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. 

Respect Your Elders

Sunflower May

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

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

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

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

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.

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.