Listening to a patient’s story and encouraging them to have their voice heard is an important part of caring, it is part of positive person work (Kitwood, 1997) in improving dementia care, these actions are a way of allowing a resident to express their anxieties at a level they can manage and allows carers to really listen and identify underlying issues that could be resolved, leading to a better quality of care. “A Crabbit Old Woman” (Searle, 1973), a poem attributed to Phyllis McCormack, is a vivid depiction of an elderly woman trapped behind her illness and wishing her carers to see her and her life story together. I felt the striking accuracy of the descriptions in the first part of the poem, an old woman “who dribbles her food and makes no reply” and “forever is losing a stocking or shoe”, to then lead into the lines about her life was a part of my care position I wish I had been able to explore. Many of the residents I met were very articulate and would talk at length about their lives, in similar ways to the poem, talking about husbands and family, the places they lived and their travels. Others could not express themselves enough to manage this and in a way their stories are lost. It was noticeably easier to interact with and think about those residents who could talk freely. I know that at times, on particularly difficult days, I have made the mistake of slipping into the mind set of focusing on the tasks in hand and performing them quickly and efficiently rather than giving all residents enough time to communicate.

When a new resident moved into our home relatives were asked not to visit for a while to allow them to settle in. This uprooting can be seen a change in the system a person was part of. Goffman (2007) described the problems of placing a person in an environment governed by regime after a lifetime of independence and Killick (1994) talks about the loss of free access to friends and family. These two factors make the change in system very harsh, a change that many residents do not adjust to properly, leading to agitation or a sense of giving up and deterioration of them as people. Residents sometimes did not adjust to this change in social system well at all, residents who could not make sense of why they had to live in our home or would regularly forget once it had been explained were often distressed. Unfortunately, I feel there is not a great deal that can be done to ease this transition. Perhaps more links to their family, previous social circle and life would improve the care that is provided.

The therapeutic relationship between doctor and patient reflects closely that of staff and residents in a care home. Building this relationship is coupled with the resident’s narrative, often giving them the time to talk and sharing yourself with them would firmly deepen the trust between you and a resident. Sadly, I feel that in many cases all you were doing it helping them form a memory of you as a carer, so that the next time you saw them you would not be a stranger and they knew someone in the confusing place they live. Many residents would be much less agitated during personal care when they were attended by certain staff, as one of the only male carers in the home it was difficult to provide same sex carers for the male residents all the time, this meant men who grew up in a different social environment must rely on women strange to them to give them personal care. One gentleman, with advanced dementia, was often very angry with female staff but when he realised a man was present would calm and start talking again, usually the same stories about his time in the RAF. A grey area around maintaining a good therapeutic relationship is that of ‘lying’ in dementia care, in a paper on the subject (Elvish et al, 2010) it was concluded that although care givers feel uncomfortable doing it can be of practical benefit and to alleviate agitation. I felt that on one hand what was an acceptable misconception to prevent upset, such telling as a resident who had asked to see a deceased husband “he’s not here right now” to avoid agitation, could easily have become an unnecessary lie to trick residents into actions to simply make the carers work easier. It is a fine line from one to the other but in all cases I feel the lie fundamentally detracts from a good and trusting therapeutic relationship.

Undoubtedly dementia care has improved in past years and will go on improving. The problems I have written about are not all easy to rectify, people will have to move to the home to be cared for so maintaining their system is difficult, but more and stronger links to their previous life would no doubt make the transition easier. Time given to residents and a better quality of interaction are what is needed to expand on a resident’s narrative and build a good relationship. These problems could be attributed to staff numbers, elderly care is mostly run as a business and therefore the staff is often at low levels and low wage, staff themselves being the major cost in providing care. This unfortunately leads to a poorer quality of care and a high turnover of staff. It is difficult to fulfil the whole person care objectives when staff are not there long enough to build relationships and are not motivated to work hard to give good care.

For my artwork I painted one of the strongest memories I have from my time working in care, I remember dressing a lady with severe dementia, she could not help apart from point to the clothes she wanted to wear and pushing her arms through the sleeves. Even this had to be done slowly and deliberately. It was a busy morning and I remember growing increasingly impatient. As I continued in caring for her I talked less and let my mind drift to the work I still had to do, planning my morning to be as efficient as possible, so that I could give as much time to getting individual residents up and not rushing. Once I had finished getting the lady I was with ready I sat her in her chair and surveyed my work. The room was neat and tidy, all personal care had been provided, and dirty washing was ready to be removed. At that point I saw a family photo of her younger self and her husband. She seemed so proud and happy in the photograph, looking out at me with a pleasant smile. The lady sitting with me was almost unrecognisable, a lost and confused look, not really focused on anything. Her pale and shrunken cheeks were nothing compared to the full and rosy ones framed in the window-sill. Her limp, pastel coloured clothes lying shapeless on her frame seemed to reflect the shell of a person she had become. Whereas the crisp blue three piece suit, slightly too small on her well-fed frame in the photograph, now hangs unworn in her closet. Two thoughts struck me at that point, one was that us as carers were the predominant part of her human interaction for the day and generally we were her life now. Secondly, I realised that I had spent the last half an hour silently dressing her, treating her as second place to work I had to complete that morning. I felt ashamed at how I had acted and that my care work left a lot to be desired. That moment influenced my future work, always interacting with residents at whatever level they could manage, trying to be more mindfully aware (Ludwig & Kabatt-Zinn, 2008) in those situations when conversation was not possible with a resident. In these cases paying careful attention to your actions and body language were much more important in communicating with a resident. The artwork is mostly in watercolour with the photograph in brighter acrylics. In my memory the image almost seems like that, with the vibrant photograph very obvious, almost jumping out at me amongst the very neutral and inoffensive colour scheme of the room. I think that this memory made me evaluate my work ethic strongly and definitely improved me as a carer. I think that more active self-observation in your work, whatever your work is, can lead to identifying how you can improve your impact on the people around you. This self-development is what I needed to expand my skills as a carer and better myself as a person.

References:

1. Kitwood, T. (1997). Dementia Recognised: the person comes first. Buckingham, Open University Press.

2. Searle, C. (1973). Elders. London, Reality Press.

3. Goffman, E. (1974). Stigma: notes on the management of spoiled identity. Hammondsworth, Penguin.

4. Killick, J. (1994). There’s so much to hear, when you listen to individual voices. Journal of dementia care, 2 (5): 12-14.

5. Elvish, R. Et al. (2010) Lying in Dementia. Ageing and Mental Health. 14(3) p.255-262.

6. Ludwig, S. Kabatt-Zinn, J. (2008) Mindfulness in Medicine. Journal of the American Medical Association. 300(11) p.1350-1352.