Category Archives: nursing home

Deal or No Deal: Choosing a Long-Term Care Home

 

Minstrel

They’ll want to show you their renovated patient rooms and their glitzy calendars. They will want you to see the art room and hear about the visiting music therapist. They’ll make sure you notice the flower-bedecked reception area and see the nicely-appointed dining room. They might even cite the training their aides receive. And these are all positives. But administrators of long-term care homes may not encourage you to examine the nuts and bolts. To spend the time it takes to make a true assessment of the standard of care and the residents’ ‘joy’ levels. (Yes, that’s what I said, JOY.) You need a more evidence-based way of assessing the quality of care your loved one will get in the long-term care home that may cost $4000 to $12,000 a month. What do you look for to judge the quality of the home?

When you visit a long-term-care home your tour guide might want to direct your attention to superficialities or to things no longer relevant for your family member, especially one declining physically or cognitively. (Smart TVs, anyone?) Here are some features that are essential for your family member’s well-being. Look for them. These are the minimum No-Frills tests your prospective long-term care home should be able to pass.

1. The Wheelchair Test, suggested by ‘May,’ a former CNA Edge contributor. When you visit a home take a good look at wheelchair footrests and frames. Are they clean? If not, other unseen areas may be neglected. Are footrests attached to the wheelchair? Sometimes a resident benefits from ‘paddling’ along with her own feet; this can strengthen ankle or leg muscles. But if you see residents being wheeled uncomfortably without footrests, this may signal minimal attention from aides and inadequate monitoring by nursing supervisors.

2. The Bathroom Linen Test: Are there clean facecloths and towels in bathrooms? Shortage of towels is a perennial problem in care homes. If management is asked they will tell you that the residents hide towels, and this is sometimes the problem. But sometimes the problem is that there simply aren’t enough towels, or not enough laundry workers to ensure that clean towels are always available. How can we maintain hygiene standards if there aren’t clean bathroom linens? Ask to visit a few resident rooms. If the tour guide discourages you from seeing occupied rooms (“Privacy Rights.”), befriend a resident and ask if you can see his/her room. This will nearly always gain you access.

3. The Warm Water Test. All medical authorities tell us that hand-washing with warm water is the best way to prevent the spread of infection. CNAs are expected to wash their hands with soap and warm water frequently. When you visit a room, check out the sink. Do warm-water faucets in residents’ bathrooms and hall toilets actually run warm? How long does it take to get hot water? If you aren’t able to enter a resident’s room, try sinks in the visitor’s toilets, in the kitchen area, wherever you can find a sink that should have hot running water. The water may warm up after two or three minutes. But when an aide might have only five or ten minutes to get a resident washed and dressed in the morning, she might not have that two minutes to wait. Your family member might get a cold face cloth first thing in the morning. Is this what you want? Do you want the most basic infection-control measure, warm water, to be MIA?

4. The Bath Room Temperature Test. Visit the bath or shower room. Is it warm enough? Older residents usually want warmer rooms for bathing. When they leave the bath or shower, they shouldn’t shiver and shudder.

5. The Call-Bell Test. Do you hear annoying call bells that go unanswered? How long does it take an aide to attend to the person calling for assistance? If these annoy you, imagine how they affect a resident who feels anxious and confused.

6. The Chair-Alarm Test. Notice the residents’ bed and seats (both wheelchairs and other seating) to see if there is a chair alarm on the seat. Virtually every group with an interest in improving the lives of residents in long-term care homes, including CMS, recommend eliminating the use of chair alarms. “But these keep residents safe,” supervisors will say. Evidence suggests that they don’t keep people safe and indeed lead to more falls. (Google it!)
7. The Noise Level Test. It’s not only alarms that can distress residents. If aides routinely shout down the hall to each other, this can be upsetting.

8. The Dining Room Test. How is the noise level? Is hot food served deliciously warm? Are residents offered condiments (salt, pepper, sugar, mustard, ketchup) they would have used at home? Are the aides attentive to residents or do they converse mostly with each other during mealtime, as if this were an extra break time? For those who can no longer use a knife, is the food served in bite-sized portions that the person can comfortably chew? Are residents offered refills of drinks?

9. The Calendar Test. Every long-term care home has its monthly calendar of activities posted prominently. Pay attention to the type of activities offered, how often the calendar matches what is happening in real time, and whether residents seem engaged when they are at the activity session.

10. The Family Council Test. In elder care homes a Family Council is one of the strongest ways we have of monitoring care and advocating for high-quality care for residents. Many homes do have resident councils, but frail elderly residents, especially those with dementia, either don’t know their rights or just can’t express their needs and preferences and criticisms. They rely on us, their family and friends, to be their eyes and ears and their mouths. Once they needed you as a caregiver, and you did that lovingly. Now they need you to be their advocates. So ask whether the home has a Family Council.

11. The Staff-to-Resident Ratio Test. You want your family member to get the attention and care she/he needs. You ask the supervisor about staffing levels and are told, “We meet all the state’s requirement for the number of staff.” And they probably do. The problem isn’t that the home isn’t staffed according to standards. It’s that the standards don’t meet today’s needs. Our expectations for care are higher today. Residents’ needs are also greater; many have cognitive as well as physical disabilities. In some homes there is one aide assigned for eight or ten (sometimes more) residents. And if an aide calls out sick or has a family emergency at the last minute, the ratio is worse. Care quality is worse. Though you may not find an ideal staff-to-resident ratio anywhere, at least ask about this. Ask whether census or resident acuity determines the staffing level. Ask how the home assesses resident acuity, and whether dementia symptoms are factored into acuity.

12. The Supervisor Test. Who is responsible for monitoring care standards of the unit your family member will live in? Where is that person’s office located: within the unit or in some distant section of the home? Ask to see that person’s job description. (After all, you’re paying the salary!)

13. Last but not least: The Aide-Engagement Test. Do aides smile and make eye contact when they engage with residents? Do they seem to know and respect the residents’ needs and preferences? When a resident calls out for something—a snack, an answer to a question, a response of some kind, how do the aides respond? This may be the most important thing to look for on a visit: how aides interact with residents. To get a truer picture of aide engagement you’ll need to visit several times, including weekends and at different times of day or evening. Midmorning. Mealtimes. After supper. Try to visit during a change of shift. Are aides still available to pay attention to residents during shift changes?

When you’re evaluating long-term care homes, don’t be overly swayed by the charm initiatives of the marketing staff. Instead, use this checklist to observe those conditions your family member will live with day in and day out. There is more involved in achieving excellence of care. But these concrete items can be clues to less visible elements of quality care. If those in charge aren’t getting even these basics right, are they really committed to the loftier goals they claim to have?

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. 

Broken System vs Personal Responsiblity

Sunflower  May

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

If there’s a story of my career in health care, it’s probably: Nothing happens the easy way, or when I have time to deal with it. Take right now, for instance.
Mr. K has a reputation for being a jokester; he loves to laugh and he loves to make others laugh. The aides are his best audience as we always appreciate a bit of levity. Unfortunately, Mr. K doesn’t so much speak as he does mumble. It’s hard to understand him…especially when he’s cracked up laughing at his own joke. I know from experience that if I keep just repeating that I can’t understand him, his joy will vanish like his independence. So, I lean down and put my face right next to his mouth, in order to catch the words of what I am assuming is a killer joke. When he repeats himself yet again, I don’t take in his words. I can’t; I’m a bit distracted.
His breath is so foul, it smells like something died in it.

I didn’t brush his teeth this morning. I haven’t brushed his teeth all week. As I gag, I ask myself “How did this happen?”

Oral care is often the last part of personal care to be done, and by the time I get to it, I’ve been in the room for fifteen minutes already and ten other call lights are going off. It seems like a quick task, so it’s easy to say “I’ll get to it in a moment,”…and then never actually find time for that moment. When you’re scrambling just to change your people, making the time to do oral care is hard. Adding another five minutes to each resident’s personal care time, when you have ten residents and you’re already running behind…yeah, that adds up quick. Sometimes it is literally a choice between brushing Mr. K’s teeth or changing Mrs. L’s brief before she soaks through her pants. In other words: when you only have ten minutes, what is the most effective way to use them? Most often, we choose the big problems to tackle, the things that have an immediate impact on our residents’ quality of life.
The other problem is that we get so used to dealing with emergencies, crunch-times and hard decisions. We get so used to cutting corners just to survive the day that we form habits around the emergencies. The little things that we had to drop during the crisis? We forget to pick them back up. We get used to not brushing teeth.

The problem of oral care is the problem of this broken system of long-term care, narrowed to razor-thin focus: too few aides taking care of too many residents. We have a system that punishes the aides who take the time to provide good care, and then punishes them again for providing mediocre care. And yet, for all that is true, Mr. K’s mouth still smells like something died in it. I am still his aide…do the flaws of the system really absolve me of my personal responsibility? Being a CNA is, in so many ways, to be forever caught in the moment of drowning: my best isn’t good enough and yet my best is always required.

I laugh, like I got the joke. “Good one, Mr. K! Tell you what, while you think of another one, I’m going to brush your teeth, ok?”

Hangman Holidays

Sunflower   May

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

Perhaps the strangest part of being a healthcare worker emerges around the holidays. A lot of my family and friends talk about how what they are going to do with their time off; I wonder if I’m going to get any time off or if I’ll have to work extra this year again. 

This is by no means exclusive to healthcare…but it often feels like it. The debate that rages around stores being open during holidays is always “Why do they need to be open? We can shop/go to the movies/eat out/do whatever another day!” You can’t really say that about healthcare. In fact, I’m pretty sure that if all nursing homes and hospitals closed on Christmas, society would come to screeching, screaming halt. No one would celebrate and many would die from lack of care. 

So, nursing homes and hospitals must stay open during holidays, which means they must be staffed. Which means CNAs (among others) must give up their holidays to show up at work and care for their residents. 

The problem is, we want time off to celebrate with our families just as much as everyone else. There’s always an increased amount of grumbling during the holiday season as we try to squeeze family dinners into our few hours off,  have to wake the kids really early in order to them open presents on Christmas morning and miss our various religious services because of our hectic work schedule. There’s a bit of resentment that creeps in even the most dedicated hearts when we’re wearing scrubs while everyone else is dressing up. 

Scheduling around the holidays is like playing Hangman on steroids. It’s trying to guess who’s going to call in because she “deserves Christmas morning off”, who’s going to be cranky all day, who’s going to trade hours with whom. Some aides always seem to be able to get off, while other aides always seem to work every holiday. The reliable/really dedicated aides get called out like vowels during a game of Hangman, which creates its own kind of resentment when you’ve worked doubles on Thanksgiving, Christmas Eve, Christmas Day, New Year’s Eve and then you’re also asked to work New Year’s Day. 

It’s not all bad. I love being with my residents on holidays…just as long as I get a chance for me to celebrate as well. Really, it’s the usual short-staffed story, just exasperated because of all the holiday cheer and emphasis our culture puts on having time off and family get-togethers.

How do you all cope with the craziness of the holiday season at work?

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.”

Small Gestures Go A Long Way

Sunflower  May

This would so much easier if there were tears, screaming or something. Hell, at this point I’d take a nightmare and violent confusion. I know how to soothe nightmares. I’m good at chasing the monsters away.
I’m not good at this.
I don’t know how to make this better, this lingering listlessness, the utter lack of energy and interest. It’s not like I’ve never seen this before: depression is wide-spread in the nursing homes. Depression is a hard thing to treat, harder still to manage in the time-crunch of Long-Term Care…the CNAs quite literally do not have the time or emotional energy to coax every one of our residents out of the deadened state of despair every time they fall into it. The sad truth is, when a resident refuses to get out of bed, that’s one less person you have to try to get back into bed later. It’s easy to let slide. It is, after all, the resident’s right to refuse. You can’t make them get up and coaxing takes time. Sometimes a lot of time. You say “I’ll get them next time,” and the next time things are so hectic that you don’t even remember your whispered promise. Eventually, you realize that you’ve let your depressed resident stay in bed for the tenth shift running…but by now it’s a habit, both for you and the resident.
I’ve seen it a hundred times, and I’ve had to turn away, had to prioritize my other residents who really wanted to get up and interact with the world over the one who continually refuses to leave their room…the one who just wants to sleep.
Not this time. I can’t make Mrs. N get up, but I can’t just leave her to wallow in her own regrets and despair.

“I’m not leaving you like this,” I say suddenly. “I’m not giving up on you, okay? I really don’t care if you appreciate it or not. I’m not giving up on you. Ok, then think, May. What helps alleviate depression?”
Sunlight.
I rush to the window and twitch the curtains open. Light floods the room, chasing away the shadows and warming the air. A thousand dust-motes swirl in the golden beams. Well, I feel better, at least…strange how quickly the sunshine can work on human physiology. Mrs. N stirs and mutters. One eye opens, just a tiny sliver and then it’s squeezed shut with a force that only a person can only manage when they’re awake.
Well, that’s sunlight. I can’t think of anything else to do and as much as I like to shut the door and say “I’m not leaving her alone,” I can’t abandon my other residents. Also, if I push too hard, I could unravel any progress I’ve made.
I lean over her and squeeze her limp hand. “I’ll be back,” I tell her.
It’s a busy day (as per normal), so it isn’t until a couple of hours later that I’m able to slip back into Mrs. N’s room to check on her. She’s still laying motionless in her bed, but she’s oriented to the window and her eyes are open. She’s staring out at the green grass, the trees and the flowers. As I watch, a tear slips down her face.
What’s it like for her? She knows that even if she musters the energy to get up, even if she goes outside, she can’t do anything help. She can’t run across the grass, she can’t reach up and touch the trees. She can’t pick the flowers.
Flowers.
I rush from the room, down the hall and out the front door. Thank God for landscaping, because I don’t have to search very long to find what I was looking for.
I head back inside, back to the room that remains gloomy, in spite of the warm sunlight still pouring through the window.
“Here,” I say loudly, ignoring the way she slams her eyes closed and pretends to sleep. I set the handful of flowers I picked down on her bedside. “These are for you.”
She’s so startled that she drops the act mid-snore. I hear a call-light go off down the hall and I reluctantly turn to leave.
“Hey, little girl.”
I turn back. Mrs. N is clutching all of my flowers in her hands.
“Bring me some more tomorrow?”
“Oh, you bet,” I agree softly.

Those of us with whole bodies and sound minds, I think we often forget to appreciate the simple things. Things like opening the curtains to let in light, going outside for a walk when we feel blue. The natural world is bound up tightly in our psyche…replaced by the sterile environment of a hospital-like nursing home, is it any wonder that depression abounds in nursing homes? We can’t give our residents back everything they’ve lost: their mobility, their independence, their careers and loved ones.
By contrast, it’s a simple thing to bring a bit of nature to those who cannot go out to nature…to open a curtain, hang up pictures of landscapes, take them outside for five minutes turn on the Nature Channel, or bring a handful of flowers to a depressed resident who won’t leave her room. But simple doesn’t mean insignificant and small gestures often mean the world to someone who has learned the hard way not to take anything for granted.

There is something about nature that speaks to our primal nature, that has the ability to soothe us even after we lose our words or our will. There’s something about natural light that makes us feel at home, something about flowers that delights us. These primal instincts are a caregiver’s best friend, if you learn how to harness them.

The Things They Never Tell You

Sunflower  May

Here’s something that’s not quite––or not at all––a newsflash: human beings are sexual creatures.
Here’s something that’s (an often quite hilarious) newsflash: old people are still sexual creatures.
They still notice and remark on certain aspects of life that maybe we young folk would prefer they do not. Occasionally, we young folk are the ones they are noticing and remarking about.

At times this attention is sweet, like the nine marriage proposals I’ve received in the course of my career–only three of which were delivered in a location other than the shower room.
Or the time I went to wake up a resident and was subjected to a long, loud verbal tirade about how I was thoroughly unpleasant person and he was his own boss. This tirade derailed the instant he opened his eyes…prompting him to interrupt himself with “My God, you’re beautiful!” From that moment on, he treated every word out of my mouth like Gospel truth, to be obeyed immediately. I admit it: I quite enjoyed being treated like the Queen of the Universe. Being told that I was beautiful enough to derail a full-fledged, would-make-a-toddler-jealous temper tantrum didn’t hurt my confidence any either.
Then there was the time that I noticed a resident’s pant leg needed adjusting. When I bent over in front of her to fix it, I ended up getting a reminder that not everybody born before the 1960’s necessarily conforms to the Norman Rockwell image of heterosexuality. I will say that of all the passes ever made at me, hers was tasteful–far more in the nature of a compliment on my, er, physique than objectifying my body for her viewing pleasure. That woman had game.

∞oOo∞

And then, of course, there’s the far less enjoyable kind of attention. This comes in many forms, from overhearing a group of male residents ranking the female employees by sexiness, to outright asking me to climb into bed with them. You’ve got the “handsy” old men, the incessant dirty jokes, the lewd comments, the creepy stares…and the list goes on. I’m sure every aide out there has had an experience of some kind or another of this nature.
There was a time when I cleaning up an extra large BM that was, in spite of my best efforts, just getting anywhere. I became distracted from the mess when I felt the resident’s hand on my leg, slowly creeping further up. When I told him to remove his hand, he just looked at me, smiled and said: “What, don’t you like it?”
“Are you going to take your hands off me?” I asked him calmly. “Or do I have to use my hands to get yours  off me?” To illustrate my point, I held up my gloved hand…which just happened to be dripping BM. To anyone who says that there’s nothing like cold water to curb a libido, I can only guess that you’ve tried using BM. I’ve never seen anyone back off quite so fast as he did, or stay backed off for quite as long. I hardly needed to report the incident to my supervisor, whose first comment was that I “had managed the situation rather handily“.

Of course, it’s not just the residents who put on such displays of sexism and lechery. I learned very quickly to wary of certain visitors. I’ve had a visitor try to get me in trouble with my boss because I told him to keep his hands to himself. He was always trying to touch the female aides, especially trying to put his hand on a shoulder or upper arm and “steer” us around by squeezing. I objected to being touched so frequently and familiarly without my consent, especially after I politely asked him to stop. Unfortunately for me, he was one of those men who have trouble to concept of “No Means No” and began complaining to my supervisors that I was “rude”, “mean” and “hateful”.
Unfortunately for him, I’m fairly eloquent with written words and not afraid to defend myself.

Nor should you come to the conclusion that it’s only the men who make unwanted sexual advances upon staff. While I have noticed that some of the female residents do as well, they are far fewer…in no small part, I think, to the cultural conditioning that encouraged men to be aggressive and women to be passive. Also, there’s the same mentality at work that leads some of our residents to treat their caregivers as “the help”, instead of a skilled worker. When you’re perceived as standing a rung below them on the social ladder, many people feel as though they’ve been given a pass to act as they want to, without regard to your feelings.
But it exists still, with or without the spotlight. All the crap women have deal with in our still amazingly sexist culture, with a side of proximity. There is, shall we say, an intimacy of the caregiver-resident relationship that often exasperates the “normal” harassment. Personal space boundaries are in a constant state of flux in Long-Term Care. You’re often operating in what Edward T. Hall, the cultural anthropologist who pioneered the field of proxemics, called “intimate distance” (6-18 inches between you and the other person). This close proximity influences the dynamics between you and the resident, especially if that resident has dementia. They either react with hostility, “What is this stranger doing in my personal space?” or an assumption of familiarity, “She’s right next to me, so we must be close.” Or “She’s leaning over me, so she must be open to my attentions”. Inhibitions are lowered or forgotten, causing many people with dementia to act without the social filter. Is it any wonder then, when they make a move and react with confusion when they are shut down?
Of course, empathy in this situation is a tricky thing. No matter how well you’ve managed to put yourself in the resident’s shoes, how much you understand the factors that lead them to act as they do––you cannot deny the validity of your emotions. Sexual harassment is a demeaning experience, even if the perpetrator is your resident. We can’t just shrug it off and say, “Oh, well, it’s not worth the fuss,”. If we aren’t taught–or don’t learn–how to shut down such advances with compassion and firmness, we only encourage more of the same behavior, making life harder for ourselves and all our residents.

Either way, it’s one of the things they never tell you about. It’s one of the areas that we are, for the most part, told to report to our supervisors and then left to figure out on our own. How do you deal with the handsy residents, the lewd comments and other objectifying behaviors without demeaning the resident who is exhibiting the behavior? It’s one of those ethical obstacle-courses we deal with every day.

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.

The Crucible

Sunflower  May

Sometimes I swear the nursing home is secretly a crucible—with myself as the bit of iron being refined and beaten into steel. Maybe I’ll come out of this stronger, or maybe I’ll shatter under pressure. Sometimes I wonder what is being purged from my being…I know something is gone from my soul, gone or altered so fundamentally that it might as well disappeared.
What is burning in that fire? Is it only weakness, my selfishness, naïveté and arrogance or am I also losing bits of my compassion, my patience, all the soft parts of me? I feel harder, more brittle. Anger comes quickly, if I let it. I’ve seen so much ugliness, so much injustice and been dismissed so many times; I’ve learned by example how you dull the voice of your conscience. I have an edge I never had before, a sharpness where I was once fluid. I am weary in a way I wasn’t before. Sometimes it feels as though my youth has been a sacrifice. I meant to lay it on the altar for God and the ones I care for, but those ruled by greed and apathy keep trying to snatch it away for themselves. I’m tired and never far from sorrow.
Sometimes I miss the person I was before. In my years as an aide, I’ve shed so much of my innocence. Also, the time and energy I give to my work have held back my own stories. Change may come to this broken system, but not soon enough to save me from the bitter taste of burnout. Some days I can’t help but resent that. I remember one time being so frustrated and raging to my mother about the unfairness of it all; I remember she told me being a CNA had changed me, that I had both lost and gained from the experience. I asked her to give me the bad.
I never asked her how it had made me better. It wasn’t what I needed at the time: I needed to feel the cold water of my own failings…needed to remember my own flawed nature, that I wasn’t perfect or passive.
And I needed to decide for myself what I had gained.

Empathy
When there are worlds and words swirling endlessly inside your head, it’s easy to get lost inside yourself, to distance yourself from other people. I was absorbed in myself and my stories, before caregiving forced me out of my head and into the stories of others. If you can put yourself in another person’s place and feel what they are feeling, it makes care go so much better–especially if there is a barrier of communication like aphasia. I am a better storyteller now for having learned to put aside my own perspective. My stories have a depth they did not before, back when I still thought I was the center of the universe.

Faith.
I used to be so afraid of my own mortality…terrified that one day I’d be gone from this world and would have done nothing to mark my existence. I was so scared to be forgotten, until I held the hand of a dying woman and recited the Lord’s Prayer with her. She took that fear with her when she left this world. I have a confidence I didn’t have been.

Strength.

Before I was a CNA, I thought strength meant stature and a rigidity of will. I thought only the unbreakable and the bold were strong. I didn’t realize that true strength…that’s resilience, to have your heart broken and your dreams shattered and then get right back up to go again. Until I was surrounded by fellow caregivers, I did not appreciate that strength is a dance between confidence and humility: a willingness to bend when necessary and wisdom to know when to stand your ground.

Purpose.
I’m the kind of person who needs a crusade, something bigger than myself to feel satisfied with my life. I’m not content to let injustice go unchallenged or to allow the dignity of a person to be disregarded, no matter how much they “contribute” to society or how much of an “inconvenience” meeting their needs causes. Whatever other heartaches and frustrations come with it, being a caregiver has certainly given me a crusade to fill a lifetime or more.

In the end, it’s heart-breaking, life-affirming trade. Everything I am, I became…or rather I am only who I became. What I lost I surrendered, and what I gained I was given. What I have retained, that I earned.

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.