One of my all-time favorite movie lines was spoken by Paul Newman in Cool Hand Luke. Luke, the non-conforming prisoner in a tough southern prison, refuses to accept the prison’s status quo. His conduct is a cascade of rebelliousness, until finally the warden orders Luke to “the box.” The box is a small tin-roofed building, the size of an outhouse, under the blazing sun in the middle of the hot, dry prison yard. After Luke spends twenty-four punishing hours in the box, the guard releases him. As he does he says, “Sorry Luke, I’m just doin’ my job. Ya got to appreciate that.” Luke replies, “Nah, callin’ it your job don’t make it right, Boss.”
Calling it our job doesn’t make things right. Among the most pernicious problems in long-termcare homes is staffing shortages. With a census of 25 to 35 residents or patients needing skilled nursing and/or dementia care, there might be only three to five aides scheduled to work a shift. (Then there are the last-minute call-outs). If the aide is lucky, very lucky, she may have only five or six persons to care for. The more frequent reality is having seven to ten persons needing care. Remember that cacophony of call bells that May wrote about? Blame it on short-staffing. And the resident pleading for you to take her to the toilet? Oops, it’s already too late… The resident teetering perilously as we rush to prevent a fall? … And the time you lifted a non-ambulatory person by yourself because there was no one around to help? What about those wheelchair bound residents who haven’t been taken out to feel the fresh air in weeks? The hits just keep on comin’. And we keep right on keepin’ on, because it’s our job; right?
No, it isn’t. We simply can’t do our jobs as CNAs adequately when we’re so understaffed. What most determines the quality of care is the staff-to-resident ratios (‘duh’). I challenge anyone to find an aide who disagrees with this. Yes, staff need to be trained in good care practices. Yes, we need to have certain supplies available (soap, towels, functioning hospital beds, appealing food, etc.). But the key to quality care, to person-centered care is PERSONS. Staff.
We continue to work in short-staffed conditions we know violate our residents’ right to good care. (See medicare.gov for a description of rights of persons in nursing homes.) If we ‘complain’ to management about short staffing (and that’s how it’s viewed, as a petty complaint), we’re told sweetly that the staffing levels meet the state requirements. And that’s probably true, because industry lobbyists have made sure that state regulators don’t burden the long-term-care industry with costly staffing requirements.
We complain about these deplorable conditions all the time. As CNAs we’re mandated reporters of abuse. (I guess we’d better not think about that one too much!) But we tolerate abuse that residents endure as a result of understaffing. Abuse isn’t just about physical or sexual assault. It’s also about neglect and emotional abuse. If I neglect a call bell for so long that a resident is left to soil himself and remain in his soiled condition for hours, that is abuse. If I say to a resident who asks to be taken to the toilet, “Janie, I just put a clean Depends on you; I can’t get you back into the Hoyer lift and take you to the toilet, you have a diaper on, you can use that,” that is abuse. Abuse is ridiculing a resident who cries for her mother all afternoon; scolding a resident who spills her drink all over the floor; ignoring the call bell of a resident who constantly asks to be taken to the toilet minutes after the last toilet trip, because we know she ‘doesn’t really have to go.’ Well, she needs something and it’s our job as aides to find out what. “But I don’t have time for all that. I have seven other residents to get to. I’m just doin’ my job.”
So what can we do? Unlike the workers of the 1920’s and ’30’s, we can’t go on strike to win better working conditions. We’re caring for the sick and the frail, not assembling cars. But if we can’t leave the floor for a sit-down strike, we can use our cell phones as weapons in the revolution for better care. Call your county or state abuse hotline every time aides have more than six residents to care for on a shift. (And don’t count the LPN or Medication Aide in your ratio if she isn’t providing care, even if management does.) The state regulators aren’t always thrilled to receive reports of abuse because they are short-staffed too, and don’t have the means to investigate all complaints properly. They don’t always to a good job, for the same reasons we don’t always: because they’re understaffed and a little intimidated by their bosses.
Revolution isn’t about violence and nastiness. (Remember Gandhi and Mandela and Rosa Parks.) It’s about patient persistence and never giving up as long as change is needed. It means taking that first step. Maybe our first step will be a phone call.