Yesterday was first day of clinical lab training for the group of Signature executives who are going through CNA certification. As challenging as the online coursework has been, the labs really brought home how difficult a CNA’s job is. There’s nothing like watching a bunch of home office executives struggle over how to change linens in an occupied bed or how to take a proper blood pressure reading to inject a little humility into our work.
Early in the day, I had the first of several “Aha!” moments.
Our instructor was demonstrating the proper technique for turning a resident when he paused for a moment to explain how to communicate with someone who is hearing impaired. One of the basic principles of good caregiving in a nursing home (or any setting, really) is that you should always explain to the resident what you are going to do and, whenever possible, encourage them to help. So when turning a resident, you want to tell them before you place your hands on them. You want to ask them to help by, for example, raising their knee to make the turn smoother.
With a hearing impaired resident, the temptation is to raise your voice in order to get your point across. But this can make the resident feel threatened in addition to disturbing other people nearby. Our instructor showed us the correct approach by turning to the mock resident and repeating his words slowly, so that a hearing impaired resident would be able to read his lips.
As an observer, I can tell you that the effect was powerful…but not necessarily in the way our instructor intended it! Where he had previously been talking to person’s body parts–knees, arms, hips, etc,–as he hovered over her and raced through his instructions, he now turned to the person’s face, made eye contact, and slowly explained what was he was about to do. You could feel the emotional balance of the encounter shift almost instantaneously. Too often in healthcare, we slip into what Karl Albrecht calls the “car wash” service model. We process people through our facilities as efficiently as possible, paying lip service to “dignity” and “person-centered care” while pushing, prodding, poking, and scrubbing our customers in a manner more befitting a machine than a human being.
And that is exactly what came to mind as I watched our instructor run through his lines without ever making eye contact with the volunteer. In the “outside world,” we don’t talk to people’s body parts while we engage them in conversation; we talk to their faces. It is a basic sign of respect. In the nursing home setting, where people already feel frightened, de-humanized, and vulnerable, it is even more important to take the time to show that basic level of respect. A simple action that comes so naturally in our everyday lives–like looking a person in the face when you are talking to them–can be transformative in a nursing home. It restores balance to the caregiver-resident relationship by reinforcing their mutual personhood.
Another breakthrough came for me when it was my turn to volunteer as the resident. I climbed into the bed, and waited as my fellow students got ready for a mock procedure. The change in perspective was startling. When you’re lying down in a hospital bed and everyone else around you is moving about freely, an invisible curtain comes down between you and the rest of the world. It is isolating, even for someone who is “perfectly healthy.” And it is so easy for everyone else to pretend you’re not there. I’ve heard stories from patients in acute care settings about being transferred to different rooms or wings. In the manic bustle of a hospital hallway, nurses and doctor’s may take time to say hello to each other, but no one acknowledges the person on the gurney. And then there is the change in the power relationship. You may be a “VIP” in your everyday life, but when you are placed in a hospital bed where everyone is taller than you and tends to speak down to you, you don’t feel particularly important.
Not long after stepping into my role as the temporary resident, I found myself being touched and prodded somewhat awkwardly by fellow students as they attempted to turn me or reposition me in the bed. Another light went off in my head. I absolutely hated it. According to the world’s foremost expert on body language, Allan Pease, we all have a built-in sense of personal space. He calls it the “intimate zone,” and for most people it is like a movable air bubble that extends 6 to 18 inches away from our bodies. Only those we truly love and trust are permitted into the intimate zone: parents, siblings, spouses. children, pets. Any intrusion by a stranger or acquaintance into that space is likely to provoke a strong negative reaction. And yet this is what our residents experience day in and day out. It’s hard to maintain any sense of dignity or self-confidence when virtual strangers are invading your intimate zone every few hours to help turn you, clean you, or give you medicine.
Just before lunch, our instructor was quizzing us on how we would react in certain scenarios. The overall theme of his questioning was clear: when in doubt, ask the nurse. When one of the executives mistakenly suggested that the CNA could handle the problem, he pounced: “You have to realize what the scope of practice is and RESPECT it. A CNA’s job is not to make care plan decisions, perform complicated clinical procedures, or replace the nurse. It’s like the military, and the CNA is a private!”
That bothered me a bit, so I approached him during lunch. “How do CNA’s feel about that role?” I asked. “Does it bother them that they’re supposed to defer to the nurse on so many things?”
“It depends on the nurse,” was his answer. “In a healthy environment, everyone understands what Scope of Practice means. It doesn’t mean that the nurse is smarter, better, more important, or more valuable than the CNA. It just means that her training and her role are different. In an unhealthy environment, the nurses talk down to the CNA’s, make them feel bad, and it becomes a battle of egos. I used to be in the military. I know that privates are the ones who get killed, but they’re also the ones who get things done. I’d be a terrible leader if I didn’t respect the privates. But I’d also be a terrible leader if I let them do my job for me.”
There is one area, however, where CNA’s have a lot of freedom, and that is in customer service. CNA’s have more contact (and more intimate contact) with our residents than anyone else, and unlike the scope of practice, the scope of service is unlimited.
I learned other lessons yesterday, too: the confidence and joy that comes once you understand how to do something right, the heart it takes to be a good CNA, how utterly dependent we as an organization are on their work, how hard it is for executives to stay “present” and focus on the process as opposed to the outcome.
And as much as I’ve grumbled about it, I think that going through this training is the single best thing that our leadership team can do for the culture of the organization. We are in the business of empathy. We can’t expect our line staff to deliver empathy to our residents if we can’t deliver empathy to them.
Please wish me (and the others) luck as we get ready for our state exam!
