Communicating with the Elderly: Choosing Respect in Caregiving Exercises for Beginners

1. Communicating with the Elderly: Choosing Respect in Caregiving Exercises for Beginners 2008, revised nov.2012 Margot Phaneuf, inf. PhD. Margot Phaneuf, inf., Ph.D.

2. Choosing Respect in Caregiving Margot Phaneuf, inf., Ph.D.

3. WARNING The case studies in this presentation illustrate situations that are unacceptable and the dialogues are unfortunately all too real. These cases unfortunately diminish the accomplishments of exemplary caregivers. We offer them our sincerest apologies. Margot Phaneuf, inf., Ph.D.

4. Ethics: a bastion against abuse Providing care to the elderly raises serious ethical questions, namely: . How to always maintain the elderly person’s dignity; . How to always respect his autonomy, even if he is in a state of confusion; . How to limit the caregiver’s temptation to build relations based on authority and the potential for manipulation; . How to maintain the caregiver’s integrity and to limit the possibility of mistreatment; . How to receive the patient’s family. Margot Phaneuf, inf., Ph.D.

5. Objectives • Generating the student’s reflection on critical situations with the elderly patient. • Raising awareness that despite the best intentions, some of the patient’s significant needs may be left unanswered. • Getting the student to realize that warm and empathetic relations can be established through minor gestures. Margot Phaneuf, inf., Ph.D.

6. Objectives • Getting students to understand that ethical principles apply to everyday caregiving activities. • Generating awareness that abusive behaviour exists and is more common than we think. • Getting students to understand that abusive behaviour is often subtle or hidden. Margot Phaneuf, inf., Ph.D.

7. Satisfying the needs and expectations of the elderly • One of the foundations of quality caregiving is to satisfy the needs of the patient. • Downsizing and repetitive standard operating procedures often impede this objective. • Organizational routine often becomes an end instead of a means. • This often results in caregivers providing inadequate responses, which demonstrate a lack of ethics, simple manners and quality of care. Margot Phaneuf, inf., Ph.D.

8. Needs, expectations and preferences vary • Every person experiences different needs. Some hate washing themselves while others enjoy baths. Some like getting up and walking while others need stimulation to engage in activities. • Quality care takes these differences into account. • It is what we refer to as personalized care. This is based on proper organization and, more simply, on politeness, respect and good manners. Margot Phaneuf, inf., Ph.D.

9. Task organization and personalized care Establishing good relations with the patient usually depends upon minor, everyday details and answering simple requests to meet his needs or those of his loved ones. • Sometimes, this can mean: • Breaking the routine • Demonstrating goodwill • Being creative Margot Phaneuf, inf., Ph.D.

10. Responding to the patient’s physical needs • The following situations illustrate inadequate responses in which the patient’s needs are not met. • How would you respond if you were in the caregivers’ position? • More practical responses will be made available later on. Margot Phaneuf, inf., Ph.D.

11. Could you let me sleep a little? I haven’t slept all night. So you think you’re the only one here! Do you think you’re at a hotel? Which articles of the code of ethics have been ignored in this case and those that follow? Which ethical principles are ignored? Dysfunctional and arrogant response Better response to follow

12. That’s not possible! Could you wake me up earlier so that I can take my bath? I like getting up early. You’ll just have to wait your turn. Dysfunctional and authoritative response. Better response to follow Margot Phaneuf, inf., Ph.D.

13. Well don’t come complaining to us that you’re constipated! I don’t want to take a laxative. It hurts my stomach and I’m embarrassed to repeatedly ask to go to the bathroom. Retaliation, mocking and intimidation are considered acts of psychological abuse. OIIQ, Le Journal, Chronique déonto novembre/décembre 2001, Vol. 9 No 2. Better response to follow

14. That’s odd! Why don’t you just pull up your blanket? Could you put on a second gown? The opening in the back gives me the chills. You’ve got hands… This is a case of mocking. The patient’s need is unmet. Better response to follow

15. You’ll have to wait a week. The attendant is on holiday. I wish someone would give me a bath. I used to wash myself every day. I like feeling clean. The patient’s values always supersede those of the nurse. The quality of the therapeutic relation relies on the ability to establish a respectful, reliable and trustworthy environment in which the primary focus is the patient. OIIQ, Le Journal, mars/avril  2001, Volume 8,  Numéro 4. Chronique déonto. Les obstacles à la relation thérapeutique » Better response to follow Margot Phaneuf, inf., Ph.D.

16. I wet my bed. Could you change my pants and sheets? We’ll have to hoist you and you know that using that machine is complicated… It is the nurse’s fundamental duty to guarantee the safety and well-being of the patient. It is our duty to provide him with the care required by his condition while respecting his physical and psychological integrity. OIIQ, Chronique déonto, Le Journal, novembre/décembre 2001, vol 9 no 2. Better response to follow

17. I saw a great movie yesterday. We have to hoist him. I was with Paul. It was a terrific evening. 2- Staff indifference is noticed. For example, it consists of talking about unrelated subjects with other staff members while the elderly person is being moved like an object and is not even acknowledged by them. (OIIQ. (2000) L’exploitation des personnes âgées).

18. I’m bringing back Mr. Dubois I’m hungry, Marge! Can’t you see that it’s too late for supper? Now he’ll have to wait until tomorrow. Unanswered need and threat. Margot Phaneuf, inf., Ph.D.

19. Responses to slides 11 to 18 Code of Ethics of Nurses, OIIQ Division I 6 – Availability and Diligence 25. In the practice of his or her profession, a nurse shall display due diligence and availability. Division II 3- Prohibited behaviour 37. A nurse shall not use verbal, physical or psychological abuse against the client.(threats and pressure are a type of abuse).

20. Ethical principles for slides 11 to 18 We should never forget the ethical principles which guide caregiving. The following principles were neglected in the previous cases: . Respecting the person’s dignity regardless of his physical or psychological state. Courtesy is mandatory. . Respecting the person’s freedom, autonomy, values and decisions (if he is competent). We must obtain his consent before proceeding with a medical act and he has the right to refuse care. . Respecting the person’s integrity, inviolability (respecting essential needs, avoiding all forms of violence, preventing risks to his health and well-being).

21. Responses which are not time-consuming and which require little effort exist and go a long way. • The following are a few examples of appropriate responses for the preceding cases. • It is often easy to respond and meet the person’s needs and expectations. • However, hiding behind standard procedures and regulations can be convenient. • This shadows the fear of getting involved and of being overwhelmed by the patients’ demands. Margot Phaneuf, inf., Ph.D.

22. Best response for slide 11 Please rest! I’ll start with someone else. I haven’t slept all night! Logical and comprehensive response

23. I’ll switch your turn with someone who likes to stay in bed. Could you wake me up earlier so that I can take my bath? I like getting up early. Best response for slide 12 Respecting the patient is also respecting his values and autonomy whenever possible. Margot Phaneuf, inf., Ph.D.

24. Best response for slide 13 I don’t want to take a laxative. It hurts my stomach and I’m embarrassed to repeatedly ask to go to the bathroom. We’ll try to find a better balance. Division II- 3. Prohibited behaviour. 37. A nurse shall not use verbal, physical or psychological abuse against the client. Imposing a treatment is abusive.

25. Best response for slide 14 I’m cold wearing this gown. I’ll get your sweater. You’ll be more comfortable. Code of Ethics of Nurses; Division I – 6, section 25. In the practice of his or her profession, a nurse shall display due diligence and availability. Margot Phaneuf, inf., Ph.D.

26. As soon as one of us is available, we’ll give you a bath. I like having baths - often. That would be nice. Best response for slide 15 Whenever possible, put aside what you are doing and pay attention to the client and his family. If you are unable to do so, inform the client and his family. By reacting promptly, you are in fact demonstrating that you are listening to their concerns. This will help maintain their confidence. (OIIQ, Le journal, mai juin, 2005. http://www.oiiq.org/uploads/periodiques/Journal/vol2no5/ss04.htm)

27. I wet my bed. Could you change my pants and sheets? I’ll ask for help and we’ll be able to change your pants and sheets without moving you too much. Best response for slide 16 Same comment for slide 15

28. We’re here to lift you. How are you feeling today? You’ll feel better getting up. Best response for slide 17 We should address the patient, get him to talk and avoid engaging in personal conversations in his presence.

29. I’m hungry, Marge! You’re bringing him back late, but there’s surely a way to find him something to eat. Best response for slide 18 Margot Phaneuf, inf., Ph.D.

30. Alleviating pain is a primordial element to consider. • Neglecting to carry out this responsibility appropriately is a serious breach of ethics. Margot Phaneuf, inf., Ph.D.

31. Alleviating pain • Alleviating pain is an essential need which raises certain problems: • Responding to the patient’s complaint requires attentive listening; • Evaluating pain is difficult among the elderly, who are often confused; • Determining the relevance of offering a prescribed analgesic can contradict our fear of creating addiction. Nurses should avoid judging another person’s threshold for pain based upon their personal limits; • Administering a medication to provide optimal relief. Nurses should not wait too long and should follow the correct intervals between doses. Margot Phaneuf, inf., Ph.D.

32. I’m still suffering. Could you give me something? Again? You’re taking way too much medication. Dismissive attitude which demonstrates lack of empathy. Next Margot Phaneuf, inf., Ph.D.

33. I’m still suffering! I understand you Ms. White. The pain has got to stop. I’ll talk to the doctor. We’ll find a solution. Best response for slide 32

34. I don’t have anything prescribed for you. You just have to talk to your phsyician! I really can’t do anything. My back is killing me! I don’t have a magic lamp! This dysfunctional response blames and casts guilt upon the patient and illustrates a lack of empathetic understanding. Next

35. I’ll call the doctor. He might be able to prescribe something. I’ll massage your back to alleviate your pain before bedtime. Now my back is really killing me! This answer illustrates that the nurse has listened and responded to the patient. Best response for slide 34

36. Inappropriate behaviour resulting in mistreatment: using rudeness and infantilization. Avoid at all cost! Margot Phaneuf, inf., Ph.D.

37. Mistreatment or abuse • It is not our job to judge fellow caregivers as if they were slaves to an assembly line; however, we should be aware of the potential for abuse and denounce it in all of its forms. • Abuse is unfortunately present among families and healthcare institutions. There is plenty of abuse, even hidden. • « Abuse occurs when a caregiver or an institution commits, tolerates or provokes an act that a healthcare professional would not commit against his own family member or a loved one." Source: Yves Gineste, 2004, Silence on frappe. Collectif, p. 17.

38. Ernest it is time you went to bed like everyone else! We’ve got more to do than just putting you to bed. Which articles of the Code of Ethics of Nursing are breached in the following situations? Which ethical principles are disregarded?

39. Can you change my diaper? Again? You’ll just have to wait. Rudeness, threat and failing to respond to a need 2- "It should be noted that incontinence pants are widely used. The Association des CLSC et des CHSLD du Québec reported that it is imposed upon 66% of residents whereas ‘it is known that 13% of these residents can manage their own hygiene if only adequate supervision were provided, and that 15% of these residents would be continent if they were provided more frequent assistance to go to the bathroom.’"(OIIQ. (2000) L’exploitation des personnes âgées). Suite Margot Phaneuf, inf., Ph.D.

40. Albert, you unplugged your collector pouch again. Could you be more careful? Inappropriate and infantilizing manner of addressing patient.

41. Bernadette! You stupid, stop going through the drawers! This isn’t your room, you know. Using insults is a prohibited behaviour, considered an acts of psychological abuse. OIIQ, Le Journal, Chronique déontonovembre/décembre 2001, vol. 9, no 2.

42. You didn’t want to eat earlier. Too bad! Now you’ll just have to wait until dinner. Lise, I’m hungry. The nurse lacks empathy, is impersonal and fails to consider the other person’s needs and expectations. This response blames the individual and is punitive.

43. I just changed your sheets. I hope it’s the last time today that you leave me with a surprise. You got chocolate all over the place. Retaliation, mocking and intimidation are considered acts of psychological abuse. OIIQ, Le Journal, Chronique déonto novembre/décembre 2001, vol. 9, no 2 .

44. Reflection I don’t understand why people enter my room without knocking, why they are impolite with me, why they bark orders, why I’m constantly being blamed, and why I’m being treated as if I were a nobody. 2- The OIIQ will not tolerate any situation involving lack of respect observed during a formal inspection or which is reported by interveners in residential and long-term care centres (CHSLD). OIIQ. (2000) L’exploitation des personnes âgées.

45. Responses for slides 38 to 44 Code of Ethics of Nursing, OIIQ. Section II- 3. Prohibited behaviour. 37. A nurse shall not use verbal, physical or psychological abuse against the client. Retaliation, mocking, intimidation or indifference are considered acts of psychological abuse. OIIQ, Le Journal, Chronique déonto novembre / décembre 2001, vol. 9, no 2. Ethical principles: - Respecting the person’s dignity, freedom and autonomy. Margot Phaneuf, inf., Ph.D.

46. Mistreatment: Violence • Abuse is more common than we may think. • Families often avoid filing a complaint because they fear reprisals against their loved one. • Complaints are not always well accepted or taken seriously when families undertake this process. Margot Phaneuf, inf., Ph.D.

47. Types of violence Abuse exists in many forms, including: • Physical abuse, which can be identified through bruising; • Psychological abuse (pressure, threats, insults, raising tone of voice); • Passive neglect, which is omitting to help an elderly person walk or to take care of his hygiene and nutritional needs; • Active negligence by depriving a person of his freedom, unnecessarily using physical constraints, hurrying care and disregarding standards; • Therapeutic violence through relentlessness or denial of treatment (i.e. neuroleptic abuse, casual administering of laxatives, omitting medications). (Yves Gineste, 2004, Silence on frappe. Collectif, p. 18).

48. Other forms of abuse Other forms of abuse: • Denying the elderly person’s sexuality; • Sexual abuse or indecent assault; • Robbing or extorting assets or money; • Living in a situation in which the individual loses the desire to live. • Abuse is often subtle and hidden. • Excuses are often found to justify it.

49. If you want me to comb your hair and look good, be kind to me! There is such a thing as tipping. Financial requests or exploitation are abusive gestures that contravene with ethical standards. "The OIIQ denounces the exploitation of elderly persons who are among the most vulnerable in our society.’’ OIIQ. (2000) L’exploitation des personnes âgées.

50. Whether you like it or not, it’s time to take a bath. I’ll show you who’s the boss here. I don’t want to get up and take a bath. The nurse is in a position of authority, but that never justifies abusing it or developing relationships of power.