Category Archives: workloads

A Not so Obvious Picture at the Grand Rapids Home for Veterans

Bob Goddard

In early August, a disturbing news story broke about the Grand Rapids Home for Veterans, my old workplace.  After an investigation by the State of Michigan’s Attorney General’s office, eleven former employees – all direct care workers – were charged with falsifying medical records. The caregivers charted that they had checked on members (the Veterans Home refers to the residents living there as members) while surveillance video shows that these checks were not done. In Michigan, falsifying medical records by a health care provider is a felony, punishable by up to four years in prison and a fine of up to $5000.

The investigation followed a scathing February 2016 report by the Michigan Auditor General. According to that report, the home failed to properly investigate allegations of abuse and neglect, took too long to fill prescriptions and operated with inadequate staffing levels. Both the Attorney General’s investigation and the audit came almost three years after the State privatized the entire direct care workforce at the home, thus replacing a dedicated, stable direct care workforce with contract workers from a demonstrably unreliable agency, J2S.

The eleven workers charged by Attorney General’s office were employed by J2S. That company was replaced by two other contract agencies last year after J2S repeatedly fell short of adequately staffing the facility.

As we have come to expect in media coverage of anything related to long term care, the local media treatment of this story displayed a superficial understanding of how a long term care facility operates and relied on sensational wording to make the story more compelling. In the process, the reporting presented a misleading picture of how caregivers go about their work. While reporters expressed outrage over the quality of care at the home, they seemed clueless regarding what it takes to make good care happen. I think it would be useful to correct this and offer a different perspective.

In one report following the announcement of the felony charges against the caregivers, a local TV reporter assured viewers that the Attorney General’s investigation “paints a pretty obvious picture of the situation” and concluded that bringing the charges does two things: “it holds people accountable for what they did,” and second, “I can guarantee you tonight at the home for veterans they’re going to be doing their member checks.”

The assumption in that last statement is that fear is a necessary and effective motivator in providing good care. This is a common fallacy among observers unfamiliar with the nature and practice of caregiving. You cannot get genuine compassion and caring from fear.

Yes, as our visibly self-satisfied watchdog reporter suggested, I’m guessing “those member checks” were indeed “being done tonight,” but as I will explain below, that form of diligence has little do with the actual quality of care at the home.

The media reports and statements from the Attorney General gave the impression that these hourly checks were at the heart of what caregivers do. They are not. In fact, the hourly checks are superimposed over normal care routines. In a typical institutional setting, each caregiver is assigned a group, usually ten or more residents depending on the shift, unit and facility, and is charged with completing a whole series tasks including assisting with the residents’ personal hygiene, bathing, grooming, dressing, toileting, bowel care, skin care, turning positioning, transferring, ambulating, transport, serving meals and feeding patients, offering fresh water and snacks, take vital signs, make beds, keep the residents’ room clean, answer calls lights and respond to requests, record intake and output information, observe and report changes in residents’ physical and mental condition. And of course, document these activities via flowsheets and other similar forms. The location sheet is one of these forms.

It’s important to understand that given the direct care staffing levels in a typical long term care facility, and this certainly includes the Grand Rapids Home for Veterans, assigned caregiver workloads are rarely possible to complete – not to the standards set forth by regulators, facility policy, and customary nursing practices, let alone family and public expectations.  This means caregivers are constantly engaged in a form of care triage, made necessary because no one above them in the Long Term Care hierarchy, including policy makers and legislators, seem able to provide the resources necessary to do the job according to standards. Either they lack adequate awareness of the problem or are simply not willing to make the hard choices. By default, this is left to the direct care worker.

Given the inadequacies of the system, the best a caregiver can do is to arrange these various tasks in some order that makes the most sense for everyone in the group, taking into account the unit’s mealtimes and other facility routines. While a good caregiver tries to plan ahead, working with human beings means that unexpected needs routinely arise and no can anticipate everything.  Each shift becomes a unique time puzzle that the caregiver must solve if the residents are going to receive the best care he or she can provide. But the puzzle is dynamic, the “pieces” change according to the immediate needs and expectations of residents, coworkers and management. The caregiver must continually adapt his or her time organization to ever changing circumstances and priorities. In essence, the caregiver spends the shift involved in perpetual problem solving with ethical implications.

At the Veteran’s Home, the check sheets are kept behind the nurses station while the majority of care is conducted in the members’ bedrooms and bathing areas. So, to properly document the checks consistently in a timely manner requires this absurdity: the already overwhelmed direct care worker must pause care and walk away from the members for whom she is providing care for the purpose of putting her initials on a sheet of paper that indicates she knows the location of the members she was just with. This may provide the facility with documentary evidence and meet an institutional need, but it does not necessarily address the needs of the members.

If we are truly concerned about the quality of care for our veterans, the real question is not whether or not the checks were properly documented, but what the caregivers were actually doing when they indicated they made the checks. Were they in the shower room with a member or making sure an unsteady member wasn’t tumbling off a commode or perhaps transporting a member to a therapy appointment? Were they in the middle of assisting a member with his meal or helping a coworker transfer a 350 pound man from his bed to his wheelchair? Were they responding to a member’s urgent request for help? Were they redirecting a confused member for the tenth time in the last five minutes? Were they assisting another caregiver who was trying to manage a combative member? Were they comforting a member who was experiencing some kind emotional turmoil? Were they on their way to nurses’ station to get the location checks clipboard when they noticed a call light? Were they with a sick member, maybe dealing with copious amounts of diarrhea or vomit? Were they cleaning up a spill that presented a fall hazard? Were they speaking with the family of a member regarding their loved ones’ care and status? Were they holding a dying member in their arms? Or perhaps they were engaged in a member’s post-mortem care.

I will leave it to the Attorney General and media reporters to decide to which of these activities caregivers ought to interrupt so that they might properly document the checks – and presumably stay out of prison.

Let’s be clear, if the workers were sitting behind the desk or off the unit or otherwise not engaged with the members when these checks were supposed to be made, then our sympathy and support for them evaporates. Not because they didn’t make the checks properly, but because they weren’t with the members and on task. Even in bad work environments, caregivers are ethically and morally obligated to the use the time and resources that they do have to do the best they can for the residents.

Of course, it could be argued that the hourly checks provide a more systematic way of accounting for the members’ location and condition. Regular checks ensure that no one gets forgotten.  It seems obvious, right?

However, when you start to look at how caregivers actually gather information and keep tabs on the members in their group, the hourly checks take secondary importance. Caregivers are routinely provided with a “cheat sheet,” a one or two page list of all the members in their assigned group. The cheat sheet includes basic care information for each member. The caregivers carry these sheets with them and will refer to them throughout the shift. Even caregivers who are familiar with the members in their group will often use the cheat sheet as an aid to help organize their time and, of course, to help make sure no one is forgotten.

Given the real needs of the members, the fact that the checks are hourly is completely arbitrary. The reality is that some members don’t need to be checked that often and some leave the grounds for long periods – as is their right, it’s a home not a prison. Other members may need to be checked even more frequently depending on their particular physical and mental status.  A lot can happen in 59 minutes and the hourly checks can no way guarantee the safety and well-being of all members. The best way to keep members safe and their immediate needs met is to have well informed, well supported, on-task caregivers. And by well-informed, we mean caregivers who are thoroughly familiar with the members – not just with their current medical status, but who they are as individuals, their daily needs, preferences, and habits.

By threatening caregivers with prison sentences and the like, we can make them jump through hoops and give the appearance that good care is being done, but we should wonder what is actually being missed while they’re putting on this show for us. As our watchdog reporter implied, fear will elicit a sure response. But with fear, the issue becomes not about the real quality of your work and how those in your care are experiencing it, it’s about how you think it’s being perceived by those who can punish you. Under siege, our actions are informed not by our sense of right and wrong nor even by common sense, but by the assessments and attitudes of those who are judging us. When those assessments and attitudes are based on faulty perceptions – which is often the case in long term care and certainly the case here – our priorities become skewed and we add yet another obstacle to good care.

Fear won’t take caregivers into the places where genuine compassion and caring will go. As a motivator, it’s a weak and insufficient substitute for the truly powerful motivations that result in the best care possible. On the other side of those closed doors and privacy curtains where caregivers engage members and actual care takes place, you really want people who are inspired by the better angels of their nature.

The quality of care in any long term care facility is directly tied to the facility’s investment in the caregivers who provide it. Paying direct care workers good wages with decent benefits not only helps attract and retain workers, but it also gives them the means to adequately provide for themselves and their families. Many caregivers have no choice but to work a lot of overtime or find second jobs just to make ends meet. The work itself is physically and emotionally demanding, and when you add the stress of double shifts and long hours, the result is a caregiver workforce perpetually on the edge burnout. You can’t get the best possible care on a consistent basis from workers who are physically exhausted and emotionally drained.

It should be no mystery why J2S had such difficulty staffing the place and why even now one of the current contract agencies continues to have problems. The shortage of caregivers has become a nation-wide crisis and annual turnover rates for direct care workers typically run between fifty and sixty percent. Prior to the State’s privatization of the direct care workers, the Grand Rapids Home for Veterans was immune to this crisis.

The cost of losing that stable direct care workforce cannot be overestimated. Caregivers who are unfamiliar with the members in their care groups cannot possibly provide the same level of care as those who have had long standing relationships. But we continue to routinely throw these workers into chaotic situations and expect them to perform a high level. Usually they feel fortunate just to get through the shift with no major disasters. Or investigations.

While a sense of duty and a good work ethic are necessary in providing adequate care, there is no substitute for the personal relationship that develops between the caregiver and resident. This bond is the single most powerful motivator in providing excellent care. In environments where these relationships are encouraged to develop and flourish, workers become more caregivers, they become advocates.

If the caregiver has a moral obligation to do the best for his or her residents despite difficult circumstances, then those above us in the hierarchy and those on the outside who seek to influence the activity of caregivers have an equally compelling moral obligation to understand the consequences of that influence. This requires a basic awareness of the real challenges faced by caregivers and insight into what really motivates them. From what I’ve seen, both the Attorney General and the local watchdog reporters have failed to demonstrate that awareness and insight.

  

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.

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.

Unsafe at any Weight

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Minstrel

I became a CNA at an age at which most people are retired. By this time most CNAs have backs, knees, shoulders that are broken down or on their way to that. On my first day on the job, the CNA I was shadowing asked, “HOW old are you? You’re never going to be able to do this job.” Biologically speaking, I could have been a grandmother to some aides. But I was in better shape than many, in terms of weight and flexibility. Some aides arrived at work groaning, “My back is killing me!” “My knees are soooo bad today.”

 In reality I could do everything a CNA needed to do. But there was one thing I couldn’t / wouldn’t do: move a two-person assist alone. At first the experienced aides helped me. But soon they expected me to care for these residents without help, as they did. There seems to be a machismo culture among aides: “I can do this on my own.” I was saved by the fact that our unit supervisor had posted a list of all residents who needed the assistance of two aides to be moved. When I needed help I asked for it and was given it. But other aides wouldn’t ask me or each other for help, except in the toughest cases.

Who is a two-person assist? A person doesn’t have to weigh much to be a dangerous dead weight when she needs to be moved. Even frail, thin persons become dead weight when they don’t have the bodily strength to stand or the cognitive capacity to follow instructions. The CDC, OSHA and other organizations have developed algorithmic guidelines which state in effect that unless a person is both fully weight-bearing and able to cooperate in the action (that is, able to understand what is needed and able and willing to do what is needed), then the resident needs two persons, sometimes more, and sometimes also requires mechanical equipment, to be lifted, repositioned, transferred. Fellow aides: How often is this the rule of thumb where you work? Given staffing levels, how many of you have time to stop to help others with residents who should, under the guidelines, have the assistance of at least two persons when they are moved? How many of your co-workers have time to help you?

Unfortunately, as far as I’ve been able to learn, failure to provide adequate staffing to ensure two-person assists for all non-weight-bearing residents isn’t an OSHA violation that has any penalty attached to it. This is a guideline and not a mandate. Thus LTC homes might not be as worried about compliance with these guidelines as they are about Medicare rules. But some states might have tighter rules. And guidelines do have some weight in policy-making in LTC homes.

Despite my facility’s two-person assist list and despite all the guidelines, many aides chugged right along, lifting residents without help. Both the resident and the aide are at risk of injury (or at least distress), but aides insist on flying solo. Sometimes we’re our own worst enemies. CNAs: Let’s call a truce with our aching bodies! It’s worth a try to work with our unit supervisors to develop a two-person-assist list, using it to transfer residents more safely and comfortably.

“I’m Just Doin’ My Job”

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Minstrel

One of my all-time favorite movie lines was spoken by Paul Newman in Cool Hand Luke.  Luke, the non-conforming prisoner in a tough southern prison, refuses to accept the prison’s status quo.  His conduct is a cascade of rebelliousness, until finally the warden orders Luke to “the box.”  The box is a small tin-roofed building, the size of an outhouse, under the blazing sun in the middle of the hot, dry prison yard.  After Luke spends twenty-four punishing hours in the box, the guard releases him.  As he does he says, “Sorry Luke, I’m just doin’ my job.  Ya got to appreciate that.”  Luke replies,  “Nah, callin’ it your job don’t make it right, Boss.”   

Calling it our job doesn’t make things right.  Among the most pernicious problems in long-termcare homes is staffing shortages.  With a census of 25 to 35 residents or patients needing skilled nursing and/or dementia care, there might be only three to five aides scheduled to work a shift.  (Then there are the last-minute call-outs).  If the aide is lucky, very lucky, she may have only five or six persons to care for.  The more frequent reality is having seven to ten persons needing care.  Remember that cacophony of call bells that May wrote about?  Blame it on short-staffing.  And the resident pleading for you to take her to the toilet?  Oops, it’s already too late…  The resident teetering perilously as we rush to prevent a fall? … And the time you lifted a non-ambulatory person by yourself because there was no one around to help?  What about those wheelchair bound residents who haven’t been taken out to feel the fresh air in weeks?  The hits just keep on comin’.   And we keep right on keepin’ on, because it’s our job; right?   

No, it isn’t.  We simply can’t do our jobs as CNAs adequately when we’re so understaffed.  What most determines the quality of care is the staff-to-resident ratios (‘duh’).  I challenge anyone to find an aide who disagrees with this.   Yes, staff need to be trained in good care practices.  Yes, we need to have certain supplies available (soap, towels, functioning hospital beds, appealing food, etc.).  But the key to quality care, to person-centered care is PERSONS.  Staff.  

We continue to work in short-staffed conditions we know violate our residents’ right to good care.  (See medicare.gov for a description of rights of persons in nursing homes.)  If we ‘complain’ to management about short staffing (and that’s how it’s viewed, as a petty complaint), we’re told sweetly that the staffing levels meet the state requirements.  And that’s probably true, because industry lobbyists have made sure that state regulators don’t burden the long-term-care industry with costly staffing requirements.

We complain about these deplorable conditions all the time.  As CNAs we’re mandated reporters of abuse.  (I guess we’d better not think about that one too much!)  But we tolerate abuse that residents endure as a result of understaffing.  Abuse isn’t just about physical or sexual assault.  It’s also about neglect and emotional abuse.  If I neglect a call bell for so long that a resident is left to soil himself and remain in his soiled condition for hours, that is abuse.  If I say to a resident who asks to be taken to the toilet, “Janie, I just put a clean Depends on you; I can’t get you back into the Hoyer lift and take you to the toilet, you have a diaper on, you can use that,” that is abuse.  Abuse is ridiculing a resident who cries for her mother all afternoon; scolding a resident who spills her drink all over the floor; ignoring the call bell of a resident who constantly asks to be taken to the toilet minutes after the last toilet trip, because we know she ‘doesn’t really have to go.’  Well, she needs something and it’s our job as aides to find out what.  “But I don’t have time for all that.  I have seven other residents to get to.  I’m just doin’ my job.”  

So what can we do?  Unlike the workers of the 1920’s and ’30’s, we can’t go on strike to win better working conditions.  We’re caring for the sick and the frail, not assembling cars.  But if we can’t leave the floor for a sit-down strike, we can use our cell phones as weapons in the revolution for better care.  Call your county or state abuse hotline every time aides have more than six residents to care for on a shift.  (And don’t count the LPN or Medication Aide in your ratio if she isn’t providing care, even if management does.)  The state regulators aren’t always thrilled to receive reports of abuse because they are short-staffed too, and don’t have the means to investigate all complaints properly.  They don’t always to a good job, for the same reasons we don’t always: because they’re understaffed and a little intimidated by their bosses.  

Revolution isn’t about violence and nastiness. (Remember Gandhi and Mandela and Rosa Parks.)  It’s about patient persistence and never giving up as long as change is needed.  It means taking that first step.  Maybe our first step will be a phone call.  

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.

Bad Boss Part 1: “Work Harder”

Sunflower

May

Note: This, like most of my posts, does not tell the story of recent events. I try to chose stories that are a few months (or years) old, although I am usually inspired by recent events or conversations which remind me of the story in question. 

All I get is a whispered warning in the hall: “Watch out for so-and-so [a person of unspecified authority in the nursing home who shall henceforth be called VIP]. She’s on a bit of a power-trip today.”
“Great,” I sigh back. This bit of information has two possible meanings:

  1. The other aide is having a Bad Day, very possibly got talked to about some deficit of care and now thinks everyone’s out to get her or
  2. VIP is actually on a power-trip and I’m going to have to try to be invisible as in addition to being everywhere at once.

We’re already working short today, and seeing as how the next shift is also short, there’s a good possibility I’m going to either be asked or ordered to work a double shift. Again. I really don’t have the energy for any more drama, I really, really don’t.
“May!”
I swing around, startled and resist the impulse to shout: “Speak of the devil!” However applicable the phrase, I fear the wording would not go down well.
“I need to see you,” VIP says. She’s dressed to the nines today, I notice and mentally calculate the cost of her outfit and accessories to be roughly a month’s worth of my wages. With, you know, the usual amount of overtime thrown in.
“Okay,” I say, bracing myself for anything.
“May, I don’t want to hear anyone saying that we are ‘short-staffed’ today or any iteration of it,” she says. “We are not. We are still within acceptable and legal ratios.” Well, technically, in our state there’s no safe staffing requirements for direct care workers/CNAs…that might very well be legal, but it’s no help on the floor…no requirements that I can find, any way. She might as well say “It’s after breakfast” when asked for the time; it’s perfectly true and very little help in figuring out if you’ve missed your favorite show. “If I hear anyone saying ‘we are short today’, or any iteration thereof, or even a mention of how difficult it is today, I will be writing up that person. Understood?”
“What am I supposed to tell my residents when they ask why I’m taking so long to get to them?”
“You’re just going to have to do your best and not let them even notice,” she says. “We do not need to be adding to their burdens because you have a few extra people today. They shouldn’t even notice a difference, it’s only four people more per group. Understood?”
I nod. Well, I’ve only been forbidden to say a few phrases: how rough can it be?

As it turns out, the only thing worse than working short of staff is being forbidden to mention this factoid.
“May, I put on my call light half an hour ago, where have you been?”
“May, this person is soaked. Why haven’t you changed him?”
“May, why isn’t this person up for the meal? What do you mean, there’s nobody available to help you with the hoyer?”
“May, why can’t you help me right now?”
“Where the hell have you been, you lazy bitch? I’ve been waiting for my shower for an hour!”
It’s chaos. I rush through my shift, begging for understanding from my folks and unable to explain why it is taking me so long to get to them. Words have always been my best weapon and I suddenly feel shackled, having been forbidden to use my words to coax or cajole patience and empathy from my folks. And I really don’t think just coming out and saying “we’re short today” would be a great shock to the increasingly frustrated and soiled residents. They’re not stupid and (for the most part) they can still count. They can see how quickly I’m running between rooms, that I haven’t stopped for a break yet, that nobody has shown up to help me. Oh, trust me, they know and my refusal to admit the truth is making some of them angry.
They aren’t the only ones. I’ve always been emotional and today has strained my control. I’m running myself ragged, haven’t had a chance to stop and breathe and for my efforts I’ve been screamed at, insulted, cussed out all day. I can’t even blame them, sitting in soiled clothes for almost an hour while I try to take care of everyone who has put on their light first. In a rather disturbing turn of events, I’m apparently having the walking-talking kind of melt-down…perhaps because I don’t have time for the actual sit-down variety. That is to say, tears are leaking from my eyes, but I haven’t stopped working and, rather bewilderingly, I’m still speaking in a semi-normal voice. I’m rushing around, doing my work in fast-forward and all the while, my sweat and tears are mixing on my cheeks. This day can’t get much worse.
I really should know better by now.

I round the corner and VIP is waiting for me. “May,” she says without preamble, “what’s going on? Why is it such chaos today?”
“…” I stammer. What can I possibly say in explanation that won’t get me written up? “I can’t keep up when it’s just me on the hall, okay? There’s just too many of them and I can’t do everything at once. Which is when they want it.”
Her eyes flash…but I never actually used the words “We’re short-staffed today.” This feels so unfair. How can I explain myself after she tied up my words and laid threats against my job?
“May, these residents deserve to have a good day without having to deal with all of our troubles. They’ve earned your best, even under challenging circumstances, so calm down, put on your big girl boots, dig a little deeper and work harder.”
Work harder? What the freaking hell does she think I’ve been doing all this time, sitting on the bathroom floor and crying my heart out? I wish! Oh, how I wish. I’m about to say something that will get me written up for sure, when a call light goes off in the room behind me. Seizing upon this gift from the heavens, I blurt out “Excuse me,” and dart in the room before VIP can say anything else. The resident in the bed looks extremely grumpy.
“May, I asked to get up an hour ago.”
“I’m sorry,” I start to say, but she doesn’t let me finish.
“May,” she says in a very different tone, “are you okay? What’s wrong? Are there not enough of you girls to take care of us today?”
“I’m running behind, but I’ll be okay,” I reply, conscious of VIP on the other side of the door. It’d be just my luck today if she had her ear pressed against the door! My resident doesn’t look like she believes me. I can’t say I blame her: faced with the evidence in the mirror over her sink, I don’t believe myself.
“You’re not okay,” she says firmly, but kindly. “You need to take a break.”
“Don’t have time.”
“Did I ask for your opinion? Did I call for a vote? Now sit down and take a minute to pull yourself together. If anyone asks, we’ll say I had to shit really bad.” That sliver of concern, of human compassion breaks the last of my control and I start to sob in earnest, out loud and quite noisily. I sink down to the floor, half-hidden by her bed, bury my face in my arms and proceed to rage and storm at the injustice of it all.
Who the hell does she think…no, that’s not it. VIP isn’t wrong in what she said. She’s actually got a good point about what my folks deserve…but under these “challenging circumstances” I don’t know how to give them what they deserve. Does she think I want my folks to soil themselves? Does she think I like having my residents sit in their own urine for hours? Does she think I’m not trying my damnedest to push through these challenging circumstances?
She isn’t wrong. She’s got a good point…and yet, it’s hard to hear the words “Work harder” from someone who is calm and collected while I’m weeping silently and uncontrollably. It’s hard to accept criticism from someone who is wearing roughly a month’s worth of my wages on her person, when I’m decidedly not looking my best. I looked at her, then I looked at myself and all I saw were the differences that divided. And I hate that. I hate thinking in binary terms, us and them, the powerful and the powerless. I hate looking at her and seeing only the wealth she’s wearing, the power she holds over me. It shouldn’t be like this. We’re both persons. Everything I believe in says we are equals…but I’m so stressed I can’t even hear my own beliefs in my own head. I hate that the only words reverberating in my mind are those that scream: “She’s on a power-trip and I’m the pavement she’s pounding.” It comes down to trust and right now, I don’t trust VIP to have my back.
Okay, calm down. Breathe in, breathe out. I’m not thinking straight and it’s likely I’m misconstruing her motives or projecting my turmoil onto her. I can’t do that. She’s got a good point, the residents shouldn’t have to bear our burdens…it’s just her approach to the problem was a bit half-baked and she didn’t consider how an overwrought CNA might take her words or choice of expensive accessories.
Calm down. Pull yourself together, if not for her than for your residents.
Because if there’s one thing in this whole mess that I have reason to be upset over, it’s that between a staff member with [unspecified] authority and a resident, it shouldn’t have been the resident who made the sacrifice to give me the time I needed to pull myself together.
When my ten minutes of rage and tears are over, I rise and splash cold water on my face. My resident still looks concerned, but she allows me to get her up and together we leave the room. Back into the chaos, but this time, I am master of myself.

<oOo>

I have been blessed: while I have had experiences with bad bosses (as detailed above), I’ve also had good bosses and, more frequently, decent bosses who were neither great nor terrible. It’s not all horror stories. It’s even mostly horror stories.

But what makes a bad boss? What combination of stresses and personal flaws combine to make a nightmare experience for those who work under these people? Sometimes it’s hard to remember, especially in the moment, that a bad boss is still just a person and not evil incarnate…a flawed human being, same as yourself. It just so happens that their flaws have the power to make your life a living hell while you labor under their authority.

Call lights and promises

Sunflower

May

“Hey! Hey! Little girl!”
I’d mutter ‘what have I done now’…except I already know in this case. I seem to have perfect recall today: perfect recall and terrible timing.
Instead of going into the room, I turn and sprint the opposite way. Maybe I should turn off the call light first, but I don’t want to take another chance. No way.

Mr. C has taken to repeatedly pushing the button by the time I get back. I’m sure it makes him feel better, but it doesn’t do anything to the light. “Call light” is a bit of a misnomer, I’ve always felt. Sure, there’s a bulb lit up above his door…but the real attention getter is that incessant, irritating noise. Beep-beep-beep. I hear that sound in my dreams–not exactly as a nightmare, but rather my subconscious echoing with the sound I hear way too much. Beep-beep-beep. It’s the sound of promises I need to make, or reminders of the promises I’ve broken.
Like now.

Mr. C glares at the steaming cup in my hand.
“What the hell is that?” he demands as I switch off the call light. There’s peace for one blissful second…then, another call light goes off. Beep-beep-beep. How many more hours until shift change? One hour and four minutes.
“This? This is the cup of coffee I promised you,” I reply.
“Oh, the cup of coffee you promised to get me after breakfast?”
“After breakfast is such a wonderfully vague time-”
“-no, it’s not-”
“-as, technically, it is still ‘after breakfast’ and will be…until they bring up the trays tomorrow morning.”
I smile brightly at him; Mr. C glowers back. Okay, so this isn’t a laughing matter yet.
“Look, I’m really sorry I forgot. For what it’s worth, at least I remembered what I forgot. It’s been cr…it’s not been my day today.” It takes everything I have to pull the rest of that sentence in, but an apology isn’t really an apology with an excuse riding shotgun.
Another call light adds to the madness outside this room. One hour and one minute.
Mr. C sucks down his first sip. “Ah, that’s good stuff,” he sighs.
“I thought you weren’t fond of our coffee.”
“Anticipation equals appreciation…today. Well, go get your call lights, little girl. Those people out there aren’t as patient as I am, you know. Oh, could you get me a cookie? And specific, non-vague deadline for completing the task?”
“Yes, I’ll get you a cookie. Two cookies…before I go home.”
“Before you go home today?” he asks suspiciously.
I wave my hand at him, then rush to answer the nearest call light. I make a lot of promises during my shift; it’s like riding herd on a whole zoo. Some promises inevitably slither, fly or bound away…after all, there’s only one of me and a lot of them and their call lights.
That’s why I’m so passionate about adequate staff ratios: the fewer residents I have and the more help we have, the fewer promises I break.

We Need More Caregivers

DSC00999

 

Yang

Well, they’re at it again. Nursing home operators and advocates for quality nursing home care are bickering over nursing home regulations and how much regulation is enough. This time they’re facing off in Kentucky. The operators and their supporters claim the current regulatory environment in Kentucky invites “toxic litigation” and that the funds used in such settlements and other fines could be better used to improve care and reduce costs. The quality advocates and their supporters say that’s nonsense and that regulations and penalties are put in place to provide an incentive to put resident care above the bottom line.

This is an old battle. It’s been going on since the 60’s when Medicare and Medicaid came along and nursing home operators discovered how much money there was to be had in the LTC business. Long Term Care facilities were not as closely regulated as they are today and the resulting “hell hole” horror stories gave nursing homes a bad name. Then OBRA came along in the late 80’s and conditions seemed to have generally and gradually improved since.

While OBRA was landmark legislation, the above is an oversimplified version of events and it took much more than government oversight to put Long Term Care on the right path. It took – and still takes – many different people from many different directions to make Long Term Care work and evolve. And sometimes those people coming from different directions clash.

From a caregiver’s perspective, these two adversarial camps, the operators-administrators-managers and the regulators-advocates-surveyors, can be seen as one big group. As a group, they collectively create and enforce the standards and policies under which we work. However, by the time all of this gets to us, what they’ve come with often doesn’t make much sense.

Oh, the particulars are good. It always about making some improvement in our residents’ lives. No one is going to argue for bringing back vest restraints or argue against resident privacy rights. We all accept that regulatory oversight and the policies that result from it are both necessary and well-intentioned.

What doesn’t make sense from a caregiver’s perspective is that the additional duties created by these regulations and policies are rarely accompanied by a corresponding increase in direct care staffing levels. We are simply told to do more with what we have. When I started in 1977 my resident group included 12 residents on second shift and 10 on first. While some places have improved on this, that ratio is still pretty much the standard. And due to difficulties in keeping facilities properly staffed on a day to day basis, the reality is often worse.

Not too long ago, I conducted an informal Facebook poll of direct care workers regarding care plans. My question: “Do you feel that your workload is light enough to enable you to consistently meet the care plan goals of all the residents assigned to you?” The overwhelming response was “No,” often expressed forcefully – and sometimes, colorfully. Out of 303 caregivers, only four answered yes.

It reminds me of that classic definition of “a mess”: A mess is trying to fit ten pounds of manure into a five pound bag. When you simply pile on more work but fail to provide more direct care workers to do it, you’re going to have some kind of mess.

Dear Operators-Administrators-Managers-Regulators-Advocates-Surveyors and assorted LTC professionals: we simply cannot do what you ask with what you’ve given us. Believe us, we want to do everything you ask of us – and much, much more. Perhaps you could find a way to work together and help us out a bit here?

The Magic Wand

May

We received a lot of feedback from my last post, Do The Right Thing. Comments are always welcomed and appreciated and I thank everyone who did so.
One in particular stood out, requiring more thought and response than I could give in a comment and so I will break my tradition of telling stories to answer Laura’s very excellent questions.

May, thanks for your great posts. I’m not a CNA but I work private duty with several of them and serve as helper on a care team. I’ve spent a lot of time in nursing homes (with my Mom and with other elderly friends). Hearing your stories, and Alice’s and Yang’s, is really illuminating and so helpful. I have always understood that the CNAs in care facilities were overworked and doing their best. Yet watching the elder suffer both physically and the indignity of waiting or wetting/soiling themselves was so hard. From your perspective, is there a fix? Is this is a system that can work? Is something like the Greenhouse Project the way to go? If you could wave a magic wand and create a system that really works, what would it look like? (Thanks for your patience with all my questions. I’m so thrilled to find your blog!)

The problem, as I see it, is that the current long term care system build around the idea of disposable resources.
Aides are a dime a dozen. Policies and procedures call for changing gloves four times during peri-care. We’re supposed to bag everything, linens and trash, and not carry bags between rooms. Food is wasted due to “cross-contamination” concerns.
It’s all built around the assumption that these resources–plastic bags, briefs, juice boxes, individually wrapped Danishes, and, yes, CNAs–are readily available, cheap and easy to replace.

One of the most damaging consequences of this “disposable resources” mindset is, I think, when it applies to the direct care workers. CNAs are typically paid very little, work long hours and have incredibly heavy work-loads–and when we burn out from the stress of handling it all, we are replaced. The cycle repeats, leaving exhausted and often injured people in its wake. There’s this idea, this mindset, that those who burn out simply weren’t tough enough.

I say, expect perfection under inadequate conditions and receive reality. In eight hours (hopefully) I can’t do everything that needs to be done…not for 10+ residents. It’s just not possible, trust me I’ve tried. It’s not a question of me not being smart enough or efficient enough, or not being motivated enough–it’s about me not having enough time. Staffing and resident-to-aide ratios play a huge role in the burn-out cycle, both as why people don’t want to start a career as a CNA and why current CNAs quit.

I think many of the symptoms of our broken system can be dealt with by decreasing resident-to-aide ratios. I think it should be capped at eight residents to one aide, and the norm should be even lower…say 6:1. High quality care could realistically and consistently be given.
And let me be clear, by “high quality” I mean that every resident could be changed every two hours or more. Every resident could receive thorough oral care every shift. Every bed-bound resident could be turned every hour. Nail care could given daily, faces washed after every meal, rooms could be kept tidy, drawers kept neat. Supplies could be distributed before you’re in the middle of cleaning up an XXL BM and realize you don’t have any wipes.
By “realistically and consistently”, I really mean “can be done in a calm, orderly fashion without rushing around, without sacrificing personal time with the residents or rest breaks for the CNA.” I mean “can be done thoroughly and properly without causing undue stress to the CNA or the residents,” and possibly “can be done with the attitude of encouraging resident and aide relationships and interactions.”
I, personally, would love to work in this long term care system, this system that seeks to foster opportunities for me to engage my residents in lengthy interactions; where direct care means personable care. I would love to be able to take my group of residents outside on a sunny day and just be with them for half-an-hour or so. I would love the chance to sit at their bedside every day and chat, without having to shut the door so I can’t hear the other five call lights going off.
I would love to be able to do all this because it is my job, not in spite of my job.

Fixing the caregiver-resident ratios won’t solve all the problems with long term care; there’s still that operating mindset of “disposable resources”. Considering that we just passed Earth Overflow Day, I think it’s pretty clear that this mindset is not an accurate reflection of our world. But that, unfortunately, is a problem for another day. The long term care system isn’t going to improve overnight. It’s going to be a long, slow path of baby-steps and, hopefully, emerging common-sense among policy makers.

So, if I were given a magic wand, I would use it to cap the resident to aide ratios. Then I would hold on to it, pass it to Yang and Alice, see what they would do.