Category Archives: advocacy

A Numbers Game: Resident Acuity and Staffing – Part Three

 

 

Minstrel

We cannot provide person-centered care without the personnel.  My previous comment, Part Two, presented a list of symptoms that arise from dementia.  These symptoms are the constant companions of those living with more advanced dementia, and their care partners.  The symptoms create behavioral challenges we CNAs must and want to respond effectively, so our residents can feel secure, content, at home.  

We have our list of dementia symptoms.  But wait—there’s more.  Let’s look concretely at the workday of a LTC direct-care worker.  Aides work an 8-hour shift, with one-half hour mandatory meal break.  (In some places they are also entitled to or permitted to have a second 15-minute break.)  The first and last ten or so minutes of a shift are spent getting and giving shift updates to the previous or next shift of aides.  Aides will also need one or two bathroom breaks during a shift.  Thus an aide has about 7 hours (420 minutes) left for care tasks.  This scenario doesn’t take into account the moments an aide might need for a calming ‘time-out,’ for a few minutes of helpful conversation with another aide or a supervisor, for an important phone call from home, for time spent walking from one task to another or one resident to another.   And it doesn’t allow for other encounters we expect aides to have with residents, creating ‘moments of joy.’ 

Aides will customarily be responsible for the care of six to ten residents on a shift that has plus or minus 420 minutes of usable work time.  (And would you believe the number of residents might be higher?)  If you do the math, you see that aides may have 42 to 70 minutes for each resident.  Seventy minutes to help a person exhibiting symptoms of dementia with toileting, washing (on certain days showering), grooming, dressing or undressing, moving to the dining room, eating, returning to the day room, using the toilet during the day.  And these are just the essential ADLs.   

Other tasks aides are responsible for during a shift: 

  • for safety purposes, keep alert to where each resident is;
  • distribute drinks to prevent hydration;
  • serve snacks;
  • check toileting needs and assist residents with this as needed;
  • help with transfers (from bed to wheelchair, wheelchair to lounge chair, lounge chair to wheelchair, wheelchair to toilet and back several times in a day, wheelchair to bed) for those residents who cannot transfer themselves;
  • help other aides with two-person-assist transfers;
  • answer resident questions throughout the shift (“When can I eat?” “Where is my mother?” “When will my son be here?”  “I’m cold, where is my jacket?” “Don’t I have a doctor’s appointment today?”) ; 
  • in between ADLs engage with residents through conversation, music, activities;
  • accompany residents to other areas of the building as needed for medical care, hairdressing appointments, other events.

In some LTC communities aides are also responsible for making beds, doing laundry and putting it away, or other housekeeping duties.  Throughout the day there are spills to clean up, phones to answer, paperwork to be done, questions from visitors.  If an aide is tired from working a second job, or a double shift, this will slow the aide down.  If an aide has a bad back that day, or sore knees, or is pregnant, these things will also mean the aide has a lower energy level or slower response time.  All these factors take a toll.  If some aide should call out at the last minute and the shift is short-staffed, this further impacts care.   Even if forty or fifty or seventy minutes of care per resident were sufficient—and really, it’s not—at the current staffing levels in most LTC homes, residents don’t get even this.  I challenge administrators to refute this with data.  

Is it really acceptable to pare staff levels so thin that we impair not only the quality of care but the safety of residents and aides alike?  Is it acceptable that the owners of long-term care homes are sustaining their organizations by controlling their costs with sub-par staffing levels?  Those responsible for setting care and staffing standards should feel responsible for doing something about the unacceptably low staffing requirements they’ve established and tolerated, thanks to lobbying efforts of the long-term care industry.  (Shame on you, CMS.)  The rest of us should hold them accountable.  Families and direct-care workers and anyone who is an advocate for those living in long-term care communities:  Unite!  Lobby!  Write, email, text, twitter.  Demand that your care home managers and your state legislators see what is before their eyes.  For added clout, partner with organizations that advocate for better long-term care.  To any CNAs up for a little non-violent guerrilla warfare: sneak a copy of these comments to a few trusted family members of residents.  Ask them to bring the staffing issue up at a Family Council meeting.  Send a copy anonymously to your Administrator.  

Owners, operators, executives and regulators of LTC homes will say that we don’t need more staff, we need more or better training.  Our CNAs need to work ‘smarter.’  And there is something to this, we do need to look at work assignments and patterns and at aides’ understanding of how to interact with persons with symptoms of dementia, etc.  But tell me how all this will change the fact that an aide may, on a good day under ideal conditions, have 70 minutes to give a resident.  (A resident who may be paying $5000 to $8000 a month for memory care.)  

This isn’t a game.  Would we let a dog lie in a kennel and give that animal only seventy minutes of direct attention a day?  Long-term care homes don’t care for dogs, they care for human beings.  Tell me please, how can we sit still and stay quiet about this appalling reality, one minute longer? 

You are the Solution


Corey
Hey you. Yes! YOU, reading this. Don’t ever allow yourself to be convinced that you are less than you are. Don’t allow anyone else to define you. You are so much bigger than your mistakes, fear, and struggles. I know you’re tired. I know you sometimes ask yourself what’s the point and I know sometimes you think your best isn’t good enough. Not one of those thoughts are true. The very fact that you are reading this post shows that you are defining your position in the world of long term care rather than allowing the system to define you. I know. That’s how this whole blog began. Two caregivers found each other online and decided it was time to let the world know what it is truly like from our perspective. We are no different than you. If we can be a part of the solution, so can you.
Step one: we have to get rid of the “I’m just” mentality. I’m just a CNA. I’m just a single mom. I’m just
a high school graduate. I’m just one person. No. You are not. You are a dynamic human being with ideas and value. Your worth is not to be measured by something as simple as a degree. You are not “just” anything. KNOWING that is the key to willingness and willingness unlocks doors you can’t even begin to imagine. Willingness produces action and action produces change.
Step two: we have to stop letting others dictate our behavior. Everyone calls out. I’m going to call out too. Right or wrong, that thinking just excuses their reasonings for our poor pay, awful work loads and disrespect. Is it fair that the best and the worst of us are treated the same? No. Hell no. But the system sees no need to change it. They treat us as disposable. We react to being treated as disposable. They use this as an excuse to continue to treat us as disposable. Collectively, we have power over this. I’ve said it before and I’ll say it again: mountains move from the bottom. Rome wasn’t built in a day. We need consistent and collective moves forward and that will not happen until we excel. Until WE define what we do and how well we do it. Until we become the leaders we wish we were provided, it’s going to be business as usual. We have to stop bullying. It’s a problem from the top down. I should not know what the office people think about the new nurse. But I do. It’s no different than the floor. The new kid on the block always has it rough. We can lead by example there. We can help the new workers, regardless of their position, rather than tear them apart. We can help other shifts instead of bitching about them. Having worked all shifts, I know they each have their challenges. We can not involve ourselves in malicious gossip like twelve year old mean girls. If we feel someone isn’t pulling their weight, we can discuss it with them like grown ups. We can speak up for one another when necessary and we can speak up for the residents. We do not have to get drawn into the drama, even when those in supervisory positions often seem to be the ones stirring it up. We can CHOOSE not to play ball, to respectfully decline to participate in bullshit. In doing so, we become examples for good. We show that it doesn’t take making another feel or look bad in order to look good.
Step three: Never give up. It may seem like no good can come from all this effort. I know I’ve felt that way. Press on regardless. Change happens slowly. It takes patience and sacrifice and even then, the satisfaction of seeing the outcome of all the effort isn’t guaranteed. Trust me, it makes a difference. Once, I was a whistle blower. My entire life was thrown into turmoil. I lost my job. Had to start from scratch and couldn’t see how any good came of it, but as it turned out, it wasn’t just their one facility that had glaring and dangerous violations that had gone unchecked, but several. By shining a light on one, all of them were on the radar. It was three years before I found out that my action had any impact. I was green in the field and naive at the time. Now I realize the most impactful change in this system is not an explosion but the slow and steady burn of passion that motivates this blog. The simple act of speaking your truth consistently will leave a mark. So leave your mark. Write your own piece. Email it to us for posting. Or reach out your hand to another person in this field. Teach with patience. And know we are all in this together and you are not alone.

See Me


Alice
I am a person. I am not dementia. I am not diabetes. I am not simply a resident or client. I am not a care plan or a two person assist. I am not room 242 needs something for agitation.
I was a dancer. An ambassador. I fought for this country. I was a nurse. An engineer. I am a mother, son, daughter, sister. I am dying but I’m not dead yet. You make rules and say they are to protect me, and yet you don’t see me. You don’t ask me what I think. I am one more blurred face. I am one more bed filled. I am a number on a census.
Your voice and demeanor change when my family visits. Suddenly, we’re pals. Suddenly you are filled with concern but if I were to ask you how I slept last night or what my biggest fears were, or my favorite color or pet peeves, you wouldn’t know. That’s beneath your pay grade. That’s for the caregivers, if I’m lucky enough to have a good one that you doesn’t run off in search of greener pastures. And I don’t think you realize how truly demeaning it is to not be seen as an individual; how, more than anything else, the minimizing of who I am as a person to a checklist robs me of my dignity. There shouldn’t have to be a list of patient rights in order to be seen as a human being. Is there a more important rule than that? It shouldn’t be so complicated.
The higher up the food chain you are in this field the further you are removed from the people for whom it exists and the legislators making the calls are about as high up as one can get. The best way to find out how to improve the quality of life is to ask those who receive and provide the hands on care. It’s a no brainer.

Looking back and forward

May

Life is funny, sometimes. And it’s strange, always it is strange.
For almost three years, I have been writing for CNA Edge. Three years…it hardly seems possible. I must be getting older, because it feels like just yesterday that I was writing my very first post for this blog (Perception, now found in CNA Edge: Reflections from Year One).

But three years have passed, three wild and crazy years. Life marches on, bringing new responsibilities and opportunities. Just to be clear, I’m not leaving CNA Edge for good. I’m just stepping down to part-time contributor. Instead of once a week, I’ll be writing once a month. I’ve learned so much about the world and myself here on this blog; become a better writer and caregiver because of CNA Edge. Now it is time for me to take the lessons I’ve learned and apply them to new challenges.

Long-term care is a crazy corner of a strange world. We form deep bonds quickly with our residents and with our fellow caregivers. We have to: there’s too much work to do and too much stress to bear on our own. The relationships we form lighten the load, making it possible to bear. Not easy…but possible. Something we can struggle through, together.

The human cost of our long-term care system is something that is not counted enough. When it’s easy to justify making a profit off broken backs and burned-out hearts, you know there’s something screwy in the system. Something broken.
If I am proud of one thing I’ve accomplished in these last three years, I’m proud that I helped to empower other CNAs. My words and my stories touched people, helping them remember that they are not alone. Maybe I’ve helped to alter the perception of CNAs…that we aren’t poor, uneducated ass-wipers who can’t do any better than a crappy job. That many of us are intelligent, compassionate and hard-working people, just trying to do our best in a system that is set up against good care. We caregivers fight the clock every shift, just trying to give good care that we can be proud of…and trying to do it in five-minute windows. Drive by care, that’s what we’re forced to give. And it hurts us, to have to offer scraps and band-aids.
For so long, CNAs had no recourse but to swallow the hurt. Not anymore.
We’ve always had thoughts and feelings, voices and stories. Now, we have platforms to speak them from, safe spaces to tell our stories.
And CNA Edge has been so good to me, giving me that platform to write down and share my stories. Carving out time for good care is hard, but it’s easier now, knowing that change is possible. Knowing that there are those among management and policy-makers who do care, and try to implement lessons they’ve taken from my stories. Knowing that there are other CNAs who, like me, process feelings through writing stories.
I’m so grateful to CNA Edge, to Yang and Alice and the friendship we’ve forged here on the Internet.
Guys, you are the best and even though I’m stepping back, just know that I’m not leaving. I’ll still be here for you, even as I embrace new roles and opportunities.

To all my readers, thank you so much for all the likes, shares, comments and support. Your loyalty and support mean so much to me.

The Caregiver Shortage and Immigration

In reaction to the Trump administration’s recent immigration ban, Lori Porter, founder and CEO of the National Association of Health Care Assistants, pointed out a connection between the immigration issue and LTC staffing levels. In a recent Facebook post, she stated:

“A large percentage of CNAs are from the banned countries. Long Term Care is always testifying before congress for immigration to solve their staffing issue… I know nursing homes in this country who are largely staffed by those affected. Did anyone stop to think about who would care for the residents? Especially in a country who will not come out in sufficient numbers to take care of their own OLD citizens! … I have heard from nursing homes all day who will not have enough CNAs to staff their building because so many CNAs have left out of fear.”

In support of Lori Porter’s assessment, we do know two facts:  that over 50 percent of CNAs leave their jobs every year (PHI Factsheet) and over 20 percent of caregivers in the U.S. were not born in this country (Market Watch).

My concerned is about the vulnerability of caregivers coming into this country on work visas, especially if their legal status is tied to their employment. Since advocating for our elders is such a big part of what we do as caregivers, we need workers who feel secure enough to speak out within the facility and, when appropriate, in the public forum. Sometimes, we are the last line of defense for our residents and if we do not speak, no one will. Too often, incidents and issues that should be dealt with in the open are swept under the rug, mainly out of fear of some form of retaliation.

If Long Term Care is to rely on immigration to solve the caregiver shortage in this country, what kind of protections can we provide these workers so that they feel secure enough to speak out and advocate for our elders when necessary?

 

A Wide Movement

May

As I talk about CNA Edge more, there’s a question that keeps coming up: for whom am I writing? What is my target audience?

Whenever I’m asked, my initial reaction is always: “My audience is whoever reads it”.
But that’s a vague answer at best, and no answer at worst. There are some who tell me I should focus more on reaching policy-makers and people in positions of power. And I can follow their line of thinking and I agree with their points: there is a divide between direct care workers and those at the top. That divide hurts our residents, often badly. So yes, I would love to reach more policy-makers.
But not at the expense of also my reaching my fellow CNAs. To put it another way, I do not want to be the sole spokesperson for CNAs to policy-makers and administrators. 

Policies can change. Rules and regulations can be changed with administrations, and then swept away with the next changing wind of politics. I am not dismissing the importance of good policies and those who work so hard to affect change for long-term care. We need people fighting for good policies, and for responsible leadership. We also need people fighting to change the way CNAs think about themselves, to throw off the label of “nothing but an ass-wiper”. If I can do that, then I am not alone. One or even three CNAs speaking up can be ignored. We could even be silenced. How about one hundred CNAs? Or three hundred? How about a thousand, or a million?
That starts by letting CNAs everywhere know that they are not alone. Sometimes I think the worst affect of this broken system is that it makes people who work so closely with others feel utterly alone. We, who have the power to deeply impact the lives of our resident, are often made to feel helpless by all that we cannot change. We feel alone, helpless and burnt out. Silence and sullenness can and do follow.
But together and aloud…what can’t we achieve?
I do not ever want to talk over the heads of my fellow caregivers. I refuse to fall into the trap of thinking that I am somehow more than they are, or that they are something less than me. If I am intelligent, compassionate and eloquent, that does not make me unique among caregivers. Actually, I’d argue that makes me about average. If I stand out, it’s only because I speak out.

What we need now is change, both on a personal level and on a larger cultural one. Compassion, common sense, communication and critical thinking have got to be infused into this broken system. We have to have people dedicated to change on every rung of the ladder…including the one belonging to CNAs.
Just like a democracy cannot function without the active participation of ordinary citizens, neither can our long-term care system function without a principled and vocal base of direct care workers. CNAs who are willing and able to speak up for themselves and their residents.

Nursing-home-made

Sunflower May

In compliance with HIPAA, all resident names and identifying details have been altered or removed. 

It’s funny, how a person’s possessions can tell us so much about them. Most new residents come in with very little: just the clothes they wore in the hospital and maybe a small bag. Then, their families either start bringing in loads of stuff…or they don’t. I have seen rooms so crammed full of personal mementoes that it’s hard to care for the resident; so many clothes in the closet that the door won’t shut and every surface covered with knick-knacks.
I have also seen rooms bare weeks after the resident moved in, the only proof of occupation being the person in the bed. Only a few clothes, no knick-knacks…no decorations or pictures.

Mrs. L seems to be one of the latter category. After a week, she still only has the one bag that she had clutched so tightly on the first day, plus a couple outfits. They’re nice, but the kind of nice that has been worn for years and years. Her family comes often, but they seem more stressed each time and their visits get progressively shorter.
There’s always a learning curve, some time required to start feeling comfortable in the new environment…but Mrs. L doesn’t appear to be adjusting at all. She won’t leave the room, she hardly eats and from what I can tell, she seems to spend most of her days screaming into her phone and crying. I decide I can’t kept walking past such agony. We don’t know each other very well, but that’s about to change.
“Hey, can I sit down?” I ask, walking into her room and gesturing to the empty chair (provided by the facility) that sits by her bedside. She shrugs and I take that as permission. Good Lord, but it feels wonderful to get off my feet.
“I’m May, if I haven’t introduced myself before,” I add…although I’ve introduced every day this week. “Do you need anything?”
She shakes her head. I’m trying to decide between asking another question and telling a story about myself when she suddenly starts talking.
“You can’t help, nobody can help. Can you make me better? Can you tell the insurance company not to be assholes? Can you give my family a fortune so they won’t have to sell my house to afford ‘getting me the help I need’? Can you buy back everything of mine they had to sell, so I don’t have to look at bare walls while I wait to die?”

I can’t. I can’t wave a magic wand and sort out the economy, endow her with the money she needs to have a good life even though she is now elderly and disabled.
The only magic I have at my disposal are my imagination and my hands. I stay for a few minutes, now holding her hand as she cries yet again, then I slide off the chair and leave the room.
It only takes a few words in the right ears. When I come back, I’m not alone and we aren’t empty-handed.
We disperse over the room, laying out our various offerings. The Laundry department brought up clothes that have been donated to the nursing (usually by families of resident who have passed away in our care); Activities gave several left-over decorations from the various Arts-and-Crafts over the years. Nursing gathered personal care items from the supply room and arranged them in her drawers. Staff from every department drew pictures and scribbled down nursing-home-made Get Well cards…but the best bit came from a fellow resident. She heard of my cheering-up campaign and told me to pick out the prettiest flowers from the bouquet she got for her birthday and give them to that “poor lady”.

Small acts of kindness in Long-Term Care are not whistling in the dark. With each act of compassion, we light a candle. True, it will take a lot more candles than I can personally light to lift the shadow of greed from our broken system…but that’s the funny thing about kindness. Even when it’s not enough to turn the tide, change the culture or right the wrongs of this world––it is still appreciated and it can still mean the world to that one person.

My hope is that, one day, we will have more to give than what we can scrape up. I hope that one day, compassion will be considered along with costs, that questions of ethics will be given equal standing with questions of economics. 

Respect Your Elders

Sunflower May

At times, it’s really hard to be professional. No, strike that––sometimes it’s really hard to be nice. This is one of those times I really wish I could just open my mouth and…well.
Breathe. Breathe and move on. Do not respond. Do not reply. This is neither the place nor the time for such a discussion. You aren’t calm enough not to scream, so don’t say anything. Prove him wrong with your actions. I keep thinking these words until I wonder if they’ve been seared onto the inside of my eyelids from the sheer force of repetition. It’s hard because I have to be professional and they can be whatever they want to, even if that’s unkind.

All this started because Mrs. L’s husband had come over for a visit. And he is a man with Opinions. He’s not one to keep them to himself either…and I could perhaps forgive him his outspokenness if I wasn’t the target of his outrage. Or I should say, one of the targets. Today, Mr. L has Opinions about Millennials.
“Man, kid these days,” he rants to his wife, ignoring me as I labor to make her bed behind him. “What idiots. When we were kids, man, I tell you, nobody was so selfish. They just want everything handed to them. Afraid of hard work, that’s what they are.”
I’m putting the pillowcase on as he says these words and I am so tempted to…no. Absolutely not, May, that is utterly unacceptable behavior. You are not allowed to even think that. Never mind that I’ve been hard at work for five hours already today, with seven more to go. Never mind that I’m in overtime for the umpteenth week in a row. Never mind that I haven’t had a break or a breather since I clocked in. Never mind…
“What is this world coming to?” he muses. “These kids are crazy and they don’t know nothing. Everything wrong in this world is because of them, I think. When we were young, we were taught to respect our elders, but I wouldn’t trust a dog with these so-called Millennials. What a disgrace––”
I can’t take this anymore. I dart around Mr. and Mrs. L, leaving the bed half-made and escape into the hallway.
No, he didn’t trust a dog to a Millennial. It was his wife he entrusted to my care. Many of the CNAs and nurses I work with are among the Millennial generation and we are the front-line of Long-Term Care. We make up a large percentage direct care workers.
I lean back against the wall, fighting tears. They’re tears of rage, but I really can’t afford to shed them right now. I am the caregiver and this isn’t the time to be emotional.

One day, I might have Mr. L or someone like him as my resident. His dignity will be left in my care, to either affirm and defend, or ignore and abuse. I wonder if he realizes that, as he rants and raves about the sins of my generation.
When you are weak and helpless, crippled and confused, I will be there, I think. And when you are my resident, then maybe you will see. Maybe you won’t…but either way,
I will take damn good care of you, whether you want me to or not. I will be your advocate and I will be your caregiver. I will fight as hard for your dignity as I fight for the gentleman down the hall, who I absolutely adore. You cannot change my compassion and you cannot change my professionalism.

I am a caregiver. I am a Millennial. And I think I am calm enough to go back into that room to finish making the bed.
When I do, it’s to see the strangest scene. Mr and Mrs L are glaring at each other; he looks surprised and she looks angry. They break it off when they realize I’m back.
“Oh, hello, sweetie,” Mrs. L says to me. “Do you know, you are my favorite aide. I don’t know how you do all the work you do. Especially,” she adds with a pointed look at her husband, “since you’re so young.”

A Personal Question

Sunflower May

One of the recurring questions I heard at the Pioneer Network Conference earlier this year concerned how CNAs and other direct care workers refer to their residents/patients/clients.
I heard a variety of opinions, ranging from “Absolutely no pet names ever, it’s undignified and disrespectful” to “What does it matter?”
I don’t remember which individual it was who finally put forth the question: “Well, what does the resident think about this? Does the resident mind aides using terms of endearment?”
When I was asked for my opinion, I just shrugged and said: “I guess it depends.”

Having worked for years in Long-Term Care, this wasn’t the first time I’ve run into this issue and I doubt it will be the last. It’s one of those loaded topic, where everyone involved has surprisingly strong opinions. I think people lay bits of themselves on the line with this question…maybe it’s one of those questions that you can’t ask without thinking: “What do I want? What are my wishes and will they be respected if I can’t enforce them?”
My answer to the question is quite often met with confusion and occasionally disdain, but the truth is, I really do think it simply depends. You can’t answer this question with an absolute…it’s not that kind of question.

Some people like being called “buddy”, or “honey”, “sugar” or some other term of endearment. Some do not. Some go off the wall if person A calls them “sweetie”, but smile happily when person B calls them the same thing. (That’s me, by the way, squarely in category 3.) Residents are much the same way…being, you know, people. Individual human beings with unique preferences.

Here’s another big shocker: CNAs are also numbered among humanity. We’re people too. We each bring a different set of life experience and habits to the job. Some aides use pet names, some don’t. In my experience, good aides fall on both sides of the line. There doesn’t seem to be a one-to-one correlation.
As for me, it just slips out. It’s slightly odd, but I slip into a more Southern accent while at work (a benefit of living in multiple places is having multiple accents to switch between). “Honey”, “buddy” and “sweetie” just slide out with the Southern twang and none of my residents seem to mind…I’ve actually had residents complain if I call them only by their given names, with no endearments to follow. In front of State, no less.

Of course, I have to tailor my habits to my residents preferences. I’ve had residents ask me not to call them “honey” or “buddy” or “sweetie”––these residents are few and far between, but I’ve had them. Some prefer terms of endearment in private, one-on-one interactions and more formal modes of address in public settings like the dining room. I do my best to accommodate their wishes and preferences.
In fact, one of the very first things I’ll do when I have a new resident is to introduce myself and ask what they want me to call them. Do they want to be Mrs. P, or Mrs. Betty or just Betty? Then I play it by ear: after the initial unease, how formal is this resident in their interactions with others, with me? Do they respond better to jokes or serious discussion? How much humor on my part is tolerated? What do they call me?

In the end, this question of terms of endearment is one that I do not believe can be answered in a blanket policy. It’s a personal question needing a personal answer…and no one can supply except the resident. Even when the resident is so out of their head with dementia that they cannot remember the year or recognize their children, still they have the right to decide for themselves what they prefer. They may not be able to answer in words, but they always answer.
You just need to train yourself to hear the unspoken words hanging in the air. Don’t assume you know what another person wants. Listen before you speak for them.

“I’m Just Doin’ My Job”

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Minstrel

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.