The article sums up the feelings of thousands upon thousands of residents in long-term care facilities. Mrs. Seaver, when discussing her loss of privacy, noted: "It is not unusual, when sitting in my semi-private room, to have an aide open the door unannounced and walk in as if I am not there. Am I invisible? Have I lost my right to privacy and respect?" She further stated, "After I have asked for help more than a dozen times, and received none, something begins to create an emergency. That time I wanted to be 'taken to the bathroom'".

Like all organizations, nursing homes have procedures and routines designed to accomplish care-oriented (and mandated) daily tasks. There can be no doubt that any routine to accomplish an activity of daily living (dressing, toileting, etc.) is likely to impact on and interfere with residents' ability to do "what they want, when they want." Specifically, institutional procedures often dictate where, when and how residents spend their waking hours. Restrictions to residents' autonomy and independence occur across a variety of contexts and involve many different staff levels, ranging from CNAs, medication nurses, activities assistants and therapy (PT, OT and speech) personnel. While the restrictions are based on a variety of resident-related needs initiated by staff-oriented goals, their fundamental aim is to maximize the efficient use of staff time in providing the best care possible.

As we know, in most instances, staff time, and particularly CNA time, is spent not on acute care, but on the more mundane custodial tasks of patient ADLs. It has been noted that "the stress inherent in being occupied with primarily custodial duties toward their patients, and the emotional stress caused by caring for cognitively impaired patients, can create serious, volatile patient-caregiver interactions."[3] In many instances these custodial tasks, while necessary to help patients meet their health care needs, may often times be met unenthusiastically at best, with anger and resentment, at worst.[4]

One of the ways that we at All Saints Home have approached the "bonding" between CNAS and their patients is to have our Activities Department, working closely with our Social Service Director, "in-service" nursing staff upon a resident's admission on the highlights of the new resident's life experiences (or those of their families) and individual achievements. Residents who have vivid memories of their extraordinary life experiences are asked to share these with our staff, in an effort to enlighten the staff as regards the "real life" patients entrusted to their care.

Mrs. Susanna Kotalik was one of these patients. Born in October, 1890, she was admitted to All Saints Home in April, 1972. Prior to her marriage, Mrs. Kotalik had been one of the first women to become a Public Health Nurse for the State of Florida. She was born and raised in Jacksonville. As a nurse, she was assigned to serve with the Public Health Department during the completion of construction on the Panama Canal, and she married one of the Army Corps of Engineers working on the project. Her warm remembrances of her experiences in those days gave her caregivers a new level of awareness as to who this lovely woman "was" and "had been." Mrs. Kotalik died at All Saints on January 22, 1984, having spent the last 14 years of her life in an environment of love and mutual respect.

Mr. Naif Mussleh was admitted to the Home in February, 1986, and though he stayed but a few months (discharged that May to an independent living facility), he made himself endeared to our staff. When he first arrived, alert and ambulatory, but in need of people to talk with, he told the story of his meeting with Col. T.E. Lawrence (better known as "Lawrence of Arabia") during World War I. The family had given us no background on Neif, who was 86-years-old when admitted, and the staff began to disregard him as senile. After I spoke with a family member, who referred me to the library, a story of intrigue and daring courage unfolded.

It was 1917, and all the world was at war. Turkey, allied with Germany, was in control of the Mideast, and Mussleh, 17 years old and without surviving parents, lived under the thumb of the Turks. Naif and his siblings found themselves in Damascus, where he worked for a wealthy gentlemen who was a member of a secret underground organization opposed to Turkish domination. His employer sent him on a journey for a destination he knew nothing of -- a mission that saw him travel only at night with Bedouin guides and three pages of coded messages in his shoes. He journeyed 800 miles from Damascus through what is now Jordan and halfway down what is now Saudi Arabia to Jiddah on the coast of the Red Sea. At the end of his journey, he turned over his messages, slept for 14 hours and awoke to eat breakfast with several leaders of the Arab Forces. Upon leaving for the trip home, accompanied by a new guide, the guide asked "What was it like to have breakfast with Lawrence of Arabia?"[5] Learning of this story, the staff quickly related to Naif Mussleh.

An equally interesting life story involved Mr. Bart Crichlow, a native of St. Augustine, Florida. He was admitted to our Home on February 22, 1993, and brought with him a rich cultural and historic family heritage. Through his great-grandmother, who died in 1891, Mr. Crichlow could trace his family's roots in the "Old City" back to 1831. At the time of his admission, he addressed the resident council and shared the rich stories of his heritage in northeast Florida. Among the many facts he shared with residents and staff were those relating to the state's "Oldest Wooden Schoolhouse", still standing today on quaint Old St. George Street, just within the Old City gates. Mr. Crichlow's great-uncle Ernest Oliveros was a member of the last class to attend the school (closed in 1864). In addition, one of Bart's aunts taught in the school from 1859-1862. Again, this resident was quickly sought out by staff and residents alike for more facts about a city not far from them and forever rich in history.

Efforts made to share a particular resident's individuality and accomplishments with staff can only help them to appreciate and recognize each resident's need for and right to respect, dignity and recognition. The staff member who can develop a relationship with a resident based on mutual trust and respect has taken the first step in assuring that resident's peace of mind and cooperation. The staff nurse, as the leader of the unit/wing health care team, is in a unique position to instruct the rest of the nursing staff in a manner designed to build rapport between the CNA and the individual resident. The nurse can instill confidence in the caregiver that he/she is vital to the resident's daily well-being, and can meanwhile instill a feeling of reassurance to the resident that his or her needs will be met with empathy and in a caring manner.

Nursing home staff must honestly examine their attitudes toward working with the aged. This can often arouse uncomfortable feelings. Old age and disability imply, after all, that death is near, and that loss of coordination, function, control, and independence will someday afflict us all. Anxieties, and the occasional fear of becoming emotionally close to the aged, often arise because of this. With time and effort, though, the immense satisfactions of properly caring for these unique and, in their own right, distinguished people will overcome these anxieties and fears. Meanwhile, eliminating residents' fears and problems can spell the difference between a pleasant end of life and one of increasing isolation and frustration for the aged person.

In short, once people are in a nursing home, their successful adaptation, attitude, and peace of mind depend directly on the attitudes and principles of the home's staff. When nursing home administrators set an example by treating staff members with respect and providing the kind of supervision that permits the development of a sense of job satisfaction, chances are good that the residents/ patients will themselves retain a sense of personal dignity and worth. And mutual respect between staff and residents is indispensable, because they are in a setting where, in effect, they live together.

References

[1.] Biondi SC. Put yourself in the place of the resident. Provider 1990:17.

[2.] Seaver AMH. My world now: life in a nursing home, from the inside. Newsweek 1994.

[3.] Lidz, Fischer, Arnold. The erosion of autonomy in long term care. Oxford University Press 1992:75.

[4.] Lidz, Fischer, Arnold. The erosion of autonomy in long term care. Oxford University Press 1992:74.

[5.] Duke K. Duval man tells of wartime desert trek. Florida Times Union 1982:1,4.