It Ain’t Necessarily So – 10: Uses and abuses of routines
Caring Times, November 2013
– with JOHN BURTON
I’m particularly aware of my morning routine because I’ve just been through it, and I’m sitting at my desk writing at 7.30am. I’ll spare you the details but it undoubtedly helps me to live my life in the way I wish to because it reduces the number of decisions I have to make. It’s my routine and I can – and do – change it when I want.
If someone else was imposing this routine on me, I wouldn’t be happy and I’d probably rebel. However, I do recognise that my routine isn’t entirely my choice because I don’t live on a desert island, and I have to consider other people.
So if I was living in a care home I would need my routines to be respected; I wouldn’t want routines to be imposed on me (and I’d be angry and upset if they were), and I hope I’d be willing to respect other people’s routines. If I had lost the capacity to think things through in this way, I would depend on the home to have done the thinking, but I guess that the uses and abuses of routines would matter to me even more than they do now.
If we think about routines as ways to reduce unnecessary decision making, we get to the nub of the question. The care team needs a routine in the morning – turn up on time; handover meeting; who does what and when – and their routine must be geared to each of the residents’ individual routines. Some people are already up and about, and they will be looking forward to seeing the early staff come in, and there will be all sorts of little ritual (routine) exchanges that are comforting and reassuring. Those still in bed who need help to get up, will have very special and individual routines.
Some doors you knock on, and some you don’t. (That’s right, it ain’t necessarily so! Some residents don’t want you to knock on their door but just to come in. Heresy!) Some people like the curtains drawn back and some don’t. Some like a cup of tea and some don’t . . . and so on. Most people do not want to be confronted with a series of choices as soon as they wake up. Smooth the path to the new day. What to wear today may be the point at which a transition from routine to decision making occurs, and it rather depends what you are doing today, doesn’t it? This means that whoever’s helping you to get up, needs to know what you’ve got planned or what the home has planned.
Routines become pernicious when they are imposed. We must keep a constant watch on them. Because of their comforting nature, people cling to even the most absurd and oppressive routines.
Take the routines around incontinence. It’s no earthly good having a two-hour “toileting” routine for everyone who is incontinent if they remain incontinent. Nor is it right to have a twice-weekly bathing/showering routine with staff allocated to work their way through half a dozen residents in an afternoon.
As soon as you find staff being rostered for certain routine duties for all residents – for example toileting, bathing, bed-making – you need to question such routines because they are regimenting the activities and support that should be individual and personal.
There is a deep-seated reason why such intimate and sensitive care is readily turned into a routine (or an institutional defence) that is then clung onto by staff and even by some residents. It is because, when integrated into individual, caring relationships rather than detached as humdrum and impersonal routines, they are the most important and emotionally challenging parts of the work.
We found a different way: Caring Times readers tell their stories
DL – manager, South London: It was the first day for a new resident in our care home. As part of the care plan I asked her what time she would like to go to bed. She said “It depends what I’m doing in the evening.” I asked what time she would like to get up in the morning and her response was “I get up when my eyes are open.”
She also said that the purpose of coming to the care home was to regain her confidence following recent losses and illnesses: “I want to maintain my independence and live life to the full.”
This resident doesn’t want a routine. She wants to do what she wants on the day and at the time she chooses. So our routine has to be asking her every day what she wants to do.
And we do that by making sure at the morning handover that whoever is allocated to support her always asks and her care is adjusted to fit the choices she makes.
Grace – home manager, Lancashire: At our home we work with routines a lot. They are good for staff and good for residents, and most of our residents have dementia of some kind. People like to know what to expect.
Staff like to get into a routine – a pattern of work. Our residents like meals to be on time and most like to get up and go to bed at the same times. People are calmer and they eat and sleep better.
OK, there are abuses of routines. I don’t like things to be regimented and I want staff to be flexible but not “anything goes”. We have some real characters among our residents, and they keep us on our toes. If someone wants to get up at 5am and have an early breakfast they can. That may well have been their old routine and they can’t let it go, so we have to alter our routine to suit theirs. That’s what we’re here for.