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Feeling Fearful…Feeling Safe

“In the list that follows, compare how a person whom you serve struggles with fear and is distanced from a feeling of being safe. Reflect on the subtle interactions that the person expresses that show “I am safe with you” but always remember that we are not blaming ourselves. Yet, we need to gain insight into the fear that envelops those we serve. Look at each factor in the list and check those that apply. If fearful outweighs safe, then we know how important it is to teach the person a feeling of, “With us, you are safe!” Decide what major areas indicate fear. But, beware! We are not interested in focusing on behavior. They are only signs of a deeper anguish that is driven by deep fear and meaninglessness. Our full focus will be on dealing with fear. For now, get a sense of the fear that pervades the people we serve.

Feels fearful . . .

• Runs away
• Cries a lot
• Expressionless
• Sad appearance
• Slovenly
• Hits self
• Hits others
• Sleeps poorly
• Complains
• Refuses to participate
• Eats poorly
• Self-stimulates
• Curses
• Hordes
• Flinches

Feels safe . . .

Stays with others
• Expresses joy
• Relaxed
• Contented appearance
• Well-cared for
• Respects body
• Respects others
• Sleeps well
• Expresses love
• Enjoys participating
• Eats well
• Enjoys hobbies
• Uplifts others
• Shares
• Appears content

This initial analysis is a critical step for us since we often think that we do nothing to produce fear. We feel that the person is really “pretty happy.” Indeed, this may generally be the case. Yet, we have to look more closely. We might think that we do not do anything directly to cause fear. We might see the person as simply manipulative or seeking attention. We have to probe more deeply.

Our purpose is different. We choose not to control people. We choose to help them liberate themselves from fear and meaninglessness. We are not satisfied with, “Leave well enough alone!” We have to concern ourselves with the community of people whom we serve and teach all to live together. At school, home, work, or play, our task is to teach marginalized children and adults to feel safe with us and loved by us.”

John McGee
“Mending Broken Hearts: Companionship and Community”

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Empowering a Spirit of Gentleness

A Spirit of Gentleness is About…

Our nonviolence
• Our sense of social justice
• Our expression of unconditional love
• Our warmth toward those who are cold
• Our teaching others to feel safe, loved, loving, and engaged
• Our teaching a feeling of companionship with the most marginalized
• Our forming community
• Our sense of human interdependence and solidarity
• Our option to be side by side with the most devalued

A spirit of gentleness might seem easy; but, always remember, we do things that many can interpret as cold and controlling, often without even realizing it. The cold space that exists between us and the vulnerable person deepens and broadens without us even realizing it when we focus on control with a “Do this or else!” mentality or when we wallow in hopelessness with an attitude of “Well, that is just the way she is.”

Without even realizing it, our tone of voice, our posture, the way we look at someone, and the way we talk can tell the vulnerable person strong messages that say, “You are no good! Do what I tell you to do or else!” We do not do this intentionally. Yet, if we do not understand human vulnerability and fragility, our simplest actions can take on a horrendous meaning. Our priorities are often messed up if we focus on behaviors instead of feelings or independence instead of interdependence. We need to worry about helping each person begin to feel more safe and loved instead of getting rid of behaviors.

John McGee
“Mending Broken Hearts: Companionship and Companionship”

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Our hope is…

“As care givers, we need to be well grounded. Our hope is not in independence, but interdependence. Our primary task is not to control others or force others to be what we want them to be or do what we want them to do. It is to bring a deep unconditional love to those whom we serve. Our central purpose is not self-determination or self-reliance; it is a feeling of connectedness between those whom we serve and ourselves. Our central role is to express a profound sense of companionship and community. What we often think are our primary tasks will come in due course if those whom we serve feel safe, loved, loving and engaged.

We are community makers. Community is a gathering of gifts. Our gift in the act of care giving is the creation of companionship and the formation of community. Those whom we serve bring their mind-body-spirit, their dreams denied, and their hunger for love. They bring their troubles and sorrows, their life story, and their broken hearts. We are to bring a spirit of gentleness to mend their hearts.”

John McGee
‘Mending Broken Hearts: Companionship and Community’

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Why a Culture of Gentleness Makes Good Business Sense

The following article addresses the culture found in residential settings where the quality of life is shaped by the multiple relationships between residents and direct care support staff. I was struck by the correlation between the elements of a culture of gentleness and what LaLoux has described in “Reinventing Organizations” as new level of organization emerging that holds great promise. (see “Book Corner”) The organizing principle in this new tier is the constellation of the deep values individuals are liberated to express in their work. – Clint Galloway, Editor

Those of us in the business of providing care for others often find ourselves trying to balance sound financial decisions with decisions that directly impact the quality of care provided. Tipping the balance negatively on the economic side (we can refer to them as “scale tippers”) include staff turnover, worker’s compensation claims, unemployment claims and the cost of training new staff, all of which can lead to increased anxiety for those we support, lower staff morale, reduced quality of care and increased expenses. If we can agree that the scale tippers attribute to a majority of the increased costs then we can agree that by reducing the incidents of scale tipping we will be making decisions that can lead to expansion, fewer vacancies and other business opportunities. Fortunately, we are learning that the same things attributed to reducing expenses are also attributed to increasing the quality of care for the individuals we support.

The ever changing landscape of our system of care pales in comparison to the changes experienced by those receiving care due to staff turnover. I recently went to my dentist and was informed that I would have a different dental hygienist. “What…no Dena?” I thought, “she’s been my hygienist for many years and suddenly they expect me to have my teeth cleaned by someone else?” (Maybe if I’d flossed regularly I’d be less concerned). The care that the new hygienist provided for me and my teeth was more aggressive than I’m used to, leaving me wanting Dena back. After my initial disappointment, I’m okay now with the notion of waiting six months to find out who will do my cleaning next. But I would be much less settled if I was to experience this uncertainty with every shift change, 547 times over the next six months. This uncertainty about whom we will be interacting with in a face-to-face relationship makes us feel less safe and precipitates negative feelings and actions. It invades the entire culture of care. It is an expensive drain on our resources as well as the peace of mind of those that we support.

Providers report an average turnover rate of 49% among frontline direct caregivers. For agencies that experience high annual turnover rates (hopefully you’ve calculated your annual rate, if not this would be a good first step to take), it is likely staff will leave within the first six months of employment. This is the period in which the initial, comprehensive training will occur for new staff. At an average replacement cost of approximately $3,500 per employee, these costs weigh heavily on the economic scale.

Other scale tippers that often appear in a workplace with excessive rates of turnover include worker’s compensation, health insurance premiums and unemployment claims. Worker’s compensation claims tend to increase when the people in our care feel unsafe and are more likely to be aggressive towards staff, resulting in injury. Insurance rates increase when claims expense increases, and conversely, rates remain more stable when claims expense decrease; in some cases refund checks are cut to providers when there is a well-established “culture of gentleness.” When excessive scale tipping is present we are more likely to find frivolous worker’s compensation claims. This can reduce morale, as well as your bottom line, due to time spent resolving the issues. Another hidden cost of high turnover is health insurance premiums. Decreased turnover means that a large health insurance claim can be absorbed over time if staff continues to be employed after the claim has been paid. Unemployment claims, whether you are reimbursing or a contributing provider can be incredibly time consuming and expensive, costing up to $10,000 a claim in some cases.

Not to be forgotten in the discussion are wages and benefits. These are significant factors in finding and retaining qualified staff. According to the Michigan Assisted Living Association’s (MALA) 2009 Strategies for Improving Wages, Benefits, and Training to Staff Providing Community Mental Health Funded Residential Services, “Wages for direct care workers among the providers responding to this survey are as much as $3.25 per hour less than wages in other similar sectors of long-term care.” Although it will not bring parity to our Medicaid reimbursement rates, an established culture of gentleness will increase our ability to offer more attractive incentives for our employees.

Now that we’ve identified the scale tippers, how do we begin to tip them in more favorable directions? We cannot support the people we support without feeling supported by the people who support us.

That sentence will gain few points from English teachers, but it does offer insight into what our focus must be if we want to create a culture that is conducive for healthy bottom lines and healthy hearts alike.

Have you ever heard of “seagull management?” This philosophy is indicative of a culture that offers little or no proactive support, and when things are not going well—for example, if a group home is in chronic upheaval—management (the seagulls) intervenes by providing plenty of white droppings to go around. The flock then flies off, leaving those covered in white droppings to rectify the scale tippers. So where do we need to focus if we want to prevent the seagulls from disrupting our day at the beach?

Creating a culture of gentleness starts with the leaders of organizations recognizing that the way we train, support, and maintain our employees ultimately has a direct effect on both the quality of care provided and staff retention. Just as those we support in our system of care strive for unconditional valuing, uplifting interactions, and encouragement so do our employees. We all do. It is imperative that all levels of management have an understanding of the six elements (safe, valued, praise, demand, structure, and transitions) that lead to a culture of gentleness. The key to higher quality training includes finding quality trainers and materials. The Center for Positive Living Supports (the Center) has been involved with supporting staff in numerous Mobile Response Training Unit deployments. Overall, we find that without understanding, commitment, and congruent behavior from the host provider and CMH staff, we often find an increased amount of scale tipping.

For example, our home managers play a vital role. Staff often quit a direct care position, not because of the people they support in the home, but rather the way they feel devalued by management. Many home managers also feel devalued from lack of support from above. One way in which we demonstrate our appreciation of the value of employees is by providing tools that give them the confidence to help create a supportive culture under complex circumstances. These tools come in the form of training and gaining a basic understanding of what we can do. In a best case scenario, it is estimated that 2% of annual budgets are earmarked for training. To use this effectively we need to incorporate ongoing support within the day-to-day culture and focus less on the external classroom. This requires developing trainers and recognizing that mentors play a vital role in creating and sustaining a culture of gentleness.

When the going gets tough, the mentors get going. Not exactly the adage with which we are all familiar, but a culture of gentleness requires us to invest in some of the more skilled staff, enabling them to become mentors. They are able to assist in some of our more difficult situations that traditionally may have escalated into scale tipping events. If you can build a capacity of at least one mentor for every 50 staff you will be investing in someone who has the skill set to assist in our most complex situations. The goal of mentoring is to create a sustained environment that will begin to make everyone that lives and works in the setting feel safer, more valued and less volatile. MALA’s findings, from their aforementioned 2009 study, concluded, “Education related to this culture of “gentleness” should be broadened throughout the state.”

According to projections from Michigan’s Department of Labor and Economic Growth (DLEG), employment in the state’s long term care industry is projected to grow by 20 % over the decade from 2006-2016, adding nearly 25,000 new positions. May I take you back to the dentist chair experience for a moment? When it’s time to see your dental hygienist wouldn’t you rather have Dena, whom you have grown to trust and respect? Me too, and for the same reasons the people receiving our care and those we employ will look to you, and want to stay with you. We need entire organizations that embody the elements that constitute a culture of gentleness. Working within an organization built on trust, mutual respect and valuing, dedicated to quality service, is like a sunny day at the beach engaging in experiences that can be meaningful and fun without worrying about Seagulls hovering overhead. They have also learned the prerequisites for landing and being warmly welcomed on the beach.

Example: Ayanna is extremely bright, has a wonderful sense of humour, likes to shop, and cares deeply about her family. She has had over 15 different placements over the past several years and more recently spent two-thirds of a year in psychiatric hospitals. Ayanna spent 45 days at the Transition Home and her future caregivers attended the preliminary training offered by The Center. When Ayanna moved to her new home, our staff worked for approximately three weeks with her caregivers during which time the six elements were demonstrated, coached, and observed by the Mobile Response Team Mentor. Her current provider remains committed to supporting her in her home and for the past year she has lived successfully in her home having only been hospitalized for a week.

Ed Kiefer, B.S., L.B.S.W
The Center for Positive Living Supports, an affiliate of Macomb-Oakland Regional Center.

 

Download the PDF version of the article here: Why a Culture of Gentleness Makes Good Business Sense