Increasing Care and Decreasing Cost: An Autoethnography Demonstrating a Nursing Student’s Experience with the Importance of Higher Educated Care Givers in Assisted Living Facilities (ALF)
Andrea Chandler
Indiana University of Pennsylvania
103 Jenks St. Brookville, Pa. 15825
1-814-715-3030
Abstract
If ALF would hire higher educated caregivers, the facility would have an increase in the quality of care in the facility and also a decrease in unnecessary costs. This article documents a personal experience of working in an ALF thru the use of autoethnography. The article also compares my experience of the contrasting care techniques that were presented to me at the ALF compared to at the clinical setting.
Introduction
Working in an ALF as a mobile/direct caregiver can both reflect and challenge what is learned throughout a bachelor of science in nursing program. When I turned eighteen I began to work in an ALF. I worked at that facility for two summers, first as a direct caregiver and then as a mobile caregiver. That second summer was between my freshman and sophomore year of nursing school. It was that summer that I began to think critically about the quality of care given in ALF. In a perfect system ALF would be able to have educated caregivers that would be able to assist the resident in all activities of daily living (ADL). But what happens when you have an inexperienced staff in your facility? Does a Licensed Practical Nurse (LPN) who just recently graduated from their licensing program have the expertise to differentiate between appropriate and inappropriate care? How does the increase staffing of higher educated caregiver’s, not only affect the quality of the patient care, but also increase knowledgeable patient care and decrease cost for the ALF resident?
In the mid-1990’s best practice protocols were established for use in ALF. These protocols encompass four main areas: services, environment, resident rights and risk negotiations, and management responsibilities. These protocols are still used to produce risk protocols. (Peterson 2005) Studies show that quality of care given in ALF is directly influenced by having more than one favorable characteristic. With the increase staffing of registered nurses the quality of care would also increase. For nursing assistants job stability is important. (Castle, Engberg 2007) If ALF are looking to improve the quality of care in their facility it is important that they make staffing changes. Much research has been done to show the link between the increase staffing of ALF and the quality of the care given in the facility
To bring light on the necessity of educated caregivers, I am writing of my personal experience through autoethnography. By writing about personal experience, an author can inform their readers of what they have experienced. By using my personal experience working as a direct/mobile caregiver, I can give a first hand account of what it is like to work in ALF and what problems I have seen. This will contribute to the medical field by giving insight into the problems that continue to need to be revised in the ALF protocols. When ALF hire higher educated caregivers, not only does the quality of care given to residents in the facility increase, but the costs to the facility decrease.
Literature Review
Assisted living facilities are long term care facilities that care for the elderly. Staffing characteristics vary among assisted living facilities. However, research has been done to show what staffing characteristics are necessary to provide optimum care. Studies have shown that staff working at a facility providing 24-hour care should be of sufficient numbers and knowledge level to meet the ever changing care needs of the residents. The staff should be educated about basic changes that occur throughout the aging process and preventative measures to prevent harm to the residents (Stefanacci & Podrazik 2005). The staffing of ALF must be educated and be able to provide basic nursing skills. Research has also been done on communication between staff and the residents in the facility. Williams and Warren researched communication between the staff and residents, what living in an ALF is like, and also, communication among residents:
Local culture mirrors that of the larger society, with different patterns of communication attributed to women and men: the sociability of the women, and the dominance of the male ‘board of directors.’ The women are seen by both staff and other residents as more likely to engage in activities and gossip, while the self segregating men talk of sports and politics, and then retreat to solitary activity (p. 26 2009).
The article also states that assisted living facilities should encourage their residents and help maintain their self control. Debra Dobb states of Assisted Living Facilities, “A better understanding can result in more empathetic staff and positively affect the type of care they provide: Social scientists doing ethnographic work in long term care settings could benefit the field by….educating staff on how to seek social explanations for residents’ behaviors.” (As quoted from Williams &Warren 2009 p. 35).
One way for a researcher to bring new information about ALF into the academic world is by the use of Autoethnography. Autoethnography allows the researcher to explain personal experiences. By examining personal experiences of ALF care givers, researchers can have a better view of what working in an ALF is really like.
Methods
I will be writing an autoethnography, which can be viewed in appendix A that describes my personal experiences in an ALF. I will share my experiences of how patient care was handled and the characteristics of the staff I was working with. It is important that I write my experience to share what occurred while I was employed at an ALF. An autoethnography examines an author’s personal thoughts and feelings. Foster, McAllister, M. & O’Brien, state:
The role of the researcher in qualitative inquiry may be viewed as synchronous to that of the psychiatric mental health nurse. Both are attempting to use their selves – their thoughts, feelings, understandings, and experiences, to work in partnership with others so that further understandings and meanings of the lived experience may be understood and the lives of the ‘others’ in particular, enriched (pg. 46).
All nursing involves the use of these skills that are “synchronous” to the role of the researcher in qualitative inquiry. By sharing a caregiver’s insight into particular situations, this “story telling” can assist in making novice nurses into expert ones.
This methodology allows for the documentation of personal experience and to show the growth and ever changing understanding of the author. Working in an Assisted Living Facility as a mobile caregiver/direct caregiver can both reflect and challenge what is learned in a Bachelor of Science in Nursing Program. By using this methodology one can show their personal experiences and what they view needs to be changed/ revised in a more detailed manner. I used Wright’s autoethnography as the inspiration for the format of my article.
Discussion/ Results
During the process of writing this article I became very upset that as a nursing student I was noticing so many things wrong with the facility I worked for. In my nursing classes we are taught the importance of evidence based practice. However, these teachings didn’t transfer over to the real world for me. If the ALF I worked at, and others, would hire more higher educated caregivers at their facility, the caregivers would be in a continual learning environment. Critical thinking is necessary throughout the nursing process, and is crucial for quality of care. Undereducated individuals or even novice nurses lack this skill. To provide quality care that would essentially bring down the costs to the ALF by decreasing the amount of unnecessary or preventable care, the ALF MUST hire nurses and caregivers that can provide knowledgeable and patient centered care. Mobile caregivers and unlicensed individuals who administer medications simply do not have these skills and should not be allowed to work in ALF without continual supervision from higher educated caregivers. By sharing my personal experience in an ALF, I hope to influence the nursing environment by bringing more attention to problems with uneducated caregivers.
My autoethnography documents a personal experience with undereducated staff at an ALF. Caregiver’s in ALF need to know why they are giving patient care to their resident and the resident needs to know that they can trust their caregiver. In my opinion and from personal experience it is a necessity for ALF to hire full time, round the clock, registered nurses for their facility.
Conclusion
ALF need to hire higher educated caregivers to decrease costs and increase care. My personal experience with unknowledgeable caregivers is a testament to this fact. However, there were limitations to my autoethnography. One limitation is the fact that I am writing about myself and how I remember them. Being a novice nurse I questioned everything I wrote about in my autoethnography. My article is qualitative research. Throughout writing my autoethnography I thought about how my topic could turn into quantitative research. I would recommend future quantitative research into the number of “expert” nurses working in a facility compared to quality of care of the ALF.
References
Castle, N.G., & Engberg, J. (2007). The influence of staffing characteristics on quality of
care in nursing homes. Health Services Research.
Foster, K., McAllister, M., & O’Brien, L. (2006). Extending the boundaries:
autoethnography as an emergent method in mental health nursing research. International Journal of Mental Health Nursing, 15(1), 44-53.
Peterson, S. (2005). Developing risk-management protocols in assisted living: assisted
living has its own litigation traps for the unwary. Nursing Homes: Long Term Care Management, 54(11).
Stefanacci, RG, & Podrazik, PM. (2005). Assisted living facilities: optimizing
outcomes. Journal of the American Geriatrics Society, 53(3).
Williams, K, & Warren, C. (2009). Communication in assisted living. Journal of Aging Studies, 23 pg. 35.
Wright, J. (2008). Searching one’s self: the autoethnography of a nurse teacher. Journal of Research in Nursing, 13(4).
Appendix A:
Autoethnography
When I started working at an ALF, I was excited about being able to get a “heads-up” on my nursing clinical. I started the summer before my freshman year of college. The facility I worked for hired me for a direct caregiver position. They taught me how to give showers, transport residents, and prepare the residents for bed. When I started school in the fall, I began to see that the way the ALF trained me was vastly different from what I was learning at school. The techniques taught at the University where based off of evidence based practices that were proven to reduce injuries and prevent unnecessary wastes. At the ALF my training revolved around what would get the job done the quickest. While at school, I began to wonder about what would cause this discrepancy in the patient care techniques. I then realized that because of how uneducated the staff members at the ALF were patient care techniques were like playing a game of “whisper.” One educated caregiver taught someone who was uneducated patient care, then that individual taught someone else who was uneducated patient care, but without the knowledge of why certain things were included in the patient care techniques. Without that knowledge steps in the care giving routines were excluded to get other things done. If an ALF would hire higher educated caregivers, the quality of the patient care would increase because more caregivers would understand the “why” behind the patient care being given. This ability to ask why is very important if we as caregivers are going to give our residents quality care. This ability is critical thinking and essential to nursing. While working at the ALF I saw a huge lack of understanding as to why the residents were receiving the care plans they were assigned. The caregivers had no idea why residents were receiving their medication and as a result monitoring the residents for any changes was difficult or even impossible to do.
The next summer the ALF then made me a mobile caregiver. I was now responsible for administering treatments to the residents at the facility and collecting vitals. Looking back at it now, I am shocked at the lack of training I received on this part of patient care. I was trained at the ALF for an hour on how to do the treatment passes and how to do vitals. I was trained to do vitals at the ALF with all automated vital taking `machines. These machines can often give inaccurate readings. At the ALF we were often very rushed to collect vitals on our residents which often increased the risk of inaccurate readings. The staff however, just wanted it to be done; they didn’t care as long as they had a reading.
In the ALF I was the youngest mobile caregiver at the facility. I often noticed problems in the treatments that were given to residents at the ALF. Other mobile caregivers would not do the necessary med checks before and after administering medications and this led to medication errors. I would often have residents that were prescribed inhalers. I would work three days in a row and have two days off. The inhaler would have three treatments left. The resident was to get the treatment three times a day. After the two days off, I would come back to same resident and see the same inhaler without any medication left being used for the last day when it was empty. After checking the MAR (Medication Administration Record) it would always be signed off on. Being one of the youngest on staff, it was difficult for me to confront caregivers who had been at the facility a lot longer than I had. Communication and understanding of the residents is another problem. Caregiver’s would often get upset at a client who had dementia and wasn’t complacent. They didn’t understand the complications that were involved with the disease and the lack of understanding of their resident led to mistreatment of their resident. The ALF gave the bare minimum of care and was very task-oriented.
Appendix B
Acknowledgements
I would like to acknowledge Dr. Marlen Harrison for his incredible research writing course. Also, I would like to thank Mrs. Kuzneski for teaching her students about the nursing process and the importance of critical thinking.
