Category Archives: caregiver conflict

Break Interrupted

Sunflower  May

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

“I need a break!”
With these words, I sweep into the room, startling the occupants.
“So,” says Mrs. R, “go to your break room.”
“Can’t, they’ve already looked in there for me,” I sigh as I drop down on Mrs. R’s bed…it’s the one farthest from the door and it’s the empty one. For good measure, I pull the privacy curtain down to the foot of the bed and arrange my legs so that you can’t see tell-tale nursing shoes from the door. I don’t dare close the door: I wouldn’t be able to listen for call-lights and nothing screams “CNA in here!” louder than a closed door.
Mrs. E, the resident in the first bed, rolls back over and goes back to sleep. She’s always resting her eyes; meal times are her favorite nap times of all. Mrs. R, sitting up in her wheelchair, turns away from the window to look at me…apparently, I’m more interesting than the birds outside. “What do you mean, they looked in the break room for you?” she asks. “It is the law that you have two ten-minute breaks and, knowing you, you probably haven’t taken them already. Tell them to go away.”
I just stare at her. “How do you know that?”
“I listen,” she replies, a bit smugly. “You would have to be completely deaf not to learn every detail of the working conditions here. Someone is always complaining.”
“Um…sorry. I try not to complain in front of you guys––”
“Quit changing the subject. Why don’t you just tell them to go away and leave you alone on your break?”
“Because then they just say ‘Oh, when you’re done’. It’s not one of those things worth kicking up a fuss over. I’m sure if I went and complained to the DON, there’d be an in-service for everyone to sign…and nothing would change. Everyone would continue to interrupt my breaks for the stupidest crap.”
I sound bitter, I realize. The thing is, being fetched out of the break room during one of my few breathers never fails to irritate me. I only take my ten minute breaks when I’m about to snap, but today there is no escaping the madness. The straw that broke the camel’s back was when my nurse stormed into the break room right after I’d gone in, to tell me to get back out on the hall because “there are too many call lights for one person to keep up with”. I think she meant “one CNA” because she has said before that she is “above aide work” and I’ve never once seen her answer a call light.
The next chance I had to take a breather, I decided the break room was not a safe place to take it––so here I am, seeking refuge from the demands of my residents in the company of my residents. Funny how things work, sometimes.

Mrs. R looks at me steadily for a minute while I swing my feet. “That nurse today is lazy,” she declares. “Next time, tell the person interrupting your break to go to hell.”
“Mrs. R!”
“Or, better still, tell them to take care of the crap themselves.”
“Do you really want the nurse you call ‘lazy-ass’ to be the one taking you to the bathroom?” I grin.
“Yes. Then I could fart in her face.”
It’s a good three minutes before I catch my breath enough to answer. Mrs. E grumbles about the noise and tries to burrow deeper into the covers.
“Oh, Mrs. R, never change,” I tell her, still giggling.
“I’m sure I’ll change a bit when I die,” she says. “Can you cuss in Heaven?”
I shrug. “I don’t know, Mrs. R. But I’ve got to get back work now. Thank you for the refreshing break!”
“No, you don’t,” she replies. “You have four more minutes. Sit your ass back down and tell me about what’s going on in your life. Then, you can take me to the toilet. I promise not to fart in your face.”

Empathy vs Apathy

Sunflower  May

In compliance with HIPAA, all names and identifying details have been altered or removed to protect patient privacy.

Can I ask you something?” a newbie CNA asks me…in that tone of voice that usually means “Trouble this way”. We’re assisting Mrs. A to eat her lunch, although “assist” doesn’t quite seem like the right word when all she can do on her own is open her mouth. 

“Um,” I say, “sure.”

“That one aide. Why is she like this? How do you get to point where you just don’t care? Why does she act like giving these people your very best is a waste of time?”

“Well,” I sigh. “There’s a lot of stress that goes with being a CNA, and a lot of the time you don’t seem to be making a difference…”

He picks up the spoon, loads it up with mashed potatoes and gently gives it to Mrs. A. “There,” he says, “I just made a hell of a lot of difference for her.”

I almost come out of my seat. “Promise me you’ll stick with this,” I say fervently. “You’re right. Every little bit we do makes the world of difference…but sometimes it’s hard to remember that when you’re frustrated, over-worked and, well, when nobody else sees the good you do. And for that one aide, well, sometimes it’s easier to shut off the part of you that can feel, to spare you from feeling despair. Some aides learn how not to care to survive this broken system ”

“You didn’t,” he says indignantly. “I won’t.”

“Remember that promise,” I say gently, “but also remember this: deciding to be a good aide is not a battle you will ever leave behind you. It’s a choice you will have to keep making every single shift, to do your best even when it seems pointless, to keep being kind even when your efforts seem as terminal as your resident.”

“Is that what makes a bad aide then?” He asks. “Deciding that your best isn’t required? Choosing apathy over empathy?”

∞oOo∞

What is the good of small acts of kindness done for a person who will shortly be dead? Isn’t it a waste of time and talent? Isn’t your struggle to be kind as terminal as the disease killing your resident? One day soon, your resident will lie cold in a bed and there will be nobody left to remember how you put off your break so you could fluff her pillow. Nobody saw you give a good bed bath to Mr. T instead of just running a wet wash cloth over him. So what’s the point of trying? Why put yourself through the agony of giving good care in a system that is not set up for small acts of compassion?

Nobody wants to admit to having these feelings. Who wants to stand up and proclaim to the world that you wonder if somebody’s grandparent was worth the effort?
So instead of acknowledging these doubts, you repress them. You decide that you’re going to be a good caregiver, not like those bad ones who seem to act only on your worst thoughts. So you take your doubts and you shove them down, bury them deep, you say that you’ll never be like those CNAs…but idealism and good intentions will only carry you so far. Eventually, you will reach the place where everything exists in extremes and to feel at all is to be in pain. In that place, it easier to just shut it off, to distance yourself from that which causes you pain.
In this case, what causes you pain is the same thing that causes you doubts.
How do you handle the stress of constantly never being good enough? When you are constantly given more work than you can do and when you see your residents suffering because of it…what can you do?
Becoming a jaded CNA is not a single decision you make; there’s no switch you flip between “good CNA” and “bad CNA”. It is instead a series of small compromises. It’s slowly learning how to shut off the connection between you and the resident, until that resident seems more like work than a person. It’s getting to the place where your worst thoughts are the only ones you can hear. That’s when you become the thing you swore to never be.
This is how you surrender your compassion…because it hurt too much to care. Empathy hurts and apathy is appealing.
So, to all new CNAs, don’t go in blind. Being a CNA is like holding your heart to a cheese-grater. To feel is to feel pain. You will doubt whether you’re actually doing any good, and any difference you make will seem to die with your resident.
When these doubts came, face them. Look them straight in the eye and do not despair.
Doubts do not define you; a feeling that came over you during the struggle does not make you a bad person. But a feeling you buried deep in the bedrock of your soul, left to fester until it poisoned all the feelings that came after it…that one might, in ways you never expected. Sometimes, they chain you in such a way that you will never get free. The only way to break the chains is to acknowledge that they are there.
Remember that empathy hurts, but apathy doesn’t…because apathy means you don’t feel anything. Not pain and not joy. You can’t have one without the other, not in life and especially not in Long-Term Care.

And most of all, do not forget the other person in the room. Never forget the silent observer to the tiny acts of compassion, to all the sacrifices and struggles to carve out room for good care.
Do not forget yourself. 

Enabling Exploitation

Sunflower May

Times like this, I can really see the connection between nursing homes and haunted houses. Both have claims of being the abode of ghosts and, more relevantly, both seem to have innumerable nooks for people to hide in. Well, maybe not hide in, but it does seem like every time I need help, there’s no one there to help me.
I peak around another door, finally finding the person I’ve been looking for.
“Hey, do you have a second?” I say, panting just a bit. It’s been nonstop all day and I’m exhausted. Perhaps if I was only working one shift today, it wouldn’t be so bad, but it’s another double I’m working today. I swear, even my bones ache tonight.
My hall partner looks up from bagging up a brief. “What do you want now?” she grumbles. She’s been a bit…less than friendly with me and looks like she’s running out of patience.
“I need your help to get Mrs. H to bed,” I tell her, glancing at the clock hanging on the wall and immediately wishing I hadn’t. It’s much later than I thought and we still haven’t started our lunches. At this rate, I’ll be clocking back in from lunch just in time to clock out for the shift.
“Mrs. H is a tiny woman,” she says crossly.
“Yeah, but she’s not standing right now. I’m going to have to use the lift to get her in bed and I need a spotter.” Seeing the hesitation on her face, I hasten to add: “I just need help putting her to bed, I can handle the rest from there.”
My partner does not look happy, but she agrees to come help me…although she takes me at my literal word, standing in the doorway while I hook up Mrs. H to the standing lift and maneuver her into the bed. Before I even have the chance to unhook Mrs. H, my partner turns to leave.
“Go to lunch when you’re done,” she calls over her shoulder.
It takes me a few minutes, but I get Mrs. H finished up and head off to the break room. I haven’t had a chance to sit down since my first shift lunch break…many, many hours ago.

Oh, but sweet mercy, it feels good to sit down! I’m too tired to eat, so I just sit back and attempt to become one with the chair. I feel like all my bones have turned to jelly; like I’m going to have to be poured out of this beautiful, gorgeous, wonderful seat.
It’s entirely possible that my brain has checked out for the night, long before my body can. I fish my phone out of my pocket and open Facebook. Even if I can’t eat, I need to do something or I’m going to fall asleep.
It’s sitting there at the top of my newsfeed, only twelve minutes old.
Worst night ever. Partner is so damn by-the-book and can’t do anything by herself. Seriously, if you’re so lazy or weak, you’re not cut out for this job.”

Twelve minutes old. She must have posted this right after she left Mrs. H’s room. It isn’t until the phone starts to jump in my hand that I realize I’m shaking with anger. What the…I mean, come on! Facebook! By-the-book? Not cut out for this job? Weak because I asked for help with a resident who, while normally one-assist, needed lifting tonight? Would she have rather I took the chance of injuring myself or Mrs. H?

<oOo>

CNAs have one of the highest rates of back injuries among any other profession. Why in the world would we continue to solo-lift residents who are either require two-assist transfers or a mechanical lift?
Minstrel hit the nail on the head with her latest post. There is a “Macho” culture that has sprung up among CNAs—borne, no doubt, from the chronic short-staffed circumstances. Asking for help (and waiting for help) eats up time…time we quite honestly do not have. Every aide is therefore left with a choice: lift and take a chance on hurting yourself or go get help and fall even more behind.
You can start this job with good intentions, decide you’ll never lift a two-assist. That decision wavers the first time you see another aide lift a resident and walk away—apparently unharmed. It crumbles some more when you hear other aides rank each other by their toughness: so-and-so can lift the heaviest resident on her own. Now that’s a good aide!
That decision is left by the way side when you realize that you do not have time to things the “right way” and you take a short-cut. You lift a resident who is explicitly a two-assist. You don’t raise the bed up to change someone. You change the bariatric resident by yourself.
Now you are a good aide, a tough aide. Now you’ve earned the respect of your fellow CNAs.
And when your body succumbs to the strain, when you feel something pop or pull, when you can’t straighten your back without gasping in pain…you pick yourself back up and continue on. You grumble about the conditions that led to this injury, but you are still a good aide, a tough aide and no injury is keeping you down. You don’t have time to be hurt. You’ve seen other CNAs work injured and sick and you applauded them for their toughness. Time to prove your own.

There is, shall we say, an expectation of injury and an attitude of invulnerability at play among CNAs, two ideas that should be contradictory but are held together nonetheless. There is this mentality among Long-Term Care aides, a mentality that says by allowing ourselves to be injured, we have shown ourselves to be weak. Perhaps this is not the right phrasing. Maybe a better way to say this is by allowing ourselves to be affected by our injuries, we have shown ourselves to be sub-par CNAs, weak and “not cut out for this work”.
It’s a tough job, but we’re tougher. Those CNAs who refuse to lift, or who ask for help…these CNAs are mocked and, dare I say, bullied for their caution.

Very little of this, I’m sure, is intended to be malicious. Solo-lifting, after all, ensures that our residents are toileted when they need to be and put to bed when they ask. It ensures that they do not suffer from this broken system. Refusing to solo-lift can be construed as placing your wellbeing above that of a resident…and that’s just selfish.
Isn’t it?
Whatever the reasons and justifications of any party, the fact remains: the health of CNAs is not treated as a priority…not by management, not by the policy makers and not by the CNAs themselves.
This is a problem. True: the conditions of Long-Term Care are stacked so that injuries among CNAs are high. Yes, the resident to aide ratios are so high that doing things the right way slows you down, very often to the point that you are the last of your shift to leave every single day.

I am a CNA and I do not find it acceptable that I live in expectation of injury. I do not find it acceptable that I have to make a choice between harm done to a resident and harm done to myself. Being “by the book” is my quiet protest of the over-worked conditions of Long-Term Care. If we cut corners and finish on time, but document that we did things ” the right way”, then our complaints of being overwhelmed can be shuffled to the side. “What do you mean, you can’t care for 12 residents? You do it just fine according to my spreadsheet and your charting!”
By solo-lifting two assists, we are not proving our toughness as CNAs: we are enabling the system to exploit us.
Take care of your health. No one else is going to do it for you. This system is not set up to treat the health of CNAs as a precious resource, anymore than it is set up to treat the CNA as a valuable member of the team.
I do not solo-lift and I try to cut as few corners as I can. It is not because I am lazy or weak or not cut out for this job. It is not because I like seeing my residents wait for care. It is because this gesture is one of the few resources at my disposal to show why culture change in Long-Term Care is needed. It is my defiance of a system that exploits me and will throw me away if I break beyond repair.
As an individual, I am easy to ignore and my gesture of defiance easy to overlook. Strength comes in numbers. If every aide refused to cut corners and committed themselves to being “by the book” when it comes to lifting…well, now that would be hard to overlook.
I’d go so far as to say that would be impossible to ignore.

Bad Boss Part 2: Consistent or Crazy

Sunflower

May

I tip my chair back, enjoying this. I had to take my lunch late due to craziness on the hall and it appears as though I wasn’t the only one. The break room is packed; everyone is eating and enjoying this chance to relax. Conversation is flowing smoothly–we’ve hit on a great topic, one with legs that could run around the world.
“Oh, I’ve got one and it’ll top May’s story!” T says between bites of her casserole. “So I had this supervisor once, who decided she was going to ‘whip us into shape’. She started disciplining people up over rules that hadn’t been enforced in so long that we’d forgotten what they were. So here she is, a holy terror over everything…until one day she asked why we were so short every shift. Then we had to remind her she’d fired half the staff.”
I choke on my baked potato. “Yeah, I’d say that tops mine.”
“You’d think she would have noticed,” mutters A.
“At least she was trying,” says P, a new aide. I haven’t known her long enough to decide if she’s optimistic or naive.
“The problem,” I sigh, “is consistency. At some point, even a crazy boss is tolerable…as long as they are consistent. If I’m allowed to do something on Monday, I’d at least like to know that I’m not going to get in trouble over it on Wednesday.”
“Only for the boss to decide that the next aide can get away with it on Friday,” T finishes.
“Hard to toe the line when it keeps shifting under your feet,” A agrees. “So which do you all think is better: the boss who never comes out of the office and lets the staff get away with anything or a micromanager?”
“I don’t know about better,” P says, “but based off your stories, I’d rather deal with an absent boss than one who is all up in my business.”
“Yeah, second that,” I say. “I’ve had enough bad bosses to learn it’s best if I just take personal responsibility for my own work ethic.”
T shakes her head slowly, like she’s thinking really hard. “That works for you–and everyone in this room–but what about the bad aides? The ones who don’t care about the quality of their care?”
Three voices rise in unison: “Then they shouldn’t be CNAs!”
“Which,” I add drily, “means that either we step into the gaps they leave or the residents go without.”
“Those kind of aides should just go flip burgers,” A spits out. “They’d make about the same and our folks wouldn’t suffer from their apathy,” P agrees.
There’s silence for a few minutes. Everyone goes back to chewing their food. Thoughts are churning ceaselessly around in my head and, from the expressions on their faces, the others are thinking just as hard. Eventually P breaks the quiet, an almost desperate look etched on her face. “Please tell me you’ve all at least had one good experience with a supervisor.”
I smile at her. “Of course. Matter of fact, we’ve got a pretty good one now.”
“Yeah,” T agrees. “He’s doesn’t do the drama, doesn’t play games and he helps.”
“He’s looking pretty stressed out lately,” A sighs. “I hope he’s not on his way out.”
All four of us look at each other in horror. Truth is, as much as we boast about our ability to self-direct and self-discipline…it’s nice to have a supervisor who can take up the slack. It’s nice to have someone who will listen when we speak, pull us aside when something needs to be addressed. It’s nice to have rules that don’t change with the wind, nice to have someone who doesn’t play favorites and isn’t afraid to be stern when he needs to be. Who isn’t afraid to joke with us when he doesn’t need to be stern. Who we can trust to be fair.
“Oh, God I hope not,” I say fervently. “Let’s go write him Employee of the Month recommendations before we get back to the floor!”

<oOo>

What makes a bad boss? If only I knew. As it is, I have only guesses…thoughts inspired from seeing events from below, glimpses into Management through cracks in the floor. I can only assume it’s the same stresses that make a bad aide. There’s too much to do, not enough time to do and precious recognition or thanks. It’s an impossible job. Only instead of taking care of far too many people for far too many hours, they are juggling the constantly changing demands of Medicare, Medicaid and the Health Department–and keeping the floor in some semblance of function.

There’s also disconnect between the care plans and the living people they represent. It’s a disconnect that in some ways can’t be helped in the current system. Charts can’t convey the reality of long term care, not alone. Accurate documentation of my shift as a CNA would mean writing a novel each day before I go home–there’s just no way to communicate the reality on a glorified spreadsheet.

And in some ways, it’s a disconnect that can very much be helped.

There’s a culture of enforced silence among direct care workers, learned in the dark hours of neglect when speaking up meant losing your job. It’s a habit we’re still trying to break, to speak our truths and tell our stories. There’s a culture of enforced deafness among managers, learned in the dark hours of greed when listening meant being mocked by your peers. It’s a habit we’re still trying to break, to listen with wisdom and compassion.

If all you look at are care plans, then you haven’t seen the person. If all you look at are numbers on page, then you haven’t experienced the toll those ratios take on your employees and residents. The best of bosses know the people they are responsible for, both residents and caregivers. They are the ones who can read on my face when I’m about to break down, who care about me enough to step in and say: “What can I do to help?” But that takes time. That takes energy.

That takes a real dedication and devotion to the art of caregiving. To all good managers and bosses–thank you from the bottom of my heart for all you do and risk for me. It does not go unnoticed and, I hope, does not go un-thanked.

The Tale of Two Trainers

Sunflower

May

Training new aides is an important link in the chain of long term care. Unfortunately, it’s also a link that is neglected. Today’s post starts a three-part series on my experiences with training and my own experiences on either side of the problem. First up: it’s my first day and I’m as green as green can be!

There’s something daunting about a parking lot on your first day of a new job. Most people are creatures of habit: they’ll park in the same general spot every time. I’m rather convinced that I’m in someone else’s spot…and then tell myself not be stupid. This isn’t a club, this is a job and as far as I can see, there’s no assigned parking. I walk in the side door, trying not to show my nerves. It’s my first job as a CNA and I think I’m as green as green can be. I did my clinicals in an assisted living facility and I just know that this is going to bite me in the butt. The day I did my tour of this facility…my facility, I didn’t recognize any one of the mechanical lifts the DON pointed out. Or any of the other equipment she showed me. The other girl in orientation with me had known the names of the equipment and had seemed to know what to do with them. I push aside my nerves and approach the nurse’s station. There’s a nurse there, and another young woman in scrub pants and a blue tee shirt. She isn’t wearing a name badge, so I’m not quite sure who or what she is.
“Hello,” I tell the nurse on duty.
“What do you need?” she asks gruffly.
Well, I think, that’s a great start. “I’m May,” I tell her, “I’m new here; it’s my first day. Could you tell me who–” I check my paper–“A is? I think she’s my trainer.”
“That’s me,” says the young woman in the blue shirt. “Nice to meet you, May; have you been an aide before?”
I shake my head.
“Well, we’d better get started,” she says briskly. She turns and walks away; I scramble after her. She shows me where to put my stuff and we’re off. By the end of the shift, I’m quite impressed with A’s jaw muscles: she’s kept up a steady stream of talk all shift. She introduces me to the other aides and all the residents. Resident introductions are strange, I think, as she tells me not only their name but also their transfer method and other pertinent details of care. Hoyer, standing lift, two person, one assist. Contractures, she hits, this one’s not ours, very confused, steals other residents shoes. Don’t give her your hand.
That instruction comes a bit too late as I pull back my hand, trying not to gag at the sticky, shiny layer of saliva now covering it. The resident, a woman with curly white hair and an innocent expression, had nonchalantly used my hand as a hankie, bringing to her mouth and spitting in it.
My head is spinning and I feel like I’m drowning in information. How on Earth am I supposed to remember all the details I’ve been told. On the other hand, while I feel like A has practically buried me in names and details, she isn’t as thorough with the physical side of the job. I follow her from room to room, watching while she does all the work. Whenever I try to help her, she’s just too fast to keep up with. I couldn’t tell you how she did it, let alone how to do it myself. Oh, well, I tell myself. It’s only the first day and maybe I’m just meant to shadow on the first day. I’ve barely seen H, the other new girl, all day long and whenever I do, she is trailing J, her trainer. J is also keeping up a steady stream of instructions. J also doesn’t seem to like me very much, hardly speaking to me and shaking her head whenever she overhears one of my many questions. Apparently, I should already know this stuff. First day and I’m already falling behind. Darn clinicals held at assisted living instead of nursing homes! But then, that wasn’t exactly my fault.
At the end of the sift, A tells me she wouldn’t be my trainer on the next day (as it’s her day off) and says I will be with V…then she had added, her voice full of scorn, to watch out for V and not to pick up any bad habits from her. J scoffs, rather loudly, upon hearing that V has been selected as my trainer.
Well that’s not worrisome at all, I think, before gratefully climbing in my car and driving home. I’m utterly exhausted and my head is still spinning from all the information thrown at me today…unfortunately, the only resident whose name and information I can clearly remember is Mrs. R and that’s because it’s hard to forgot that sweet little lady who spit in my hand.
The next day starts the same as the one before. I get to work, park in the same spot, notice that all the other cars are more or less parked in the same spots too and go through the side door. The same gruff nurse is there, but this time she’s alone.
“Hello,” I say again.
“V is always late,” she tells me. “Just wait here for her.”
So…always late and don’t pick up any bad habits from her. If V is the kind of employee I’m getting the idea she is, why is she the one training me today? H and J arrive and get straight to work while I’m still standing at the nurse’s station, waiting for V and trying not to get testy with impatience and nerves. At last a tall blonde sweeps in through the door. The nurse jerks a thumb at me and says: “This is May. She’s with you.”
V greets me warmly. Ok, then, I think. Maybe J and A just don’t like her. Maybe she’s not actually a bad aide. This comfortable idea last until the first room we go in, whereupon V begins to change the resident without putting on gloves.
“Um,” I say, my own gloves halfway on.
“Oh, don’t worry about it,” V says airily. “If you’re a good enough aide, you won’t get anything on your hands.”
Excuse me? What? I stare at her, a sinking feeling in my stomach. Then I snap my gloves on with a bit more noise than strictly needed. V points to the other resident in the room. “Get her dressed,” she says. Ok, then, I think.
It’s the first time I’ve ever gotten a resident dressed on my own and I’m not quite sure what’s the best way to go about it. V isn’t helping. She’s finished her own resident and is now just standing against the wall. She only speaks to tell me to hurry up…eventually she does unfold herself from the wall, only to push me aside and finish the resident herself.
Well, I guess that J and A have good reason to dislike V. I don’t think I’m too fond of her either.
The rest of the day is just more of the same. V sets me a task without telling me how to do it, mutters impatiently while I try to accomplish it, then pushes in to finish it herself. There’s no talk of hoyers or standing lifts or two assists–V insists that if you’re a good enough aide, everyone is a one assist. I’m always back from our breaks long before she is and so spend a good bit of the day waiting. The gruff nurse is still at the nurse’s station and she also doesn’t seem too fond of me, so I take to waiting on the bench outside the clock-in room. If I had a clue what I was doing, I’d go ahead and start working without V. But I don’t, so I just sit and wait.
J and H pass by; J slows down long enough to ask me: “How’s it going?”
People have called me timid before…and I know I’m shy, uncertain. I’m also young, in a strange new job and terribly frustrated. “V is hard to keep up with,” I say shortly. “And I thought you always wear gloves when providing care.”
“V!” snaps J and I turn around to see V glaring at me. Great. Just great. “While you are training new aides, you will wear gloves or I’ll tell the nurse. Got it?”
What? While you’re training? Shouldn’t that be something more along the lines of “while you are changing briefs you will wear gloves”? V just glares at me and ignores J. The rest of the day goes worse. V’s still upset with me, but she’s decided to talk to me now. She talks non-stop the rest of the shift, like A did the day before but I don’t even bother trying to remember anything she says. It’s just the same thing repeated over and over. “There’s the way you do things for your test and there’s the way you do things on the floor. You don’t have time to do things the right way. You’ll see.”
I’m quite glad when the shift is over. I ask the nurse, quietly, if it can be A that trains me next. She goes too fast, throws too much information at me and doesn’t show me how to do things as thoroughly as I’d like, but at least she wears gloves. At least she doesn’t disappear like V does.
The next day it’s A. I’m so happy I completely ignore V, who is still glaring at me.

All about the money…except it’s not

MaySunflower

The world of long-term care is changing. CNAs are no longer a silent workforce, an easily replaced part of the machine inside healthcare, and labeled “ass-wipers” outside. Earlier this month, CNAs around the country raised their voices together for better pay. For the most part, the response to this was positive.
And yet, there were still seemed to be some who were blindsided.
“Where’s this coming from? You said you weren’t in this field for the money!” “So I guess money is what you care about after all.”
“If you want real money, get a real job.”
Even worse, I think, are the unspoken accusations: a good, selfless CNA shouldn’t be concerned by how much money they make an hour. A good and selfless CNA isn’t in this for the money.

You see, it’s not really about the money. It’s about what the money represents: respect. Call us angels or ass-wipers, but still we are shoved under the rug, forgotten in the corner. But we do not stand alone. Behind every stressed out CNA there are 10-20 residents. People who are soiling themselves because there are not enough aides on the floor to meet their needs in a timely fashion. People are often quite aware that their needs have been placed very low on society’s priorities.

“But with the current pay and workloads, the job is still getting done!”
I hear this one a lot. It’s true, I suppose: CNAs work jobs that have pathetically low pay and where they have to care for over a dozen residents by themselves.
The workloads go hand in hand with low pay: we’re often paid a less than living wage to do the work of two or more people. But fewer people are willing to do this anymore. There’s a CNA shortage, and a turnover rate that is mind boggling…well over 50%.

So many of us work multiple extra shifts a week or struggle just to keep our families fed. It might seem an “acceptable budget measure” to keep the pay and staffing low,but I assure you, it is not “acceptable” on the reality of the floor. You cannot give from emptiness and there is little as draining as exhaustion and stress. And yet we are still expected to provided the best care or else…here come the ambulance chasers. Here come the lawsuits and state complaints.

Policy makers, I’m speaking to you personally. If you truly believe that excellent, personal care can be provided to 12+ people by an exhausted, stressed out and fiscally struggling caregiver…come be my resident. Come live in the world you have created. Come be my resident, dependent on me for everything and having to share me with 12+ other people. Tell me then that below average pay for caregivers is an “acceptable measure”. Tell me then that my residents are not worthy of enough respect to give their caregivers a living wage and good working conditions.
Tell me then that pushing for higher wages is a sign of greed; that pushing for better resident-to-aide ratios is a sign of laziness.

It’s not about the money. It’s about what the money represents: respect. Respect for me, for my chosen field…respect for the elderly and disabled that I care for. They are worthy of having a caregiver who isn’t scrapping by. They are worthy of having a caregiver who isn’t a few double shifts away from having a nervous breakdown. They are worthy of my time and they should be worthy of the money it will take to give them proper and personal care.

Suffering the consequences

MaySunflower

“I just can’t believe it!” my supervisor rants. She’s red in the face, her breath coming in quick and angry. “I hope you all know you’ve done this to yourself! Why do you keep shooting yourself in the foot?”
It’s a typical: something’s happened and we’re in a meeting. The supervisors are informing us of our mistakes and we are silent on the opposite side of the room. Typical. Happens a lot in long term care.

But don’t jump to conclusions. This isn’t a story about the problems of leadership of long term care (that’s for another day). My supervisor might be angry, but she’s got reason to be. This situation is, maybe miraculously, exactly as she’s said.

Anyone who’s set foot in a nursing home knows exactly what I’m talking about. Gossip. Older aides being mean to new staff. Working in cliques. Aides refusing to a call light because “it’s not my resident”. Saying, in the middle of the hall way with residents around “I hate my job!” Acting like it’s an inconvenience to take care of a resident.
You know, shit like that.
My supervisor is asking a valid question when she demanded “Why?”
Why do CNAs shoot themselves in the foot? I’m not saying every aide does it, but I’m not going to deny it happens…more often than it should.

I think, in part, it’s because this is a hard job and so personal in every detail. I was trying to explain to a friend how long term care was a different beast from other kinds jobs. Without belittling the importance and value of other jobs,
“Imagine every mistake you make at work. Now imagine that mistake happened on a human being. Now imagine that mistake happening on someone who has lost the ability to do anything for themselves.”
Is it any wonder we aides get stressed? But it’s not just stress. It’s also guilt. I got in a hurry and tore the skin from this human being’s arm. I walked past that call light because I was so hungry and that human being soiled himself. I got frustrated and the human being, whose wellbeing is my responsibility, heard me say how much I hate this place.
That’s a lot of guilt and you’d better believe it stings.
At the same time, every aide knows all too well that feeling of helplessness. It’s not a good situation and who knows when it will get better. Some days, it feels like it never will.
I did my best today. It wasn’t enough. My residents still went too long between changing. I haven’t brushed their teeth in so long. I did my best today, but it’s not enough. It’s never enough. My personal passion can never cover the flaws of the system.

Guilt combined with helplessness and pure stress turns into frustration. Frustration spills out.
Even worse, frustration can turn some people numb. It’s a losing battle anyway, so what’s the point? Why exhaust myself when the effort doesn’t change a thing?
Have you ever seen a caregiver turn numb? Have you ever seen a caregiver lose their sense of empathy for the resident? When their perception of the resident shifts from “human being whose welfare is my responsibility” to “nuisance in the way of getting my work done on time”.
It’s not good. It’s also not rare.
In this state of mind, it’s easy to lash out, say things we shouldn’t. It’s easy to exude a toxic atmosphere when there’s so much resentment, guilt, helplessness and other negative emotions built up inside us.

I get it. I really do: I’ve been an aide long enough to be familiar with both the guilt and the helplessness. When your best isn’t enough, when nothing you do seems to make a difference, when exhaustion sinks its claws into you…I get it. We’re only human; we aren’t infallible angels. It is too much to ask of us, at times. How can we be positive and cheerful with new aides when we’re just so damn tired?

The flaws of the system do not absolve me of my personal responsibility to take care of my residents. Proper care means proper staffing…means not running off new aides with a toxic attitude. I’m the one who chose to fight this battle…so either I keep fighting for their dignity or I quit. No other options, no other door.

Simply put, CNAs do not have the luxury of shooting ourselves in the foot because it is not just us who suffer from the consequences. Other human beings, whose welfare is our responsibility, suffer as well.

That is the question, part one

Sunflower

May

It’s the oddest conversation I am not part of.
I mean, I’m just sitting here quietly, chewing my food and watching two other aides fight it out. Neither one of them is backing down and I honestly agree with both of them…which is odd because they cannot agree with one another.
Like so much of the world of long term care, this argument arose over being short staffed.
“We have a responsibility,” A says with conviction. “You see how many open shifts there are this month! I have a responsibility to my residents not to let them suffer and that means picking up shifts when I can. Working over, to make sure they get the quality of care they deserve. If I don’t do it, who will?”
“I have a responsibility,” B says firmly. “I have a responsibility to my residents not to burn myself out. You see how often people quit! I have a responsibility to my residents to make sure I’m here for a long time. That means pacing myself and not working insane hours. If I’m not here for these people down the road, who will be?”

Ah, that is the question. Questions, I should say…although, at their root, both seem to be of a similar flavor to me. But my lunch break is over and I need to get back to the floor.
The questions linger in my head, possible answers swirling around.

The appropriateness of black humor

Sunflower

May

It’s suddenly become very quiet in here. Laughter dies away, awkward silence chasing away the echoes. The new aide stands there, fuming and furious.
“I don’t know what you all think is so funny,” she snaps. Her anger is pitched much higher than our mirth and I wince. “Show some respect, would you? It’s not appropriate–”
“To laugh?” I ask. “To enjoy the memories of the woman we’ve all cared for? Mrs. Z was a hilarious lady and how is it not appropriate to laugh at her final joke?” Other aides around the table nod in agreement.
Taken slightly aback, the new aide blinks rapidly and tries a different approach. I’ll give her points for courage: she is most definitely not afraid to speak her mind. “You’re laughing about a dead woman. What if her family hears you?”
She’s once again interrupted, but this time it isn’t by me. The break-room door opens and in steps Mrs. Z’s daughter, as if summoned by our words. Her eyes are red, her cheeks stained with tears…and she looks blazingly angry.
Aw, hell. A part of me wonders why a family member is in the staff break-room, our safe haven from the floor–but that question is almost completely drowned by sheer panic. It’s not that I’m ashamed of what I said, it’s just that I chose the place I said it with great care..all for nothing now. Any doubt that the daughter heard our conversation is quickly laid to rest.
“What final joke?”
I seem to be voted spokesperson by the entire break-room. Well, I suppose I was the one telling the story…”Her dentures wouldn’t stay in. When I was getting her cleaned up, they kept, um, popping out whenever I’d turn my back. She always hated those dentures,” I add wistfully. Mrs Z used to spit them out any chance she’d get and I swear she would aim for me half the time.
Mrs. Z’s daughter doesn’t laugh.
She smiles. It’s kind of weak and watery, but there’s no doubt it’s genuine; the anger fades from her face. A couple rough swallows later, she speaks again.
“Sounds like Mom. Feisty to the last,” she sighs. “Did you get them to stay in? I didn’t even notice.”
A collective sigh seems to go around the break-room. Everyone looks relieved, except the new aide who mostly looks confused.
“No,” says another aide, setting down her sandwich and speaking for the first time, “she sure couldn’t. May is stubborn, but she’s no match for your mom.”
“Nobody was,” the daughter agrees. “Um, I’m just here to, um…” Her throat seems to close around her words and she just waves a hand clutched around a somewhat squished Danish. Someone must have pointed her to the break-room as having the closest microwave.
Someone stands and takes the Danish from her, popping it in the microwave. Not another word is spoken until the microwave beeps and the Danish is returned to her.
At the door, the daughter pauses. For the first time, she looks directly at the new aide who was scolding me. “Thank you for thinking of my feelings,” she says, “but Mom always preferred her jokes to be laughed at. Said it made her feel useful, to make you guys’ day a bit brighter, like she wasn’t helpless after all. I’m glad…she was able to one last time.”
The door shuts and a different silence falls on us. Most of us are furiously blinking back tears.
Finally, the aide with the sandwich turns to the new girl. “Your problem,” she says, waving the sandwich around to punctuate her words, “is that you still think grief only wears a sad face. Everybody knows May loved that lady and the only thing she’s guilty of is terrible timing. Don’t get bent out of shape and don’t tell me how to grieve my resident.”

One the most shocking things coming into long term care (or indeed any part of the medical profession) is the humor. It’s so markedly different from anything else in the outside world.
It’s often seen as calloused, disrespectful and symptomatic of a lack of compassion. While that might be the case some of the time, I’d submit that it is not the case as often as you’d think.
Humor is how we cope. It’s how we deal with what we have to see. It’s just that what we see is wildly outside the norm of American culture that our humor falls outside the normal bounds. We see bodily fluids, crumbling minds, lots of shit and death…and so our jokes reflect that.
That being said, there is a time and a place for CNA humor and in front of grieving families isn’t it. I’m just grateful the daughter understood the substance of my story and didn’t stop at the unusual surface.

Horizontal Violence Among Direct Care Workers

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Yang

In my last post, I suggested that there may be something about the Long Term Care work environment that makes conflict among caregivers almost inevitable. Some – or perhaps even most – of the behaviors associated with this conflict could be described as “horizontal violence.”

Horizontal violence is a form of hostile and aggressive behavior exhibited by individuals or groups toward others within the same peer group. It is usually not a physical kind of violence, but relies more on emotional and social pressure. It includes a wide range of negative behaviors, both overt and covert. Examples include such things as direct verbal abuse, belittling gestures, threats, intimidation, gossip, “humorous” put-downs, sarcastic comments, social exclusion, nitpicking, ignoring legitimate concerns, withholding support, and slurs based on race, ethnicity, religion, physical appearance, gender or sexual orientation. In a word: bullying.

The thing that makes horizontal violence “a thing” is not a big list of nasty behaviors. These can happen anywhere and for a lot of different reasons. Horizontal violence is a phenomenon that occurs within oppressed groups. That is, groups of people who do not feel as though they have the means to adequately address the most significant problems and issues associated with their group. Some respond to this sense of powerlessness by becoming submissive and exhibiting learned helplessness. Others respond by adopting feelings and attitudes of superiority over others within their group. In a sense, both are coping mechanisms, characterized by inappropriate and self-defeating behaviors.

If a sense of powerlessness is at the heart of what it means to be an oppressed group, than direct care workers certainly qualify. Overworked, underpaid, and unsupported, LTC caregivers generally do not believe that they have the means to independently create the kind of fundamental change that would address these issues in a meaningful way. You either accept “that’s just the way it is” and learn to do what you can with what you have – or you leave.

At the bottom of the LTC hierarchy, the caregiver brand of horizontal violence plays out in one of two ways. The first way is the classic division of Older Workers vs. Newer Workers. This divide is typical in nursing in general and most of the literature I’ve come across regarding horizontal violence has to do with career RNs, but it applies just as well to nursing assistants.

New workers enter the field with a set of expectations of what caregiving is all about and are soon disillusioned by the reality of what they witness on the units. If they are unable to adapt to “the way things really are,” the more experienced caregivers have ways of putting them in their place. Newer workers are regarded as both naïve and judgmental – and perhaps even threatening – because they base their impressions of experienced workers on unrealistic expectations.  They often become victims of horizontal violence, not fully comprehending why they are being mistreated.

The second situation is created by the absence of adequate and appropriate involvement of management in the typical LTC work environment. The formal rules and standards are enforced inconsistently, sometimes capriciously, depending more on personality and circumstance, such as inspections or any other time the facility is under public scrutiny. Good workers go unnoticed and poor workers go uncorrected.

By default, caregivers are left to fill the vacuum and develop their own norms and standards. These can be very different from facility to facility and even from unit to unit within the same facility. To one degree or another, they are informally enforced by the strongest personalities among the established caregivers.  In the best circumstances these norms and standards are communicated through example and positive leadership, but often they are enforced by various forms of horizontal violence.

Caregivers frustrated by their inability to formally address the larger problems of the Long Term Care workplace find an outlet by dominating their coworkers. Others simply acquiesce, doing their best to keep to themselves as they struggle to find a balance between the official standards, pressure from their workgroup, and their own sense of right and wrong.

In my next post, I will share my take on how we as caregivers should approach the problem of horizontal violence in the LTC workplace.

For more information on horizontal violence:

http://www.nursingassistants.net/horizontal-violence/

http://www.cnaboard.com/2010/useful-cna-information/certified-nursing-assistants-and-horizontal-violence-in-the-workplace.html

https://www.birthinternational.com/articles/midwifery/69-horizontal-violence-in-the-workplace