In 1955, Mr. Joseph Luft and Mr. Harrington Ingram gave educators and psychologists a technique to better explain communication and
relationships with the self and others. The relationship with self is known as intrapersonal, while interpersonal describes relationships with two or more people. The picture of a window with four quadrants is frequently used to describe the Open,
Hidden, Blind, and Unknown ways in which we interact with ourselves and others. The Johari Window is a useful tool for analysis of the realities of long-term care to include assisted living, nursing,
and dementia units.
In the Open Quadrant, people essentially know themselves and are aware of their traits, but equally important is the fact that others observe and are aware of the same traits. What we see in ourselves is the same that others see in us. As a result, the lines of communication are open and trusting, because people know what they are dealing with in one another. The Hidden area is information the self knows, but may or may not disclose to others. The Blind area represents information that others see, but the self is unaware. Last but not least is the Unknown quadrant. This represents behaviors that are unknown to both the self and others. In other words, everyone in the circle is ignorant of personality traits, or motivations in the self and others. In an analytical sense, this can represent the collective unconscious. However, on the positive side, it can represent the human potential.
Unfortunately all of the quadrants with the exception of the Open area are typically found in the dynamics of life in long-term care. The following is one poignant story that Ms. Barbara Starr shared during the month of January 2015.
“I do not have good typing skills, but I wanted to tell you that I had problems with my mom in long-term care and I needed to report it. I’m waiting to find the right person who will be someone to help me change what is going on. There is so much to my story about my mother. It all started when she was sent from rehab to the hospital with pneumonia. The hospital released her to a long-term care facility without consulting me. There was a private room and they started giving her medication and morphine. The next day I noticed a bruise on her temple, but no one knew where she got it. The day after that she didn’t talk, react, or eat. The following morning I found that they had wheeled her in a Geri chair to breakfast. When I got to her, she whispered that she needed to void. I asked the nursing aides to take her back to her room. They used a lift on my mother. The reason my mother did not want me to tell the nursing aides she had to go to the bathroom is because they hurt her. I did not know how it happened until I saw that they had the lift on the wrong way! Her eyes were as big as saucers while I yelled, “YOU’RE HURTING HER! She never spoke or looked at me again. My mother passed away at 5:30 PM the next day.
This haunts me every day. The nursing aides were poorly trained and two out of three doctors plus the social worker didn’t have a clue. I asked for help for my mother, but only got excuses.
My heart aches every day because I didn’t know what was going on and what to do.”
In an online communication on January 18, 2015, Ms. Rosita Owens a retired registered nurse talked about her friend’s experience with assisted living. “The facility where she moved her father was only assisted living and nursing care. Then, they added a Memory Lane for Alzheimer’s patients. All they did was transfer employees from one department to the other without any training in dementia. She volunteers at the center several days a week, just so she can keep an eye on her dad and know what is going on.”
Mr. Garth Clark wrote in an email on January 25, 2015, “Life in long-term care facilities is a microcosm of our society in general. We cannot lower our expectations in order to align with the current realities. We should be better and we can be better.”
How can things improve in long-term care? Is it a matter of more open dialogue with people who are well-balanced and aware of themselves and the circumstances around them? Is there a place where long-term care facilities are safe havens for people unable to defend themselves? Is getting a job in the facility where you place your loved one the only way to ensure that family member will receive good care? Is a spycam the only answer?
Mr. Dave Berry sent this information on February 16, 2015 about, Two Nursing Home Staff Didn’t Know Camera Was On When They Did Something Horrific To Elderly Woman. It was written by Mr. Joseph Perticone.
In 2012, video evidence surfaced showing a brutal abuse of an elderly woman by two aides at a nursing home in Oklahoma City. Last week, jurors awarded the woman’s family $1.2 million for emotional distress with an additional $10,000 in punitive damages.
l Creek Nursing and Rehabilitation Center in Oklahoma, two aides shoved latex gloves down the throat of Eryetha Mayberry while she sat helplessly in her wheel chair.
Mr. Wes Bledsoe, an advocate for reforms in nursing homes, discussed the harrowing footage:
“In my mind, there’s absolutely no question that these aides had abused other residents before this… This was not the first time that they had ever abused a resident and if it had not been for that camera they would have continued to abuse other residents.”
Lucy Waithira Gakunga and Caroline Kaeseke, the two women caught abusing Mayberry, were found guilty of abuse. Kaeseke is rumored to have fled the country while Gakunga served two years and was subsequently deported for her crimes. Mayberry passed away less than six months after the abuse took place. She was 96 years old and suffered heavily from dementia and Alzheimer’s disease.
Here is the link to the video that launched the public firestorm:
Could it be that long-term care facilities are operating in the Unknown quadrant of the Johari Window? Is there a collective ignorance or disbelief that anything so atrocious as stuffing latex gloves down the mouth of a 96-year-old woman could ever occur? Are security cameras and spycams the only answer? Even with a spycam in the room, nothing could have prevented that 96-year-old resident from being attacked. Unfortunately, that is not an isolated case.
Ms. Dale Kromroy, a Gerontology Counselor who worked in Lebanon, Indiana, describes the problem this way on January 20, 2015 she wrote, “The difficulty of finding people to work in healthcare and take care of old folks is only going to get worse. When I worked in Lebanon, Indiana, at a nursing home, I saw the staff could leave one facility and get a job at another facility or go to other facilities in town closer to Indianapolis. It’s so hard to find good people. Even when people are rehired, they are on their best behavior for a while. There is nothing illegal in hiring someone who has been fired and the majority of businesses release very little information about their employment.”
It is also very easy to get hired when a shift needs coverage. When a nursing aide who was fired and then rehired was asked the question, “How did you do it?” The nursing aide who was rehired responded with a sideways glance and wry smile, “I just told them what they wanted to hear.” The nursing aide is hired, there is coverage for the shift, and the case is closed.
“No one wants to live at the mercy of someone else, but sometimes circumstances dictate it. It doesn’t make a difference how productive or successful we are when we are young, we will all grow old. We should be making an investment in our future wherever it may be.” Ms. Gail Stroud Billings, January 26, 2015.
Is the investment for the future saving as much money as possible? The recent numbers in the news indicate that 78% of the people who go into bankruptcy do so because of medical expenses. Long-term care is costly. Many retirees are afraid of outliving their savings accounts. Is there a more universal way to care for our elderly? “I doubt it” says Ms. Pam Williams Harrell on January 26, 2015. “The assisted living facilities only seem to care about the bottom line (profit).”
How does management of any facility balance the needs of residents, family members, and staffing? Which is the most important? The members of the nursing staff are by far the most important. Nursing, as a profession, recently moved to the top of the list as the most dangerous of all careers leading firefighters and police. The dangers for injury occur on a daily basis and these are sometimes permanent injuries, moved nursing into first place. Nursing aides are at the front line for eight-hour, twelve hour or sixteen-hour mandated shifts. They can be the best and the worst of the employees, but they usually know a great deal about the needs of the resident. Yet, sad to say, good nurses are frequently treated like they are in the wrong or causing trouble when they try to call attention to the problem nurses, family, or other members of the staff in managerial positions. Just as well-informed residents can be marginalized when trying to call attention to a problem, good nursing aides can be largely ignored or treated as outcasts when trying to correct a situation. So, what does the nursing aide do to cope?
One aide answered very quickly with the word, “Vent! I know another nurse in the same predicament and talking it out really helps. Nobody listens. Thank goodness I have somebody that I can vent because I try to avoid the drama and stay out of the problems and just do my job.” This nursing aide preferred to remain anonymous, but she further explained that if anyone ever complained about me, I would go right to that person and correct the situation. At the opposite end of the spectrum, poor performance is frequently rewarded. A nursing aide that is not allowed to work with a particular resident, for whatever the reason, means that another nursing aide has to cover that call bell, room, or floor. It also means that the nursing aide creating the problem gets to kick back and do less work.
LTC simply means long-term care. For people who reside in LTC, it is their home. Yet sad to say, so much remains Hidden. There is a huge Blind area where unconscionable behaviors occur, but families find out too late. There are Blind Spots where a total lack of awareness is ubiquitous. Even worse, there is so much that is Unknown by the public and cannot be perceived accurately by residents with debilitating conditions, nor the managerial staff that remains ignorant of personalities and motivations of employees working at the facility.
“There are a lot of things I would like to change if it were up to me. Facilities including assisted living would be more like home and less institutional. Staff would be well trained, caring people who enjoy working with others. Not everyone is cut out for this work. I think people believe it will be an easy job and then they find out it isn’t.” Ms. Terry White is the Operations Manager for the Local Long-Term Care Ombudsman Guardianship Senior Care and National Family Caregiver Support Programs (January 20, 2015). Perhaps in time with the help of administrators like Ms. Terry White, we can enlarge the Open quadrant of the Johari Window to improve communication and relationships in long-term care.
Questions for Consideration:
1. Investigate what is done to residents in the beauty parlor at a facility. Is there a security camera in the beauty parlor? Does the beautician actually wash the hair of the resident or just use some shampoo on her fingers and massage it into the hair? Is there an actual rinsing of the hair or does the beautician use a wet towel for the rinse by taking it over the scalp and hair that has the shampoo? Nursing aides have complained about how difficult it is to get a white crusted residue off the scalp of residents when they are showering them. That is because the hair has not been correctly shampooed and rinsed in the beauty parlor. Another alternative is for residents to be showered and hair washed before an appointment with the beautician. The latter is a better way to be sure the scalp and hair are really clean.
2. Check to see if there are security cameras with audio in the facilities, before making a decision about relocating. Find out if there can be a spycam installed in the room where your loved one will be living. Even a spycam is not a guarantee of safety for your loved one, but it can provide hidden documentation that holds up in court.
3. From the Indiana University Kelley School of Business, the patient is the consumer. The word “resident” is just another way of describing a patient. Anyone in long-term care is also a consumer and deserves the best treatment and care. Try to ascertain how a resident in long-term care is treated. Ask questions of people in the facility. Observe whether or not they are treated with dignity and respect, or marginalized and their needs disregarded.
4. Ms. Barbara Starr encourages you to look at the article, To CollectDebts, Nursing Homes AreSeizing Control Over Patients. One day, last summer, after he disputed nursing home bills that had suddenly doubled Mrs. Palermo’s co-pays, and complained about inexperienced employees who dropped his wife on the floor, Mr. Palermo was shocked to find a six-page legal document waiting on her bed. It was a guardianship petition filed by the nursing home, Mary Manning Walsh, asking the court to give a stranger full legal power over Mrs. Palermo, now 90, and complete control of her money. Few people are aware that a nursing home can take such a step. This article can be found on MSN.com. Take time to research newspaper articles about elder abuse and the facility you wish to relocate your loved one. Like Ms. Barbara Starr’s story about her mother, or other stories of loved ones enduring horrific circumstances, contact the media and get the story out in the public so that more information is known by everyone and the Hidden area is exposed.
5. There are borderline personalities everywhere. There are sick people in every walk of life. Question credentials! Take nothing for granted. Even if the title is physician, registered nurse, licensed practical nurse, nursing aide, physical therapist, occupational therapist, manager, or chief executive officer, do your own investigative work in advance. Leave no stone unturned. Read reviews and ratings of the facility. Critically analyze those ratings. For instance, Maryland came in number 34 on the US News survey measuring quality of care in nursing facilities. Multiplying that number times two equals 68 from 100 puts Maryland at the 32 percentile. In other words, if a facility in Maryland earns a five-star rating, how credible is that rating?
6. Stay in the facility and observe behavior on the part of nursing aides. Do you hear any name-calling? It is not appropriate for any nursing aide to call a resident in distress, “Crybaby.” This recently happened at GRC when a resident had fallen and unbeknownst to staff, had broken her pelvis. Even the x-rays at the hospital did not show any fractures of the pelvic area. It was thought that the resident was just in need of encouragement, when in fact the tears were flowing because of great pain. Ms. Terry White, Ombudsman, is quick to point out that sometimes there is a need for reeducation with the nursing staff. It is important to teach the difference between abusive behaviors versus the appropriate way to address residents in any long-term care facility. Watch and listen to the word choices and patterns of language used by members of the staff.
7. It is no coincidence that television shows and series such as Ben Casey, Dr. Kildare, Marcus Welby, M.D., ER, or Grey’s Anatomy, and the daytime soap, General Hospital all deal with medical drama. Television programming imitates life. There is great drama with anything medical, but it is not likely to be a drama of nursing home struggles on television. Even though Betty White in her 90s is beautiful and talented as ever, where could a storyline go with long-term care? Alternatively, could the elderly have played roles on Baywatch? The show would not have been a success without Pamela Anderson, and beautiful bodies in bathing suits. Did anyone care about the plot? That said, there is so much drama in long-term care that will never be a part of television programming, but needs media exposure. If not television, then thanks to the Millennial Generation, there is a social media to relay the word of the realities in long-term care. Look at Facebook and find people who are working at the facility where you may be locating a loved one. Sometimes their pages are very telling, and that includes people in managerial positions.
8. Mindfulness is the practice of being present in the moment. From the Buddhist traditions, this contemplative state embraces not just the happiness of a moment, but the human suffering that is such a big part of life. With the exception of those in a dementia state of pleasantly unaware, most people in long-term care are in a compromised state and quite simply, they are suffering. There is much written about mindfulness in pop culture magazines such as Psychology Today and online with Wikipedia. When researching a facility, try to find out if there are some activities that are more meaningful for loved ones that are capable of more than balloon tennis or watching a video of the Honeymooners? Is there a class available to teach the benefits of yoga, transcendental meditation, or mindfulness?
9. I would describe the personalities of so many people working in healthcare settings as a hair pulled at both ends and ready to snap. There was a recent occasion at GRC with a nurse Stephanie Friend who came to my room to administer a B12 injection. I was concerned because I did not see her use the alcohol wipe on the vial and I called it to her attention. The communication escalated from that point on, but why? I would have expected a good nurse to say “thank you for the reminder.” Instead the altercation ended with the nurse asking me if I wanted more air bubbles in the syringe? This question occurred just before she was going to insert the syringe in my left hip. I remained calm and simply said “No.” In 1994, I heard the same question from a nurse at Sacred Heart Hospital in Cumberland, Maryland. I was very sick at the time with a viral infection. With this nurse, my response was, “No, smart ass.” She left the room in a very agitated state and I was glad. Sacred Heart Hospital is now closed, but these types of people in healthcare are everywhere. I do not know all of the reasons why it is now a commonplace for people to refuse to work with one another, physicians who fire patients, and an abundance of defensive behaviors because of incompetence at every level in every field, but protecting your loved one requires exhaustive research and a vigilant watch.
10. Along the same lines as number nine, there was a nurse Pam Rugg who came to my room to administer the flu shot this past fall. I noticed that she did not recap the syringe when she laid it down on the computer table. I called her attention to that contaminated needle while she was proceeding to use alcohol on my arm for the injection. She became agitated and told me that she would get some other nurse to do the shot because my arm was too small. The question remains, what is happening? Is this just a microcosm of the macrocosm as stated by Mr. Garth Clark earlier in the blog entry? Is it a trend with people working in stressful jobs that cannot handle the stress? Is it really a matter of people making their own stress? I routinely hear about how bad problems are at home with so many of my students and most people working in the healthcare field. I feel sorry for the stressors that younger generations endure. The majority of students who graduate from college have a minimum of $40,000 in loans that have to be paid back and that is before they even start a job. The minimum monthly payment is about $380-$400. Many of the nursing aides that I meet have suffered immensely in their lifetimes. Not just single-parent families, but abuse both verbal and physical, alcoholic parents, loss of a mother at a very early age, lifestyles relying on assistance of all kinds, poor health probably due to poor nutrition, and living from paycheck to paycheck with very little hope of changing the pattern. Are people who need a lot of help capable of helping others? Can you get a sense of whether or not members of the staff at any facility you are investigating seem to be reasonably well-adjusted personalities? Finding a facility where members of the staff are aware and living in the Open quadrant of the Johari Window is the best place for your loved one to reside.
February, 2015