Page 7 - One Nursing Home's Journey

IV. One Year After Move-In: Slipping into Old Habits
Slip slidin’ away, slip slidin’ away. You know the nearer your destination, the more you’re slip slidin’ away.
– Paul Simon
“We thought we were doing breakfast on demand when people get up, but really the nurse aids had their own schedules... getting people up when they wanted to get them up,” says Aube.
Caregivers are slip sliding into old ways just as the transi- tion to cooking breakfast in the neighborhoods is about to begin. Thus, the revolutionary change from institutional to “home” cooking adds to the stress for CNAs trying to kick the habit of rushing people out of bed and into the dining room.
With routines for dietary and nurse aides in turmoil, the rumor mill is abuzz about what will happen next. Heath has heard some whoppers. Communication, she says, “keeps com- ing around as the key thing we have to do better.”
It is “eye-opening” for her to see that caregivers don’t fully understand that neighborhoods are allowed—indeed, encour- aged—to develop their own unique character. Also, staff still acts as though the hierarchical, top-down command structure is still in place, treating her as the DON and ultimate decision maker instead of as a member of the team.
Rather than proceed with an in-service already scheduled, she decides to convene learning circles instead. Eighty-six per- sons participate, more than has ever attended an in-service.
The neighborhoods agree to begin cooking breakfast onsite within a set timeframe, and each proceeds toward that goal at its own pace. Several meetings between leadership and neighbor- hood teams are held in advance to discuss what must be done and how it will affect everyone’s job. Just giving people time to talk about their frustrations and fears helps a lot, says Aube.
Since fire codes allow only breakfast to be cooked using the neighborhoods’ residential-style appliances, the main kitchen is still central to the nursing home’s overall dining experience. Dietary workers are literally caught between the neighborhoods and the main kitchen.
“They’re rushing around down in the kitchen pulling things they need and coming up to the neighborhoods to prepare breakfast for people who arise early, then staying long enough to cook for those who want to sleep longer,” says Hiltner.
It is especially problematic that there are no automatic dishwashers in the neighborhoods. If dietary workers stay in the neighborhoods too long, they can’t get the dishes back to the main kitchen and washed in time for lunch.
“It’s a matter of how to be in both places at once,” she says.
It also is a question of how late to let residents sleep, and if they are not ready to get up, what does staff do in the mean- time? Regulations require residents to be offered breakfast within 14 hours of their evening meal, so residents not up by 9 AM are awakened by staff.
Caregivers experienced some anxious moments during the first few days of cooking breakfast: “Nobody was waking up, that was really awkward,” says Rathbun, “but now they’re wak- ing up earlier.”
(Staff in Wendy Meijer’s neighborhood gave one resident an alarm clock after the woman com-
“The learning circle was, ‘tell me your best rumor and what is stressing you out, and tell me what you like best about what we are doing.’ It worked wonderful, it calmed everybody down and all that frustration went away.”
plained about oversleeping.) During the adjustment period for
breakfast-on-demand, the CNAs’ lives are even more hectic in neighborhoods like Rathbun’s where staff already is stretched thin.
“It’s not a routine anymore. Breakfast is just scattered and if we don’t have all the staff who are supposed to help us,
“The learning circle was, ‘tell me your best rumor and what is stressing you out, and tell me what you like best about what we are doing.’ It worked wonderful, it calmed everybody down and all that frustration went away,” says Heath.
“They don’t trust the change initially,” says Aube. “But once they start doing it and see the value to the residents, they are good with it. This has happened over and over.”
“It takes a lot of patience and listening. They (dietary and nurses’ aides) have ideas on how to make it work, but it takes a lot to get them to share those ideas, and that’s a big frustration for me,” she adds.
Breakfast on Demand
“You know how people get grumpy in the morning? We have a couple of residents like that. Formerly, we would get them up and they would have their meal and then lie back down, or some would fall asleep in their chairs and have to be laid down. That was just the norm. But now, they sleep in a little bit longer. They stay awake longer and they’re more active. Actually, their whole being is a bit different. They’re a lot more pleasant.”
– Julie Moreno, Activities CNA (RSA)
then we’re in a lot of trouble,” she says.
With residents continuing to awaken throughout the early
morning and needing help to get out of bed, she and another CNA split their time between the resident rooms and the kitchen. Usually there are a few residents who need someone to sit and assist them at mealtimes, and if dietary workers leave before all the residents are up, that task, along with the rest of the cooking and cleanup, falls to the neighborhood team.
“If our housekeeper or coordinator isn’t in there, then one of us (CNAs) has to stay in the kitchen,” she says.
Though she has a list of administrative staff to call when they need extra help, it often takes too long to find someone available.
Another problem, says Heath, is that CNAs feel a loss of companionship with other nurse aides now that there is no central nurses’ station or common dining room where they routinely gather.
“We can work through a whole day and not even know who’s working on the same floor,” she says.
Aides are learning to reconnect by coming to work earlier to meet informally in the break room, and some gather in com- mon areas between neighborhoods.
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