The Magic Wand


We received a lot of feedback from my last post, Do The Right Thing. Comments are always welcomed and appreciated and I thank everyone who did so.
One in particular stood out, requiring more thought and response than I could give in a comment and so I will break my tradition of telling stories to answer Laura’s very excellent questions.

May, thanks for your great posts. I’m not a CNA but I work private duty with several of them and serve as helper on a care team. I’ve spent a lot of time in nursing homes (with my Mom and with other elderly friends). Hearing your stories, and Alice’s and Yang’s, is really illuminating and so helpful. I have always understood that the CNAs in care facilities were overworked and doing their best. Yet watching the elder suffer both physically and the indignity of waiting or wetting/soiling themselves was so hard. From your perspective, is there a fix? Is this is a system that can work? Is something like the Greenhouse Project the way to go? If you could wave a magic wand and create a system that really works, what would it look like? (Thanks for your patience with all my questions. I’m so thrilled to find your blog!)

The problem, as I see it, is that the current long term care system build around the idea of disposable resources.
Aides are a dime a dozen. Policies and procedures call for changing gloves four times during peri-care. We’re supposed to bag everything, linens and trash, and not carry bags between rooms. Food is wasted due to “cross-contamination” concerns.
It’s all built around the assumption that these resources–plastic bags, briefs, juice boxes, individually wrapped Danishes, and, yes, CNAs–are readily available, cheap and easy to replace.

One of the most damaging consequences of this “disposable resources” mindset is, I think, when it applies to the direct care workers. CNAs are typically paid very little, work long hours and have incredibly heavy work-loads–and when we burn out from the stress of handling it all, we are replaced. The cycle repeats, leaving exhausted and often injured people in its wake. There’s this idea, this mindset, that those who burn out simply weren’t tough enough.

I say, expect perfection under inadequate conditions and receive reality. In eight hours (hopefully) I can’t do everything that needs to be done…not for 10+ residents. It’s just not possible, trust me I’ve tried. It’s not a question of me not being smart enough or efficient enough, or not being motivated enough–it’s about me not having enough time. Staffing and resident-to-aide ratios play a huge role in the burn-out cycle, both as why people don’t want to start a career as a CNA and why current CNAs quit.

I think many of the symptoms of our broken system can be dealt with by decreasing resident-to-aide ratios. I think it should be capped at eight residents to one aide, and the norm should be even lower…say 6:1. High quality care could realistically and consistently be given.
And let me be clear, by “high quality” I mean that every resident could be changed every two hours or more. Every resident could receive thorough oral care every shift. Every bed-bound resident could be turned every hour. Nail care could given daily, faces washed after every meal, rooms could be kept tidy, drawers kept neat. Supplies could be distributed before you’re in the middle of cleaning up an XXL BM and realize you don’t have any wipes.
By “realistically and consistently”, I really mean “can be done in a calm, orderly fashion without rushing around, without sacrificing personal time with the residents or rest breaks for the CNA.” I mean “can be done thoroughly and properly without causing undue stress to the CNA or the residents,” and possibly “can be done with the attitude of encouraging resident and aide relationships and interactions.”
I, personally, would love to work in this long term care system, this system that seeks to foster opportunities for me to engage my residents in lengthy interactions; where direct care means personable care. I would love to be able to take my group of residents outside on a sunny day and just be with them for half-an-hour or so. I would love the chance to sit at their bedside every day and chat, without having to shut the door so I can’t hear the other five call lights going off.
I would love to be able to do all this because it is my job, not in spite of my job.

Fixing the caregiver-resident ratios won’t solve all the problems with long term care; there’s still that operating mindset of “disposable resources”. Considering that we just passed Earth Overflow Day, I think it’s pretty clear that this mindset is not an accurate reflection of our world. But that, unfortunately, is a problem for another day. The long term care system isn’t going to improve overnight. It’s going to be a long, slow path of baby-steps and, hopefully, emerging common-sense among policy makers.

So, if I were given a magic wand, I would use it to cap the resident to aide ratios. Then I would hold on to it, pass it to Yang and Alice, see what they would do.

2 thoughts on “The Magic Wand

  1. minstrel

    The issues you bring up are so critically important, May. I’m a dementia-care CNA. The elephants in the room which long-term care operators don’t want to address are the issues of caregiver wages and the quality of care. Obviously, these issues are related. No one wants to look at inadequate wages because this is a huge problem to solve: where to get the money to pay every aide a LIVING wage? (Well certainly not from the pockets of the for-profit LTC owners, I guess.) Regarding the quality of care that aides give: I have seen many LTC homes: as an employee, as a family member of residents, as a hospice volunteer, and as a plain old visitor. Most aides do their tasks with kindness. Some are angels. But once the ADLs are done, most aides seem to think it’s time to sit and text, or socialize with each other, or make cell-phone calls–or just sit and rest, because most aides I know work two jobs just to get buy, and often have families to take care of in addition. They come to work already tired, and are often asked to work a double shift. And then, as you point out, we have an impossible number of residents/patients to care for. How can we actually give them the two-hourly toileting or repositioning that is required, and the hydration they need–to say nothing of the human interaction and patience and individual attention each one needs, all the while ensuring that they are getting sufficient exercise and intellectual stimulation–and this is all in addition to dressing, bathing, meals. How can we do this, when we have six or eight residents each to care for? Into this mix add the number of residents who cannot assist with their own transfers and require at least two persons to assist them, and we get a picture of what life is really like for aides and the residents/patients who depend on us for so much.

    I don’t know what the answers are but I know it is we aides who have to start to stand up for ourselves and for those we care for. Our people are suffering because we can’t give them the level of care and attention they need, and we can’t because we are exhausted, physically and emotionally, from having to work such long hours for insulting wages.

    I love the being a CNA, I love the residents, and I have great respect and gratitude and empathy for the aides I work with. But the system is failing us all. And the powers that be don’t seem to notice how bad things are. Isn’t it our job to show them this?

    1. May Post author

      Very true! It’s sometimes difficult finding a way to “show them” in a manner that will be listened to, though.


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