In his time at the Terence Cardinal Cooke Health Care Center our intrepid intern, Raphy Rosen, has learned of the intricacies of staff-patient relationships. In his next two posts, Raphy discusses the complications of closeness and asks the deceptively simple question, who cares about care?
5- Not too Attached
One of the dilemmas that a facility like TCC faces is how to facilitate the best possible relationship between a C.N.A. (Certified Nursing Assistant) and a patient. On an average floor there are 50 residents and a maximum of 6 CNAs, meaning that each aide cares for at minimum an average of 10 patients. Each floor decides on its own how they divide their patients among the CNAs. For example, on the Huntington’s floor, each aide works only with their group of patients and there is no switching. This is done because Huntington’s patients are often distressed by change, and giving them a permanent aide lends some degree of stability to their lives. The disadvantages with this setup are twofold:
1) An aide is fairly ignorant about the other 40 patients on that floor, and if a crisis arises in the absence of a patient’s specific aide, they are not well equipped to deal with it.
2) Each aide is deeply connected to his or her patients and may become overly emotional concerning their care. One of the necessary responsibilities of the job of a CNA is to remain somewhat objective and removed, which is in the best interest of the patient and also in the best interest of the aide, so that the aide is not devastated at the passing of a resident.
On one of the nursing home floors, each CNA is assigned 10 patients for one month and then switches to another 10 for the next month and so on. While solving the above problems, this detachment is not lost on the residents. Consider the following story:
Sophia, the recreational therapist on floor 7, was playing a current-events trivia game with the residents. One of the topics that was discussed was Obama’s appointment of Elana Kagan to the Supreme Court. This led to a full-blown argument about the wisdom of lifetime appointments for justices. One of the objections that was raised was that if a person is on the bench for too long, they become entrenched in their beliefs and unable to assimilate new perspectives and realities. Lauren, one of the feistier elderly residents, quipped: “Yeah, it is like you guys [referring to the aides]. You switch around who you take care of so that you don’t become too attached to any of us!” The whole room laughed heartily at this comparison, but the uncomfortable truth of this statement was not lost on anyone who was paying attention. The CNAs switch around their assignments so they do not become overly invested in their residents, as a logical defense mechanism. As necessary as this may be, the residents were acutely aware of this strategy and its implications about their confidence in the resident’s survival.
6- Respect and Care
I want to describe the kind of people who work in this extraordinary institution and please forgive me for waxing poetic. The uniqueness expresses itself in two ways:
I have never heard a patient or staff member referred to by anything other than Mr/Ms X. This instills a level of professionalism among the staff by conferring dignity to patients who have had much of their dignity compromised. Imagine you are caring for Filipe. You arrive at 11pm for your 8-hour shift which includes changing Filipe’s fecal bag, stripping off his badly soiled sheets, cleaning off spilled rice and gravy from his gown and listening to Filipe conversing incoherently with thin air. Would you be able to treat him with respect? I doubt I could. This one unofficial but effective measure, calling Filipe “Mr. Gonzalez” instead, reminds staff that Filipe was not always in this pathetic dependent state, and deserves courtesy like any other human being would. Another formality that TCC utilizes is that they will never define a patient by their disease, rather they separate the disease and the human underneath. For example, no one will refer to a “demented resident”, instead they will call him a “resident with dementia”. These conventions are subtle but are extremely valuable in instilling a place with an undercurrent of respect.
In addition, even the patients who prove frustrating and difficult are given the maximum feeling of autonomy. One case arose in which Michael was picking fights with his roommate Julio. It was clear that Michael would need to be moved to a different room, and possibly to a different floor. However, the staff did not just move Michael without first asking his permission, giving him a choice of options of other rooms, and cajoling him to agreement. The staff devoted their precious time to making Michael feel that, despite his extremely belligerent behavior, his opinion mattered and he was able to take an active role in deciding his placement.
I regularly attend the morning meeting in which the care teams discuss interesting or problematic patients and brainstorm for solutions. What is fascinating about these meetings is that they are rarely medical in nature. More often, they are discussions about which patients hate their roommates and need to be moved, or patients who report ‘stolen’ (read: lost) items, or which air conditioners are broken, or which patients can’t sleep at night since other people are too loud. It is almost comical to hear internists, psychologists, nurse practitioners, and upper echelon administrators discuss issues so mundane that every camp counselor has encountered them. The reason that these issues are given significant time is that the entire staff care deeply about their patients’ quality of life, as distinct from their quantity of life.
I also attended an orientation of new staff members in which we were taught the horribly boring intricacies of TCC bureaucracy. The meeting was mostly uninteresting except for one point which sparked much protest from the audience. The instructor said that it is forbidden for nursing staff to give patients money or treats, even if they claim to be hungry. This seems extremely logical to me- the patients are given three meals a day, as well as snacks and drinks, why would they need anything else? In addition, giving treats to one resident will cause jealousy among the rest and dependency on the treat.
However, for some reason, the staff argued vehemently. They said that it is part of the way that they bond with residents, and that it gives the residents a reward for being particularly well behaved. One R.N. put it best “Due to the nature of our job, you can’t take our humanity away from us!” a bit of an overreaction, but impressive nonetheless. In his mind, preventing staff from giving residents special treatment turns them into emotionless automatons. Even though the negatives of special treatments outweigh the benefits, I was quite surprised and impressed with the degree to which new caregivers valued the relationship that they would be building with their patients.