Tag Archives: job satisfaction in long-term care

The Tough Talk


I had to have the big hard conversation. It is handsdown the most difficult part of being a caregiver for me. Long hours, short staffing, poor management, bodily fluids…even dealing with death itself is easier than telling someone that I am leaving them in order to embrace a better opportunity. I’ve done it before. You would think that having previous experience with such conversations would make it easier. You would think.
All of my reasons for making the change are valid ones. I gave notice. I’m even doing my best to find someone to fill my position, knowing full well that is not my responsibility. I have all the emotional support in the world from loved ones who know
how hard it is for me to change jobs. I know this is about taking the next step forward and not abandoning a client…but it still hurts. I still feel guilt and I don’t get to minimize the hurt my client is feeling in order to make myself feel better. As always, the woman who was once a client is now a friend and it is never easy to disapoint a friend.
Work boundaries have never been my strong suit. In caregiving, this is a double edge sword. On the one hand,it keeps me flexible and this is a field that demands flexibility. On the other hand, it takes a good kick in the ass and a shitstorm of chaotic emotions for me to move forward. And it’s not just my overblown sense of responsibility or protectiveness; it’s not just the underlying feeling that I am abandoning someone in need. It’s not just about them missing me…I will miss them. I always do. Letting go is also not my strong suit.
Tomorrow, I will go in for my usual twleve hour shift. I will not wallow in my fear or sadness. I will not be morose. I will let them be wherever they need to be emotionally. This may feel like walking on knives but no one can love every aspect of what they do. I will allow this to teach me. Maybe I will set better work boundaries in the future. Maybe I’ll learn how to let go of outcomes outside of my control. The one thing that I refuse to learn is how to not be so close to those in my care. This is hard. This SHOULD be hard. Just because this move is the right one for me does not mean it doesn’t negatively affect others. Just because it’s the right choice does not mean it should be easy. I take care of people for a living. Taking proactive steps forward does not mean minimizing the emotions that are derived from those actions. It means walking through them and using the experience to grow.

Underneath our Scrubs

Underneath our scrubs beat hearts that celebrate each success and bleed for each loss of those within our care. We know that our time with them is limited and we can not cure them. We can’t turn back the hands of time and we can’t change the situation that led them to our care. But we walk with them. We do what we can to improve their quality of life. We tell them they are not alone. We try to coax smiles from weathered faces worn down by time and experience. We listen. We translate. And when they pass, we grieve.
Underneath our scrubs are muscles that ache from running up and down halls or up and down stairs as we do the work of three people because of short staffing. Sweat runs down our face as we prioritize needs on the spot in order to provide the best care we can in an imperfect situation. Carefully compartmentalizing the very real frustration that comes from being overworked and underpaid; constantly facing impossible situations and feeling unappreciated, as if what we do is of little value. As if we are disposable. And isn’t that how those in our care feel? Invisible? Overlooked? So we run harder. Try harder. Uphill battles become our bread and butter.
Underneath our scrubs are souls of true grit. Whatever we look like, whether we wear it on the inside or out, we do not give up. Caregiving does not stop for holidays or inclement weather. It is not nice and neat. The most important and necessary tasks fall between the lists of activities of daily living. We face our own mortality every single shift. We face worst case scenarios and see the people beneath; see the strength and courage of those living through them and their strength fuels our own.
Underneath our scrubs, we are tired. We are weary. We are disgusted with the poor pay and misunderstanding of what we do and why we do it. We are tired of being dismissed. Tired of those in our care being misunderstood and dismissed. Tired of “it looks good on paper” mentalities and tired of people with little experience on the floor and no real world knowledge of those in our care deciding what is best for them without our input. We deserve better. Our residents certainly deserve better. And until we get better, we will be relentless and consistent in speaking our truths.

Who’s the One with Dementia?





For those who might not have seen the ‘goddess’ of dementia care (imho) Teepa Snow in action yet:  Teepa has a wonderful skit she performs in her training programs.  At these programs the audience members are generally caregivers.  Teepa will play the role of the caregiver while an audience member takes the role of the person with dementia.  (Every caregiver becomes an expert in this role!)

Caregiver, smiling:  “OK, Jeannie, time for bed.  Let’s go to your room.”

Person with Dementia: “No.”

Caregiver: “C’mon, time for bed.”

PwD: “No.”

Caregiver, now frowning:  “Now Jeannie, it’s time for bed.  You know you’re tired.”

PwD: “No, I’m not.”

Caregiver, in a louder voice: “Jeannie, it’s time for bed.  Come with me.  You need to go to bed.”

PwD:  “No!  I’m not going.”

Caregiver, louder still:  “Yes, you are!  It’s bedtime and I have to get you ready for bed!!”

PwD, now pushing and screaming:  “There’s a stranger after me!  He wants to rip my clothes off!  Stop it!  Somebody HELP me!!  I want my Mother, where’s my Mother!!  I want to go home!!”

Caregiver, louder than ever and totally exasperated: “You come with me right this minute!  You are COMING WITH ME NOW!!

As Teepa asks at the end of her role-play: Which person seems to be the one with the cognitive problem?  The one who seems to know what she wants (not to be put to bed yet), or the one who is hell-bent on getting the dementia-impaired resident to change her mind.  The resident probably can’t change her mind at this point, especially not in response to a caregiver who repeatedly sends, in an ever louder and more frustrated voice, the same message: DESPITE YOUR WISHES, I’M GOING TO PUT YOU TO BED NOW.  If anything, the caregiver’s rising frustration triggers the resident’s fight-or-flight instincts.

For CNAs, this is the question of the hour: What do I do when a resident won’t cooperate?  Do I become more and more insistent, and in the process arouse further defiance in the resident?  Maybe I worry “I need to rush.  If I don’t get everyone ready for bed by the end of the shift, the unit manager will be furious with me.”  (PS: Remind her of that person-centered care she’s trying to sell to families—and which the brand new CMS regulations confirm.)  Do I gripe to my co-workers?  Or do I try something new.  We CNAs develop great ‘tricks of the trade.’  My secret weapon is music.  Others try chocolate.   Sometimes a short walk will help.  Or we might initiate discussion of a favorite family photo.  Trial-and-error is the name of the game.  Creative redirection.  The point, as Teepa Snow and Naomi Feil teach us, is to connect with the person.  To empathize with the underlying emotion being expressed and validate that emotion.  To engage the person in an experience they might enjoy before moving back to the ADL.

All this takes time.  But taking time to engage a resident isn’t a frill.  It’s an essential part — the best part, of being a CNA.

The Simple Things




How many moments do we waste away worrying? How much time is wiled away as we stew and fret over missed opportunities? How much of our lives do we willingly hand over to resentments and anger and fear?

The people for whom I have cared throughout the years remind me of that in a million ways, both with words and by action. Many of them have survived cataclysmic events that forced them to redefine what exactly it is to live, and yet the sheer joy they derive from the simplest things is truly a sight to behold. It humbles me.

The scent of freshly brewed coffee, the comfort of a familiar routine, a well-timed joke, a large bowl of ice cream, a certain song; the small, simple joys that I so often take for granted transcend those in my care from their current situation to the time “before”. 

They don’t know they’re brave, but I know. I see it. I see it in their strength to live and love and embrace what moments bring them happiness in the face of overwhelming challenges. How could I NOT be changed by such quiet courage? How could I NOT be motivated to embrace my own moments? They inspire me. I’m slowly learning how to get out of my own way. I have a daily reminder to never take the moments for granted and that life is for living and to not waste my time with regrets. That is a hell of a job perk.

A Teachable Moment





        Private Care is kind of like a weird Tim Burton version of Mary Poppins, except instead of love starved, dysfunctional children, I’ve got an elderly couple who have been married for nearly fifty years.
Technically, only one of them is my client but the fact is it’s a dance. As I am working independently, any work boundaries that need to be set have to come from me and setting and accepting my own limits in a work environment is an area in which I sorely lack.
I don’t like to rush my client. It is quite simply my favorite part of home care. If she wants to take an hour to brush her teeth, she can! The shifts are long and we have the time. I fail miserably at curling and teasing her hair and helping her with her make up, but the end result isn’t nearly as important to her as the fact that I’m willing to try. The trouble comes when her husband feels the need to rush. If I don’t act quickly, he’s a bundle of nerves and then she’s a bundle of nerves and then HELLLLOOOO ANXIETY, as I try desperately to keep everyone happy while maintaining an air of serenity.

I find myself tip toeing on that line of co-dependency far too often. Staying late and coming early, letting those little bits of time go without mentioning pay, cooking for their children and grandchildren on occasion, it does add up. I’m learning though, and not just how to be a better cook either. For one thing, I’m negotiating with myself. I like it when my client’s family comes to visit. It fills her with pure joy, like turning on an inner light switch. I am willing to cook for ten and clean up after for my client to have those moments. It gives me joy too. But then I have to put on my big girl pants and have that oh so scary conversation about being compensated for the hours that I stay late or come early. That’s the deal. Some things, I am learning to bend on and others I have to stand firm.

I’m learning how to teach someone who doesn’t even realize he’s a student. I love that!
“You have to speed her up. Sometimes she needs reminding that she’s handicap.” Her husband said to me one day. I explained to him that my job is to do all that I can to make it so she feels LESS powerless over her condition and owned by her limitations, not to remind her of them. He was quiet and for minute I thought I was in for it.

“You know, I never thought of it like that before.”  It was a teachable moment for both of us. I forget sometimes that not everyone can see what is obvious to me after working in this field for a few years.

Often I miss facility work. I felt more at home with the pace and home health can be very lonely. It’s long days with only the client and her husband to interact with. So much is dependent on moods. If her husband is in a bad mood, it throws my client off too and then I’m in for a long and uncomfortable fourteen hours. But it definitely isn’t boring, as I thought it would be. There is plenty to do and learn. I feel like I’m still exploring the parameters of my job in this area of the field.

Do I want to be in private care in a year? No. But for now that doesn’t matter. This is where I landed and this is where I’m needed. At least I’m not in Long Island!

The CNA: From Image to Identity





Several things come to mind when we consider the image of CNAs. Stereotypes exist on both ends of the spectrum. On one end, we have the demonized version of direct care workers as presented in negative media reports. On the other, we have the LTC industry’s idealized image, the compassionate yet professional, self-sacrificing “CNA Angel.” Somewhere in the mix we find the clinical version of the CNA: a vital part of the team, but with limited scope of practice – the caregiver defined by a particular skill set and specific tasks to perform. Finally, we have the unhappy image of caregivers as the poorly trained, dispensable bottom of the totem pole, the ones who do the hard and dirty work, or in the crude vernacular of the breakroom, “Butt Wipers.”  Or even worse, “Just a CNA.”

While there is an element of truth in all of these images, none of it really gets to the essence of what it means to be a caregiver. To grasp that, we have to take a closer look at how caregivers actually experience the work and where in that experience they find meaning. When caregivers are able to express this they are defining themselves. In doing so, they move away from image and toward creating their own identity.

One approach to understanding what caregivers find meaningful in their work is to look at a typical response to the notion of “Just a CNA.”

Here’s an excerpt from a poem I often come across online:

Who are you to refer to us,
As “Only” a CNA?

We’re the ones who take the time,
To listen to them speak.

We listen about their lifetime,
In a forty hour week.

We take the time to listen,
By lending both our ears.

We listen to their worries,
Or how they’ve spent their years.

We chose to do this job,
The job did not choose us.

This from a post on a CNA Facebook page:

Yesterday a nurse put me down, went as far as saying that I was “basically just a helper.” I was VERY OFFENDED. Yes I know that a CNA is below a nurse, but when it comes down to it I’m the one that holds the patients hand when they are sad, I’m the one that they call when they just need someone to talk to, I’m the one that will sit there and engage them in a conversation for hours. I’m the one that is on call 24-7 for all of my case load

There should never be JUST in front of a CNA. We are not just CNAs. We are Family when you’re not there. We are here through the good, the bad, the ugly, and even through death. Think twice before you call us just a CNA.

This from a CNA t-shirt:

I’m Not Just A Nursing Assistant
I’m A Trusted Friend…
I’m Part Of The Family…
I’m A Comedian That Puts A Smile On A Sad Face…
I’m A Counselor…
I Listen To Stories & Share My Own…

I’m A Proud Nursing Assistant

These examples, as well as just about every response I’ve ever read or heard to “Just a CNA,” have one constant underlying theme: the meaning of our work – and thus how we define ourselves – is inextricably bound with the connection we have with our elders. If we are “Just CNAs” than the people we care for are “Just residents.” If we are “butt wipers” then our elders are reduced to just so many butts to be wiped. You cannot disparage our work without dehumanizing the people we care for. The two cannot be separated.

Our identity as caregivers is not based on the most disagreeable aspects of the job. Nor is it based on a job description, nor on our place in the LTC hierarchy, nor on how the public may view us. It is based upon how our elders experience our interactions with them. This relationship is the single most important factor in how a resident will experience life in long term care. Our awareness of the significance of this bond and our desire to express it is more than just a form of self-validation, it is also a potentially powerful antidote to much that is wrong in long term care.

How we can employ the power of this awareness is the subject for my next post.

A Glance Back




  It was such a surreal feeling, driving into the parking lot of my old facility. Like being a visitor in my old home. It was Christmas day and I had promised the residents that I’d spend the afternoon with them. Truth be told, it was as much for me as it was for them. I missed them. These past few weeks have sent me adrift and I needed the reminder of what started me on this caregiving path in the first place.

      “ALICE! You’re BACK!” Shouts and greetings that warmed my heart and healed my spirits from residents and co-workers bounced from the walls. I felt at home, as if I never left.

      In that moment, I remembered how much I once loved working in that facility. The challenge of having to solve problems in a moment’s notice, the constant testing of my every limit, the ability to look at someone I’m training in the eye and tell them that this is a tough gig if you do it correctly but if you’re open to it, this will be the one of the most worthwhile experiences in your life. I loved all of that. I found it endlessly challenging.

         My greatest joy are the people. These interesting, difficult, demanding, funny, people who became my friends over the years; who have more wisdom in one pinkie than the rest of us have combined. How I’ve missed the stories. It’s safe here.

      Suddenly my reasons for leaving seemed so remote; the pain and financial struggle and inability to blindly accept the status quo seemed a dim memory compared to the joy I took in my work. My etch-a-sketch mind quickly erased the rough edges of the actual working conditions and replaced it with a smooth and calm mental image of a reality that never existed.

      In this time of upheaval, the familiarity of my old job is appealing. I know my residents, their preferences and routines. It would be so easy for me to just turn back. As tempting as that thought may be, I know it’s the wrong answer. It broke my heart to walk away the first time. It would just be harder to do it again in a year. Or two. Or three.

      No. There is no going back. I don’t know where this new experience is going to lead me, but I have to believe that it’s not back to the starting gate. I have to believe that it’s leading me forward. Besides, my residents are what bring my life a deeper depth; a wealth of experience. That connection can happen just as easily over a cup of coffee as it can by punching the clock.

The Dynamics of Dementia




  Dementia. A chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning. Such a clinical and concise definition for a condition that wreaks such emotional, mental and physical havoc. I hate the disease. I hate what it does to those living with it and their families. It’s a vicious, unrelenting condition that robs people of their very essence.

        For years, I worked in facilities where the heart breaking reality for my residents living with this disease was that they either outlived or were essentially abandoned by their families. It was in this environment that I realized that I love and admire those living with dementia more than I hate the disease itself.

        It’s their courage. It never failed to amaze me, especially in the early stages, when they are aware that they are foggy. They are aware that they are losing pieces of themselves. Can you imagine the sheer bravery it takes just to live with that knowledge? Just to get up and face the day? I knew then that I wanted to do everything within my power to make their lives as full and meaningful as possible.

          My daddy used to beat my momma. I just can’t handle it. I’m too busy. He never bothered with us when he was well…I’ve heard countless reasons as to why these folks have ended up in a facility over the years. I am not discounting or judging the difficulties for the families. Sometimes a facility is the best solution. Sometimes it’s the only solution. As a caregiver, it’s very clear cut for me. ANYONE who lives with such a condition, regardless of their history or past mistakes, deserves the utmost respect and best possible quality of care. End of story. We do not pick our residents.

       Now I’m in a new environment. I have one client with a family who is very involved. Very invested. It really is an amazing dynamic. After so many years in a facility, I forget at times that the family may not know my reasonings for certain actions. My client was having a tough day. She was in her wheelchair but was rummaging and reaching for everything she saw on the floor. As a caregiver, I knew it was going to be a day that required extra close supervision. I quickly assessed potential fall risks, higher difficulty in transfers, and came up with a mental list of therapeutic redirection ideas that I could employ. All of these tools are second nature to me, almost muscle memory, so I didn’t articulate it. When a family member asked why I was staying so close by her, I told him that I didn’t want her to fall and left it at that. Later, when I was discussing her day and her mobility in more detail, I saw the light of understanding in his eyes. He then understood the potential for a head injury if she tumbled out of her chair while reaching for something on the floor. That those incidents can happen quickly if I’m not on top of it. I took for granted that “I didn’t want her to fall” was enough of an explanation simply because I was used to working in a facility where such knowledge is commonplace. These are the sort of teachable moments that I am finding incredibly valuable! In the process of explaining such situations to the family, I am reviewing the knowledge for myself. Almost like a refresher course. Muscle memory is nice, but the ability to articulate, employ and address such challenges with conscious awareness is much more valuable.

        Dementia is a family illness. There are good days and bad, but much like addiction, it affects the family unit as a whole. I stress the need for self care. I love this family’s enthusiasm and willingness. I love their honest desire to learn all they can about the nature of this illness. I love my client.

      Caregiving to me is more of an art than a science, especially when it involves dementia. With love, communication, consistency and support, we can make massive strides towards improving the quality of life for those in our care. The first step is seeing the person instead of the illness with which they live. The family unit is the biggest key to this. I value their input and opinions every bit as much as they value mine. There is gold in their memories; information that I can use when redirecting. They know her fears, taste in music, favorite foods, potential triggers. I feel part of a team effort whose sole intention is to provide the best quality of life for someone we all care about. We are united in that common goal.

       There are 7.7 million new cases of dementia every year. I am very blessed to be in the position to see how good intentions and proactive decisions from a core group of caring family members can positively impact the life of one. To be a part of such an experience is deeply enriching.

A Different Kind of Career Path




Two glorious days off! IN A ROW! It had been over a month and a half since I’d had that luxury and I was counting down the minutes on Friday. I planned to have a creative, productive, friend filled weekend and intended to enjoy every moment of it. I gave myself a strict “no work talk” rule and actually managed to stick with it. I drew, wrote, went to a movie, rested, caught up with friends and volunteered. As much fun as I had, by Sunday night I knew I was ready to return to the hustle and bustle of the floor.

         The idea of “career people” used to conjure up images of high powered entrepreneurs, doctors, nurses or lawyers rushing to and from important meetings; people very dedicated to their careers, sometimes to their own detriment. It never occurred to me that the term could apply every bit as much to those of us scraping by on an hourly wage in broken down facilities in a broken down system and yet, here I am, just as much of a career woman as those with advanced degrees.

       Let’s look at the facts: I’m single, without children. When I’m not at work I’m writing about work, or attempting ways to improve work. I’m incredibly dedicated to my residents and have the lofty long-term goal of doing whatever I can for as long as I can to greatly improve the system in which they are forced to live from the bottom up. That is the very definition of a career woman.

         The SYSTEM may think we are disposable, our pay, bosses, and the ethic of those who have been so burned out that they can no longer care the way they should may reinforce that idea, but it isn’t true. Ask the residents who they count on, who they trust, who knows them the best, who SEES them, and their answer will be us; the caregivers. We cannot allow anything else to dictate our self-worth or the value in what we do. I wish I could burn into the heart of every caregiver the knowledge that they are uniquely gifted and desperately needed in the lives of those who have so little. Our skills are different, not less. We are not diet nurses. We are not “ass wipers”. We are the frontline.

     I will learn and forget countless bits of knowledge as I go through my life. I don’t know if I will always be a caregiver, but I do know that whatever path I may end up on in the future will be richly informed by the career that I hold right now. As I punched in early Monday morning, I was met with smiles from my residents and fellow workers on the floor. I missed them while I was gone and though I don’t know what my future may bring, in that moment I felt like I was coming home.

Two Open Letters






To Potential new hires,

I want you to be responsible for the care, protection and quality of life for a hall full of people with a wide variety of physical and mental illnesses. Make sure they are clean and dry, supervise their gait, and make certain that their oxygen tanks are full and on the appropriate setting. If they have a doctor’s order for TED hose, please make sure they are on in a timely manner.

Because these folks are unwell, they are occasionally combative. We will offer no help to you in these matters, other than suggesting that you get another aid to help, if you can find one. Often, you won’t be able to because we have a bare staff. We are also desperate for help, so many of the people we DO hire are unable to lift and are squeamish about body fluids, so they will not be much help to you. We hope that you are not like that, but if you are, eh. You get what you pay for. Someone will pick up the slack. Someone always does.

We can’t promise that we’ll remember to tell you if your hall partner called out or your shift relief will be late. We are very important and busy people. You can’t expect us to value your time and effort enough to interrupt our own.

You will be covered in any number of body fluids, we will often run short of supplies and expect you to figure it out. As a matter of fact, we pretty much expect you to handle any situation with little or no input from us. Oh! We will make rules and change them without telling you and we will apply them with inconsistency, as we see fit. This applies to both you and the residents. There will be no raises. No benefits and no rewards for doing an excellent job. But there will also be very few consequences for doing terrible job. Life’s a balance. We’ll pay you 9.00 an hour. What do you say?




To Potential new hires,

This job is tough. It is not for everyone. It will break you into a million pieces and teach you how to put yourself back together in ways you never thought possible, if you allow it.

There are facilities with kind, involved supportive management who offer substantial training and ample rewards for good work ethic. There are facilities with relatively calm residents who are not living with severe mental illness. This is not one of them, a fact that over time I have grown to appreciate, oddly enough. When there is no one willing to solve problems, it motivates you to first understand the problem and then figure out how to solve it yourself.

I have learned more about life, love, courage, vulnerability and perseverance than I could have in any other facility. I have explored, hand in hand with my residents, the subculture in which they live. I’ve learned to trust and be trusted. I’ve learned how to speak my truth, and more importantly, to speak theirs.

None of this will pay my bills, and there are times that I am resentful at the lack of pay, and basic lack of respect for what we do; a job that matters deeply to me is dismissed by those who should know better. I don’t wallow in that though, because I believe that WE can change that. If enough of us refuse to allow our pay rate to dictate our level of care, if we use the systems flaws and mismanagement to teach us how to problem solve and lead ourselves rather than embitter us enough to lose our empathy, then we really can make a difference. I believe this in my heart of hearts and truly hope that you will be a part of the solution. It’s easy to be a light in the day. My facility needs lights in the dark.


Your fellow Caregiver