Category Archives: The state of long-term care

A Numbers Game: Resident Acuity and Staffing – Part Three

 

 

Minstrel

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

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

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

Other tasks aides are responsible for during a shift: 

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

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

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

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

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

The Facts About CNA Wages

 

Bob Goddard

There is a great deal of confusion within the CNA community regarding the issue of wages and how it fits into the larger long term care picture. While there is general agreement that caregivers are underpaid, that perception is primarily based on personal experience, that of our own and of others. This anecdotal evidence is useful in its own right, if for no other reason than it is overwhelming. However, discussions regarding the wage issue are characterized by emotional responses and typically lack references to data that back up the arguments.  Solid facts are sometimes offered within the CNA online forums, but usually not in any kind of comprehensive or purposeful way.

In order to help us get a more accurate picture of the state of direct care work in this country, below is a list of just a few of the more significant statistics. The primary source for these is a PHI fact sheet published in August of 2017.

I think this kind of short list might be useful for those who argue for better wages for caregivers. In future posts, I’ll give my take on what I think these statistics mean.

First, just to get a sense of the scope:

15,400 long term care facilities in the United States

1.4 million residents live in these facilities

600,000 CNAs work in them

But those 600,000 are only 13 percent of the total of direct care workers employed in the United States, because…

4.5 million direct care workers are employed in all types of situations, including home care, Continuing Care Retirement Communities, Assisted Living Facilities, Hospitals, Centers for Developmentally Disabled, Mental Health, Substance Abuse, Employment & Rehab.

Second, the demographics of caregivers:

91 percent are female

Half are under age 35

Half are people of color

Half have some college, (about 1 in 7 have associates degree or higher)

20 percent were born outside of the United States

Third, the money issue:

$12.34/hr is the median wage of CNAs (half make more, half make less)

$20,000 is the average annual income

Half work part time at least part of the year

17 percent live below the poverty line (compared to 7 percent of all American workers)

40 percent receive some form of public assistance

72 percent of long term care is finance through public programs (mostly Medicaid and Medicare)

Finally, the demand for caregivers is growing:

60,000 more caregivers will be needed by 2024. It is one of the fastest growing occupations in the United States workforce.

1 in 2 caregivers leave the job within 12 months. And more LTC workers are leaving this sector than entering it.

I would encourage anyone who is interested to visit the PHI site where more information like this can be found. Of current interest is the ongoing 60 Caregivers Issues series where they tackle a whole range of issues regarding our work, such as caregiver wages, training, recruitment and retention, and advocacy.

Next week, I’ll share what I think some of these numbers mean for the larger long term care picture.

A Step Backward for Long Term Care

 

 

Yang

Last week, PHI posted the third installment of their 60 Caregiver Issues Campaign. This issue brief highlighted how the Affordable Care Act brought coverage to many caregivers who previously had no healthcare insurance and discussed how proposed changes now before congress could impact the nation’s direct care workforce.  The link to PHI’s report is at the bottom of this post.

It boils down to this: among its many provisions, the ACA included an expansion of Medicaid that benefited the working poor and thus provided healthcare coverage to caregivers who did not previously qualify because they “earned too much.” 

Here are the numbers directly from the PHI brief:

  1. From 2010 to 2014, approximately 500,000 direct care workers nationwide gained health insurance following implementation of the Affordable Care Act.
  2. The uninsured rate decreased 26 percent during the same time frame, from 28 percent to 21 percent.
  3. These coverage gains are primarily attributable to a 30 percent increase in the number of workers insured through Medicaid programs.

The repeal of the ACA threatens this coverage and many caregivers may again find themselves without the means for adequate health care. In a field where workers are at high risk for injuries resulting in musculoskeletal disorders and face the risk of serious infection every day, this lack of healthcare coverage is devastating. It not only leads to higher turnover rates that negatively impact the care of our elderly and disabled, it also reinforces the tendency to view caregivers as short-term workers, an expendable resource that can be used up, disposed of, and replaced.

We cannot properly care for the most vulnerable of our citizenry if we overlook the health and well-being of those who care for them. The two cannot be separated. In a time when the demand for caregivers has reached a crisis, reducing direct workers’ access to adequate health care is an unwise – and unhealthy – step backward.

The PHI report can be found here.

 

 

 

60 Caregiver Issues: Whose Issues Will We Hear?

 

 

Minstrel

In his recent post Yang brought our attention to PHI’s campaign to educate the public about caregiver issues, and gave us a link to their introductory video.  In that video PHI posed these questions:   

1. How can we ensure caregivers get the training they need?

2. How can we keep care affordable to families? 

3. What data is needed to help policyholders take action? 

While these are important questions, if you ask caregivers themselves why some are leaving the field and others wouldn’t think of entering it, they’ll no doubt raise a different set of issues.  At nearly every conference or webinar I attend I ask about staff-to-resident ratios and caregiver wages.  Usually there is no reply, as if I were speaking from some parallel universe and couldn’t be heard.  If there is a reply it’s on the lines of “Yes, we know.  But it’s complicated.  These things take time. You can’t expect things to change overnight.” 

Yes, there is a shortage of caregivers.  And yes, good care isn’t affordable.  In fact good care can’t be bought.  By that I mean whatever you might be paying, either for in-home care ($20/ hour? $40?) or for care in a long-term care home of some sort ($6,000-10,000/ month), the more care the person needs as health declines, the wider the gap between the person’s needs and the quality of care the person actually receives.   

Everyone is selling solutions like workshops and videos and toolkits and new business models to long-term care administrators or home healthcare systems’ owners.  Some groups are advocating on a state or even national level and some gains have been won.  But from the outcomes I’d say that a lot of the effort is wheel-spinning.  (An increase in the NYC minimum wage for home care workers to $15/hour by 2021??)   Today’s aides have rare luck if they earn $15 an hour and have a regular 40-hour work week.  An aide may have six to ten residents/patients to care for, and many of those will suffer from dementia and/or be unable to walk alone safely or even support themselves standing.  (Yes, I know I’m a broken record…)  Do you know what it’s like to try to wash, toilet, transfer these residents several times a shift, and keep them from falling the rest of the time?  (If not, go back and read CNA Edge.)  This is before we even begin to provide enrichment a la ‘person-centered care.’   

I want the whole healthcare industry – including those championing reform — to acknowledge what the biggest issues are for caregivers: our obscenely low wages and our outrageously onerous, even unsafe, working conditions.  These organizations don’t yet tackle caregivers’ most urgent needs: a living wage, safe work conditions, and a work environment that supports person entered care.  We need to ask them, What are you doing about these issues and what can we CNAs do to support you in this?  

When Malcolm X called for a change in Americans’ attitudes on race and was told that such changes (culture change, if you will) take generations, he reminded us of this: At the beginning of World War II Germany became our enemy and Russia became our ally.  But when the war ended we, America, saw Germany as our ally and Russia as our enemy.  That attitude-change didn’t take even one generation.  The healthcare industry needs an attitude adjustment.  It is not okay for long-term care operators or owners of home healthcare agencies to charge exorbitant fees to clients and return a too-small fraction of these fees as wages to their direct-care workers, while management and professional staff and consultants are handsomely compensated.  It is not okay to hire employees unless you train them in the skills they need to work with the elderly frail, starting with English language skills.  It’s not okay for the industry to tolerate poor work ethics: last-minute callouts; texting while on duty; and most of all, failure to interact with residents in a way that says to them “I love being with you.  Thank you for letting me be part of your life.” 

There are thousands of followers of CNA Edge.  As Yang exhorted us, we need to support PHI in their effort to educate the public about caregiver issues.  Let’s ensure that when they frames their 60 Issues, they don’t airbrush our issues out of the picture they’re drawing.

Looking back and forward

May

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

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

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

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

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

60 Caregiver Issues: PHI and the Caregiver Shortage

 

Yang

Last week, the Paraprofessional Healthcare Institute (PHI), the leading expert on the nation’s direct care force, launched a two-year online public education effort called “60 Caregiver Issues.” Over the next two years, the campaign will identify 60 policy and practice ideas that can begin to address a problem that we, as CNAs, are all too familiar with: the growing shortage in direct care workers.

The first installment, “8 Signs the Shortage in Paid Caregivers is Getting Worse” can be found here.

The purpose of the campaign is to focus public attention on the problem and offer some real solutions. CNAs have a vital role to play in this effort. No one has greater awareness than we do of how chronic understaffing and turnover rates actually impact the care and well-being of individual residents on a day to day basis. We know what it looks like and we know what it feels like to our residents in a very real way. By sharing our real-life work experiences we can offer a perspective that gives these problems texture and a real sense of the human cost.

As advocates for our residents – and for ourselves – CNAs can become part of the solution by joining and supporting PHI in this effort. In the coming months, CNA Edge will share posts from the PHI campaign and, of course, we will offer our own take on the issues surrounding the nation’s caregiver shortage.

To kick off the campaign, PHI offers this 60 second video which highlights the problem:  Caregiving Crisis: 5 Million Workers Needed

 

The Caregiver Shortage and Immigration

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

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

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

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

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

 

A Wide Movement

May

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

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

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

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

Nursing-home-made

Sunflower May

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

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

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

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

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

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

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?”