Mrs Kulkarni

It is important to be clear about the difference between what a person may need and what nursing home staff and other caregivers may view as an efficient way to manage care work. In this case, nursing home staff is aware that a care routine (e.g. diapering) that may not be needed has been started in a previous care setting, such as a hospital. Mrs Kulkarni is right to be concerned that shortcuts of this kind fail and are unethical because they do not show appropriate respect to nursing home residents.

The problem with shortcuts

The use of shortcuts as a response to staffing shortages is a common problem found in nursing homes all over the world. These shortcuts take many forms. Staff may rush residents through activities, they may use feeding tubes in cases where comfort feeding may be more appropriate or, as in this case, they may use diapers as a substitute for bringing residents to the toilet. Many of these practices can harm patients. Even if these practices do not result in immediate physical harm, they may disempower patients by not allowing them to use the abilities they have and infantilise them by treating them as if they are children. These actions are unethical because they violate the principle of respect for persons. Not only may these actions humiliate nursing home residents, they may eventually lead to further physical and mental decline.

How can shortcuts be avoided?

Beyond staffing, shortcuts may become a problem because certain practices become routine and are not challenged by the leadership and staff of the nursing home. In many nursing homes, routine practices that undermine quality of care and disempower residents go unchallenged because they are not discussed.

Leaders in nursing homes should be aware that organisational policies and practices can influence the quality of care. Mrs Kulkarni recognises that this is an ‘upstream problem’ in which the discharge process in the hospital is creating an unintended problem for the patient and the nursing home staff. She is demonstrating leadership by placing the issue of routine, unnecessary use of diapers on the agenda of her staff. It may be difficult or impossible for the staff of an individual nursing home to influence change at staffing levels or the budget of the organisation, but it may be possible to identify changes in policies that can help to avoid these practices.

In the cases being discussed by Mrs Kulkarni and Ms Yeo, the residents arrive from the hospital in diapers even though they may have the ability to use a toilet. There are a number of strategies that Mrs Kulkarni and her staff might pursue to address this issue. For example, if Mrs Kulkarni has an opportunity to meet with hospital administrators, it may be useful for her to address the hospital discharge planning process with them. It is important for the hospital to understand the consequences of their actions for patients and the nursing homes to which they discharge their patients. Focusing on what the nursing home could do without relying on a change in hospital practice, it is possible that if these residents are given the option of using the toilet immediately after they arrive from the hospital, they would retain the ability to care for themselves with minimal or no assistance. This would eliminate a dependency that takes up staff time. It is important to recognise that none of these strategies are simple and would require significant commitment.

Eighty-five per cent of aides in nursing homes in Singapore are migrant workers supervised by staff nurses. Foreign workers are contracted to work for a specific nursing home, and may even sleep in a staff dormitory. Nursing aides provide most of the hands-on care to nursing home residents who need assistance with activities of daily living – bathing, dressing, grooming, toileting, eating, taking medications – and who need help to engage with activities that are of interest to them. In wealthy societies throughout the world, it has become common for this intimate, physically demanding work to be provided by migrant workers, usually women from poorer nations or regions.

In any type of institution that provides care, it is impossible to improve care or to sustain improvements without the participation of care workers themselves. Efforts to improve nursing home care in Singapore should consider the role of the migrant worker in shaping care. Jargon such as ‘manpower’, suggesting that paid care work is a matter of filling quotas, obscures the reality that migrant workers are individuals who bring their own perspectives and experiences to workplace situations.

In the situation at hand – a discussion of a routine, time-saving practice in nursing homes that may undermine the dignity and choices of some nursing home residents – it is the migrant workers who are doing the diapering, and who will experience the consequences of any change to work routine. Some workers may see no problem with the current practice, or can foresee challenges in keeping up with their work if they do not resort to diapers (or another default practice) routinely. How should nursing home administrators invite these workers to be part of the discussion?

This casebook includes two cases set in the same nursing home, both depicting different types of staff discussions. In the other case, the director of nursing Cindy Yeo has invited Carla, a long-time member of staff who, we can assume, is likely to be a migrant worker, to consider another common, challenging question: how to respond to a nursing home resident with dementia whose behaviour includes hitting others? By inviting Carla to consider the question and prepare for the discussion in advance, and by introducing Carla in terms of her experience, Cindy has made distinct efforts to diminish the gap in status between ‘boss’ and ‘staff’, and between citizen and migrant. In the staff discussion that is likely to follow from the senior-level discussion initiated by Vandana Kulkarni in this case, turning again to Carla and her colleagues, to get their perspectives and to also listen to their concerns about time pressures that could result from a change in routine aimed at treating residents with greater respect, would be the right move.

Working in a nursing home is challenging, even for the most experienced in the healthcare sector or those who believe it is their calling. The work is gruelling, the hours are punishing, and the glamour is non-existent. At the same time, healthcare staff in the nursing home are entrusted with the heavy responsibility of caring for the most vulnerable in their last years, many of whom depend almost entirely on the staff for support. It is a position of privilege but it is also one of immense responsibility.

Nursing home healthcare staff need and are expected to have great fortitude. It is a tall order, and we have seen many care staff struggle with these demands. This has often led to the adoption of unhealthy practices in the nursing home, which undermine staff morale and the delivery of proper care. One such example is in the area of diaper use.

Incontinence is a common ailment amongst nursing home patients. Ideally, a patient should be assisted by nurses in toileting as and when the need arises. However, given the persistent yet unpredictable nature of incontinence, nursing homes frequently find this arrangement difficult to manage. Often, they resort to the general use of diapers as the silver bullet. In the name of manpower efficiency, nursing home patients are made to wear diapers which are changed at scheduled timings.

However, while the use of diapers obviates the trips to the toilet, it makes patients (even those who are ambulant) passive and dependent. Patients are also exposed to greater hygiene- and health-related risks if their soiled diapers are not immediately changed. These concerns are not insignificant and they arise from nursing homes taking the easy way out, however well-intentioned the staff may be.

The second and larger issue is a common human failing – not knowing enough yet thinking we know best. This is usually seen in the treatment of foreign staff. Most foreign healthcare staff possess formal training qualifications back in their home country. A good number are professionals and have sound nursing knowledge, skills, and experience. However, due to the rules of the Singapore Nursing Board (SNB), foreign trained nurses are required to sit for an examination before being allowed to practise nursing here. Therefore, they usually come to Singapore with a lower position before being sponsored by the employer for the examination with SNB.

This is probably the reason why foreign care staff are still not adequately tapped on to shape the care practices in nursing homes. Their views are often not sought, or taken seriously, despite their experience and knowledge. They are left to play a passive role and expected to do as they are told, and the situation is exacerbated by the language barrier they have with the patients and local staff. Concerning the use of diapers, one foreign care staff in this case related that back in her hometown, the staff in the nursing homes did not make their patients use diapers routinely but would instead assist patients to the toilet for his/her elimination needs. She was taken aback by the widespread use of diapers in the nursing home here, where she worked. However, her suggestion of regular potting to wean some patients off diapers was met with derision from the local staff. She was chided for disrupting the ‘work routine’ and being difficult.

This same work attitude is also found in staff interactions with patients. Too often, patients are treated impersonally and regarded as digits in the process. These patients are not consulted on their care plans and treatment. Many are not even asked about how they are feeling, what they would like to do, and whether they are happy to be put on diapers. Nursing homes simply assume they know best; unfortunately, this may not always be the case.

So how can we make things better? The first step is to ensure the foundations of respect and empathy are in order. We must remind ourselves that the focus is on the patients and on what they want. It should always be about what is good for them. This means they need to be consulted on and convinced of their care plans, and to be enabled and empowered to do as they prefer based on their optimal functional status. This in turn entails a shift in the care vision and culture towards a more enabling setting – ability-oriented instead of inability-focused.

To achieve this, we need to foster an inclusive and positive environment where manpower resources, knowledge, and expertise are optimised towards common objectives. This means involving foreign care workers more meaningfully in care practices and also understanding the patient issues more holistically.

Once the practices of performing proper assessment and administering individualised continence management is in place, there will be the understanding that there are different types of incontinence and that they do not warrant the same response. There will be the understanding that each patient requires some variation in continence management, based on his/her personalised care plan. Some will truly need diapers and regular supervision while others simply require minimal and temporary facilitation to get by. There will be the understanding that a better solution is to implement scheduled potting or assistance to toilet use at regular intervals.

Needless to suggest, there will be the understanding that diapers are only to be used as a last resort.