Editor's note:In 2007, Philip C. DuBois, a Maine nursing home administrator, was involved in a car accident that claimed three of his family members and seriously injured four others, including himself. As a result, he spent 2½ months as a resident in his own nursing home. He has used this life-changing experience to speak to long-term care professionals nationally regarding lessons he learned, the perspective he gained, and the impact this experience made on his administrative style.
When my wife and I adopted our 13-year-old son, we promised him a trip to meet our extended family in Virginia and North Carolina. On that trip in April 2007, our family was involved in a car crash that claimed the lives of my wife, uncle, and cousin, and seriously injured my son, my two aunts, and myself. After two weeks of hospitalization, I became a resident of my own nursing facility, with my son as my roommate for three weeks. During and following my 2½ month stay, I reflected upon lessons learned and perspectives gained from my experience.
I had walked out of my facility as a strong, secure leader. Staff wished me well on my vacation. I didn't expect to return through the doors on a stretcher, weight-bearing on only one limb, a widowed single father. We like to believe that we are holistic in our approach to long-term care, but there are many issues on the minds of our residents; physical recovery may not even be the most important priority.
Cast of characters
At the end of a shift, the caregiver can go home to a normal routine. As a resident, I had a new cast of characters to figure out. I recall three daytime charge nurses from the hospital: Amy, Brenda, and Adele. Amy was a picture-perfect nurse. She had the world under control and had time for a friendly chat, putting me at ease. With Brenda, I had a bad first impression. She couldn't answer any of my questions, and often gave me a blank look. I decided that she didn't know anything, and therefore, I was on my own for the day. I especially became nervous when she started playing with my IV pump! Adele was a frenzy of nerves, always in a rush, dealing with some crisis, mumbling about her hectic day. I decided not to bother her either, since my call bell might push her over the edge.
With little to do but think, I mused, “Every day in healthcare is crazy. Why do my feelings change depending on my nurse?” The demeanor of the caregiver is quickly ascertained by the patient and can affect his/her sense of well-being. A confident nurse can handle the wildest day without communicating the tension to the patient. Not once did I ask for data or statistics on quality measures; my perception of quality was based on my caregivers, shift by shift. Do they know what they're doing and are they compassionate?
In the middle of one night, I was in severe pain. As I reached for my call bell, I remembered, “Oh, she's working tonight.” We had a competent yet eccentric nurse on 11 to 7. I decided I didn't want to deal with her. As the hours crept slowly by, I berated myself for not calling for pain meds. I felt I could make it until 7:00 a.m., when the next shift came in. I thought, “I wonder if my MDS is due? Right now, my pain is about a 6, but by 7:00 it will be a 10. Then I'll flag for uncontrolled pain, and I know the facility's had problems with that quality measure.” (I couldn't turn the administrator's brain completely off!)
We had tried every approach, bringing in outside experts, even volunteering for a pilot project with our QIO [Quality Improvement Organization], but we couldn't seem to bring our pain scores down. I continued, “What if the root of our quality problems isn't always objective? What if no residents like the 11 to 7 nurse, and they would rather wait until morning, just like I am? How would I ever know? And if I knew, what could I do about it?” When I returned to work, I asked my director of nursing to put herself in that position; would she ring the call bell? After a long moment, she quietly replied, “Probably not.” If I can't trust her to take care of me, how can I trust her to care for anyone else?
When I interview a nursing applicant, I always ask, “Why did you want to be a nurse/CNA in the first place?” Usually, I hear something about relationships: “I love to put a smile on someone's face,” “I learn so much from the elderly,” “I took care of my grandmother when I was growing up.” We want staff who are invested in relationships with our residents. Eventually, the first performance evaluation comes due. By what criteria are they measured? Most nursing home evaluation forms could equally be applied in a factory, because we measure productivity. We catch staff doing the wrong things wrong, rather than the right things right. We track issues such as incomplete documentation, tardiness, and absenteeism. Have you ever seen an evaluation that says, “I saw you put a smile on a resident's face times this past year? I saw you take a resident outside on a sunny day times this year?” Staff quickly and subconsciously recognize what our true priorities are, so they shift into assembly-line mode, bringing our criticism for treating humans as objects. Exit interviews show that a leading reason for staff turnover is that “I didn't have the time to form the relationships that I wanted.” Indeed, relationships are at the root of quality outcomes.