- Email: [email protected]
A new perspective on nurse's aide training
COMMON CONCERN A N e w Perspective on Nurse's Aide Training Experience as a nurse's aide in a small, family-owned nursing h o m e convinced this author that its values and controls should be built into larger facilities. J A N E L. BARNEY Considerable attention is being focused on the training of nurse's aides, and with good reason: they provide 70 to 90 percent of the direct care given to nursing home residents. Several states now require the completion of programs certified by a board-approved provider of education as a condition of nursing home employment. Many facilities conduct training programs and provide follow-up supervision of the aide's clinical performance. Yet, not long ago, a college student described beginning a nursing home job this way: The first morning a nurse went around to s h o w m e and another new aide what to do. The second morning the nurse wasn't there and the two o f us were given a list o f patients to care f o r on our own, s o m e o f w h o m we hadn't even met. It was very hard, and the third day the other girl didn't show up.
Part of the explanation for the plight of many modern nurse's aides lies, I believe, in the dual staffing heritage of today's nursing home. That heritage is derived Jane L. Barney, MSW, is a project associate, Institute of Gerontology, University of Michigan, Ann Arbor. She directed the lOG Nursing Home Community Councils Project, and the lOG Nursing Home Staff Development Program.
from two distinct traditions, each appropriate at the time of its development, each reflecting important social values. A new perspective on nurse's aide training can be derived by looking backward at the origins of the nurse's aide role, presenting a close-up of that role today, and pointing to implications for training in both past and present practices. Origins of the Aide Role The contemporary nursing home developed from three types of institutions: homes operated by religious orders, almshouses and poor farms operated by government, and room and board homes operated by private individuals. The religious home apparently was established early in the Christian era to provide for neighbors in need. One institution in the third or fourth century, the Gerontochia, was specifically for the old. Such refuges were later taken over by moaastic orders, but as the numbers of needy people exceeded the capacity of religious homes, other ways to care for the sick developed. Public relief provided almshouses and, later, workhouses admitting all types of destitute individuals who fell through the network of family support. From the beginning stigma attached to these institutions, conditions in them were harsh by design to discourage use,
and elders were neither segregated from other persons nor given special consideration. The third precursor of the modern nursing home was the small, informal, family-operated, board and room establishment developed for the elderly who, by the terms of the Social Security Act of 1935, could qualify for federal support if they were being cared for in private institutions. Here, too, only custodial care was offered to poor elderly. A fourth institution, the hospital, multiplied in the eighteenth and nineteenth centuries as the science of medicine devised treatments that could be used more effectively in an institution than at home, and as training and research became necessary in educating physicians. These hospitals, however, were more likely to serve acutely ill and middle class patients. They did little to improve the care of the chronically ill and low-income aged. The workers in early custodial institutions are scarcely mentioned in historical sources. And nothing in the purpose and functioning of these homes suggested the need for special skills. As these institutions came under greater control, and in voluntary and small proprietary homes, the most enlightened standard of care was that the elderly receive the comforts associated with home. Therefore the workers' only job
Differing perspectives on a p r o b l e m that nurses share with other caregivers.
44 Geriatric Nursing January/February 1983
8eln~ an: aide t~ k l ~ of ,taugh,
Jas_rytm ~ qualification was the housekeeping-homemaking skills learned in their own experience. Institutions for the infirm elderly and indigent were being operated, then, according to standards derived from home life. At the same time, hospitals, as institutions for the sick or dying, were independently training professionals to provide care according to more specific medical and nursing standards. Public and church-sponsored institutions for the elderly were little affected by the Social Security legislation. Proprietary homes, however, grew rapidly in numbers, size, and diversity of function. The terms "nursing home" and "convalescent home" came into use, suggesting that these facilities, originally residential, had now undertaken health and illness care. Gradually, efforts were made to bring all care under professional nursing supervision. Ratios of nurses to residents and to nurse's aides were recommended and responsibility for resident care was assigned to the nurse. While this was happening, however, most nursing homes continued hiring untrained workers to perform both housekeeping and health care services. Thus two incompatible traditions became established in the nursing home: the nursing tradition with its health-illness orientation expressed in the required use of professional staff, and the home-care tradition with its maintenance-comfort orientation expressed in the permitted use of untrained staff. I question the contemporary view that, with training, the long-term care of elderly people will improve to the degree that the medicalnursing orientation and values of the staff prevail over the more instinctive home-care orientation and values. I am convinced that no
~n~
when die gotn~ ga~ eauglt
"~tve at~ a ~ug~an~ 1 ~ ~ n g ~ ~ " g ~ 8 aglt~. ~ ~ t Ia~! a~ ~he graunar, ~ang a~ a l ~ ~a~'re a~ ~aRr ~r l~ ~ goad' It.gs, vacM ~ ~ ~ l i k anZ~a nose. S~owe~. d~ang~ xaaas, an~ ~p~x-luggIe ~ oll Ibr tust a J ~ n~,ast~ ~ . ~ n g art attic r be ~ srtts The~ ~ never e~m~gh~~fme. wlffr m a l ~ m~ mad; mal~ :hat ltv~ ~easan;, a~ ~ cou~ ~e gel e v e ~ h l n g done by Iralf post zl~ree. Being an aide's never qutte done. For all the effort, nozhing tangible is won. ~ u r shift is over and you've done your best. So you have to turn your back and trust, the ~est. BeJng an aide doesn't seem a career. Very few of us ever last more than a year. But these folks touch us. We'll never forget The joy and the pain in the lives that were met. Jan Rick, nursing assistant higher standards for care of the diate care facility, under the superaged exist than those standards vision of its inservice director (Ms. generally identified with family H.) and with the approval of its adand home life. ministrator (Mr. D.) Here are exI am not suggesting that the cerpts from notes written immedimodern applicant for a nursing ately after that experience. home job can be assumed to have Residents appeared very old. gained relevant skills at home, nor Many were almost or entirely helpthat such home-acquired skills are less. Many required feeding, or adequate preparation for nursing help with eating. Most seemed to home service. Quite the opposite! eat well, and aides were quick to reI urge an all-out effort to insti- port those who did not. tute nursing-home staff training Many residents needed the serthat emphasizes the values implicit vices of two aides. This required in home-family-ethnic-community that aides plan and work together, life as well as the values of nursing interrupt one another, leave one practice. resident in mid-process to help anThis broadened philosophy of other; and resulted in aides forgettraining for employment in long- ting details, delaying responses, term care settings is strongly advo- and upsetting routines. cated by the nursing profession, as Many residents were hard to the American Nurses' Associa- communicate with; either they tion's Standards of Gerontological couldn't see, or hear, or speak, or Nursing Practice clearly demon- be understood. They ranged from strate(l). slightly confused to almost comatose. (I was assured to my satisfacToday's Nurse-Aide Role tion that drugs were prescribed I recently did the work of a sparingly.) nurse's aide for two days at "Arbor All residents appeared to need Home," a 46-bed, local interme- considerable assistance and I could
Geriatric Nursing January/February 1983 45
COMMON CONCERN see that care at home would be diff i c u l t - e v e n with in-home services of all kinds. T h e average resident tenure in the h o m e was 38 months. S t a f f attention to residents, visiting with them, and finding activities for them was encouraged as time permitted; it was considered i m p o r t a n t in keeping them alert. Walking residents and doing exercises also was approved but not m u c h practiced. Each aide had one resident assigned for special attention, and this, for some persons, had led to observable progress. T h e new aide will find aseptic technique complicated to learn on the job, time-consuming, and easy to neglect when not supervised. At a certain point, following aseptic procedure seemed to become a m a t t e r of practical compromise. A sheet slightly wet under the plastic pad might not be replaced, for instance, if time or the supply of sheets was short. In a rush period, the bed springs and mattress might not have their weekly washing, a bedpan might be set m o m e n t a r i l y on the bedside stand, a g a r m e n t that had touched the floor m i g h t be put on the resident, and so on. In fact, a confused, harried, or careless aide could get a w a y with cutting m a n y corners that affect the quality of care, because supervision was extremely limited, and a i d e s did m u c h work alone. Even if a supervisor observed improper care, she might do nothing about it because she didn't want to m a k e waves or offend and possibly lose the aide, lacked time or occasion for corrective instruction, or thought that the problem was not solvable. I n a d e q u a t e staffing appears to be a perennial problem. While I believe A r b o r H o m e is more liberal than most in providing enough staff for patient care, the conflict between the values of profit and good care was clearly evident. Ms. H. said aides fequently failed to report for work and there were no aides in
46
Geriatric Nursing January/February 1983
reserve. In such crises, Mr. D. called in aides who were having a day o f f - - a poor recourse because time off from such work is important. Ms. H. believed that, in view of m a n y residents' helplessness, an assignment of seven or eight per aide was extremely heavy. Also, the home's rapid turnover rate m e a n t there were always one or two new aides who needed support, assistance, and supervision if they were not to become discouraged and leave or develop bad work habits and attitudes. Usually M s . H. was trying to provide such help to all aides, while at the s a m e time orienting a n d training a new aide. Mr. D., like all nursing h o m e administrators, is concerned about containing costs as well as providing the good nursing care represented in an a d e q u a t e work force. He cannot afford to have more aides at work than resident care requires, and yet he must avoid so overloading the aides that they resign. T u r n o v e r in the last y e a r had been high and everyone s u f f e r e d - the residents most of all. T h e aides seemed, from m y limited observation, to be well motivated to give good care. O n e aide said, " I try to take care of the patients the way I want someone to take care of me when I need it." I saw aides greeting residents as they passed them, sitting talkingquietly to them, exclaiming about their progress. On m y first morning, an aide mentioned at report that Ms. A. held her own glass at breakfast. During the day I heard several aides refer enthusiastically to that bit of news. Again, it was a happening of general interest when two aides helped Mr. B. walk a short distance down the hall. W h e n the bingo p a r t y was announced several aides offered to help, not for pay, I g a t h e r e d , but because it might be fun. N e w aides face special problems. A f t e r caring for person after person who seems out-of-it, one is inclined
to assume that all residents who are not obviously alert are incapable of response. O n e is in danger of treating those residents simply as bodies to be cared for. While helping them, it is easy to talk a b o u t them or other matters as if they were not there, easy to forget that they can feel pain or e m b a r r a s s m e n t . Ms. H. encouraged aides to speak to residents by n a m e as they cared for them, to explain what they were doing step-by-step, and to try to gain the resident's cooperation. Aides were supported in learning to tolerate angry, even abusive, resident behavior, and to understand the cause of mental and physical conditions that m a k e care difficult. M y unfamiliarity with the residents m a d e it very hard for me to give them considerate care, so I was impressed by the problem that aide turnover presents. It seemed to me that neither I nor any new aide could care for a resident appropriately until we had been told specifically, and also learned by experience, his or her individual characteristics and capacity to understand. It was strikingly evident that residents were best served by aides who were familiar with them, so familiar, indeed, that they could serve as surrogate family m e m b e r s , for in the last analysis that is the role of the nursing home aide. M y gravest concern had to do with controlling the quality of care giving. T h a t quality, I thiiak we can agree, consists to an i m p o r t a n t degree in the tone of voice, the gentleness of touch, the unsolicited greeting, word o f praise, act of consideration. H o w can we ensure that aides, when working quite unobserved with helpless people, people often without voice or recourse, will care for t h e m with respect and kindness? This question applies to all who care for people in their own homes, a vast c o m p a n y composed of mothers of children and, increasingly, of
4t
the childrcn of elderly parents. W e know abuse occurs in isolated instances. However, social controls generally operate to assure care that is based on family affection and guided by standards of behavior accepted within families, communities, ethnic groups, and larger societies, and possibly internalized through religious faith. Ultimately it is the inner and largely unarticulated individual values and shared standards of human behavior that will determine the quality of the care we give the people who depend o n US.
My experience at Arbor H o m e reinforced my earlier, researchbased point of view(2). T h a t is, it convinced me that the quality of care given by the staff (usually aide) to resident can never be totally determined by our present nursing home controls, notably, adequate payment for cost of care, government regulatory processes, professional standards, peer pressure, and business self-regulation. All those controls are essential and we need to make each as effective as possible. However, my experience in Arbor H o m e persuaded me that the best way to assure for our chronically ill and infirm elders-and eventually for ourselves--the kind of care we believe in is to make operative in institutions the social controls we take for granted in private settings. At Arbor H o m e these social controis were strong. More than anything else they may have accounted for the fact that an architecturally disjointed, environmentally drab, cluttered, and resources-sparse home full of extremely dependent people seemed so comfortable, socially lively, and concerned about residents as individuals. These social controls could be glimpsed in several ways. A r b o r H o m e is a f a m i l y enterprise. It was started and expanded to its present size by its owner, Mr. D., now in his late forties. Each day his wife brings their three-year-old
r
Residents were best served by aides who were so familiar with them that they could act as surrogates for their family members.
grandson to the home in his stroller and spends time chatting with aides and residents. M r . D's mother, a woman of 70, has always worked in the home, and now helps in the kitchen and dining room. A r b o r H o m e is a c o m m u n i t y institution. Located on Arborville's main street, in a residential area a few blocks from the center of town, its original building, an old house, looks like other houses and one scarcely notices the nursing home sign partly hidden by shrubbery. T h e florist, just down the street, brings in flowers. Church and community groups come to entertain. T h e community's presence is evident when an aide says of a large, helpless, confused, and gently smiling patient we are laboring over, "Ms. C. was a saleslady in the clothing shop and I used to buy dresses from her." Or when a nurse tells me of a limp, barely responsive woman, "Ms. R. was a secretary at the Ford C o m p a n y until she had a stroke last year." The indication that community standards count in this institution shows u p again in the framed testimonials hung near the nurses' station. These certificates of membership or special recognition from the R o t a r y Club and other local organizations suggest that Mr. D. values the respect of his neighbors and fellow businessmen. A r b o r H o m e is culturally h o m o geneous. Most aides, professionals, and residents come from Arborville and the surrounding rural areas. I
have felt the same atmosphere of comfortable at-homeness in several Detroit area homes where the ownership and most of the residents were black, Jewish, or Polish, and ethnic characteristics were affirmed. When we include community involvement among the forces which serve to control the quality of life in our institutions, we are dealing in subtleties difficult to pinpoint, measure, and analyze. Considerable progress has been made in identifying and developing measures of what we mean by good in terms of patient care and the environmental quality, but the more subtle conditions and determinants that are the keys to good care still elude us. W e know that these subtle factors and forces can make all the difference between a comfortable and a disagreeable context for living. W e realize that they have much to do with the care givers: their individual values, native sensitivity, and alertness; their sense of purpose and self-worth. And the subtle forces have to do also with corporate staff morale, teamwork, and mutual support; with personal and group attitudes and capacities in working with elderly people. While education, training, and natural capacities can influence these staff attitudes, they are shaped to a significant degree by social contexts and controls. How do we find, and incorporate in nurse-aide training, social controis capable of substituting for
Geriatric Nursing January/February 1983,17
COMMON CONCERN those of family, c o m m u n i t y , and culture, in the m a n y homes where such benign influences are n o t present?
Implications for Training Elderly people in A m e r i c a have become a large, growing, identifiable, self-aware, and politically potent force. T h e y and all of us are beginning to insist that the nursing home any one of us m a y need to enter must be an appropriate setting for assisted living.
tions and shape t h e m to m e e t our corporate h u m a n needs. Robert Butler, writing a few years ago " C o n c e r n i n g Decent Institutional C a r e , " concluded: " I come to the end with emphasis on the need for a continuing fluidity between the c o m m u n i t y and the institution so that one eventually fuses with the other . . . "(3). I propose that the staff of the nursing h o m e is p r o p e r l y the strongest agent of the c o m m u n i t y present in the institution and plays
/
The aides s e e m e d well motivated. One aide said, "I try to take care of patients the way I w a n t s o m e o n e to take care of me when I need it."
W i t h strong d e m a n d for nursing h o m e beds in the years since the ena c t m e n t of M e d i c a r e and Medicaid, developers had little stimulus to consider the preferences of workers and consumers but great incentive to adjust the environment, pattern of daily life, and plan of care to regulatory and financial objectives. It is not possible, however, to create a h u m a n e institution using a formula composed of g o v e r n m e n t health-care regulations and business principles of cost efficiency. In the case of the nursing h o m e the effort produced an institution nobody wanted and few would enter voluntarily. W e know how to solve the dilemm a that has resulted. Our c o m m u nities must repossess these institu-
4 8 Geriatric Nursing J a n u a r y / F e b r u a r y 1983
a key role in the flow of people, ideas, concerns, and activities between c o m m u n i t y and institution. Therefore, a p r i m a r y goal of training must be to prepare the staff to serve as the c o m m u n i t y surrogates in the place where the comm u n i t y ' s older citizens find t h e m selves estranged, isolated, and powerless. In-addition to skills and knowledge a b o u t resident care, the nurse's aide requires an equally important body of skills and knowledge enabling her or him to provide a psychosocial context for living a d a p t e d to individual particularities. This is a large order, even larger when we recognize that, to be the bearer of c o m m u n i t y values, the aide needs to experience these val-
ues in her working situation. She needs to feel that she is equipped for her work, respected, valued as a person, treated fairly, and fairly rewarded. H o b a r t Jackson put it this way: " . . . wholeness is a goal for every resident and patient in their effort to reach full potential for living and to sustain good mental health. But it is a goal for those serving as well as for those served"(4). Training that addresses the whole environment and the wholeness of persons confined to and working in that environment is now being developed. Professional nurses and gerontologists are taking the lead in this effort, and other health professionals are also interested. The interest and the training activities, however, are slow to reach into the nursing homes. A r b o r H o m e does not represent the w a v e of the future. But as a small, family, c o m m u n i t y , culturally homogeneous h o m e it embodies the values and d e m o n s t r a t e s the controls t h a t larger, more sophisticated nursing homes now need to build into their operations through training. T h e nurse's aide's r e m a r k , " I try to take care of the patients the way I want someone to take care of m e when I need it," contains the utterly serious view of self and other that is f u n d a m e n t a l to that training and to a therapeutic environment.
References 1. American Nurses' Association. Standards o f Gerontological Nursing Practice. Kansas City, Mo., The Association, 1976. 2. Barney, J.L. Community presence as a key to quality of lifo in nursing homes. Am.J.Public Health 64:265-268, Mar. 1974. 3. Butler, Robert. Concerning decent institutional care. IN Mental Health: Principles and Training in Nursing Home Care. Materials developed for a national conference. ( D H E W Pub. (HSM) 73-9046) Washington D.C., U.S. Government Printing Office, 1972, p. 16. 4. Jackson, Hobart. The concept of wholeness in long-term care facilities. IN Mental Health: Principles and Training in Nursing Home Care. Materials developed for a national conference. ( D t t E W Pub. (HSM) 73-9046) Washington D.C., U.S. Government Printing Office, 1972. p. 8.
Part of the explanation for the plight of many modern nurse's aides lies, I believe, in the dual staffing heritage of today's nursing home. That heritage is derived Jane L. Barney, MSW, is a project associate, Institute of Gerontology, University of Michigan, Ann Arbor. She directed the lOG Nursing Home Community Councils Project, and the lOG Nursing Home Staff Development Program.
from two distinct traditions, each appropriate at the time of its development, each reflecting important social values. A new perspective on nurse's aide training can be derived by looking backward at the origins of the nurse's aide role, presenting a close-up of that role today, and pointing to implications for training in both past and present practices. Origins of the Aide Role The contemporary nursing home developed from three types of institutions: homes operated by religious orders, almshouses and poor farms operated by government, and room and board homes operated by private individuals. The religious home apparently was established early in the Christian era to provide for neighbors in need. One institution in the third or fourth century, the Gerontochia, was specifically for the old. Such refuges were later taken over by moaastic orders, but as the numbers of needy people exceeded the capacity of religious homes, other ways to care for the sick developed. Public relief provided almshouses and, later, workhouses admitting all types of destitute individuals who fell through the network of family support. From the beginning stigma attached to these institutions, conditions in them were harsh by design to discourage use,
and elders were neither segregated from other persons nor given special consideration. The third precursor of the modern nursing home was the small, informal, family-operated, board and room establishment developed for the elderly who, by the terms of the Social Security Act of 1935, could qualify for federal support if they were being cared for in private institutions. Here, too, only custodial care was offered to poor elderly. A fourth institution, the hospital, multiplied in the eighteenth and nineteenth centuries as the science of medicine devised treatments that could be used more effectively in an institution than at home, and as training and research became necessary in educating physicians. These hospitals, however, were more likely to serve acutely ill and middle class patients. They did little to improve the care of the chronically ill and low-income aged. The workers in early custodial institutions are scarcely mentioned in historical sources. And nothing in the purpose and functioning of these homes suggested the need for special skills. As these institutions came under greater control, and in voluntary and small proprietary homes, the most enlightened standard of care was that the elderly receive the comforts associated with home. Therefore the workers' only job
Differing perspectives on a p r o b l e m that nurses share with other caregivers.
44 Geriatric Nursing January/February 1983
8eln~ an: aide t~ k l ~ of ,taugh,
Jas_rytm ~ qualification was the housekeeping-homemaking skills learned in their own experience. Institutions for the infirm elderly and indigent were being operated, then, according to standards derived from home life. At the same time, hospitals, as institutions for the sick or dying, were independently training professionals to provide care according to more specific medical and nursing standards. Public and church-sponsored institutions for the elderly were little affected by the Social Security legislation. Proprietary homes, however, grew rapidly in numbers, size, and diversity of function. The terms "nursing home" and "convalescent home" came into use, suggesting that these facilities, originally residential, had now undertaken health and illness care. Gradually, efforts were made to bring all care under professional nursing supervision. Ratios of nurses to residents and to nurse's aides were recommended and responsibility for resident care was assigned to the nurse. While this was happening, however, most nursing homes continued hiring untrained workers to perform both housekeeping and health care services. Thus two incompatible traditions became established in the nursing home: the nursing tradition with its health-illness orientation expressed in the required use of professional staff, and the home-care tradition with its maintenance-comfort orientation expressed in the permitted use of untrained staff. I question the contemporary view that, with training, the long-term care of elderly people will improve to the degree that the medicalnursing orientation and values of the staff prevail over the more instinctive home-care orientation and values. I am convinced that no
~n~
when die gotn~ ga~ eauglt
"~tve at~ a ~ug~an~ 1 ~ ~ n g ~ ~ " g ~ 8 aglt~. ~ ~ t Ia~! a~ ~he graunar, ~ang a~ a l ~ ~a~'re a~ ~aRr ~r l~ ~ goad' It.gs, vacM ~ ~ ~ l i k anZ~a nose. S~owe~. d~ang~ xaaas, an~ ~p~x-luggIe ~ oll Ibr tust a J ~ n~,ast~ ~ . ~ n g art attic r be ~ srtts The~ ~ never e~m~gh~~fme. wlffr m a l ~ m~ mad; mal~ :hat ltv~ ~easan;, a~ ~ cou~ ~e gel e v e ~ h l n g done by Iralf post zl~ree. Being an aide's never qutte done. For all the effort, nozhing tangible is won. ~ u r shift is over and you've done your best. So you have to turn your back and trust, the ~est. BeJng an aide doesn't seem a career. Very few of us ever last more than a year. But these folks touch us. We'll never forget The joy and the pain in the lives that were met. Jan Rick, nursing assistant higher standards for care of the diate care facility, under the superaged exist than those standards vision of its inservice director (Ms. generally identified with family H.) and with the approval of its adand home life. ministrator (Mr. D.) Here are exI am not suggesting that the cerpts from notes written immedimodern applicant for a nursing ately after that experience. home job can be assumed to have Residents appeared very old. gained relevant skills at home, nor Many were almost or entirely helpthat such home-acquired skills are less. Many required feeding, or adequate preparation for nursing help with eating. Most seemed to home service. Quite the opposite! eat well, and aides were quick to reI urge an all-out effort to insti- port those who did not. tute nursing-home staff training Many residents needed the serthat emphasizes the values implicit vices of two aides. This required in home-family-ethnic-community that aides plan and work together, life as well as the values of nursing interrupt one another, leave one practice. resident in mid-process to help anThis broadened philosophy of other; and resulted in aides forgettraining for employment in long- ting details, delaying responses, term care settings is strongly advo- and upsetting routines. cated by the nursing profession, as Many residents were hard to the American Nurses' Associa- communicate with; either they tion's Standards of Gerontological couldn't see, or hear, or speak, or Nursing Practice clearly demon- be understood. They ranged from strate(l). slightly confused to almost comatose. (I was assured to my satisfacToday's Nurse-Aide Role tion that drugs were prescribed I recently did the work of a sparingly.) nurse's aide for two days at "Arbor All residents appeared to need Home," a 46-bed, local interme- considerable assistance and I could
Geriatric Nursing January/February 1983 45
COMMON CONCERN see that care at home would be diff i c u l t - e v e n with in-home services of all kinds. T h e average resident tenure in the h o m e was 38 months. S t a f f attention to residents, visiting with them, and finding activities for them was encouraged as time permitted; it was considered i m p o r t a n t in keeping them alert. Walking residents and doing exercises also was approved but not m u c h practiced. Each aide had one resident assigned for special attention, and this, for some persons, had led to observable progress. T h e new aide will find aseptic technique complicated to learn on the job, time-consuming, and easy to neglect when not supervised. At a certain point, following aseptic procedure seemed to become a m a t t e r of practical compromise. A sheet slightly wet under the plastic pad might not be replaced, for instance, if time or the supply of sheets was short. In a rush period, the bed springs and mattress might not have their weekly washing, a bedpan might be set m o m e n t a r i l y on the bedside stand, a g a r m e n t that had touched the floor m i g h t be put on the resident, and so on. In fact, a confused, harried, or careless aide could get a w a y with cutting m a n y corners that affect the quality of care, because supervision was extremely limited, and a i d e s did m u c h work alone. Even if a supervisor observed improper care, she might do nothing about it because she didn't want to m a k e waves or offend and possibly lose the aide, lacked time or occasion for corrective instruction, or thought that the problem was not solvable. I n a d e q u a t e staffing appears to be a perennial problem. While I believe A r b o r H o m e is more liberal than most in providing enough staff for patient care, the conflict between the values of profit and good care was clearly evident. Ms. H. said aides fequently failed to report for work and there were no aides in
46
Geriatric Nursing January/February 1983
reserve. In such crises, Mr. D. called in aides who were having a day o f f - - a poor recourse because time off from such work is important. Ms. H. believed that, in view of m a n y residents' helplessness, an assignment of seven or eight per aide was extremely heavy. Also, the home's rapid turnover rate m e a n t there were always one or two new aides who needed support, assistance, and supervision if they were not to become discouraged and leave or develop bad work habits and attitudes. Usually M s . H. was trying to provide such help to all aides, while at the s a m e time orienting a n d training a new aide. Mr. D., like all nursing h o m e administrators, is concerned about containing costs as well as providing the good nursing care represented in an a d e q u a t e work force. He cannot afford to have more aides at work than resident care requires, and yet he must avoid so overloading the aides that they resign. T u r n o v e r in the last y e a r had been high and everyone s u f f e r e d - the residents most of all. T h e aides seemed, from m y limited observation, to be well motivated to give good care. O n e aide said, " I try to take care of the patients the way I want someone to take care of me when I need it." I saw aides greeting residents as they passed them, sitting talkingquietly to them, exclaiming about their progress. On m y first morning, an aide mentioned at report that Ms. A. held her own glass at breakfast. During the day I heard several aides refer enthusiastically to that bit of news. Again, it was a happening of general interest when two aides helped Mr. B. walk a short distance down the hall. W h e n the bingo p a r t y was announced several aides offered to help, not for pay, I g a t h e r e d , but because it might be fun. N e w aides face special problems. A f t e r caring for person after person who seems out-of-it, one is inclined
to assume that all residents who are not obviously alert are incapable of response. O n e is in danger of treating those residents simply as bodies to be cared for. While helping them, it is easy to talk a b o u t them or other matters as if they were not there, easy to forget that they can feel pain or e m b a r r a s s m e n t . Ms. H. encouraged aides to speak to residents by n a m e as they cared for them, to explain what they were doing step-by-step, and to try to gain the resident's cooperation. Aides were supported in learning to tolerate angry, even abusive, resident behavior, and to understand the cause of mental and physical conditions that m a k e care difficult. M y unfamiliarity with the residents m a d e it very hard for me to give them considerate care, so I was impressed by the problem that aide turnover presents. It seemed to me that neither I nor any new aide could care for a resident appropriately until we had been told specifically, and also learned by experience, his or her individual characteristics and capacity to understand. It was strikingly evident that residents were best served by aides who were familiar with them, so familiar, indeed, that they could serve as surrogate family m e m b e r s , for in the last analysis that is the role of the nursing home aide. M y gravest concern had to do with controlling the quality of care giving. T h a t quality, I thiiak we can agree, consists to an i m p o r t a n t degree in the tone of voice, the gentleness of touch, the unsolicited greeting, word o f praise, act of consideration. H o w can we ensure that aides, when working quite unobserved with helpless people, people often without voice or recourse, will care for t h e m with respect and kindness? This question applies to all who care for people in their own homes, a vast c o m p a n y composed of mothers of children and, increasingly, of
4t
the childrcn of elderly parents. W e know abuse occurs in isolated instances. However, social controls generally operate to assure care that is based on family affection and guided by standards of behavior accepted within families, communities, ethnic groups, and larger societies, and possibly internalized through religious faith. Ultimately it is the inner and largely unarticulated individual values and shared standards of human behavior that will determine the quality of the care we give the people who depend o n US.
My experience at Arbor H o m e reinforced my earlier, researchbased point of view(2). T h a t is, it convinced me that the quality of care given by the staff (usually aide) to resident can never be totally determined by our present nursing home controls, notably, adequate payment for cost of care, government regulatory processes, professional standards, peer pressure, and business self-regulation. All those controls are essential and we need to make each as effective as possible. However, my experience in Arbor H o m e persuaded me that the best way to assure for our chronically ill and infirm elders-and eventually for ourselves--the kind of care we believe in is to make operative in institutions the social controls we take for granted in private settings. At Arbor H o m e these social controis were strong. More than anything else they may have accounted for the fact that an architecturally disjointed, environmentally drab, cluttered, and resources-sparse home full of extremely dependent people seemed so comfortable, socially lively, and concerned about residents as individuals. These social controls could be glimpsed in several ways. A r b o r H o m e is a f a m i l y enterprise. It was started and expanded to its present size by its owner, Mr. D., now in his late forties. Each day his wife brings their three-year-old
r
Residents were best served by aides who were so familiar with them that they could act as surrogates for their family members.
grandson to the home in his stroller and spends time chatting with aides and residents. M r . D's mother, a woman of 70, has always worked in the home, and now helps in the kitchen and dining room. A r b o r H o m e is a c o m m u n i t y institution. Located on Arborville's main street, in a residential area a few blocks from the center of town, its original building, an old house, looks like other houses and one scarcely notices the nursing home sign partly hidden by shrubbery. T h e florist, just down the street, brings in flowers. Church and community groups come to entertain. T h e community's presence is evident when an aide says of a large, helpless, confused, and gently smiling patient we are laboring over, "Ms. C. was a saleslady in the clothing shop and I used to buy dresses from her." Or when a nurse tells me of a limp, barely responsive woman, "Ms. R. was a secretary at the Ford C o m p a n y until she had a stroke last year." The indication that community standards count in this institution shows u p again in the framed testimonials hung near the nurses' station. These certificates of membership or special recognition from the R o t a r y Club and other local organizations suggest that Mr. D. values the respect of his neighbors and fellow businessmen. A r b o r H o m e is culturally h o m o geneous. Most aides, professionals, and residents come from Arborville and the surrounding rural areas. I
have felt the same atmosphere of comfortable at-homeness in several Detroit area homes where the ownership and most of the residents were black, Jewish, or Polish, and ethnic characteristics were affirmed. When we include community involvement among the forces which serve to control the quality of life in our institutions, we are dealing in subtleties difficult to pinpoint, measure, and analyze. Considerable progress has been made in identifying and developing measures of what we mean by good in terms of patient care and the environmental quality, but the more subtle conditions and determinants that are the keys to good care still elude us. W e know that these subtle factors and forces can make all the difference between a comfortable and a disagreeable context for living. W e realize that they have much to do with the care givers: their individual values, native sensitivity, and alertness; their sense of purpose and self-worth. And the subtle forces have to do also with corporate staff morale, teamwork, and mutual support; with personal and group attitudes and capacities in working with elderly people. While education, training, and natural capacities can influence these staff attitudes, they are shaped to a significant degree by social contexts and controls. How do we find, and incorporate in nurse-aide training, social controis capable of substituting for
Geriatric Nursing January/February 1983,17
COMMON CONCERN those of family, c o m m u n i t y , and culture, in the m a n y homes where such benign influences are n o t present?
Implications for Training Elderly people in A m e r i c a have become a large, growing, identifiable, self-aware, and politically potent force. T h e y and all of us are beginning to insist that the nursing home any one of us m a y need to enter must be an appropriate setting for assisted living.
tions and shape t h e m to m e e t our corporate h u m a n needs. Robert Butler, writing a few years ago " C o n c e r n i n g Decent Institutional C a r e , " concluded: " I come to the end with emphasis on the need for a continuing fluidity between the c o m m u n i t y and the institution so that one eventually fuses with the other . . . "(3). I propose that the staff of the nursing h o m e is p r o p e r l y the strongest agent of the c o m m u n i t y present in the institution and plays
/
The aides s e e m e d well motivated. One aide said, "I try to take care of patients the way I w a n t s o m e o n e to take care of me when I need it."
W i t h strong d e m a n d for nursing h o m e beds in the years since the ena c t m e n t of M e d i c a r e and Medicaid, developers had little stimulus to consider the preferences of workers and consumers but great incentive to adjust the environment, pattern of daily life, and plan of care to regulatory and financial objectives. It is not possible, however, to create a h u m a n e institution using a formula composed of g o v e r n m e n t health-care regulations and business principles of cost efficiency. In the case of the nursing h o m e the effort produced an institution nobody wanted and few would enter voluntarily. W e know how to solve the dilemm a that has resulted. Our c o m m u nities must repossess these institu-
4 8 Geriatric Nursing J a n u a r y / F e b r u a r y 1983
a key role in the flow of people, ideas, concerns, and activities between c o m m u n i t y and institution. Therefore, a p r i m a r y goal of training must be to prepare the staff to serve as the c o m m u n i t y surrogates in the place where the comm u n i t y ' s older citizens find t h e m selves estranged, isolated, and powerless. In-addition to skills and knowledge a b o u t resident care, the nurse's aide requires an equally important body of skills and knowledge enabling her or him to provide a psychosocial context for living a d a p t e d to individual particularities. This is a large order, even larger when we recognize that, to be the bearer of c o m m u n i t y values, the aide needs to experience these val-
ues in her working situation. She needs to feel that she is equipped for her work, respected, valued as a person, treated fairly, and fairly rewarded. H o b a r t Jackson put it this way: " . . . wholeness is a goal for every resident and patient in their effort to reach full potential for living and to sustain good mental health. But it is a goal for those serving as well as for those served"(4). Training that addresses the whole environment and the wholeness of persons confined to and working in that environment is now being developed. Professional nurses and gerontologists are taking the lead in this effort, and other health professionals are also interested. The interest and the training activities, however, are slow to reach into the nursing homes. A r b o r H o m e does not represent the w a v e of the future. But as a small, family, c o m m u n i t y , culturally homogeneous h o m e it embodies the values and d e m o n s t r a t e s the controls t h a t larger, more sophisticated nursing homes now need to build into their operations through training. T h e nurse's aide's r e m a r k , " I try to take care of the patients the way I want someone to take care of m e when I need it," contains the utterly serious view of self and other that is f u n d a m e n t a l to that training and to a therapeutic environment.
References 1. American Nurses' Association. Standards o f Gerontological Nursing Practice. Kansas City, Mo., The Association, 1976. 2. Barney, J.L. Community presence as a key to quality of lifo in nursing homes. Am.J.Public Health 64:265-268, Mar. 1974. 3. Butler, Robert. Concerning decent institutional care. IN Mental Health: Principles and Training in Nursing Home Care. Materials developed for a national conference. ( D H E W Pub. (HSM) 73-9046) Washington D.C., U.S. Government Printing Office, 1972, p. 16. 4. Jackson, Hobart. The concept of wholeness in long-term care facilities. IN Mental Health: Principles and Training in Nursing Home Care. Materials developed for a national conference. ( D t t E W Pub. (HSM) 73-9046) Washington D.C., U.S. Government Printing Office, 1972. p. 8.