"The Respect-Worthy Supervisor: Receiving and Giving Respect in Home Health Care Supervision.“ Rita A. Jablonski, Ph.D., RN, ANP Anthony J. DeLellis, Ed.D. "The Respect-Worthy Supervisor: Receiving and Giving Respect in Home Health Care Supervision.“ Rita A. Jablonski, Ph.D., RN, ANP Anthony J. DeLellis, Ed.D.

Respectful Supervision Begins with respectful communication Begins with respectful communication

Give respect to get respect? Usually get respect if you give respect, but no guarantee Usually get respect if you give respect, but no guarantee Get no respect if you give no respect, guaranteed Get no respect if you give no respect, guaranteed ?

Giving respect - names are important Call people what they want to be called: If her name is Mary Jones, do you call her Mary, Ms. Mary, Miss Mary, Mrs. Mary, Ms. Jones, Miss Jones, Mrs. Jones? Call people what they want to be called: If her name is Mary Jones, do you call her Mary, Ms. Mary, Miss Mary, Mrs. Mary, Ms. Jones, Miss Jones, Mrs. Jones?

Giving respect - names Ask people what you should call them, and then just do it

Respect is listening Listen actively Listen actively Look, stop, wait - let them finish Look, stop, wait - let them finish Don’t interrupt Don’t interrupt Turn off radio, TV - completely off Turn off radio, TV - completely off Let them know you heard and understood Let them know you heard and understood Paraphrase Paraphrase

Respectful communication - Respect is something we feel, even if we don’t show it. Respect is something we feel, even if we don’t show it. So show it! So show it!

Tone and choice of words matter Use respectful tones. Use respectful tones. Use courteous language, always. Use courteous language, always.

Clothes matter How we dress sends a message to the people around us about how we feel about them. How we dress sends a message to the people around us about how we feel about them.

Assertive vs Aggressive Communication Assertive - say what is on your mind, but keep in mind the feelings of others. Aggressive - say what is on your mind, but don’t care about the feelings of others or deliberate try to hurt or offend them.

Politeness and Power Powerful people can afford to be polite. Powerful people can afford to be polite. Politeness isn’t weakness. Politeness isn’t weakness. Politeness isn’t being somebody you’re not. Politeness isn’t being somebody you’re not. Politeness to rich and poor alike is - powerful. Politeness to rich and poor alike is - powerful.

Addressing Unsatisfactory Performance Opportunity to help the NA to concretely understand workplace obligations Cultural differences regarding “on time” Differences in work ethic among members of various age cohorts, e.g. “entitlement” in workers under the age of 30 versus “work until you drop dead” ethic of workers in their 60s

Addressing Unsatisfactory Performance May be the first time a worker has had to problem solve Instead of telling the worker, “Late again, you are fired,” try asking the worker a series of questions to help him or her figure out options “Coaching” type of management

Be assertive when coaching Speak assertively, not aggressively. Speak assertively, not aggressively. Stick to the point. Stick to the point. Describe the behavior, don’t characterize the employee as a loser. Describe the behavior, don’t characterize the employee as a loser. Don’t be afraid to praise someone who is not perfect - when praise is due. Don’t be afraid to praise someone who is not perfect - when praise is due. Don’t use praise to avoid conflict. Don’t use praise to avoid conflict.

Coaching is shared risk Coaches rise or fall when their teams rise or fall. Coaches rise or fall when their teams rise or fall. Coaches find inner motivation of team members. Coaches find inner motivation of team members. Team members eventually have to go it alone. Team members eventually have to go it alone.

Disagreement Disagreement with an employee is never an excuse to switch from assertive communication to aggressive communication. Disagreement with an employee is never an excuse to switch from assertive communication to aggressive communication. Respect, assertiveness, listening, and politeness are especially important during disagreement. Respect, assertiveness, listening, and politeness are especially important during disagreement.

Effective Supervisors Compassionate Compassionate Creative Creative Decisive Decisive Empathetic Empathetic Fair Fair Flexible Flexible Humble Humble Objective Objective Problem-solver Problem-solver Respectful Respectful Self-directed Self-directed Self-evaluative Self-evaluative Understanding Understanding Visionary Visionary System-thinker (able to see big picture) System-thinker (able to see big picture) Hewlett, et al., “Minnesota Frontline Supervisor Competencies & Performance Indicators,” U. of Minn., Hewlett, et al., “Minnesota Frontline Supervisor Competencies & Performance Indicators,” U. of Minn., 1998.

Some Guiding Principles for Supervisors Internal motivation. Internal motivation. External motivation. External motivation. Recognition. Recognition. Importance of staff development & training. Importance of staff development & training. 2 important questions: 2 important questions: What motivates you? What motivates you? How do you want to be recognized? How do you want to be recognized? LaLiberte, Hewitt and Larson, “Staff Motivation and Recognition.” LaLiberte, Hewitt and Larson, “Staff Motivation and Recognition.”

Challenging Issues in Home Care

Legal and Ethical Situations that Accompany Supervision

Legal Definitions Assault (criminal act) An attempt to inflict physical injury on a person; the unwanted touching of one individual by another Assault (criminal act) An attempt to inflict physical injury on a person; the unwanted touching of one individual by another Battery (criminal act) The actual infliction of physical injury on a person. Includes “every willful, angry, and violent or negligent touching of another’s person or clothes or anything attached to his person or held by him” (Creighton, 1986). Battery (criminal act) The actual infliction of physical injury on a person. Includes “every willful, angry, and violent or negligent touching of another’s person or clothes or anything attached to his person or held by him” (Creighton, 1986).

Legal Definitions Unlawful use of restraint Could be considered assault and battery Unlawful use of restraint Could be considered assault and battery –Care must be taken to use only with a physician’s order; to monitor the client frequently (minimum, every hour); to remove the restraints and exercise the limbs (minimum, every 2 hours)

Legal Definitions Tort A legal wrong, not a crime (a crime must have evil intent and involve a criminal act). Tort A legal wrong, not a crime (a crime must have evil intent and involve a criminal act). –A legal right of a person is somehow violated, and the violation is called a “tort.” –A legal case involving torts is heard in civil, not criminal, court. –Example: two drivers are involved in an automobile accident. No criminal charges are filed. One driver sues the other.

Legal Definitions Negligence “The omission to do something that a reasonable person, guided by those considerations that ordinarily regulate human affairs, would do, or as doing something that a reasonable and prudent person would not do” (Creighton, 1986, p. 141) Negligence “The omission to do something that a reasonable person, guided by those considerations that ordinarily regulate human affairs, would do, or as doing something that a reasonable and prudent person would not do” (Creighton, 1986, p. 141)

Legal Definitions Malpractice “any professional misconduct, unreasonable lack of skill or fidelity in professional or judiciary duties, evil practice or illegal or immoral conduct” (Creighton, 1986, p. 141) Malpractice “any professional misconduct, unreasonable lack of skill or fidelity in professional or judiciary duties, evil practice or illegal or immoral conduct” (Creighton, 1986, p. 141)

Legal Definitions Defamation The ruining of a person’s reputation by verbal or printed statements; any verbal or printed statements that could be considered detrimental to a person’s personal or professional reputation Defamation The ruining of a person’s reputation by verbal or printed statements; any verbal or printed statements that could be considered detrimental to a person’s personal or professional reputation –Slander Oral defamation –Libel Written/published defamation

Legal Definitions Neither slander nor libel refers to a conversation or written communication between 2 persons, unless overheard or witnessed by a third person. Neither slander nor libel refers to a conversation or written communication between 2 persons, unless overheard or witnessed by a third person.

Legal Definitions Defamation is not an issue when there is a legal duty to speak. Defamation is not an issue when there is a legal duty to speak. Confidentiality Confidentiality –Be aware of potential HIPAA violations, especially when carrying client records and information in your car. –Be aware of your surroundings when using your cell phone in the field. Password protect laptops, Palm devices

Types Of Legal Issues

Living Wills Living Wills –Also known as Natural Death Acts, Patient Self-determination Acts –These documents state which specific treatments may be rendered if a client is unable to make medical decisions for him or herself.

Types Of Legal Issues Patient-specific treatment instructions Patient-specific treatment instructions –Designation of a proxy to make these decisions –Do Not Resuscitate Orders –Medicaid regs do not require that DNR orders be kept in the client file in the agency, and as a practice, agencies do not obtain a copy. –The DNR notice is to be posted in the room or on the client’s door.

Types Of Legal Issues –The RN’s responsibility is to discuss this with the family and instruct the aide as to the family’s wishes regarding who to call should the client become unresponsive. That may be the rescue squad, hospice, or a family member. That may be the rescue squad, hospice, or a family member. If the family wants the rescue squad called, it is important that the nurse instruct the family to have DNR orders posted in an obvious place. If the family wants the rescue squad called, it is important that the nurse instruct the family to have DNR orders posted in an obvious place. The RN would insure that the aide understands what DNR orders are and what the aide’s responsibilities are as a result. The RN would insure that the aide understands what DNR orders are and what the aide’s responsibilities are as a result. Usually, DNRs stipulate that no “heroic” efforts be made in the event of severe illness or cardiovascular arrest. Usually, DNRs stipulate that no “heroic” efforts be made in the event of severe illness or cardiovascular arrest. Can be modified, e.g., may not administer CPR and intubation but may use medications Can be modified, e.g., may not administer CPR and intubation but may use medications

Ethical Issues

Ethics Ethics –A body of knowledge concerned with the rightness or wrongness of an act. In the professional arena, ethics refers to the rightness or wrongness of professional conduct. –Something may be legally “right” but ethically “wrong,” depending on a person’s own code of ethics: e.g., abortion

Ethical Issues Types of ethical views Types of ethical views –“Do no wrong” –“The end justifies the means” –“The individual’s choice takes precedence over society’s views” –“I know what is best for you”

Ethical Issues Clients should be active participants in decisions about matters that involve themselves or their lifestyles Clients should be active participants in decisions about matters that involve themselves or their lifestyles

Ethical Issues Decision-making is problematic with cognitively impaired individuals Decision-making is problematic with cognitively impaired individuals

Ethical Issues Supervisors must be able to help PCAs realize that individuals with cognitive impairment may be unable to make decisions is some areas, but may be able to make decisions in other areas Supervisors must be able to help PCAs realize that individuals with cognitive impairment may be unable to make decisions is some areas, but may be able to make decisions in other areas Mental capacity fluctuates, resulting in periods of lucidity and confusion Mental capacity fluctuates, resulting in periods of lucidity and confusion –Respect for others as one useful guiding principle in remaining ethical

Violence in the Client’s Home

National Institute of Occupational Health and Safety National Institute of Occupational Health and Safety “Physical assault, threatening behavior, or verbal abuse occurring in the workplace” “Physical assault, threatening behavior, or verbal abuse occurring in the workplace” Usually client-caregiver; also caregiver- client,, caregiver-caregiver, family- caregiver Usually client-caregiver; also caregiver- client,, caregiver-caregiver, family- caregiver

Violence in the Client’s Home Violence is not often recognized as a problem in the home. Violence is not often recognized as a problem in the home.

Violence in the Client’s Home Many administrators and licensed nurses have been acculturated to view violence as “part of the job” Many administrators and licensed nurses have been acculturated to view violence as “part of the job” Many administrators think that physical abuse upsets PCAs more than verbal abuse; actually, PCAs can be just as upset with verbal assaults such as racial slurs, cursing, and demeaning remarks Many administrators think that physical abuse upsets PCAs more than verbal abuse; actually, PCAs can be just as upset with verbal assaults such as racial slurs, cursing, and demeaning remarks

Impact of verbal and physical abuse on PCAs Feelings of hurt, anger, frustration, resentment, sadness, disrespect, being violated, shock, and fear Feelings of hurt, anger, frustration, resentment, sadness, disrespect, being violated, shock, and fear Less willing to spend time with offending clients, less willing to care for them Less willing to spend time with offending clients, less willing to care for them Absenteeism, negative behavior toward supervisors, quitting job Absenteeism, negative behavior toward supervisors, quitting job

Making a difference Put a mechanism in place for PCAs to report violent behavior by clients Put a mechanism in place for PCAs to report violent behavior by clients Ask about the existence of physical or verbal abuse during supervisory visits, and be prepared for more information than you expected; make sure you document interactions and interventions in your notes Ask about the existence of physical or verbal abuse during supervisory visits, and be prepared for more information than you expected; make sure you document interactions and interventions in your notes

Making a difference Recognize that the violent or abusive behavior may be triggered by a specific event (e.g., bathing) or may be due to feelings that cannot be expressed by a cognitively impaired individual. Recognize that the violent or abusive behavior may be triggered by a specific event (e.g., bathing) or may be due to feelings that cannot be expressed by a cognitively impaired individual.

Making a difference Once PCAs alert the nurse supervisor about this behavior, the nurse needs to do the following: speak to the family regarding what they have done to successfully handle the abusive and violent behavior; advise the PCA as to the best approach. Once PCAs alert the nurse supervisor about this behavior, the nurse needs to do the following: speak to the family regarding what they have done to successfully handle the abusive and violent behavior; advise the PCA as to the best approach.

Making a difference If the family is also grappling with the same issues unsuccessfully, the RN should urge the family to discuss possible solutions with the health care provider (MD, NP). If the family is also grappling with the same issues unsuccessfully, the RN should urge the family to discuss possible solutions with the health care provider (MD, NP).

Making a difference The nurse should advise the family that solutions to violent and aggressive behavior must be sought if the client is to remain in the home with the NA. In fact, this is a common reason for NH placement. The nurse should advise the family that solutions to violent and aggressive behavior must be sought if the client is to remain in the home with the NA. In fact, this is a common reason for NH placement.

Making a difference Need to stress that UNDER NO CIRCUMSTANCES IS IT ACCEPTABLE FOR CAREGIVERS TO “HIT BACK” OR RESPOND IN KIND TO A CLIENT’S ABUSIVE BEHAVIOR. Need to stress that UNDER NO CIRCUMSTANCES IS IT ACCEPTABLE FOR CAREGIVERS TO “HIT BACK” OR RESPOND IN KIND TO A CLIENT’S ABUSIVE BEHAVIOR.

Making a difference Virginia has a mandatory reporting statute and it is the nurse’s obligation to make an APS referral for all cases of suspected or actual abuse and neglect. Virginia has a mandatory reporting statute and it is the nurse’s obligation to make an APS referral for all cases of suspected or actual abuse and neglect.

Making a difference Sometimes agencies and individuals are reluctant to report because it becomes very uncomfortable and is sometimes impossible to continue to provide services for a client when a family member is angry with the agency for reporting suspected or actual abuse. Sometimes agencies and individuals are reluctant to report because it becomes very uncomfortable and is sometimes impossible to continue to provide services for a client when a family member is angry with the agency for reporting suspected or actual abuse.

Recognizing abuse towards clients Unexplained bruises, cuts Unexplained bruises, cuts Pattern to bruises, cuts: fingerprints, cords Pattern to bruises, cuts: fingerprints, cords Sometimes the result of violence against the family caregiver—“payback” Sometimes the result of violence against the family caregiver—“payback” Sexual abuse does occur Sexual abuse does occur –May see vaginal/rectal bleeding, spotting, complaints of pain with urination Caregivers who are emotionally and physically exhausted are at risk for abuse—important for PCAs to recognize this and report to supervisors, so that the agency may help avert future problems Caregivers who are emotionally and physically exhausted are at risk for abuse—important for PCAs to recognize this and report to supervisors, so that the agency may help avert future problems

Helping Your Staff Care for Clients with Dementia

Explanation of Dementia Explanation of Dementia –Dementia is an all-inclusive term that refers to global confusion and forgetfulness. –It is gradual in onset and proceeds at a slow rate. –It is irreversible –Can be aggravated by depression

Helping Your Staff Care for Clients with Dementia –Associated with many diseases Alzheimer’s Disease Alzheimer’s Disease Cardiovascular disease Cardiovascular disease Atherosclerosis Atherosclerosis Cerebrovascular accidents (CVA or stroke) Cerebrovascular accidents (CVA or stroke) AIDS AIDS Is not a ‘normal’ part of aging Is not a ‘normal’ part of aging

Helping Your Staff Care for Clients with Dementia –Common behaviors in dementia Non-aggressive Non-aggressive Moaning, repetitious words or sentences Moaning, repetitious words or sentences Wandering, rocking Wandering, rocking Aggressive Aggressive Yelling, cursing, screaming Yelling, cursing, screaming Hitting, spitting, biting Hitting, spitting, biting

Helping Your Staff Care for Clients with Dementia Paranoia is not uncommon, especially when the person with dementia is trying to make sense out of the environment or situation. Paranoia is not uncommon, especially when the person with dementia is trying to make sense out of the environment or situation. –In early stages of dementia, the person knows that something is wrong. In later stages, the person does not know that something is wrong, and blames other people for missing items, changes in the routine, etc.

Helping Your Staff Care for Clients with Dementia Sexual behavior, such as masturbating in public is also not uncommon. Sexual behavior, such as masturbating in public is also not uncommon. –Sexuality is present in aging and disabled persons, and the confused person is often seeking sexual solace. –Persons with dementia may confuse another client for a spouse or may forget they were ever married. –Inhibitions are removed, which explains why sexually inappropriate behavior may occur in public.

Helping staff work with clients with dementia Several researchers have developed a model to explain the disruptive behaviors associated with dementia Several researchers have developed a model to explain the disruptive behaviors associated with dementia

Helping staff work with clients with dementia Need-driven, Dementia-compromised Behavior Model Need-driven, Dementia-compromised Behavior Model –All behaviors, no matter how distasteful, are the result of the clients’ response to some emotion or fear. Clients with dementia have difficulty interpreting stimuli and may react with violence if they believe that they are being harmed. –It is important to realize that the person with dementia does not exhibit disruptive behavior because they choose to, but the behavior is the result of the dementia—communication patterns are altered by the disease causing the dementia

Helping staff work with clients with dementia –Assessing reasons for disruptive behavior Misinterpretation of surroundings Misinterpretation of surroundings

Helping staff work with clients with dementia Persons with dementia have limited capacity for learning new information. Even though they are told several times, “this is the bathroom,” they may still misinterpret the surroundings and may react with fear Persons with dementia have limited capacity for learning new information. Even though they are told several times, “this is the bathroom,” they may still misinterpret the surroundings and may react with fear Vision and hearing impairment may further create problems with correct interpretation Vision and hearing impairment may further create problems with correct interpretation

Helping staff work with clients with dementia Pain and painful procedures Pain and painful procedures May be aggravated by clients who are resistant to taking medication and may not receive their pain medications May be aggravated by clients who are resistant to taking medication and may not receive their pain medications Stress Stress Sensory overload Sensory overload

Helping staff work with clients with dementia –Meaningless noise –Desire for immediate attention –Loss of control/autonomy –Fatigue

Helping staff work with clients with dementia –Desire for sexual intimacy –Change in routine –Psychiatric co-morbidities –Failure of staff to acknowledge communication attempts and failure to anticipate and meet resident’s needs. This can only happen when they know the resident. KNOW THY RESIDENT should be the gospel of disruptive behavior management

Helping staff work with clients with dementia Strategies for helping PCAs to cope with disruptive behavior Strategies for helping PCAs to cope with disruptive behavior –Determine antecedents to the disruptive behavior –This may be challenging because the cause may not be immediately apparent, and the cause may not always be consistent (i.e., whatever caused the disruptive behavior yesterday may not cause disruptive behavior today). A pattern needs to be determined. Important for staff to discuss what they believe precipitated the disruptive behavior.

Helping staff work with clients with dementia –Bathing is a usual antecedent. If water is near the face or head of a confused person, he or she may react in an aggressive manner –Let the client get into the tub slowly –Approach client in a relaxed manner –Less likely to provoke agitation. If one approaches a confused person in an authoritarian or “bossy” manner, the client may react in an unfavorable way.

Helping staff work with clients with dementia –Avoid being focused solely on the task: “Hello Mrs. Jones, how are you? Here, let me help you get this dress on. How’s that?” “Hello Mrs. Jones, how are you? Here, let me help you get this dress on. How’s that?” “Hello, Mrs. Jones. I’m going to help you get dressed.” “Hello, Mrs. Jones. I’m going to help you get dressed.” –The second approach will more likely result in agitation than the first approach.

Helping staff work with clients with dementia –Have the client control the flow of water (e.g., using a hand-held shower head to direct the flow of water) –Sometimes, the client does not understand what is expected of him or her with a specific task, and may become frustrated and act out.

Helping staff work with clients with dementia –It is a good idea to talk to the client about personal things of interest to him or her during tasks (e.g., grandchildren, previous occupation, favorite activities) –Be flexible in approach with client –The use of gestures and pantomime to show the client what you want him or her is helpful

Helping staff work with clients with dementia –Do not limit your conversation to the client because of the confusion. “Chatting away” with the client has been shown to improve agitated behavior. The client may respond to the verbal stimulation. –However, when asking the client to do something, use short, one-step REQUESTS, not commands. Do not keep repeating the same request, otherwise the client may become agitated

Helping staff work with clients with dementia –Show interest in the client, both verbally and nonverbally –Avoid interruptions

Helping staff work with clients with dementia –Studies have shown that interruptions resulted in increased agitation and tension on the part of the client and decreased flexibility and personal contact on the part of the nursing assistant. –Remember not to take aggression personally, unless you have deliberately done something to provoke the client, it is not your fault! –Praise the client in an adult-like manner.

Helping staff work with clients with dementia –Have manipulatives in the environment –In the home environment, encourage families to have items available that are associated with activities that the client previously enjoyed. One family kept jumbo blunt knitting needles and bits of yarn in a basket for their grandmother, who was an avid knitter prior to the dementia. She derived comfort from sitting and holding the items in her lap.

Helping staff work with clients with dementia –Use touch judiciously –Some clients respond well to touch; others may react negatively. Find what works with your clients.

Helping staff work with clients with dementia –If the client is already agitated, touching in a forceful manner may escalate the agitation –Remove client from the disruptive area, if possible –If the client is engaging in sexually inappropriate behavior (e.g., masturbating in public), will need redirection. Depending on the severity of the client’s dementia, you may be able to encourage him or her to refrain from this behavior in public and to engage in it in a private area.

Helping staff work with clients with dementia –Distraction –Humor or playful responses may divert the client’s attention from the discomforting situation and may stop the aggressive behavior

Helping staff work with clients with dementia –Keep clients busy –In one study, disruptive behaviors rarely occurred during organized activity or when clients were proceeding to an activity. However, 72% occurred during periods of inactivity

Supervisory Meetings and Plans of Care Encourage participation from PCAs Encourage participation from PCAs –By alerting the agency if disruptive behaviors become unmanageable –By identifying triggers to disruptive behavior –By sharing proven intervention that work in preventing disruptive behavior

Supervisory Meetings and Plans of Care Communicate these interventions to the scheduling coordinators, and asking that those interventions be passed on to any new aides assigned to the case. May want to document this information in the nurse’s notes as well Communicate these interventions to the scheduling coordinators, and asking that those interventions be passed on to any new aides assigned to the case. May want to document this information in the nurse’s notes as well

Supporting Your Staff When a Client Dies

Help PCAs recognize that loss is a part of life Help PCAs recognize that loss is a part of life Can be sudden (death of a young person) or expected (death of a terminally ill person) Can be sudden (death of a young person) or expected (death of a terminally ill person) Can be bittersweet Can be bittersweet –Transition of a child from infant, to toddler, to preschool, to school age –Loss of a child leaving home, but going to college and growing up –Some losses seem bad initially, but then turn out to be a blessing (a man is laid off from one job, only to find a better one)

Supporting Your Staff When a Client Dies When losses are ‘bunched’ together, as in older years, multiple effects can be devastating When losses are ‘bunched’ together, as in older years, multiple effects can be devastating

Supporting Your Staff When a Client Dies Reactions to Loss Reactions to Loss –Because losses are personal, reactions to loss are individualized –What may be a small loss to me may be a larger loss to someone else –The process of grieving is called “bereavement”

Supporting Your Staff When a Client Dies –Although the process is individualized, there are some general components Sadness Sadness –The person is unhappy with the loss. He or she expresses sadness, cries. Denial Denial –“This isn’t happening.” “If I ignore it, I won’t have to deal with it.”

Supporting Your Staff When a Client Dies Anger Anger –Can be at self or others –May belittle others, may become a “difficult” or “demanding” client –Sometimes, PCAs are targets because they are “safe;” a client may be angry at a son or daughter, but can ill afford to antagonize that person, so he or she takes out the anger on a PCA May express anger by trying to exert control over those items that the person still has control over. –Example: a quadriplegic client who calls the PCA every five minutes for a minor, trivial requests, and/or verbally abuses the PCA

Supporting Your Staff When a Client Dies Blaming Blaming –May seek to make someone else the culprit for the loss. This is an attempt to make meaning out of a loss—This bad thing happened to me because… –May blame self or others: “If only I had taken my medicine, I wouldn’t have had this stroke.”

Supporting Your Staff When a Client Dies Bargaining Bargaining –“If I can learn to walk with this walker, you will let me go back to my apartment, right?” –Can be with family, health care providers, even God Depression Depression –The person may lose interest in food, enjoyable activities –May sleep all of the time or most of the day

Supporting Your Staff When a Client Dies Acceptance Acceptance –Reconciles the loss with overall picture of self –Adjusts self-concept to “fill up” hole left by loss –This process may take days to years, depending on the extent and importance of the loss –Some people move out of one stage, only to return to it later –Some stay “stuck” in stages

Supporting Your Staff When a Client Dies Role of the Supervisor Role of the Supervisor –Anticipate the loss and prepare PCAs

Supporting Your Staff When a Client Dies –Know the persons most at risk: Start of care Start of care Holidays Holidays Holidays hold memories of family gatherings and rituals. Losses may be felt most acutely the day of the holiday or immediately after, when family members or friends leave. Holidays hold memories of family gatherings and rituals. Losses may be felt most acutely the day of the holiday or immediately after, when family members or friends leave. May cry easily and all of the time May cry easily and all of the time Anniversaries Anniversaries Birthdays, wedding anniversaries, and death anniversaries may trigger memories and feelings of loss Birthdays, wedding anniversaries, and death anniversaries may trigger memories and feelings of loss

Supporting Your Staff When a Client Dies Persons with previous histories of depression Persons with previous histories of depression Persons who are rigid or negative Persons who are rigid or negative Persons who are flexible and resilient cope better with loss than those who are not. Example: Mrs. S. was a morose individual who was rigid and negative her entire life. She was very demanding during each visit when the PCA was with her. She would also complain during the entire visit about the care she had received from other caregivers and agencies. The PCA began to dread her visits and asked to be reassigned to a different case. How can the aide be helped to deal with her frustration in order to remain on the case with Mrs. S.? Persons who are flexible and resilient cope better with loss than those who are not. Example: Mrs. S. was a morose individual who was rigid and negative her entire life. She was very demanding during each visit when the PCA was with her. She would also complain during the entire visit about the care she had received from other caregivers and agencies. The PCA began to dread her visits and asked to be reassigned to a different case. How can the aide be helped to deal with her frustration in order to remain on the case with Mrs. S.?

Supporting Your Staff When a Client Dies –Determine at what stage the individual is in –Communicate this information to the family member. –The person may benefit from psychiatric and spiritual counseling –Work with the individual

Supporting Your Staff When a Client Dies –Avoid even more losses Give the client as much independence as possible Give the client as much independence as possible Give clients choices regarding meal ideas, daily activities – make choice options realistic. Give clients choices regarding meal ideas, daily activities – make choice options realistic. Listen to clients’ ideas about the care Listen to clients’ ideas about the care Sometimes care revolves around agency schedules. Allowing the client to voice his or her opinion, and listening, empower the client. Sometimes care revolves around agency schedules. Allowing the client to voice his or her opinion, and listening, empower the client. –Help the PCA to not take things personally

Supporting Your Staff When a Client Dies –The best response of the PCA to the client is to personalize their actions based on the client’s needs and history. While this strategy is ideal, the realities of staffing and workload may make this approach very challenging. This is also extremely difficult This is also extremely difficult No one likes to be the scapegoat, but realize that the client is not striking out at you, the person. No one likes to be the scapegoat, but realize that the client is not striking out at you, the person. Tell the client, gently but firmly, “I don’t like it when you (fill in blank). I understand that you are upset and hurting, and I would like to help you.” Tell the client, gently but firmly, “I don’t like it when you (fill in blank). I understand that you are upset and hurting, and I would like to help you.”

Supporting Your Staff When a Client Dies –Keep yourself aware of the resources of your agency, and use them

Dying Trajectory

Various Shapes Of Dying Trajectory prolonged or rapid prolonged or rapid characterized by uncertainty characterized by uncertainty

Response To Trajectory closed awareness closed awareness –the client is not told that he or she is dying, but the family and caregiver know mutual pretense mutual pretense –everybody knows the person is dying, but everyone pretends it is not happening open awareness open awareness –the dying process is openly discussed by all

Physiological Changes –peripheral circulation decreases first in feet, later in hands, ears, and nose first in feet, later in hands, ears, and nose mottled & cyanotic skin, esp. in extremities mottled & cyanotic skin, esp. in extremities –internal temperature may remain high, so keep patient's room cool

Physiological Changes –changes in vital signs respirations rapid & shallow, irregular or abnormally slow respirations rapid & shallow, irregular or abnormally slow cheyne stokes or agonal cheyne stokes or agonal decreased and weaker pulse decreased and weaker pulse decreased blood pressure decreased blood pressure

Physiological Changes –loss of sensation, power of motion, & reflexes in legs and gradually in arms –diminished touch sensations –pain and pressure remain intact –loss of muscle tone –cool, clammy

Physiological Changes –relaxation of facial muscles; jaw may sag –difficulty swallowing; gradual loss of gag reflex

Physiological Changes –muscles in back of throat and tongue leading to snoring sounds or death rattle –GI system shuts down May not require or tolerate food or fluids. Do not force food. Offer sips of water for comfort only. May not require or tolerate food or fluids. Do not force food. Offer sips of water for comfort only. Nausea, flatus, abdominal distention, constipation Nausea, flatus, abdominal distention, constipation Decreased sphincter control leads to incontinence Decreased sphincter control leads to incontinence

Physiological Changes Physical Signs of Actual Death Physical Signs of Actual Death –cessation of heart activity & respiration –pupil dilation & absence of reaction to light –body changes –algor mortis gradual decrease of temperature with cessation of circulation (falls about 1.8F per hour) until reaches room temperature gradual decrease of temperature with cessation of circulation (falls about 1.8F per hour) until reaches room temperature –livor mortis discoloration that appears in dependent areas of the body; caused by breakdown of RBCs with release of hemoglobin discoloration that appears in dependent areas of the body; caused by breakdown of RBCs with release of hemoglobin

Physiological Changes –Psychosocial Signs of Impending Death Detachment Detachment life reflection life reflection speaks of death with increasing frequency speaks of death with increasing frequency puts affairs in order puts affairs in order speaks of seeing loved ones who have already died speaks of seeing loved ones who have already died

Physiological Changes There is a difference between death and the dying process There is a difference between death and the dying process –Most aged persons are at peace with the idea of death –There may be apprehension about the dying process: fear of inadequate pain management, heroic measures, life support machinery, impending transfer to a hospital, etc. –Important for the PCA to know who is in charge when a client is actively dying; when to call family member, nursing supervisor, or 911 –IMPORTANT: cultural differences in attitudes and customs concerning the dying process, death, and burial

Physiological Changes Help the PCA to support of family/significant others Help the PCA to support of family/significant others –research has shown most important thing is to know that loved one receiving compassionate, competent care –reassure the family that their loved one is comfortable –“It was important for me how they cared for my husband. They called him by name and told him what they were going to do before they did it.” (Wilson & Daley, 1999, p. 24) –OK to cry with family after relative has died –In waivered services, after care is not a covered service. The NA is instructed to leave once a family member ahs arrived in the home.

Physiological Changes Support the PCA with his or her own emotions and reactions Support the PCA with his or her own emotions and reactions –Both the family of the deceased,, and staff caring for the deceased have similar emotions: –IT IS OK FOR PCAs TO ACKNOWLEDGE THAT THEY CARED FOR THE PERSON AND WILL MISS THEM –Some PCAs believe it is better to not get attached. –These individuals may avoid caring for a dying person or will be aloof, so as not to become emotionally involved.

Physiological Changes –As people come to grips with their own sense of loss, they may avoid the dying person and the family. This negatively impacts the care of the family and the client. –Let yourself grieve. Give yourself permission to feel your feelings. Accept sadness as a consequence of having a rich relationship with the client. –Find your own support system through co workers or your family.

Physiological Changes –Best for persons who are struggling with their own emotions and feelings of loss to work with a chaplain or social worker, so that the care they give is not affected. –The role that the PCA may play during a death can be frightening for some, especially those new to the role.

Putting It All Together What are the things I can do? What are the things I can do? What are the most important principles for me to follow and instill in others? What are the most important principles for me to follow and instill in others? What are the five most important principles related to this workshop for me to follow? What are the five most important principles related to this workshop for me to follow? What are the five most important lessons for me to pass along to others? What are the five most important lessons for me to pass along to others?