Eldercare: Creating Compatabilities Part II
by Mary Ann Zettelmaier, MSN
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When we move outside the home to consider issues of safety for senior citizens, we’re getting into areas that are multiple, complex, and sometimes beyond control or simple fixes. And they frequently require more assistance than families and friends can provide. But family and friends (and sometimes neighbors) CAN at least do the detective work to identify risks.
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Given their constant exposure to the weather, porches and outside stairs can require more upkeep than a home’s interior spaces. Wood porches and stairs can rot and boards can loosen; nails can protrude. Concrete and/or brick exterior spaces are subject to the heave of the ground and can crack, loosen, and separate. All of this adds up to setups for falls and missteps, particularly if there are no handrails to compensate for diminished vision, compromised balance mechanisms, and stiff joints. Additionally, house foundations that are cracked or otherwise not intact can lead to basement leaks or the invasion of rodents.
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Likewise, yards can be hazardous when the ground is uneven or those lovely garden paths, complete with stepping stones, heave and loosen, becoming nice to look at but potentially disastrous to use. Ditto for the hoses that we tend to drape across the lawn when it’s time to turn on the sprinkler or the push lawn mower—motorized or not—that exceeds the strength of the elderly pusher. We’ll talk about riding lawn mowers and garden tractors later.
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Consider, too, the state of a home’s windows. The exterior frames that are subject to wood rot if/when the paint peels, double-hungs that no longer open and close easily (or sometimes too easily and uncontrollably), crank-outs that are beyond the strength of the elderly resident to open and close, and locking mechanisms that no longer work. And for sure, window washing, such a simple task in our prime, can be complicated by diminished strength and vision and the need to use a ladder. The potential disasters are all too easy to imagine.
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Next stop on the trail of assessment is exterior lighting. While many seniors spontaneously decrease nighttime activities, sheer safety from unwelcome/uninvited visitors drives the need for working porch lights, garage lights, and sometimes, yard lights.
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And then there’s the operation of motorized vehicles. It’s no secret that a senior’s reaction time is slowed and that diminished vision can lead to misjudgment of distances, misreading (or no reading) of stop signs and traffic lights, and problems with seeing what, or who, is on the periphery of vision. Add to this the potential confusion of accelerator and brake pedals and the uncertainty about forward and reverse gears. And then there are additional problems related to diminished ability to hear horns, sirens, or even human voices.
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I’m not talking only about automobiles, although all of the above scenarios tend to be bigger problems on the road. ANY motorized vehicles, including riding lawn mowers and garden tractors, can be hazardous. An additional hazard with the smaller vehicles is that they can tip over and/or lurch—not a good situation under any circumstances.
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If by now you’re wondering how life can possibly be safe, much less rich and rewarding in the twilight years, be assured that risks to safety can usually be addressed. I’m not talking about guarantees, but rather, some practical problem solving that can make a difference.
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If the repairs or adjustments necessary for environmental and personal safety are beyond what family members have the skill or financial resources to do, it’s worth exploring who can help. Many churches can provide assistance, through programs, volunteer services, or access to networks of care. Most towns, cities, and local communities have some kind of senior services that can help with anything from meals, day care resources, and transportation to volunteers willing to help with home repairs or personal assistance. If nothing else, state governments can provide information about senior services and can help with identifying what’s available locally. Surf the internet: government services are usually “.gov” and probably come under a heading about human services or something close to that. Private organizations that provide similar services are usually listed as “.org.” Do what you must to talk to a live person. If you want to contract for services such as repairs or personal assistance, check with the local Better Business Bureau or Chamber of Commerce, or state licensing bureaus, to determine what’s a legitimate business and what isn’t. That’s particularly important if you’re not in the same locality as your elderly relative.
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If you need to help a senior friend, neighbor, or relative assess her/his own physical abilities, a family physician can be an invaluable help. It’s usually worth it to get to know that person and either attend appointments with the senior or set up an arrangement for contact and communication. The latter may involve legal considerations related to patient privacy laws and medical power of attorney, which I’ll address in a future post. Additionally, there are some geriatric medical centers around the country, and if there’s one close to you, by all means use it. These are usually multidisciplinary services that include a range of services and caregivers whose special focus is the elderly. Some even include services for assessing driving skill; many auto insurers also offer the same service.
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Everything I’ve discussed so far is aimed at keeping seniors in their own homes as safe and independent as possible. But sometimes there’s a point at which home and safety are no longer compatible. In future entries, I’ll address some issues about alternatives to independent living and the legal and logistical resources that help seniors and their family members make the transition.
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You’ll notice that I’ve never suggested that any of this is easy.
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Read other posts in Mary Ann Zettelmaier’s Eldercare series here.
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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Eldercare: Creating Compatibilities
by Mary Ann Zettelmaier
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In the previous post I listed some of the most common risks to a safe living environment for the elderly among us. Now I’d like to suggest some modifications to a home that can make, or keep, it safe. The following isn’t an exhaustive list, but it may point you in the right direction for customizing a plan that meets your, or your elderly parent’s/neighbor’s/friend’s needs.
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THROW RUGS: Eliminate them wherever you can. If you still need them (e.g., on a bathroom floor that might otherwise be wet and slippery), you can do one of two things:
-Make sure they have a rubber backing (most bathroom products do), or
-Purchase some separate rubber backing, cut it to fit the rug, and put it under the rug.
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STAIRS: Again, decrease or eliminate their use. This may mean organizing activity to minimize their use, or, if possible, getting all the necessities for living (laundry facilities, bedroom, daytime living space) on one floor. If stairs continue to be necessary, make sure sturdy rails are in place, preferably on both sides, and consider doing something to highlight the edges of the stairs, e.g., painting the edges in a contrasting color. Night lights can also help, even if everything is on one floor.
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STOVES: This can be especially challenging, since cooking is such an integral part of life for so many of us. So what are the options, short of a brand new stove that may be too expensive? A reminder sign near the stove (STOVE OFF?) may help, as may a nightly routine that includes checking lights, open doors and windows and appliances that don’t have an automatic shutoff. Routines have their merits.
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Alternatively, if none of the above is workable, it may be time to consider some kind of food service, such as Meals on Wheels. Another alternative might be supplying meals from other sources. For years, prior to her moving to an assisted living facility, I made meals for my mother and froze them in single-serving sizes. Then all she had to do was remove them from her own freezer and microwave them. I simply made extra portions when I was cooking for my own family, so it was minimal extra work for me. Or, there’s always my husband’s solution: McDonald’s (help us!).
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CABINETS: This usually takes some help for an elderly homeowner, and if you’re the helper, do respect the fact that, for most women, a kitchen is her turf. Proceed with sensitivity. Basically, the important part is to get the necessities (everyday dishes, glassware, eating utensils and high-use cooking utensils) within reach without stretching or bending. The highest and lowest cabinets, shelves, and drawers need to become off limits for independent use, and that convenient little stepstool needs to disappear. It’s too much of a temptation.
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TUBS/SHOWERS/TOILETS: Thankfully, there are many aids that can keep a bathroom safe and usable. Consider an elevated toilet seat that fits over an existing toilet or a commode chair that works essentially the same way. Also, there are side rails available that attach to a toilet of standard height. The latter alternative is sometimes all that’s necessary. For tubs, there are tub transfer chairs, with seats on both the outside and inside of the tub. With a transfer chair, you can sit on the outside of the tub, get your legs over the edge, and then slide to the part of the chair on the inside of the tub. Some people have replaced a standard tub with a walk-in tub or shower. This may be a reasonable alternative for some, but there’s a price tag that may be beyond what a senior on a fixed income can afford. Additionally, some or all of the aids listed above may be covered by health insurance. As necessary, it’s worth a conversation with your physician.
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This gets us to the “I’ve lived here all my life/I don’t want to move” issue. Given this and the previous discussion, it may be necessary to initiate a conversation about alternative living arrangements. Basic safety issues can be a compelling argument, but it may also take discussions with other family members as well as with physicians and attorneys. I sympathize with anybody who has to engage in such a discussion: as necessary as it may be, it’s never easy.
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And under any circumstances, we’re left with those most basic of human needs: connection and communication. If you’re the senior citizen who has to modify or change your living arrangements, stay connected with your larger world. If you’re the friend or family member who assists an elderly person, keep in touch, and/or find somebody who’s nearby to do it for you and then communicate with you. All things being equal, isolation is probably the biggest risk for diminished quality of life in old age.
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Next time I’ll address some issues related to safety outside the home.
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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Eldercare: Safety First
by Mary Ann Zettelmaier, MSN
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At some point, it may be necessary to consider what constitutes a safe and manageable environment for your parents, elderly friends, or even yourself. This is when you begin to realize how easy it is to take for granted the little details that make the difference between safety and risk.
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I’ll focus here on typical in-home risks, realizing at the same time that external threats (e.g., safety of a neighborhood) also impact in major ways.
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So put on your “detail spectacles” and start looking: it’s frequently the simple stuff that can prove to be hazardous. For example:
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- Throw rugs: Consider that, by definition, aging means that you don’t lift your feet very much when you walk. The shuffle is not a dance in old age. So those cute little rugs—in the hallway, at the door, next to the bed, in the bathroom—are setups for tripping, especially if they’re not secured by rubber backing or some kind stabilizer under the mat. Additionally, they can slide and their edges curl, easily causing a loss of balance.
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- Stairs: They become problems primarily when they are necessary to get to parts of a home you need for daily living, such as second-floor bedrooms, basements with laundry facilities, entrances and egresses. And the problem gets compounded when there are no rails. So not only do we risk not lifting our feet enough to get up those stairs, but we gradually lose internal balance mechanisms that allow us to go down the stairs without pitching forward. Add to that hip and knee joints that stiffen or give way, bifocals that blur where the edges of the stairs are, and the frequency of needing to carry something on those up and down trips. Necessary stairs can be recipe for disaster.
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- Stoves: Most elderly people don’t have those fancy new stoves on which the surface doesn’t get hot. Gas or electric stoves are far more likely in the homes of the elderly, and each kind carries its own risks. If gas stoves are turned on but don’t ignite right away, gas escapes into the home. And it’s easier than you think to walk away from a gas burner that is open but not ignited without realizing it—until it’s too late. With an electric stove, it’s easy to forget that the burner is still on, and contact burns can be the result.
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- Cabinets: Most cabinets require reaching up or bending over, both of which can be a threat to an elderly person’s compromised internal balance mechanisms. Additionally, cabinets frequently store things that are heavy, and can push a senior citizen’s strength capacity beyond what’s safely manageable.
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- Tasks that require a ladder: Changing light bulbs in ceiling fixtures or getting that “necessary” celebratory platter out of an overhead cabinet or top shelf can be problematic. By now I think you can see that a task a younger person takes for granted can put an elderly person right over the edge (literally and figuratively).
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- Solo living: Here we go with all the risks previously considered being compounded, because there’s nobody else on site to help prevent problems before they happen or act quickly if they do occur.
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- Tubs, showers and toilets: You never realize how something as simple as the standard height of a tub can be a barrier to hygiene until the hips and knees of an elderly adult of average height can’t bend or lift enough to get over the edge. Likewise, both tubs and shower stalls frequently have slippery bottoms that can cause sliding and losing balance, resulting in fractures, drowning or burns. Additionally, it takes old age to realize that the standard height of toilets is only standard for the hale, hearty and young. It can be as much as a foot too low for the infirm and/or elderly, and even if you can sit down you can’t always get up. Enough said.
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And last but not least, “We’ve lived here all our lives and we want to die here.” This is the bottom line that frequently colors everything else. We can all understand what a sense of “home” means—security, familiarity, independence, competence, memory—so many things that are constant feedback about who we are and what our lives have been, and are, all about.
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So as we think about the best way to spend our latter years, or are children who are concerned about helping our aging parents maintain meaning and quality in their lives, safety becomes a primary concern. Next time, I’ll address some resources and strategies that can be helpful in either keeping home safe or, as necessary, broaching the subject of re-location.
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Read other posts in Mary Ann Zettelmaier’s Eldercare series here.
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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Eldercare: Trading Places
by Mary Ann Zettelmaier, MSN
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You’ve raised your children and are looking forward to grandchildren and retirement. Your nose-to-the-grindstone days are over and you can sit back, take a deep breath, and, finally, live life on your own terms.
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But not so fast. In these days of lengthening life spans, your parents are still alive and may or may not still be independent. Either way, it is or soon will be incumbent upon you to turn your attention to their needs. At some point, like it or not, these people who always seemed totally competent, in charge, and able to handle anything will experience some level of physical and/or mental decline and turning them out to the proverbial pasture is not an option you’d even consider.
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I write this as a daughter and daughter-in-law who has walked this path and as a septuagenarian whose own children will likely, at some point, have to walk a similar path. I would never profess to have all the answers—there are too many issues specific to individual people on both sides of the equation. Still I’ll try to address some issues, suggest some strategies I’ve employed or know about, and, short of biography, describe some lessons I’ve learned along the way.
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To my mind, the first challenge comes from the realization that your parents do not, in fact, have the same competencies you’ve always expected of them, nor are they in the same emotional/psychological space they used to be. So, short of the ties that bind under any circumstances, there’s a kind of reorientation you need to do to become an effective caregiver for your elderly parents. And you need to do this against the backdrop of a lifetime of experience and relationship, which may have ranged from primarily wonderful to largely problematic, and likely somewhere in between.
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I would be the last person in the world to suggest that such a personal reorientation is easy. More than anything else it’s an exercise in empathy. It may be necessary to put aside old expectations (and all that history) to respect your parent’s situation right now. Without reinforcing his/her own sense of declining competency—guaranteed they’ll have it, and it may not look pretty—it’s important to gently meet them wherever they are, be it providing for physical needs and safety, assisting with problem solving or life skills, working with declining memory, and perhaps even coming to terms with the fact that he or she doesn’t even know who you are any more.
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Concurrent with the personal/emotional reorientation you need to make, there are usually some hard-headed decisions involved, ones that need to be workable for both you and your parents, and sometimes also for your siblings, your own spouse and children, and extended family members.
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So fasten your seat belt, just in case the ride gets bumpy. In future posts I’ll address some typical legal, logistical, and health-care components of trading places. Stay tuned.
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Read other posts in Mary Ann Zettelmaier’s Eldercare series here.
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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Caring for the Family: Part III
by Mary Ann Zettelmaier, MSN
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Under any circumstances, the heart of family-centered care lies in caregivers’ commitment to providing it and families’ willingness to effectively communicate their needs. Still, there are institutional/service structures that facilitate and support family-centered care. In this last installment on the topic, I’ll describe a few.
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Maternal, newborn, and pediatric services that are structured for family-centered care have accommodations for parents, partners, and family members to stay with whoever is a patient … which also means that it’s up to the family to decide who needs to be close by.
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Many maternal and newborn services have rooms in which a mom can labor, deliver, and recover in the same space, and her baby can be cared for and stay with her as much as she wants. Additionally, there should be a bed for dad or other significant family member to stay with mom and infant. There is also now a trend to provide spaces for parents to stay with sick babies in newborn intensive care units (NICUs). For sure such places should provide at least a minimum of space for parents to be with their babies during flexible visiting hours. When babies can be at least touched, if not held, by parents, the benefits for the babies’ physical stabilization (temperature, heart rate, breathing function) have been well-documented. Certainly there are exceptions, at least for very small or micro-preemies, but even then parental contact is important. It’s amazing, for instance, how the sound of a parent’s voice can have a calming effect on the smallest of preemies.
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As for the presence of siblings with newborns (sick or well) or older sick children, my experience has been that it’s a matter of negotiation. As long as a sibling is free of infection, I think parents know their children best and are in the best position to determine the amount and quality of contact a child has with a hospitalized sibling. I’ve also discovered that most kids self-regulate: if the situation is more than a child can handle, they tend to want to remove themselves. Thus it’s important that an extra adult is available to the visiting child for supervision and safety, and that there are visitor areas to accommodate family members.
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Pediatric services can frequently provide space and furnishings for parents (or sometimes grandparents) to stay with sick children in their rooms. Many also provide close-by access to light snacks and beverages for visiting family members. Again, nearby visitor spaces, or the availability of places such as Ronald McDonald Houses, keep family members in touch with each other.
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Let’s move now to family-centered care of adults. More and more, hospitals are providing private rooms for their patients so that it’s possible to maintain family contact and cohesion at critical times. Additionally, flexible visiting hours and policies support variations in family schedules, and family-friendly waiting rooms (read comfortable and close by) make the waiting process more manageable.
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An aspect of family-centered care that’s easily overlooked is the availability of private consultation space. Sometimes it’s very hard for families to process complex and/or difficult information at the bedside of a loved one, and the more difficult the information, the more important it is to understand it. Sometimes, too, family members simply need time and space to debrief, decompress, or otherwise step back from critical or highly charged situations. Enter consultation rooms, and the caregivers and social workers who are willing to use them.
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In discussing processes and structures that support family-centered care, I would be remiss if I didn’t also reference home care and/or hospice care. In many ways this is the ultimate in family-centered care, since it can be provided in a setting patients and families usually consider most comfortable, safe, and secure. Many hospitals and healthcare systems now include such programs, which provide necessary equipment for care and include specially trained staff (nurses, physicians, therapists, pastors) who knows how to provide care on the family’s turf and in view of the impact of illness on an entire family. As hospitals move away from the provision of chronic or extended care, there is increasingly greater development of programs of home care.
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I’ve discussed family-centered care from the perspectives of concept, process, and structure and hope that I’ve communicated its dynamic and flexible character. Caregivers and care recipients are always partners, and the conversation between the two should never end.
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Read other articles by Mary Ann Zettelmaier
Caring for the Family: Part II
Caring for the Family: Part I
The First Hour after Birth
Asleep, Awake, and In-Between
Infant Temperament
Getting to Know You
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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Caring for Family: Part II
by Mary Ann Zettelmaier, MSN
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The core of family-centered care rests in communication and dialogue, which means that both caregivers and families are responsible for making it work. So where to start?
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I would suggest that step one involves some homework on the part of you and your family, and it’s called an Advance Directive. This is basically a written statement of the scope and limits of care that you want, as well as an identification of who can/will/should advocate for you if you are unable to speak for yourself. There are many formats that can be used. Some can be found online, some institutions can provide them, and attorneys can incorporate them in your will. Clearly, this involves some serious thought on your part as well as an equally serious conversation with your partner, your adult children, and whoever else you consider “family.” And it may well change depending on your age, your children’s ages, and/or your life circumstances.
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Once you’ve settled on an Advance Directive, the next question is “What do I do with it?” Make sure that your physician and your designated advocate both have copies of it. If you’re admitted to a hospital or other facility, make sure you provide a copy for your medical record. In these days of electronic medical records (EMRs) that are supposed to talk to each other, my experience has been “don’t count on it.” Carry a copy with you, or at least carry contact information for where to find it, especially if you’re traveling. Personally, I carry information about how to contact my patient advocate, as well as a small card in my wallet that says, “DO NOT RESUSCITATE.” (It’s OK … I’m old.)
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Having done your homework, you’re now ready to engage in a conversation with caregivers at the actual time of care. In my experience as a caregiver, I’ve found that if patients and families have thought about, and can answer, two questions, they’re a long way down the road of getting the care they want and need. These are:
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1. What is important to you (during your hospital stay, when your baby is born, for your hospice care, etc.)?
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2. How can I/we/caregivers help you?
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That may not sound complex or sophisticated, but a caregiver who is really invested in family-centered care can take your answers to those two questions and build a plan of care that addresses your needs and concerns. Sometimes it’s necessary to negotiate and clarify what’s doable, what’s realistic, and what your deeper concerns are. For example, and specific to maternal and newborn care, parents frequently indicate that it’s important that their baby stay with them, or that they want to learn baby care, that a mom wants help with breastfeeding, that they want to know about progress in labor, that they do or don’t want medication for discomforts in labor. Sometimes they want significant family member(s) to stay with them. Sometimes it’s really important that they know right away how their baby is doing. The latter is especially important if there are anticipated problems with the baby’s health.
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I could probably write a whole book of responses to the two core questions that I’ve received over the years. Overwhelmingly parents’ and families’ requests are reasonable and doable, or at least amenable to negotiation to achieve concrete results.
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So, you may have caregivers who initiate a conversation about care, or you may not. Under any circumstances ask YOURSELF those questions, preferably ahead of time, and be prepared to state your case in a way that will encourage people to help you. Saying, “This is what’s important to me …” is usually a good start. Sometimes you need to identify which person will most likely help you get the results you need. It may be a physician, a direct caregiver, a nurse-manager, a charge nurse or care coordinator, or a nurse-midwife/practitioner/clinical specialist. Those are the typical titles of people to ask for if you need help. Some institutions even have people who are designated as patient/family representatives or advocates. Again, it’s helpful if you have a copy of an Advance Directive and/or have written down what’s important to you. Remember, too, that care can be an ongoing negotiation, especially if circumstances change. So keep talking.
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Next time, I’ll discuss physical structures and caregiver standards that support family-centered care. Stay tuned.
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Read other articles in Mary Ann Zettelmaier’s Caring for the Family series.
Caring for the Family: Part I
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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Caring for the Family: Part 1
by Mary Ann Zettelmaier, MSN
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In the next three posts, I’ll be addressing issues related to family-centered care—what it is, how to get it, and what it looks like (in settings that are physically and administratively structured to provide it). My own orientation is to maternal and newborn care, and most of my examples will come from that setting. In addition, I’ll also include examples from other settings, based primarily on my own (and others’) experiences as either patient or family member. I’d like to consider what I write not as prescription or dictum but rather as a starting point for discussion and dialogue, so don’t hesitate to weigh in!
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Long ago and far away, in a galaxy all too familiar to those of us of retirement age and beyond, “patient care” meant that individual recipients of care were isolated from their families and subjected to the routines and rules of caregivers … no questions permitted/no explanations given. Even visiting hours were restricted to a few hours a day, and who could visit was usually limited to one person. Visiting hours were also determined by the convenience of the caregivers. As an example, I’ve been told a story about my grandfather’s attempt to visit my mother and my newborn sister in 1943. As an Italian immigrant, American rules and regulations were, at best, peripheral to his life and frequently incomprehensible. So he got all dressed up (a rare happening for him), likely traveled by bus or streetcar, and went to the hospital to visit. He was summarily turned away at the door … he was not the patient’s husband, and the possibility of seeing the baby was even more remote (even the mother barely saw the baby). Confused and humiliated, he left. He was, as it turned out, close to his last illness and died less than a month later, having never seen his granddaughter. What’s interesting is that I heard this story for the first time from my mother some fifty years later, so you know the impact it made.
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Fast-forwarding to the present, what, then, is family-centered care? At its core, it is care that proceeds from recognition that human beings are connected to one another in groups we call families, and that the health or illness of one can’t be separated from the context of the individual’s family. Quite literally, families make a difference in health maintenance, in healing and/or in the quality of dying, and one sick member means everyone is affected. It’s care that respects multiple types of family configurations and recognizes whatever a person says constitutes his/her family. It’s care that recognizes the rights of families to both information and accommodation and that provides mechanisms for communication between and among caregivers, patients, and families. How this care is actually structured may well vary, but no structure or process can exist without that core.
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Here are a few clues to how you can determine if an institution or health system is committed to family-centered care:
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1. Is a copy of a Patient’s Bill of Rights posted in one or more prominent place(s)? This could be the basic statement from the American Hospital Association or something more specific to the institution or service. In either case, look for statements about incorporation of families into care.
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2. Is a copy of the above available to both patient and family, especially at the time of admission?
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3. Does the mission statement reflect commitment to family-centered care? As an example, the University of Michigan Medical Center’s mission statement includes, “Patients and Families First.” That doesn’t mean that the long-standing mission to research, education, and care has changed, but how that mission is configured has shifted.
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4. Is there a patient/family advocate or representative available?
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5. Does the institution have patient/family/parent advisory groups?
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6. If the institution says it provides family-centered care, can it tell you what that looks like?
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7. Does the institution provide a decision-making process that incorporates families?
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To determine those elements (and possibly more) of family-centered care, look for web sites or phone numbers that can give you the answers. Short of common courtesy, don’t worry about how you ask your questions; just keep asking until you get the answers you need.
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All of this means that, besides rights, families also have responsibilities in getting the care they need and want. These responsibilities lead to my next entry about processes to achieve family-centered care. Stay tuned.
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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A Mother’s Journey: Ghosts in the Nursery
by Mary Ann Zettelmaier, MSN
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In the previous discussion, I described elements of effective parenting and suggested that those elements play out across a broad range of parental personality and infant temperament. In other words, parenting is a learned process, marked by some level of trial, error, and readjustment around a core of relationship and emotional and physical ties. It’s that “tolerance for mistakes” thing.
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I also suggested that there are times and circumstances in which, despite our best intentions, learning to be a particular parent to a particular child presents challenges that can’t be ignored or avoided.
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Enter “ghosts in the nursery.” This isn’t my phrase; it belongs to the late Selma Fraiberg, who was instrumental in developing the field of infant mental health. Basically, what she said was this:
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1. All parents experience “ghosts in the nursery,” or some memories of their own experiences of being parented that were painful or confusing, and so challenge their sense of competence as parents. Since no parent is perfect, we all have them. These memories are elicited when we parent our own children.
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2. Under most circumstances, the ghosts are only minor discomforts that parents can recognize for what they are—only ghosts—and set them aside so that they don’t adversely affect their own journey into and through parenting.
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3. But under some circumstances, the ghosts become so overwhelming and so painful that they dominate the nursery and create barriers to effective parenting. Try as we might, we can’t get them out of the way, at least not by ourselves.
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There seem to be some circumstances that make it easier, or more likely, for the ghosts to dominate the nursery. Clearly, a parent’s own experience of abuse, neglect, or problematic attachment makes it likely that, without help, s/he is likely to replicate that experience with her/his children. A new parent whose own parent was depressed or mentally ill easily fears that the same thing will happen to them.
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But other experiences can also challenge a parent’s sense of competence and effectiveness, such that even small ghosts take on big proportions and turn a normal sense of initial vulnerability and uncertainty into what feels like an insurmountable barrier.
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Typical small-ghosts-that-grow include having a sick, atypical, and/or pre-term baby, one who requires more than baseline parenting and/or stands in the way of self-regulating parent and infant contact. The parent who was ready for all the challenges of parenting a typical baby questions their competence at a very basic level and may even have trouble accepting help, perceiving that to be only a reinforcement of a sense of inadequacy. Another potential ghost rears its head when there is a bigger-than-anticipated gap between the idealized baby and the real baby. A quiet, undemanding parent who wants a quiet, undemanding baby and instead gets a high-reactivity, active baby who isn’t easily satisfied or consoled might have trouble finding a level of interaction that is satisfying to both parent and child. Conversely, an active parent who has a quiet child, who doesn’t provide a lot of feedback, may be confused and discouraged in their efforts at parenting. Sometimes an adoptive parent, despite their basic competence as an adult and potential competence as a parent, initially experiences the actual baby as final and permanent evidence of inability to create a biological child. And these are but a few examples. Basically anything that stands as a barrier to a parent’s sense of, or actual, effectiveness is a ghost that won’t leave the nursery, at least not without help.
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In an earlier post, I talked about some basic strategies that every parent benefits from employing in the early days and weeks after childbirth. These are types of help that any new parent needs, actually deserves, as they embark on the most significant journey of their life. Not only are there ways to get healthy parenting off to a good start, but there are also ways to make the ghosts in the nursery manageable, when and if they appear. The goal is not for us to be perfect parents but rather to be real, genuine, good enough parents, ones who give our children their elemental experience in being good enough, genuine human beings themselves, capable of healthy relationships in their own lifetimes. Dr. Fraiberg suggested that the infant’s biggest need in the first year of life is to learn to “Love love,” which is only learned, actually concretely experienced, in relationship with a loving, attentive parent.
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The bigger the challenges that parents perceive and experience, the bigger the need for lots of support, not only from others in the parents’ social network but also from professional caregivers. The next few articles will be devoted to discussions about family-centered care, what parents need, and how to get it.
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Read other articles in Mary Ann Zettelmaier’s A Mother’s Journey series.
The First Hour after Birth
Adjustment Strategies
How Babies Sleep
Asleep, Awake, and In-Between
Infant Temperament
Getting to Know You
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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A Mother’s Journey: Getting to Know You
by Mary Ann Zettelmaier, MSN
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In the previous entry, I described variations in infant temperament and what those variations tell us about how individual babies express their needs. But no baby can live in isolation, and the primary persons with whom babies interact and depend on are their parents. It is not an exaggeration to say that the quality of parent-infant relationship is the first and most influential experience that an infant has with the world, and it will shape future interactions in her/his life. What makes this relationship unique is that both infant and parent come to it with different capacities for interaction and potentially dissimilar behavioral styles. While an infant can’t talk, they can still express needs as well as respond to others; while a parent can’t regulate the infant’s behavior, they can still learn to respond in helpful and appropriate ways. In other words, the development of this most important relationship in the lives of both is a kind of dance, largely nonverbal, that involves a great deal of improvisation, novelty, and trial and error.
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Rest assured: there is no more a single prescription for parenting style than there is a single style of infant behavior.
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One expert in newborn/infant behavior, J. Kevin Nugent, PhD, has described some common threads in effective parenting, no matter what the unique characteristics of a parent’s personality. Briefly, these are:
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Contingent responsiveness, or the parent’s attentiveness to the infant’s expression of need;
Respect for, and acceptance of, the infant’s unique behavioral style of expression, as well as acceptance of the developmental limitations of the infant’s contribution to the relationship;
Empathy, or the ability to understand, appreciate, and identify with the commonality of human experience and need, despite developmental and stylistic differences;
Time, insofar as any relationship requires the willingness on the part of the partners (primarily here the parents) to invest in the time it takes to develop a relationship. The challenge here is that the parent needs to be willing to suspend an adult approach to time management to meet the infant on their own terms, or availability and capacity for interaction;
Tolerance for mistakes. Because no infant is ideal and no parent is perfect, both need the lived experience that love means flexibility and healthy relationships “offer avenues for repair.”
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Having said all this, it bears repeating that parents need to take the initiative in engaging an infant in the first interactive experience of their life … not that our infants don’t have the capacity to engage, enthrall, and hold us to them. For varieties of reasons, though, this process sometimes presents us with overwhelming, but usually not irreparable, challenges (it’s that “tolerance for mistakes” thing).
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Next time I’ll discuss such challenges, or “ghosts in the nursery,” and the idea of the “good enough” parent. Stay tuned.
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Read other articles in Mary Ann Zettelmaier’s A Mother’s Journey series.
The First Hour after Birth
Adjustment Strategies
How Babies Sleep
Asleep, Awake, and In-Between
Infant Temperament
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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A Mother’s Journey: Infant Temperament
by Mary Ann Zettelmaier, MSN
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It doesn’t take long for parents to realize that individual babies have unique, identifiable characteristics: they are not, never have been, and never will be blank slates upon whom we, as parents, write the entire script for their lives. It’s best to consider each baby his/her own special blend of nature and nurture … our job as parents is to find a balance between establishing limits and promoting autonomy, such that a baby’s inborn capabilities grow and develop in safety and security. In other words, even before they can speak, babies can tell us a lot about their needs.
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Enter the idea of infant “temperament.” Basically, this is a way to describe a baby’s “style” of interacting with and learning from her/his world. Surely there are a number of methods to evaluate infant temperament, and at some point your pediatrician or nurse practitioner may use some of the fine-tuned methods to help you understand your baby. For practical purposes, I’ve found the basic framework developed by Dr. T. Berry Brazelton, the renowned pediatrician, to be particularly helpful. It’s simple and it captures a range of normal infant behavior, suggesting there’s no one standard to which all infants can or should comply. What he suggests is that most babies’ temperaments can be described as active, average, or quiet.
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Building on the previous discussion about infant sleep and wake patterns, here are some major characteristics of each “type” of infant behavioral style.
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“Active” babies tend to spend more awake time in an active alert state. They’re also the babies whose sleep time is on the lower end of the spectrum of normal. They’re easily aroused and react intensely to sensory input. They tend to cling tightly when they’re held; they smile and laugh easily and usually early. If they’re breastfeeding, they actively search for the nipple and suck vigorously. While this level of responsiveness is usually a great source of satisfaction for parents, these are the babies who sometimes have trouble moving from one state of sleep or wakefulness to another, fussing when falling asleep, crying loudly and easily, and having a hard time turning off stimulation when they’ve had enough. These are the babies who need a quiet environment for sleeping, who need gentle, soothing voices and sequential, rather than multiple, inputs when awake. They need to be held a lot and usually have clear preferences for how they’re held. They benefit from being stroked and/or swaddled if they seem to be thrashing arms and legs when they’re upset.
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At the other end of the spectrum are the “quiet” babies. They can sleep through thunderstorms and other loud sounds; they react slowly to stimulation and spend more awake time in a quiet alert state, looking around without much vocalization or activity. Multiple sensory inputs don’t seem to bother them, and they tend to self-soothe pretty easily. These are the babies who cuddle more than cling when they’re being held. When they nurse, they sometimes need help grasping the nipple. They’re sometimes described as “gourmet” nursers who suck gently and take longer to feed, in contrast to the active baby, the “barracuda” nurser, who tends to feed vigorously and fast. Where an active baby will “announce” developmental milestones (like growth spurts and teething) with maximum upset, the quiet baby seems to glide along with hardly a glitch. But sometimes quiet babies make it harder for parents to “read” their signals and needs, because they’re not as demonstrative and demanding. Thus they need more parental sensitivity to small cues, like the little sucking motions that indicate readiness to feed, the beginnings of drowsiness that indicate time for a nap, the quiet alertness that indicates readiness for interaction. The rule of thumb for meeting these babies’ needs is respect for their lower level of reactivity but enough stimulation to provide opportunities for interaction and engagement.
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In between are the “average” babies, the ones who fit the middle range of sleep and awake states and developmental milestones, who develop feeding routines fairly easily. These are the babies who self-soothe with some, but not a lot, of help, and who negotiate movement between sleep and awake states in a fairly predictable manner. They’re usually fairly easy to console and require less trial-and-error experimentation to figure out their needs and how to meet them.
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When all is said and done, and with all babies of whatever temperament, trial and error are the most operative words for parents in learning how to identify and meet their babies’ needs. In the next entry, I’ll discuss some of the “basics” in building relationships with our children and how we as parents are the other half of the equation in the dance of connectedness.
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Read other articles in Mary Ann Zettelmaier’s A Mother’s Journey series.
The First Hour after Birth
Adjustment Strategies
How Babies Sleep
Asleep, Awake, and In-Between
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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A Mother’s Journey: Asleep, Awake, and In-Between
by Mary Ann Zettelmaier, MSN
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The first year of a baby’s life is a time of rapid development and maturation, only slightly, and gradually, slower than the growth that occurs prior to birth. Some have suggested that, for about the first nine months, an infant experiences a pace of brain growth similar to that before birth, and perhaps we would do well to consider our infants still fetal during the first months of extrauterine life.
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We know from ultrasound (as well as from maternal experience) that babies go through fairly predictable cycles of waking and sleeping prior to birth. Ditto for the first months afterward. The following six “states,” three of sleeping and three of waking, have been identified. On a continuum, they are:
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Deep sleep
Light, or random eye movement (REM) sleep
Drowsy, semi-alert or transitional sleep
Quiet alert wake state
Active alert wake state
Crying
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Newborn infants spend about 16–18 hours of a 24-hour period sleeping. Most of that is light, or REM, sleep. Although there’s variation from infant to infant, it’s typical that any single sleep cycle lasts only about 4–6 hours. So in a 24-hour period an infant will usually go through about 3 to 4 sleep cycles. A great deal of maturation, especially of the neuromuscular and digestive systems, occurs during REM sleep, which likely explains why this state occupies the better part of the sleep cycle.
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What do these states of sleeping and waking look like?
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In deep sleep (about 35% to 45% of sleep time), an infant’s breathing is regular and shallow, and movement is minimal. There may be a few startle movements, but they are brief and don’t seem to disturb the infant. There is little to no eye movement.
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In active/REM sleep (about 45% to 50% of sleep time), breathing is more irregular (shallow and deep breaths), and movement is irregular. The baby sometimes makes sucking movements, and though her/his eyelids are still closed, you can see movement of the eyes under the lids.
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In transitional sleep (5% to 20% of sleep time), the baby’s eyes may be partially opened, activity levels are variable, and sucking movements may be more pronounced. Some babies go into and through this state easily; some fuss until they either wake or get into a deeper sleep. Either way, a complete sleep cycle is usually characterized by movement back and forth between sleep states.
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Then there’s the remaining 6–8 hours of a newborn’s day spent in some state of wakefulness, but which won’t occur in a single stretch and won’t completely occur during the day. As a baby rouses from sleep, she/he may or may not cry (the high end of awake) and will spend some amounts of time in states of quiet and active alertness.
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In the quiet alert state, babies are bright-eyed but not overly active. It’s in this state that babies are most receptive to interaction. They will follow a parent’s voice, make direct eye contact, and within a very few weeks will start to smile and imitate a parent’s facial expression. This is the beginning of socialization, of learning about feedback from the world around him/her, of learning whether or not that world is safe, secure and predictable.
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In an active alert state, babies are wide-eyed and more physically active. They may be fussy, and for sure they are more sensitive to their surroundings, thus requiring less stimulation. Some babies will signal that they’ve “had enough” input or stimulation by shutting their eyes or turning their heads to break eye contact.
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Crying is, well … the state that most disturbs our babies and ourselves. It’s more than fussing and varies from a few minutes of mild distress to ear-splitting, interminable screeching, what someone has described as “table-pounding.” Either way, it’s a signal that requires our attention, and as parents we’re left to figure out how much and what kind of response best addresses our baby’s signal that he/she needs help managing her/his internal or external world.
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In forthcoming entries, I’ll address variations in the style of response that infants can demonstrate, sometimes described as infant temperament or personality, and what a particular style tells us, as parents, about meeting our own infant’s needs. Stay tuned.
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Read other articles in Mary Ann Zettelmaier’s A Mother’s Journey series.
The First Hour after Birth
Adjustment Strategies
How Babies Sleep
Infant Temperament
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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A Mother’s Journey: How Babies Sleep
by Mary Ann Zettelmaier, MSN
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In the last twenty years, there has been considerable attention paid to how babies are positioned for sleep. To make sense of all this, it’s worth taking a look at babies’ inborn competencies and why sleeping position is probably important.
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First of all, babies come into the world with some, but not a lot, of the head and shoulder strength they need to turn, and hold up, their heads. Additionally, they are “obligate” nose breathers, which means they have to have their noses free in order to breathe. They don’t breathe through their mouths, which is why they can suck and breathe at the same time. If babies are sleeping on their stomachs, it may be hard for them to turn their heads and keep their noses free. And it will be some months before they can hold up their heads independently and turn over to get off their stomachs.
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In the meantime, they are at risk for Sudden Infant Death Syndrome (SIDS). Under the best of circumstances, and for reasons not totally understood, a very small percentage of babies between one month and one year of age stop breathing, and die, in their sleep. This, by definition, is SIDS. Sleeping position seems to make a difference: babies sleeping prone (on their stomachs) and on a soft surface, as well those exposed to parental smoking and drug use and/or of low birth weight, seem to be at greater risk for SIDS.
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In 1992, the American Academy of Pediatrics issued recommendations that young babies sleep on their backs, on a firm surface, and in a bed separate from their parents or other siblings. Since then, the rate of SIDS has decreased by half in the United States, from 1.2 per thousand live births to 0.6 per thousand in 2000. The rate has remained essentially stable since then. Still, the United States lags behind all developed countries studied (13 total), except New Zealand, in SIDS deaths.
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The common threads in all the evidence, including that from traditional cultures where SIDS rates are even lower than in developed countries, seem to be that babies are best off sleeping on their backs, on a firm surface, with nothing to cover their faces. Breastfeeding also seems to be protective against SIDS. Where they sleep is not nearly as clear an issue and certainly does vary by culture. Very recently, the American Academy of Pediatrics made the additional recommendation that crib “bumpers” never be used, since there is a risk of babies getting their faces entrapped against a bumper and/or of being strangled by the bumper ties.
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Now that most babies are sleeping on their backs, many of them have started to look like the backs of their heads are flat. Actually, babies’ skull bones are still pretty flexible, and as long as they have time off their backs their heads will round out. By the time they’re upwards of a year old, they’re rolling around in bed anyway, and SIDS is not a risk after a year. Prior to a year of age and/or prior to the baby’s ability to roll over, this can mean “tummy time” during play, as long as a responsible adult is paying attention. Or, it can mean what human babies need the most anyway: being held and carried, in contact with what and who means the most to them: another human being.
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Read other articles in Mary Ann Zettelmaier’s A Mother’s Journey series.
The First Hour after Birth
Adjustment Strategies
Asleep, Awake, and In-Between
Infant Temperament
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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A Mother’s Journey: Adjustment Strategies
by Mary Ann Zettelmaier, MSN
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You are a competent, responsible, successful, high-functioning adult. You thought long and hard about taking on the joy and challenge of starting a family. Or, even if your pregnancy was a surprise, you’re happy about your baby. You have a good relationship with your partner and have a host of friends and acquaintances. Then why do you feel like a bumbling, awkward, tongue-tied, can’t-even-think-straight, irrational jerk?
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Welcome to parenthood.
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I wish I knew an easy, shortcut way around the most profound adjustment you’ll ever make in your life, but I’ve yet to find one. And I’d venture to say that for those of us who are parents in the good old U.S. of A. at this point in time, the adjustment is a particularly challenging one. Here’s my take, based on some beginning research, of why this is so.
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We are a culture that greatly values individualism, self-sufficiency, independence, equality, self-determination, and doing our own thing. We have few models for valuing, to the same degree, interdependence, complementarity, connectedness, and difference. We want things to be clear and not fuzzy, communication to have one clear, easy-to-figure-out meaning.
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Then all of a sudden our lives, as new parents, are totally dominated by a little creature who doesn’t talk, signals with behavior that we’re left to figure out by trial and error, remains as connected to us as if the umbilical cord were never cut, is totally dependent, has absolutely no concern for our feelings, our schedules, our desire for private time with our partners, and doesn’t care if we’ve had time to eat or sleep, much less shower and get dressed. None of this means we don’t love our babies. In fact, we’re frequently so overwhelmed by a new kind of love that we can’t easily grasp the breadth and depth of it.
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We know that our babies are new, but until it happens, it’s hard for us to appreciate how new we are, too.
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While I will address many aspects of new parenting in forthcoming posts, for now I simply want to suggest some adjustment strategies that might help along the way.
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1. Give yourself a break. Keep your expectations of yourself and your partner pretty minimal. Given the gap I’ve described between your public world, with its prevailing values, and your new lived reality, you need time to put the two together. Parental work leave is an opportunity to at least begin that process. The findings of my own small study, plus those of others, suggest that it takes the better part of the first year of your baby’s life for you to completely emerge into a new personal reality. Your baby isn’t the only one celebrating that first birthday.
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2. Get help. As a new mom you need to be mothered, too, at least through the initial adjustment of the first couple of weeks. Confine yourself to feeding and caring for your baby. Let somebody else—frequently your own mom—take care of you, your house, and the rest of your family. Many cultures have clear rituals to help a new mom with initial adjustments, but ours doesn’t. So make your own arrangements. If your mom isn’t available, many areas now have doulas, or mother’s helpers, who can fill the bill. Sometimes they’re available through home health agencies. Check to see what’s available to you, and whether or not your health insurance covers such services. If friends offer to prepare meals, accept and thank them.
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3. Make a list of caregivers who can help. That could mean your midwife, your obstetrician, your pediatrician or pediatric/family nurse practitioner, your childbirth educator or a lactation consultant. Perhaps even before you deliver, list your potential helpers and their phone numbers. Post the list in a place that you can access without having to think twice. And don’t hesitate to use it.
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4. Sometime in the weeks and months after your baby’s birth, you may find yourself making new friends of others with young families. Frequently these are people you’ve met in childbirth classes. You might also forge new relationships with siblings or other relatives who have young families. That doesn’t necessarily mean giving up old friends who are either single or don’t have children, but don’t be surprised if you find yourself with new and different interests. You need these new friends to share your journey.
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Future discussions will address other issues that affect new parents, such as “reading” your baby’s behavior, variations in baby personalities, sleeping issues, and situations in which adjustment to parenthood is especially troublesome. Stay tuned.
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Read other articles in Mary Ann Zettelmaier’s A Mother’s Journey series.
The First Hour after Birth
How Babies Sleep
Asleep, Awake, and In-Between
Infant Temperament
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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A Mother’s Journey: The First Hour after Birth
by Mary Ann Zettelmaier, MSN
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After the intensity and inward focus of the latter part of labor, a mother’s psychological awareness literally opens up on a new existence, for herself and her baby, in the first hours and minutes after birth. It’s not unusual for a mother to feel a new kind of alertness, although it’s limited in scope. Some moms will describe a kind of “halo” of awareness that surrounds herself and her baby, but beyond which her surroundings are literally blurred and insignificant. Within that halo, fascinating and important things are happening.
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First, and under most circumstances, both she and her baby are especially alert and sensitive to each other. At that time, most babies are quiet and looking around. While some moms quietly cry (in wonder and relief), most are like their babies … quiet and simply pondering what has happened. This is a time of re-acquaintance and of adding a new dimension to a bond that has grown with pregnancy and gestation.
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To the extent that it’s possible, this is a time for moms to hold their babies so that the two of them can gaze at each other. Babies are usually wide-eyed at this time, and while their vision is not perfect, it is functional and effective at about eight to twelve inches from what the baby is trying to focus on. The very best thing to focus on is his/her mom’s face. Her voice (and that of her partner’s) will be familiar, and the baby will usually respond by turning to the source of quiet, soothing words within that little “cocoon” of focus and awareness.
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Typically, there’s a lot of baby care going on right after birth, but most of it can occur with a mom holding her baby, or at least within her sight. Additionally, most babies (unless heavily medicated during labor) are ready to suckle and can be put to breast. Note, too, that the distance from a mom’s face to her breast is about eight to twelve inches, or within the baby’s best visual range. If she can and does breast feed, the baby will benefit from early suckling and ingestion of colostrum, a precursor to human milk and a good source of calories and protective antibodies. Early nursing will also release maternal oxytocin, a hormone that will help the mother’s physical recovery from birth.
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If it’s possible and if a mom desires, there are also benefits to skin-to-skin contact between mom and baby. A baby’s skin surface—relative to body weight a newborn’s largest sensory organ—will usually respond to mom’s touch by calming and quieting. Additionally, a mom is a better source of temperature regulation for a baby than any warming machine. In some hospitals a warming light can be placed over the mom as she holds her baby skin-to-skin, but under any circumstances she herself does more to keep her baby appropriately warm than anything or anybody else. If a blanket is used, it can be placed over both of them, together.
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One aspect of care that occurs during that “magic” first hour is installation of antibiotic ointment to protect the baby’s eyes from infection. Use of antibiotic ointment is frequently regulated by law, but in order to make optimal use of the baby’s capacity for vision early on, parents can request that the ointment be instilled toward the end of the hour.
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At about one to one and a half hours after birth, most babies will begin to get drowsy and will go into a fairly prolonged, deep sleep. At the same time, most moms are ready to sleep also, and they need and deserve that quiet time to begin to recoup the energy expended in delivering their babies. While mutual regulation is a “dance” that will occupy many months (if not years) of a baby’s new life and a mom’s new life, this first step is an important one that gets both of them off to a good start.
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Read other articles in Mary Ann Zettelmaier’s A Mother’s Journey series.
Adjustment Strategies
How Babies Sleep
Asleep, Awake, and In-Between
Infant Temperament
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Mary Ann Zettelmaier, MSN specializes in maternal-infant communication, with a comprehensive clinical focus on developing programs of family-centered care.
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