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ONWARD ~ and
~ UPWARD
Judith Florian,
R.N.
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Featuring articles and
discussion of diverse topics and issues, including:
Disabilities, Home Health Care, Sexual Abuse of Children, and Advocacy.
The Training of Caregivers
and Home Health Aides
This discussion will center
on current training and
needed reforms in the home care industry.
HIRING and SCREENING CRITERIA: Finger-printing,
drug testing, police screening, references, sometimes one-year of experience,
and a personal job interview.
Truth of Hiring: Often,
one or more of the above criteria has been skipped and sometimes is never
completed. Some workers tell of walking in the door of an agency and being
hired within 10 minutes, with no testing, no personal interview, etc.
Sometimes drug-testing is skipped; sometimes the finger-printing and police
screening has not been completed before the worker is sent to their first
assignment in that agency.
PAPERWORK: Companies primarily focus on only a few things in
orientation programs -- if they do any orientation at all .
One area that IS addressed usually is how to complete that company's paperwork,
but often Aides ask the PATIENT about HOW to fill out the forms.
ALL
companies do not share the same type of paperwork, nor do they require the same
bits of information on the paperwork. Even signature requirements are
different: some require initials and full signature, while others only use full
signature.
CHANGES NEEDED:
Confusion would be lessened if care plans and paperwork completed by Home Health
Aides were standardized to include the same types of information gathered.
Patients should NOT have to teach a
worker how to fill in the paperwork. (Do not sign blank papers or ones
that are not fully completed.)
Copies of completed forms should ALWAYS be given to the patient after each
shift.
Much of what Aides need is common sense. Companies need a strong
in-service program to teach and reinforce tasks that involve common sense.
SAFETY:
Review of standard safety practices in the home should be emphasized, especially
since they are working in many different private homes! Apparently, some
aides never learned typical safety measures and do some very dangerous things.
The following are things that have been done by Aides in patients' homes:
--- Papers and plastic bags were left
on a gas stove (like a single unused garbage bag or the plastic bag that
newspaper-flyers
came in.)
--- Large items, like a wheelchair, or
an empty box being left in the pathway to an outside door (an escape route if a
fire occurred);
--- Ammonia was mixed with bleach,
causing toxic fumes in the house;
--- Drain cleaner was poured full
strength into drains with NO water added to flush the drain, creating toxic
fumes in the house, and the Aide then left for the day;
--- Dirty clothes were thrown down
steps and left on the stairs (could cause slip & fall accident or an off-balance accident if patient tried to pick up the clothes);
--- Aides secretly smoking in obscure
areas of the house and discarded lit cigarettes in wastebaskets (they should not
smoke in patient's homes at all)
--- Running the dryer for two (2) hours
on a small load of laundry (fire hazard, especially in older appliances).
CHANGE NEEDED: These
common safety hazard examples show a need for specific instructions about home safety.
Companies could ask for Speakers from the Fire Department to come to talk at
in-service training. Simply because a person has reached adulthood, no assumption
can be made that they know in-home safety. [Scary, huh? Imagine
being a patient in this situation.] A University Home-Ec instructor
could also address home safety issues, and safety in meal preparation also.
PRIVACY &
CONFIDENTIALITY: - Communication with others...
With the new HIPPA Law concerning privacy and confidentiality, companies
probably devote a large portion of training on these issues. But more is
needed. For example, how would your Aide respond to these situations?
How should they respond?
Situation 1: Nosey neighbor Mrs. Hockey
stops the Aide in the driveway as the Aide is getting in her car to leave for
the day. "How is she today?" Mrs. Hockey asks.
"Oh, she's had a bad day. It didn't help that her son called and
upset her - what a horrible person he is - I met him and he treats her
terribly!"
Regardless of who the person is, the Aide should never, ever, ever discuss a
patient. Even if the patient's church pastor drops by, no information
should be given - to anyone! Even if an Aide knows the person is a
relative, no information should be given without the patient's consent.
ALL an Aide should do is say: "You'll need to talk to Mrs. Smith (the
patient) the next time you see her." If someone pushes for
information, the Aide should say: "I'm really not at liberty to say; It was
nice meeting you but I need to get going now."
Sometimes patients have friends who help out. Even though they are friends
of the patient, it does not mean friends get told everything about the patient.
A patient's mood (happy, sad, irritable) and patient's conversations are not
things that should be shared with friends of a patient. Nor what was
eaten, how much was eaten, whether the patient went to the bathroom etc.
These are issues of privacy that Aides usually don't think about at all.
CHANGE NEEDED:
Companies should discuss the types of situations that may arise when
"others" ask personal questions about the patient. Talk about
what to do when "others" try to corner an Aide into giving
information, and ways to tactfully NOT answer the questions being asked.
PRIVACY: -
Personal privacy for the patient -
Imagine, you are in your bedroom in bed and it is the only place you can
independently blow your nose (or pick it, if 'ya wanted to), or scratch your
butt, or insert vaginal yeast cream.... and.... in walks your Aide without
knocking on the bedroom door! And... there you are doing something
very private... and there stands your Aide... or the Aide is putting away your
p.j's or your shoes...or is asking you some question that they could ask LATER!
Imagine that you've had the Aide's help to get to the toilet. You're
seated now and quite safe! But, there stands the Aide, 3 inches from your
knee! Have you ever been in a public bathroom and had
second-thoughts about letting out gas (farting), or felt a bit embarrassed when
you involuntarily grunted during a bowel movement because you were in a public
place? Some people have trouble even starting their urine stream when
other people are close by, and will wait till the other person(s) leaves the
public bathroom. You may have found that it is even harder to use
the bathroom in a friend's house... So, if you feel awkward going to the
bathroom in a public place, you'll understand how much harder it is when another
person is standing right in front or beside you! Move away, preferably
outside the bathroom if the person is safe. If you HAVE to stay with the
patient, give some privacy! Turn your back, look away. If the
patient can stand without your help, they do not need an audience when pulling
up their underwear! (Same thing at the beginning - they don't need to be
watched while pulling down their underwear - unless the patient clearly needs
help.)
Imagine that (fill in the blank: your mother, your child, your boy/girlfriend,
your pastor, your doctor, a bill collector) calls on the telephone and, the Aide
STANDS there in the room... just stands there, staring at you while on the
telephone. Maybe it is the only call you get from your boyfriend each day.
Maybe you need to ask your doctor about discharge from your penis.. or breast.
Maybe you want to make an act of confession to your Priest. Maybe you
don't want everyone to know your financial state. A patient has every
right to total privacy during telephone calls! TOTAL privacy! This
means, remove yourself to a room far enough away that you cannot hear ANYTHING
the patient is saying to a caller. (You can return in 20-30 minutes to see
if the call has ended; if it hasn't, leave the room again.)
Imagine that you have laid aside a personal letter (or a bill) to finish later.
You notice your Aide is standing so that they can sneak peeks at what you have
written, or peek at your bills. When caught, the Aide denies they were
looking at the papers/bills or reading it. Or imagine that your Aide is
snooping in your purse or wallet! Aides should take care to always avoid
looking at any personal papers, EVEN if your patient has asked you to move
papers from point A to point B. Aides should also avoid looking at a
patient's mail, even if the Aide is the person who takes the mail from the
mailbox and brings it into the house.
CHANGES NEEDED:
These are just a few examples of personal privacy. It is amazing how many
Aides violate basic personal privacy and seemingly are unaware of how intrusive
they become for a patient. Patients need personal boundaries -- a
space around them and their business which is strictly off-limits.
Companies should be aware that these issues arise in patients' homes and take
proactive steps to educate all Aides BEFORE sending an aide to the first
patient.
COMMUNICATION is
much more than talking....
A person who applies for a job in
health care should be friendly, compassionate, caring, personable and have
patience. They should know the balance between interacting with a person
and giving the person "space" and quiet time.
Many Aides, however, seem to think all patients want to talk all day, and to
talk about concerns of the Aide (not of the patient).
Persons who are ill don't always want
to talk - or hear another person talking. Aides need to understand some
basic ground rules about talking, such as:
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Persons who are sick need quiet
times during every "shift" of care;
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Persons who are sick are not
uncaring, but do not need to be forced to listen to every problem a home
worker has now or has had in the past;
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If a worker is having marital
problems, legal problems, child behavior problems, or mental health
problems, that Aide needs to find a counselor - a patient is not their
personal counselor;
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A worker and patient may become
very close, but it is still always the worker's responsibility to keep good
boundaries about talking too much about their own problems;
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Patients have their own problems
and emotions to deal with - please don't add a worker's problems to the
patient's often overloaded mind and emotions;
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Just because a patient *may* have
problems of their own does not mean they wish to discuss their thoughts and
feelings with persons employed to help them bathe, dress, to prepare food
and to keep their home and clothing cleaned - let the patient decide how much to
share, what to share, and when;
-
Some topics are NOT appropriate in
any health care setting - if a worker has a tendency to focus on subjects
about the deaths of babies from the news, or seeing dead animals on the roadway, that
worker should probably not be in home care (those 2 examples are from real
patient-worker interactions, where an Aide brought up these subjects every
day);
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Aides should avoid any comment that
is demeaning, such as "Whew, this stinks! You really let a load
go!" when cleaning a bowel movement from the bed and patient. Or
comments like "You know you've gotten to be a fat old man!" or
"Some men like a fat butt on a woman" when a patient is
overweight. These seem SO obvious as things to NOT say, but Aides HAVE
said these to patients!
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And, body language is
"communication" too, often stronger than words. When an Aide
rolls their eyes, it tells a patient that their concern is
"irrelevant." When an Aide holds their nose when
removing the potty to dump it in the toilet, the patient feels their need to
use a potty chair is "disgusting."
CHANGES NEEDED:
These are not uncommon examples in Home Care! New workers in a company
need in-services that address these supposedly obvious "no-no's" in
communication. In-services should be re-done every year for all Aides.
Role-playing should be included in the education. Directors of Nursing and
Nursing Supervisors need to hear from Aides what responses they might use in
given examples. And, anytime a patient complains of inappropriate
communication, there should be a written notification to the Aide with a copy in
their personnel jacket, especially if the Aide was demeaning or humiliating
about soiling themselves or their bed. If an Aide is communicating
about their own severe situational or emotional problems, there needs to be
mandatory counseling required. A patient should NOT have to hear that
their Aide is being beaten by a boyfriend / husband, how the Aide is depressed
and suicidal, how many times they have been hospitalized for emotional problems,
or how an Aide is fascinated by seeing dead animals on the road.
Currently, if complaints are made to the companies, the reaction is (1) shock
(the aide said what?!); (2) denial (she couldn't have said THAT); (3) inaction -
no supervisory visit is made; (4) action based on a different reason (like, the
Aide is let go for another reason - "Well we haven't liked that she is late
to her clients.") The action needs to be clearly based on the
complaint. And the first action should be a written complaint.
The preventative action should be repeated in-services and appropriate screening
of potential workers, so that inappropriate communication does not happen in the
first place.
BOUNDARIES
....this thing, this place, this area, this body, is MINE...
We've talked a little about boundaries already in discussing privacy and
confidentiality. Personal boundaries are set by each individual, so
technically speaking, a boundary can be anything a person decides they want.
Let me give you some examples.
| Reverend Paul Calisopa collected
rare theological books for 37 years as he worked in churches across the
United States. He has some of these books opened on stands and
lecterns in his living room and dining room and he states that no one
except his son is allowed to touch the books, even to dust. So
that means hands off, totally. Don't put your glass of water down
on the book. Don't lay your paperwork on the open books.
Treat those books as if they are in a national museum. Respect
what the Reverend has asked of you. |
| Mrs. Susan Palainine, an 84-year
old widow, has a chest of drawers with an assortment of toiletries and
perfumes sitting on top. Mrs. Palainine instructs that no Aide
should open the bottom drawer; all clothing should be put into the top 5
drawers. But, Mrs. Palainine has to constantly watch, because
Aides continue to reach for the bottom drawer when putting away clothes.
One Aide continually asks the patient "What's in the drawer?"
as though it is a guessing game. What is inside that drawer is not
the issue. The issue is that the patient has asked no one open THAT
drawer, for ANY reason. Aides should follow her wishes, and
not even ask about what is inside. [Would you be surprised if I
told you that all that was inside the drawer were newspaper clippings
about when she was a teenager in the 4-H Club, showing her prized cow
Betsy? The point is, whatever that drawer conceals, it is
something so personally private that the patient has specifically excluded others
from seeing the contents.] |
| Mr. Joseph Doboloskavich has an
entire room closed off. The room has no door, but he has hung
curtains across the doorway. Anytime anyone gets close to the
curtains, he barks "Stay away from that room!" It sparks
curiosity among his Aides. 'What could be in that room? What
is he hiding? Maybe he's got a girlfriend living in there,' one
Aide jokes to the others. [If the truth be known, and only the
closest relatives know, that was little Joey's room, Mr. Doboloskavich's
almost-2-year old son who died in his sleep one night...long, long ago.
Mr. Doboloskavich has left the room exactly as it had been back then,
with little Joey's crib still standing in the corner. The grief he
carries is so private, so intense, that he cannot tell anyone about
little Joey.] Nor should Mr. Doboloskavich have to tell
anyone, if he chooses not to. ALL an Aide needs to do is follow
his instructions: "Stay away from that room." |
CHANGES NEEDED:
Yes, personal boundaries can be about anything.; But, a patient's
boundaries should always be respected at all times. Since
home care companies are employing persons with GED or high school education, who
have not had formal home care training (usually), Aides may have few boundaries
in their personal life. They may not even know what "boundaries"
means! Boundaries should be an important subject to cover in orientation
and in-service training. When an Aide breaks a boundary, the focus should
not be "Oh that's just Mrs. Jones, she's fussy about her belongings"
but the focus should be "ALL patients have boundaries which should be
respected, just as we should be respectful of their belongings, their homes,
their relationships with family and friends."
Other patients are intensely private about their body.
This can be from a number of reasons like (both sexes): their upbringing/ a
value of modesty; scars or physical imperfections; normal issues about body
image and aging; childhood abuses; rape or sexual abuse; or simply the fact that
they've had "a hundred" different workers come to their home!
These types of issues should be covered during in-service training of
workers. Patients should NOT be left to figure out HOW to tell an Aide to
give the patient physical privacy.
SPACE, PRIVACY AND QUIET TIME... or put simply,
quit talking so much!
Along with setting personal boundaries (whatever they are), patients also need
space and quiet time. This is especially true of patients who live alone
or who are very private or very quiet in their daily life.
When a patient says they are not a very talkative person, what they are also
saying (without saying this outright) is "please be quiet and quit
talking!" This isn't meant to be rude; the patient just does
not LIKE talking. They are quiet, and they need the Aide to be quiet.
Too many Aides try to engage a quiet patient in MORE conversation. Or,
Aides chitter-chatter pleasantly about this 'n that. Most often this
one-sided talking is not welcomed by an ill patient. Take your cues from
your patient. If they enjoy conversation, feel free to converse.
But, if your patient says to you "I'm a quiet person," they probably
wish you'd say LESS. Don't make your patient have to come across as
"rude" by being forced to tell you that you talk too much. And,
if you already know you talk too much, work on figuring out if you are talking
because you are nervous, and figuring out when it is important to talk versus
being quiet.
SPECIFIC DIFFICULTIES, LIKE MEMORY PROBLEMS,
CONFUSION (EVEN BRAIN-FOG OF MIDDLE AGE!), SPEECH OR VOICE PROBLEMS:
Workers are MOST familiar with "old age"
infirmities, such as speech problems after a stroke. But, even middle-aged
persons can experience memory problems (such as during menopause). Some
patients may have difficulties with "finding words" (can be from
stress or a physical problem or medication side effect). Many medications
can cause "brain-fog" or confusion (and an Aide needs to know when
confusion should be reported to the nurse). Speech and voice problems can
be caused something as simple as allergies (causing laryngitis), or something
more severe such as a medication reaction.
Many, many workers do NOT know what they should do when a
patient experiences confusion, "brain-fog," or cannot find
words. Workers try to rush the patient, or guess what the patient is
trying to say.
CHANGES NEEDED: Training needs to
focus on these very common issues, and to emphasize that patients of ANY age can
& do experience memory problems. The primary thing workers need
to remember is: WAIT.
The most important thing you can say is "Take
your time, I'll wait."
Don't immediately try guessing the word or the sentence your
patient is trying to say. Give the patient time to find their own
words -- this may take several minutes. Do not go on to another subject -
it will only increase confusion because the patient is still stuck on the word/s
they are trying to find or speak. Stay in the room, but don't just
stare at the patient because this can cause more stress and make it harder for
the patient to get the word they are trying to speak. IF you are pretty
sure you know the word or what the patient wants, AND if several minutes has
passed, offer ONE or TWO suggestions: "Are you wanting your
eyeglasses?" (if that is not correct, offer ONE more suggestion IF
you think you know... BUT, do NOT keep repeatedly
"guessing.")
Likewise, workers need trained about laryngitis and voice
problems. A patient with speech or throat disorders should be encouraged
to rest their voice, not "speak up." Aides need trained in
patient listening.
These are just SOME issues that need addressed in specific
training and in-service meetings.
Read more about needed changes within the Home Care Industry.
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Facts....Do You Know...
* Many of those hired as
Aides in Home Care do not know basic home safety, do not know basic
personal care or grooming, nor know how to perform simple home chores,
such as laundry.
State Tested Nursing Aides have met minimum standards in
training and testing, but this varies from state to state.
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The title "Onward ~ and ~ Upward" is a
"motto" I used as a teenager and young adult --- then forgot about for
a number of years. I feel it is a fitting motto to strive for and a
fitting title for the topics of this website.
(c) Judith Ann Florian
159 E. Main St.
Girard, Ohio 44420
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This page was last updated on Saturday, April 22, 2006 15:27
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