“My passion for working with people with dementia, for making life better for them, has been my major motivating factor. But over time, I keep saying to myself: ‘It’s the direct-care worker, stupid,’” says Joanne Rader. “The only way to make the lives of people with dementia better is to improve the working lives of the direct-care workers. We need to put the things in place that let them provide relationship-based care.”

Now a consultant, Rader has helped pioneer key advances in reducing the use of restraints and finding conflict-free ways of bathing in long-term care. The co-author of Individualized Dementia Care: Creative, Compassionate Approaches and Bathing Without a Battle, which won Book of the Year awards from the American Journal of Nursing in 1996 and 2002, she is one of the founders of the Pioneer Network.

She learned to appreciate the contributions made by direct-care workers early in her career. “I’ve always had a tremendous amount of respect for the work they do, and also for the informal power they have. I might have had the best solution in the world, but if I didn’t have their buy-in, it wasn’t going to get anywhere.”

“I had some ideas, but the bulk of them came from the direct-care workers”
Rader spent about 27 of her 35 years in long-term care as a mental health nurse specialist in Providence Benedictine Nursing Center in Mount Angel, Oregon. “I’m a pretty hands-on person - I like to get in right at the care level,” says Rader. “But I’ve had to pull back and look at systems, because you can’t get the good stuff into practice unless the system supports it.” And most long-term care systems, she found, fail to tap the “absolutely essential information about the residents” that only direct-care workers hold.

In her work to improve care quality at Providence Benedictine, she says: “A lot of the ideas came from the direct-care workers. I learned that the way to succeed in problem solving was by tapping their expertise.”

Take Bathing Without a Battle, a popular video and curriculum co-authored by Rader that teaches caregivers how to transform the way people with dementia are bathed. “I’m just the messenger,” says Rader. “I had some ideas, but the bulk of them came from the direct-care workers.” CNA Cathy House, for instance, was “just a master at figuring out all the possible ways to get people clean.” And CNA Beth Parker not only contributed her own ideas but marshaled those of her coworkers, taking the initiative to teach what she had learned when helping Rader pilot the program to the other aides in her facility’s dementia care units. “Together, they revamped the bathing plans of all the other residents,” says Rader. “They were very creative about how to do it.”

Direct-care workers can be ”very powerful teachers”
Rader brought in CNAs as often as possible to help her teach the bathing curriculum. “I knew I was really doing culture change when I was at a conference and an aide I had worked with was presenting with me, and at the end, the questions were almost all directed at her. It was clear that she had answers I didn’t - she was the one doing it on a daily basis.”

She regrets not having tapped into that expertise earlier in her career, when she was teaching about restraint-free care. “By the time I did the bathing work, I had picked up the resentment direct-care workers had about people who come in to teach them about their work who don’t really understand their work,” she says. Besides, she says, their passion for providing good care and the stories they tell about things that happened on the job can make direct-care workers “very powerful teachers.”

“It’s not easy unless you have a facility that supports the workers”
Bathing Without a Battle is part of the Pioneer Network’s larger mission of making long-term care facilities true homes, replacing the top-down, hospital-style care delivery model with a “person-directed” method of responding to individual preferences and needs.

But person-directed care can only work, Rader says, if direct-care workers are empowered. Bathing Without a Battle is “not that expensive, and the skill base needed is pretty minimal. You can learn it in about a few hours. But it’s not easy to do unless you have a facility that has consistent assignment and that supports the workers to make decisions and act on what they know about the residents.

“If we’re going to provide person-directed care, we need to really listen to what people want; we can’t just impose things on them. For direct-care workers, that means the way that they relate to people is more important than getting certain tasks done at certain times. The workers know when it’s a good day to give someone a shower, or whether they need to try something different than a shower. So rather than make them spend time explaining themselves to the nurse, just let them go ahead and make the adaptation.

“I hear from aides who are criticized for talking ‘too much’ to residents,” she adds. “But if you ask almost anybody who works in long-term care why they do it, they’ll say it’s because of the relationships they have with the residents, the elders. That’s the hub that everything else comes from.”

Interview by Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org