The second Pandora's box wants to open the current mystery of missing staff in social care facilities and the mystery of why doctors are cursing at us.
Has the Ministry of Labour forgotten social services?
Please answer this question for yourselves after finishing this blog. Over the last two years, the situation in social care facilities has become highly dramatized due to the lack of staff. Already two years ago, as consultants and quality auditors, we had warned about so-called “dangerous services.”
Why dangerous services?
The first reason is that in recent years, the client population in social care facilities has changed. If someone imagines that in so-called nursing homes there are seniors who simply live quietly there, eat, occasionally walk slowly through the corridor, and sit on a bench outside reminiscing about youth, while staff create various and mainly low-effort recreational activities for them, then they are very mistaken. Today we admit more and more clients with severe disabilities and serious diagnoses to homes for seniors, specialized facilities, and also social service homes. Clients require daily, very intensive and demanding nursing, care, rehabilitation, and psychological support.
The second reason is stated as a question from the quiz “What do you know about social services in the Slovak Republic.” What do you think, how much staff should the Social Services Act provide for comprehensive and individual care that is supposed to be provided in a social care institution? A follow-up question: how many clients must one caregiver comprehensively attend during a shift of 24, nine, twenty, or thirty? A supplementary question: how many clients does one caregiver look after at night? The theoretical answer: according to the staffing standards set out in the social services law, according to which the authors told us these numbers are enough and that everything needed will then be ensured. What they apparently meant was bare survival. The practical answer: in every facility it is different. I can responsibly state, however, that in every facility where I have been able to be, given what is demanded of staff today and what inspections, professional procedures, clients themselves, and their families demand, it is not enough. We have alarming figures. In some facilities, there are even twenty clients per caregiver at night. You might say, after all, not all of them are immobile and besides, they sleep at night. Yes, true. But primarily they require real supervision due to their health condition, assistance at any time throughout the day and often at night, especially if they are psychiatric “patients,” or they suffer from addictions.
In advisory work, we often receive the question: how many clients should standardly be assigned to one caregiver? Hm, a very good and completely basic question for good operations. But that can only be calculated when caregiving and nursing standards are defined. And we do not have them in social services. Here, care is provided as caregivers learned in caregiving courses, which in some cases lasted only four days, with the amount of staff the operation can afford from its own budget. Not based on client needs and requirements, not based on their real social and health status, and not based on professional caregiving and nursing standards. That is chilling. What do you think, how much time does a caregiver have for one client during comprehensive morning bed care? A professionally prepared standard says this care should take about 23–27 minutes, including conversation with the client and documentation. One caregiver laughed at me when I described this procedure by the standard during training. She told me that, by their standards, morning care for them would take until noon, and they must get clients ready for breakfast by eight o’clock. She claims she has three minutes per client. Dear readers, I ask you: how long does your morning care take every morning? Three minutes? You have healthy hands, healthy legs, stable mental health, you are not restrained by anyone except your family members, who may only occupy the bathroom or toilet just before you. But even then, you don’t sit on the floor crying and scratching your face or cursing the postwoman who brought the mail. And you are not incontinent or stiff from lying down for 12 hours, etc.
How many times can a caregiver come and ask in a room whether a client needs anything? How much time is there to escort one to the toilet? How much time for escorting to the dining room? Or clients are better confined to avoid using the toilet, because there is a risk they might fall on the way there or back and injure themselves. And in the evening, we administer prescribed sleeping medication so they do not wander at night and do not suffer the same fate. This alarming state is not only in Slovakia. It is also in Austria and Germany. In the past year, a professional and political debate on these topics has officially opened on German public television. Last week, when the new German government promised to immediately release funds for 8000 caregivers/nurses, the German public—and especially social care staff—responded with strong criticism. To this day, 30,000 nursing-care staff have left services for other sectors because they cannot work for such low wages under such difficult conditions and with such low staffing levels. Across Germany, staff are reporting severe burnout syndrome. What do you think it is like here, and what salaries would keep not only caregivers but also nurses and social workers here? Not German wages. Slovak wages. Why should they go to machines if they can earn twice as much there?
Exhausted and burned-out staff have only two options: take sick leave or resign. Many handle it through “sick leave.” Those who cannot afford that, or who have such strong empathy that they cannot leave their clients “in the lurch,” are, thanks to their sense of responsibility and personal character, being punished with excessive burden. We know that an exhausted body, but also soul, loses not only vitality but also immunity, and a person can become seriously ill. We have dozens of such testimonies from our visits to social care institutions. These are not only caregivers, but also nurses and managers who, under years of stress and carrying responsibility for clients, forget their own health, well-being, and quality of life. Every day they are exposed not only to heavy physical effort but also psychological strain. Imagine you have sick children at home and you do not feel well. But you know that if you stayed home, your entire care load would fall on your colleague. So you push yourself in the morning or evening, come to work, and there a client sends you to “pi..,” yells at you aggressively, spits at you, or hits you with a stick. What is even worse is that sometimes an arrogant official is waiting there—a control inspector—who is not interested in your work but whether you documented everything correctly. Whether in some small detail you have violated something, and they do not even try to explain what is actually at issue. Whether you keep documentation according to THEIR STANDARDS and whether it is signed also by clients who cannot even lift a hand, or whether you have an approved individual care plan signed by people who are in a fully awake coma.
It is not over yet. Can you not secure doctors for your clients? Of course not, because many doctors do not even want to have them in their care. Or those who would like to help cannot take on more clients because they are also overloaded, and health insurance also does not take these conditions into account. The points are gone; so is care. Many clients in social services do not have realistically accessible specialized healthcare despite constitutional guarantees. Perhaps human rights ombudsmen should be interested in this. If I do not count emergency medical help, where sometimes a doctor in a night shift yells at the poor caregiver for calling, saying it was not urgent. I believe no decent person would want to hear words from some emergency workers with which they address an anxious caregiver and sometimes even the client themselves. And this adds another heavy burden to her psychologically, telling her that while she is here unnecessarily, someone might die because she is not there. What do you think—should a caregiver decide that emergency care is unnecessary and therefore not call an arrogant or merely frustrated doctor? Is she truly morally responsible for the possible death of another person because the doctor was at her client and another doctor is not available in the system? Maybe that doctor too is just as exhausted and stressed by the whole system. But she does not know that, and as a human being she does only what any normal person would do. She demands help for the person entrusted to her. That is the correct decision. And perhaps that doctor also does not know she is alone on the whole ward: while she waits for RZP, in the meantime she must run to another client in dementia trying to leave the ward, while a bell rings from another room calling staff, and from yet another comes snoring that might be sleep or breathing distress. Perhaps caregivers and RZP staff should make time for themselves, stop shouting at one another, and say that both are trying as best they can and both suffer from the same systemic failure.
It is clearly evident they do not have time for themselves, so I am trying to say this for them. Or those who are competent should start addressing this and not wait until it collapses completely and, instead of patients, doctors from RZP begin rescuing caregivers during calls. Not that it has not already happened...
Honorable Minister, honorable deputies, or today's social government, or “experts,” consultants, researchers, and various working groups and discussion circles: you should know that, on average, social care facilities are missing almost 25% of staff. And let me remind you that social care workers also deserve certainty because they are often the only certainty clients have. Take, for example, nurses. We have facilities where not a single nurse works because the director cannot recruit one at the offered pay and working conditions. And in some facilities from which they previously worked, nearby hospitals have pulled them away. That means in such facilities no medication should be administered. Nothing less, because this would endanger clients’ health and even lives. There must be someone professionally or at least politically responsible that caregivers as well as management are pushed into a critical dilemma—should I break the law by administering medication even when I have no nurse, or should I break another law and endanger my clients' lives and health by not giving medication? The shortened version of the question is: “Should I break the law by obeying it?” Taken to the absurd, the same caregiver can give medication in home care, while the same caregiver cannot do so in a facility. What changes in her education, skills, and overall competence when moving from home care into institutional care? It is deeply depressing that this dilemma exists. I cannot imagine what morbid reality prevents the ministries of labor and health from solving this long ago for the benefit of this country's citizens and not for the benefit of some “experts” and interest groups summarized under the concept of “political will.”
Thanks to God we still have the “old” nurses, and we truly could kiss their hands and feet for working here for 25 to 29 years. More than criticism that they are stiff and burned out and do not know much about modern care processes, they would deserve support. Of course they are burned out and do not know much about modern concepts anymore. They do have a “craft” skill, and their intervention at a client’s bedside can be relied on completely, even without a title. These interventions are often at odds with existing laws, but in line with common sense, duty, and above all humanity. But in two or three years, these nurses will leave, and we will suddenly be caught off guard by the question of who will replace them and who will have daily bedside access with the required nursing craft skill and corresponding authority at the same time. For new healthcare assistants, the nursing competency exception will no longer apply. Who will then actually perform nursing procedures? The hospital will simply send a senior to us, often in worse condition than they were when admitted. They arrive with pressure sores, with diapers, and immobile. Cases arise where this is not even in the medical record, and then it appears to the family member as if the bedsore developed in the social care facility in an “accelerated process” after returning from hospital—that is, care was grossly neglected there. The fault is neither the hospital nor the doctor, because that is authority. The fault is the caregiver, who has no way to defend herself.
What services are offered in these facilities? Quality? Safe? Neither. At survival level. At this moment, it is proposed: let's conduct an inspection—that will be the PROTOCOL! We will issue fines, sanction staff, “fire” the director, be strict as iron, because this is about helpless citizens of this state and public funds thrown at a “bad” service—for which the management of that facility can be charged—then we will hold a press conference about how we solved it, mainly by reducing the already meager care contribution or suspending it completely. As if no other tool existed for solving anything than bending a broken reed and smothering a smoldering flame. But the future is coming when we will be short of every straw, every little spark willing to work in social services.
Yes, this is all very bleak, but fortunately there are exceptions. I note, however, that those exceptions are truly exceptions, because they are not built on systemic social policy steps and concepts for social services that are promoted or set up here, but are resolved individually through private or other resources (for example, shroud-type funds, sponsorships) or the extreme commitment of a handful of employees. They need support; they need more.
Do you not want the Minister to comment on this? We invite you and your staff not for inspection, but for experiential practice. We have facilities prepared for you. Not for ministerial prestige, but as citizens.
Someone here should wake up, open their eyes, have proper analyses done, and above all re-evaluate the concepts built on false or misleading ideologies and insufficient statistics, including the ideological concept of deinstitutionalization, according to which paradise on earth is only the client's home, while institutions are slowly becoming their grave.
This new deliberate stigmatization of institutions and their managers only multiplies uncertainty and chaos in the minds of professional staff in these institutions, turning them into villains without relevant evidence.
I know that today all of Slovakia is speaking out about the tragic situation of the murdered young couple. In Slovakia, this is how it is. The wind of discussion with questions rises only when a real tragedy happens. It was the same when six caregivers died. What changed after that tragedy? What did competent people prepare, besides the official receptions of members of the newly formed civil association, and did they propose night supplements? Who seriously thinks that in this working environment full of insecurity and aggressively behaving controls, thousands of caregivers from Austria, Germany, or Switzerland will return for a basic wage? Are we going to recruit from Romania or Ukraine? Come on, let's strip them of staff the way Austria, Germany, and England stripped us. Let's push the solution across borders further. Maybe then workers will come from Africa or Mongolia to patch the gap, and there aliens will cover it. And we will live happily until we die and save a thousand, even if it costs us a million.
In conclusion, read the text that came to me by email today.
“Good morning, Ms. Kovaľová. After finishing the trainings, we immediately started writing the quality service forms, but since we have client mobility very often, and sometimes every day it is completely crazy and they really don't have time for everything else, and for one person that is like running with a horse. Last Friday I already went home exhausted and crying ::( :( :( This is burnout syndrome, when one has to do their work honestly and caregivers already have enough to do on the unit with clients, and I still help them. We have short-term stays, sometimes only 3 days or a week, and there is a lot of paperwork to write. It would be good to seriously consider, and perhaps come to see how the operation works as it works here, so that someone from government can understand that this is not about paperwork, but about the recipient of social service and their thorough care around them by the caregiver and a dignified life expectancy, since we already have states where health is already what it is. This is my statement. I have worked here for 24 years and everything always functioned at 100%, and above all PSS and their relatives were always satisfied and we had no complaints, only praise. P.S.: I am looking forward to early retirement in 2019. :):):):):):) if I live that long. I have always done my work conscientiously and thoroughly over the years. With greetings, your caregiver; wishing you a wonderful day and no flu. No one is doing things for me now; 3 caregivers have flu. I would be very grateful if you asked the minister how one person should manage what the law requires from us. The law is the law, but where are the people? They too will age, and we just need someone to care for them. We need to address essential and serious matters of life, so all of us can live with dignity here, not under pressure and disgust. With best wishes for a nice day and warm greetings”
So, dear citizens, how do you answer the question: Did the Ministry of Labour forget social services, or has it prepared something extra modern and magical? For example, omnipotent, all-healing, and omnipresent deinstitutionalization?
I sincerely thank the caregivers, nurses, cooks, directors, and head directors, and other people who not only do their jobs despite daily uncertainties and many misfortunes, but also serve with a big and good heart. May the Lord God help them.
Author: PhDr. Mária Kovaľová, PhD. MHA
The author is a theologian with a focus on diaconal social work and a master of public health with a focus on managed documentation and risk management. Since 1991, she has been engaged in caregiving with a focus on seniors. She is a consultant and quality auditor in social services. Since 2014, she has been the president of the Association of Professional Workers in Social Services and co-founder of NGO Planéta malého prínca. www.aopss.sk