Bob - Created to Work

"But as for you, be strong and do not give up, for your work will be rewarded."
2 Chronicles 15:7

When the kids were little,  I would read to them from the book "Created to Work."   
Work, the author proclaims, is a gift from God.  In fact, when we first meet God in the book of Genesis, He is working; making the heavens and the earth. Then, having set the example, one of the first things God gave his newly-created people was a job to do. Adam was assigned to name the animals, right from the get-go.  God knew that he would be much happier and more fulfilled with a job of work to do.  After the Fall, when they were exiled from the garden, God gave them work to do to help them deal with their grief and shame.  

Scripture is replete with examples of people whose lives were enriched through work, like the Proverbs 31 woman.  We are also given examples of people who got into trouble when they weren't working.  For example, in the Spring when  the Kings went out to war, David stayed behind.  And in one of his idle moments, he got his first glimpse of Bathsheba.  

Much of the hopelessness found in nursing homes comes from a lack of purpose.  Residents will describe feeling "useless" or "bored to death."  Keeping them engaged is part of my job as a Life Enrichment Director - to ferret out what God has gifted each person to do and help them re-engage in that activity. Physical disability, injury, pain, and cognitive disability complicate this process immensely, but when it works it can be amazing.

I was thinking about this today, and I recalled "Bob."  Bob started out in our long-term-care floor, but after a year or so his dementia progressed and he was moved downstairs to our self-contained memory care wing.  For a week or two he was showing signs of adjusting well to the smaller, safer environment.  But then, one night, his obsession started.

Many patients with dementia suffer from a confusion of their circadian clock.  They'll sleep half the day and be awake half the night.  Bob entered this phase near the end of his first month in residence.  At first he only wandered, propelling his wheelchair all over the unit and into other residents' rooms.  Staff put up STOP signs to help him remember which rooms were not his.  Since there was only one room that  WAS his, he was pretty much limited to the hallway, dining room, and his room.  He became agitated by all the stop signs, and stayed up later and later every night. He forgot that he couldn't stand without help, and he fell a couple times.  Sometimes after breakfast he would try to go out the door, because "I need to go to work!"  Bob had been a handyman, and had been going out to work after breakfast for most of his life.

One morning, the AM shift arrived and began trying to set up for breakfast. But when they went to the credenza to take out the clothing protectors, they found the knobs were missing on that drawer and one other.  A brief but thorough search revealed no knobs.  After two more shifts failed to locate them, maintenance was enjoined to provide replacements.

But the next day the replacements were gone as well.  Staff began watching, and soon it became clear that Bob had found an amusement: as soon as the lights were dimmed in the evening, he began going around unscrewing knobs.  He stored them in the cupholder of his wheelchair, then when it was full he took them to his room and transferred them to the drawer in his nightstand, and then went back for more.  When we looked in his nightstand, we found all the other knobs from previous nights.

Mystery solved, the staff began emptying his nightstand drawer and re-applying the knobs as soon as Bob was asleep every morning.

But every morning, they'd have to do it again, because as soon as everyone else went to bed, Bob went to work.  It became irritating. Then annoying, as Bob expanded his efforts and removed every knob on every drawer he could reach.  The staff cried foul.  Something had to be done.  First line of defense was maintenance: they tried putting wingnuts on the backs of the knobs, which Bob seemed to consider a delightful puzzle to solve.  It took him half an hour to figure it out.  He removed the wingnuts, placed them all very carefully in his eyeglass case, and then went back and removed the knobs. 

As soon as the nurses realized he could get the wingnuts off, that was the end of that, as they could be swallowed by him or others. Maintenance tried gluing the knobs in place, but Bob twisted and twisted until he'd stripped out the holes, and he could still get the knobs off.

At our Interdisciplinary Team meeting, it was suggested that the Activities Department should find something for Bob to do  that wasn't "destructive." It was actually a comment from the Director of Nursing that helped me think of the solution. "Why do the behaviors have to be destructive?" she complained. "Why couldn't he build something instead of taking it apart?"

You know that niggling feeling you get when you feel an idea coming on but just don't quite know what it is?  That feeling followed me around for a couple days.  I tried leaving a set of building blocks out for Bob, but he had no interest in them.  I felt badly for the care staff who now had to screw knobs on while setting up for breakfast. I worked early, so I helped out when I could by taking a turn at retrieving and re-attaching the knobs.  

One morning, Bob was up earlier than usual, and watched what I was doing with interest.  "Here, Bob, I bet you can get this one back on," I said, exasperated.  He nodded philosophically and, taking the knob from my hand, screwed it back in.

The idea that had been stalking me ambushed me as I watched, and I grabbed my coat and left the building.

The Dollar Store had little plastic tackle boxes that were black with yellow latches.  I got two of them, and a "receipt" pad and hustled back to my office.  That night, before I left work, I went to the Memory Care Wing and began removing the knobs from the drawers.

"Hey!" said the care staff. "What are you doing?"

"Trying something," I said. "Don't worry - I'll come in early tomorrow and put them back before breakfast if it doesn't work."

The looks they exchanged said quite clearly that they thought I'd be moving into that wing next.  In my office, I put all the knobs in the tackle box. Dinner was just being cleared away when I returned to the wing.  I sat down at Bob's table and placed the tackle box on the table in front of me. His eyes were riveted on the box.

"Bob," I said, "We have a problem"
"Oh?" he said.  By this point, he was down to monosyllables.
"Look around," I said.  "All the knobs are gone from the drawers."
"Yes."
"The staff can't pull the drawers out without the knobs." I made my voice sad.
"Yes." He sounded sad for the poor staff as well.
"Look here."  I opened the box and showed him all the knobs.  His eyes lit up and he reached for them. I closed the box and sighed.  "I have new knobs for the drawers, but nobody has time to put them on. I don't know what we're going to do."
Slowly, he reached out and pulled the tackle box toward himself. I sat up as if having an inspiration. 
"Hey!  You put one of the knobs on this morning.  Do you think you could maybe put these on all the drawers?"
"Yes. Yes!"
"I don't know," I said, pulling the box back toward me. "There are a lot of them.  It could take HOURS."
"Yes."
"And it would have to be done before breakfast....won't you be in bed?"
"No. No."
Well, if you'd be willing to try, I'll talk to the nurses and make sure it's OK with them."
"OK.  Yes."
I walked out of the dining room, stood in the hall for a few minutes, then went back.  
"You're all set. I'll leave these with you, and you see what you can do.  OK?"
Bob slid the tackle box down next to him in his wheelchair, and I went on my way.

When I came in the next day, I was excited to see that all the drawers had knobs.   

That was the beginning of a very happy period for Bob.  A call to his family gave me some details I needed about his handyman business.  The second night, I took the knobs off and went to Bob's room.  
"Bob, some of the knobs have fallen off the drawers again.  Those pesky knobs!  Do you think you could put them back on for me?"
"Yes, yes."
"Well, that's very kind of you. Thank you for helping.  How about any time the knobs fall off I put them in this toolbox for you, and you can put them on?"
"YES! YES!"
"Good. Oh, but how will the nurses know it's for you.  I know!"
I took my metallic marker out of my pocket and wrote his name right on the box.
"There. Now it has your name. It's your box.  And here...." 
I took out the receipt pad and scribbled "WORK ORDER: Install knobs on drawers. Thank you!"
Bob couldn't read any more, but I read it to him and he was in awe.  He folded the work order carefully and put it in the pocket of his robe.

Every evening I did the same thing: remove the knobs and put them in Bob's tool box, which was kept carefully for him on its own little shelf in the nurses' station. Sometimes he picked it up and carried it around with him, but he never lost it. I taped a work order to the outside of the box and left.  The nurses would call him over and say "Bob, we have a job for you!"
Sometimes he didn't understand, but as soon as he saw the box he was all business.  

One day the Charge Nurse came to me and said, "Your great plan backfired."
"Oh?  How so?"
"Bob wants a paycheck."
He'd started saying "Pay me!" when he brought his box back to the nurses.
So then I supplied the nurses with some realistic-looking play money.  We settled on $5 a night as the going price for knob installation.  Most nights he forgot to ask, and some nights he asked but promptly lost his "pay".  If he did manage to keep it until he woke up the next day, the nurse would bring him down to my office to buy "groceries." He liked Pringles, Fun-size Snickers, and Diet Pepsi and would smile proudly when I handed him a grocery sack with his loot, took his play money, and thanked him for his business.
Once he said hopefully
"Beer?"
and I told him,
"No beer, but I have rootbeer."
It was clear what he thought of that idea.
I probably spent a total of $20 for his "groceries," and it was a bargain for all the peace of mind it gave everyone.  Bob was contented and happy with his job, the knobs were always on the drawers when needed, and instances of agitation and wandering into others' rooms were gone.

 As with all phases of dementia, this one was short-lived, and after a few months Bob would take his box down and carry it around all night but couldn't remember what to do with it.  I put the knobs back on and went in early one morning to find them still attached. I realized sadly that Bob wasn't interested in them.  Eventually he stopped going to the nurses' station, and I put the toolbox with a spare knob or two on his dresser.  He wouldn't pick it up any more, but he would look at it and open it and finger the knobs.   He no longer spoke, and his smile faded away.

Depression, fear, and agitation are common with dementia, but tapping into Bob's God-given handyman gifts broke through it all and gave him back some pride and dignity. 

"He has filled them with skill to do all kinds of work...."
Exodus 35:35