Told I need to have a more dominant personality

[Maddymorphosis]

Work in community care, and sometimes I feel like people's element of choice is taken away.
I completely understand the statement in my question, but I also dislike insisting (forcing) people to do things and wonder if I am cut out for this job.

For instance we have a lady with dementia who I went to visit yesterday morning. In her care plan it is stated that we are to support her to get washed and dressed. Yesterday she said she just wanted to stay in bed and asked me to bring her breakfast in bed. I asked once more to check if she was sure, said ok and then noted on the report that she hadn't been ready to get up yet.

When I arrived for the lunchtime visit her granddaughter was there. She asked me for 'a word' , told me that she was not happy at all that her grandmother was still in pyjamas and that I hadn't done my job correctly.

I explained she had not felt like getting up and that I had logged it, she then seemed to empathize and say her Grandma was sometimes stubborn and that it was hard but that I needed to 'have a more dominant personality'. She then compared me with another carer called Hannah who is 'much more dominant'.

I do understand the issue but also think the lady should be entitled to remain in bed if she wishes.

I've had it with another family where their elderly father doesn't always want to eat. We still make his meals and leave them out for him, but he won't always eat even if we prompt. The family complained we 'need to make sure he eats them'.

Outside of force feeding, there isn't much we can do.

Another lady who needed to be prompted to use the toilet. Sometimes she'd refuse, we'd try and prompt again but she'd still refuse, again we couldn't force her.
My agency sent out an email saying that "Walking to the toilet is not an option for her, we are to insist that she goes on every single visit."
My colleague also told me I needed to be 'firm' with her.

Maybe I am the problem, but I don't agree with trying to force the clients, they are grown adults but sometimes treated like babies. I'm not going to shout at them or get angry just to coerce them into things.

What would you do in these situations? Does it seem like I need to be stricter?

I did not agree with the way the granddaughter took me into a room to 'tell me off' and essentially tell me to change my personality.

Fwiw OP I think you are absolutely in the right. I completely agree that you can't remove all personal liberty and choices from people, as long as they are able to communicate what they want that should be respected as far as possible.

The problem will be that you are dealing with very emotional and anxious family members who will take out their worries on you.

Rise above it - I would want someone like you taking care of my elderly relatives rather than a dominant bossy person.

Yes I understand they are worried completely, they do seem to expect magic sometimes and take it out on us.

On the occasional day I don't really feel like getting up and dressed so I don't, she could have had her personal care at lunchtime, she shouldn't have that choice removed because she's elderly.

I agree with you unless they the client is in danger then they can choose whether to eat get up wash etc.The granddaughter should not have spoken like that perhaps she could do more to help her grandmother.You I am sure have very little time to convince someone to get up.A one off day in bed not eat is not a problem.I have worked professionally in this field.People can choose.Good luck.

You might need to be a bit more (politely) pushy. Everything not being done is something that is going to have to be dealt with later. The gentleman who doesn’t eat will rapidly decline if he loses weight. The lady in bed could get bedsores if she won’t get up and move (though if it’s only occasional that she fancies a lie in, that’s different - though the question is then whether someone else would be needed to attend when she decides to rise - which clearly isn’t in the budget).

Maybe you could phrase things differently. (‘I’ll just change the bed while you nip off the the loo’ rather than ‘would you like to visit the loo’)?

You cannot make them do things, but it may be a matter of presentation. If they still refuse - all you can do is log it.

@KleineDracheKokosnuss OP mentioned that the elderly lady has a lunchtime visit too so getting her up could be dealt with then.

OP you sound like a great person and you’re clearly helping your clients preserve their dignity and autonomy which is important.

Thanks for the advice. Yes it could have been dealt with on the lunch visit. Unfortunately we are allocated 20 minutes to prepare breakfast and a drink, administer medication and cream, eye drops, assisted to wash and dress, wash any pots, make bed, ensure everything is plugged in etc and record the next log entry, we have expressed 20 minutes is not sufficient but nothing has been done yet.

Colleague thought the granddaughter was out of order and I should report it to my agency, would you?

I agree with you OP. If someone wants a lie in and breakfast in bed once in a while, they should be able to do that. If her granddaughter was visiting in between the two carer visits and nan wants to get up she can help.

If nan was distressed about being in bed I might understand but what's the point in upsetting your clients? They're vulnerable enough as it is. These little decisions are the only little bits on independence they have left. Being old or unwell doesn't stop them being human.

As the daughter of someone having care, we get a much better response to the carers that she likes, and has rapport with. The stricter ones she tends to push against, the one who can cajole her in a kind but firm way tend to get a better response.

The trouble can be that people continue to refuse personal care and this becomes detrimental quite quickly but obviously you can not be forceful or “dominant”. Maybe phrasing things differently as mentioned above. Also your employer should be clear that adults can make choices if they have the capacity to do so. I wonder how your colleague approaches it. I’m sure she doesn’t march in and snap “Get up!”

It's a difficult balance to strike - obviously people should be allowed autonomy where they can, but some people who have a carer aren't capable of making judgements that are in their best interest and part of caring for them is getting them to do things they might not want to do but will be benificial.
I feel like if multiple people have pulled you up on not being firm enough regarding seeing to personal needs such as food and toileting then you might want to consider if you're leaning a little too far towards the first part and neglecting that sometimes care does mean being firm about the necessaries even if they aren't keen.

I'm a HCP ( not a carer) and I sometimes have to be more direct and firm with patients than I would choose to be. I also work in a job where I have to encourage people to move who may not want to - for fear, pain, tiredness etc.

Personally I think the time allocated to personal care for the elderly and vulnerable is shocking.

The people you are working with have dementia and the key is whether they have capacity ( the ability to understand) to make decisions and understand the consequences of those decisions.

As pp have said - the lady who didn't want to get up, if she said that on every visit she could end up weak, losing her mobility, and ultimately worse off.

I don't know what the answer is and would feel very conflicted. I would look up more information about dementia care. I know in my job we spend time building rapport, working with families to understand what motivates them. It's not easy.

You were completely in the right. I always think could I make that choice? Can I choose to have a pj day? Yes. Can I choose to stay in bed all day, it wouldn't go down well with my job or family but it's still my choice. Your job is to offer the option and opportunity and then record.

’The people you are working with have dementia and the key is whether they have capacity ( the ability to understand) to make decisions and understand the consequences of those decisions’

This ^
You’re there to get them up, clean, dressed, to the bathroom or fed. They can’t accomplish that on their own or you wouldn’t need to be there. You’ve only got 15 minutes or so to get it done. You obviously can’t force them but you need to use every bit of your ability to charm, encourage, cajole, bargain and chivvy them along.

My Uncle had carers in because his wife couldn’t manage to lift and manoeuvre him on her own. If left to his own devices he would have stayed in bed eating biscuits. He had the quality of life he did for as long as he did because he was up, cleaned and dressed every day.

Patient choice is well meaning, but there's no doubt it has unintended consequences that would sometimes be for the better under old regimes.

DM has dementia and due to a fall and subsequent hip surgery had carers 4 x a day for 6-8 weeks
I was confused that whenever I visited she wasn’t dressed - she was telling them not to bother so she never had a shower/wash of any kind or clean nightwear
She was only getting one meal a day and becoming dehydrated
DD and I had to step in and be firmer - even now we have to persuade her to eat properly and take care of personal hygiene

I think the challenge is
A) presumably many of these individuals have major care needs. Are they compus mentis? While it's important to respect their wishes, it can be critically important that you manage things like toileting.
B) people often resist care before hand. My grandfather would have said he would stay in bed. It would have been either a) pride b) ingrained fear of getting up and dressed being hard work or c) that he'd perhaps had a toileting or similar accident etc in bed that he was ashamed to have found.

I think there's a sort of brisk, reassuring but encouraging persona that happens to be quite effective. People often express reluctance to get up but feel much better once they have and it can be much better in terms of their health needs.

It sounds to me like you are just really good at your job, but you’re in a system where you are expected to treat your charges like objects.

Tricky isn't it. I think it's probably in someone's best interests to get out of bed every day to keep their strength. Unless they are for palliative treatment

It’s a very difficult balance to strike.

This is a long, cautionary tale where capacity can lead to horrific circumstances.

My Dad had issues with personal care and movement (he has no dementia & has capacity). In the 18 months before we brought him 400 miles to our home town, he refused to have a shower or be washed by his 3 times a day carers. And, deeming him to have capacity, the carers just didn’t shower him. He ended up with pressure sores, maggots, and was in such a poor state my county SS team immediately issued an inquiry that dragged in the CQC & a host of litigation between his last county & this one. Due to his capacity, the previous care team & local authority tried to squirm out of their duty of care, and a settlement was reached so his previous authority now take on the majority of his care bill. I’d kick his arse & shower him myself every month I could make the 800 mile round trip (which was most months when work would allow, but a once a month shower goes nowhere when you have toileting issues & diabetes).

Now, in my local care home, he may have signed forms to show consent to loss of liberty, but he still has capacity. Does he always want a shower? No. Is his health a lot better off because he has a fantastic care team around him 24/7 who will (nicely and with good humour) kick his metaphorical arse until he showers? Hell yes.

Dad had to have amputations due to unmanaged diabetes in the previous county. If his carers hadn’t just said, “Do you want a shower Sid? No? OK then, see you tomorrow,” and had said, “Come on Sid, it’s time we got you up & showered!” then on one visit up there I wouldn’t have been readying him for a shower, taken his sock off and had 2 toes drop off into my hand. And gangrene is a bloody horrible smell to get out of your nostrils.

If he’d had a shower in the month before my visit, would they have caught his gangrene earlier? Of course. And heaven knows how they couldn’t smell that & the toileting issue. And then Dad, already suffering mobility issues due to a stroke, may still be up and walking now (he’s only 75 now, he wasn’t even 70 when this occurred).

Being caring & compassionate isn’t just about doing what your client wants, even if they have capacity. It’s about encouraging them to do what is in their best interests. I had countless calls with his social worker & care team after visiting Dad (& writing notes in his care record) to see if they could change the approach to encourage Dad to have basic hygiene needs met, and every time they’d make sympathetic noises but say if he didn’t want to have a shower, he didn’t have to. It transpired, as we’d told them & as Dad told us, he was embarrassed by his accidents.

Should we shout & rant & force anyone to do things against their wishes if they have capacity? Of course not. But should we use our knowledge & compassion to gently encourage clients to bathe, shower wash or eat as it is in their best interests?

Absolutely.

You are promoting choice. She is in her own home and has refused to get dressed. You asked more than once. You did the right thing. Sometimes family just don’t understand it. As long as you have written it in your notes there’s nothing more that you could have done.
I went to visit my pop in a care home yesterday at 1pm (dementia and turns night into day) he was in bed, pjs sound asleep. I was angry as a family member, but then thought that he has probably refused to get up and dressed because he is exhausted and they are to promote sleep. I checked his notes and he had fluids and toilet checks etc so there’s not much I could have said. Sometimes family need to try and be a bit more realistic.

I’m very sorry that happened to your father CentrifugalBumblePuppy. It must have been incredibly upsetting and frustrating for you to try and get him appropriate care.

That’s the reality of what neglecting a patients basic needs can lead to. No one has carers coming to their house to wash them or help them to the toilet unless they are dependent on that assistance to see to their toileting needs and clean them. If carers don’t get them to the bathroom they are going to get UTIs, sores and rashes. If they are in bed and not being dressed things like foot ulcers can be missed.

YANBU, if they have capacity.

The way some carers and Healthcare staff treat the elderly is awful. As long as they understand their decision and possible consequences, they're allowed to make a decision even if we don't agree to it.

Unless they think you should start forcefully stripping people's clothes off. And if they do, they need to never be in your job.

Sounds like you do need to be more assertive. Could you shadow another carer to get some ideas on how to approach your clients perhaps, if their relatives are complaining about you?