Tag Archives: nursing assistant

What do you do for a Living?



The other day I was in a resident’s room getting ready to administer a nebulizer treatment.  Her TV was turned to the Game Show Channel with “Family Feud” going on.   My fellow care givers can attest “Family Feud” is a staple in the LTC environment with Turner Classic Movies a close second.  You can’t walk down a hall without hearing at least 3 different versions of “Family Feud” blaring out of multiple residents’ rooms. 

It was the beginning of the show where the host, Steve Harvey, has each of the family members introduce themselves before they provide an answer to the question he is asking. I wasn’t paying much attention to the show as I am busy getting the treatment ready and assessing my resident’s shortness of breath.  I am vaguely aware of Steve Harvey talking to the first three family members.  I didn’t hear their names, what they did or the answers to the question.  The fourth family member made me stop and look at the TV screen.   I half heard Steve Harvey ask her, “What do you do for a living?”  It is difficult to explain the fullness of what happened next.

She said, “I am a CNA at a long term care facility.”  It wasn’t the words she spoke as much as her tone of voice that made me whip my head around to look at her.  I see and hear so many CNAs when asked what their occupation is a sort of apology tends to follow.  “I’m a CNA but I plan on (insert a perceived better career choice here)…” or “I work as a CNA while I figure out what I want to do.”  The body language that accompanies those statements relays uncertainty, self-consciousness, and/or humility.  

This woman on that game show was different.  Those brief seconds she was on the TV screen showed a confident woman who was proud of her career choice, proud to be a CNA.  Everything about her body language supported the self-assured tone of voice in which she spoke those words.   “I am a CNA at a long term care facility.” End of sentence.  The words “courageous”, “bold”, “empowering”, and “confident” all ran through my brain in those few precious seconds.  She offered no apologies or explanations.  She stood tall, looked Mr. Harvey in the eye and declared her right to be proud of herself, of her career and those in her care.  I am proud of her, too. 

CNAs, be proud of your career choice. Do not ever, not even once, apologize in any way for working as a CNA. Stop feeling like you have to rationalize being a CNA with sentences like “I’m a CNA but…” You don’t have to do that.  Part of changing the LTC environment and other health care settings involves how we speak about ourselves and each other. Talk about your job with pride, with confidence.  What CNAs do is challenging, emotionally rewarding and taxing, sometimes all in the same day.  Not everyone can do the work. It takes a special kind of talent and perseverance to be a CNA for 2 years, 5 years, 15 years.  The more each of you declare with confidence and pride in your voice, “I am a CNA” the more empowered you will become.  The more empowered you are, the more others will want to hear what you have to say. Be bold; declare with confidence your career choice just like that wonderful woman on a popular game show did.  Be confident in yourself. Be proud to be a CNA.  I am proud of you, too.

Cueing for Caring





I volunteer in a long-term care home which serves, among others, those with dementia.  The aides in this home have had dementia training and the care level is already exceptional.  I think this is because management expects the aides to…well, to care — not just to ‘provide care,’ and because management models this value.  Still, the nursing supervisor wanted a performance boost.  Training.  

Aides benefit from understanding dementia and from exposure to the best ideas on dementia care.  But what’s most important about staff education is that their new knowledge lead to new workplace habits.  Training that doesn’t result in improved care is about ‘CYA’ compliance for CMS, not about caring.  How do we ensure that training actually improves how we do our jobs?  How do we transfer the training lessons from the training site to the workplace?  As a reinforcement tool, cueing is used very effectively in memory support homes which adopt Montessori methods.  Are there some short-and-sweet (and fun) cueing tools we might use to reinforce training? 

If there were just a few practices that would transform care, I believe it’s those illustrated in the poster below.  These are tried-and-true best-care practices from experts like Teepa Snow and Naomi Feil.  Let’s try turning these ideas into cues to use where we work: nurses’ stations, employee lounges, food prep areas, in the laundry, at the time clock.  Hanging icons separately in the halls—for example, the little cheerleader—may remind us all to encourage and praise residents’ efforts.  We’d be surrounded by encouraging reminders.  Cues keep us mindful of the kind of environment that is most beneficial for all residents, especially those with dementia.  

Along with cueing, another way to reinforce training lessons is the use of rewards of some kind.   The next step is to develop a rewards program for aides who go the extra mile to use these ‘care commandments.’  This is trickier but surely warranted for aides working to create an environment that says, “We Love Our Residents.”

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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.

Keeping the Faith




Some shifts, the world seems against me as if some dark cosmic force with an appreciation for irony is pulling the puppet strings of everyone with whom I come in contact. My residents lash out. My body aches. The weather doesn’t cooperate for my walk to work and I spend eight hours running around in wet shoes and scrubs. Management that cares only that there are bodies on the floor, trained or not. Not enough money to pay my bills, crossing my fingers each month that nothing gets shut off. On those days it just feels…impossible.

         And I have my fair share of them. Days when I question why I stick with this. Days when my patience feels short and my humor is rusty; when I begin to wonder if I genuinely love what I do or if I’ve just convinced myself of that out of this desperate need of mine to see the bright side.

       Some days I’m bitter and angry and frustrated and weary and sad; my insides as covered in “yuck” as my scrubs. Those are the days that make me wish I didn’t give a damn. They make me want to scream YOU WIN, REALITY! YOU WIN, DEFEATISM! This system is beyond hopeless. These people are screwed. I am only one person and I. Can’t. Do. This. Anymore…I give up.

       But then I look at the poster above my front door, the one that says going in one more round when you don’t think you can, THAT’S what makes all the difference in your life, and I lace up my sneakers, grab my stuff and head to work. Because that poster is right. Time and time again it has proven true for me.

       I do not always love my job. Sometimes I resent the unending uphill battles and impossible situations that relentlessly whisper “You will fail in this”. And unless there are major changes from the top down, that is true. We will all fail because the system will eventually collapse upon itself. Still, every day I put on my scrubs and show up. I love my folks and that love has created in me a faith bigger than my resentment at my bosses, bigger than my fears of financial insecurity and bigger than the occasional despair during the rough stretches. From that faith a commitment to change the system and improve the lives of those who live and work within it has taken root. I don’t know where this commitment, this fire that oscillates between burning me and guiding me, will lead. I hope that we reach people. I hope we defy the odds. And I know that it begins with us.

Meet Them Where They Are





Unreasonable, misplaced anger, unrelenting fear, heartbreak from deeply felt emotional wounds, a lack of trust both of others and of their own capabilities, powerlessness, despair, frustration, feelings of abandonment, and utter lack of control over their own surroundings are only some of the negative emotions that those living in Long Term Care facilities face on a daily basis.  My residents who struggle the most with the above mentioned feelings are usually the ones who are the least capable of clearly articulating it.
So what happens? They act out. They become verbally and on occasion, physically abusive. They often yell or become obstinate over seemingly innocent little tasks. They manipulate situations in a way that they feel best benefits their needs. They are the residents labeled “difficult”, “trouble makers”, “problems”, not just by those of us on the floor but also by those in the office.
God knows, I’m guilty of it; inwardly sighing, as I make my way to a resident who is furious at me for something over which I have no control. Or a resident who is vengeful because I’ve had to set a boundary that she doesn’t like. Some days, I wonder if all of my uphill battle folks had a meeting and decided that they would join forces in order to make a shift impossible just for their own entertainment. Those are the days that I leave work questioning both my sanity and my capabilities; the days when I think I suck at this gig and wonder why I am so determined to stick with it.
The thing is, though, when I step away for a minute, I realize that I have a level of awareness that is desperately needed in this field. I really do know that these “difficult” residents are not behaving in such a manner simply because they’re “mean”. The powers that be may know that, but in all honesty they don’t care. They can’t possibly care because their only solution appears to be medication, a problem that I will be discussing in a future post. A facilities treatment of their caregivers directly corresponds to their level of interest in their residents’ quality of care. They are not invested in us, then they are not invested in them.
SOMEONE has to be, though. Someone HAS to see beyond the behavior, which is nothing more than a symptom to the greater underlying illness. That responsibility lies on the floor. We are the witnesses and the carriers of their emotional wounds. While we are unlikely to heal them, we can step outside of ourselves and use their behaviors to learn how to better care for them, much like the pain from touching a hot stove teaches us to not touch it again.

Unreasonable, misplaced anger, unrelenting fear, heartbreak from deeply felt emotional wounds, a lack of trust both of others and of their own capabilities, powerlessness, despair, frustration, feelings of abandonment, and utter lack of control over their own surroundings…that’s a lot for any human being to have to live with. Sometimes adding “fit into my concept of acceptable behavior” on top of all that is just too much to ask of them and they can’t meet US where WE are. That’s when our empathy and understanding needs to stretch in order to better meet THEM where THEY are.

I am not an Angel




If someone calls me an “angel” one more time today, I think I’m going to puke all over their shoes.  Really, I mean it.  I am not a messenger of God dressed in a long white robe with wings.  I am a CNA: a certified nursing assistant, a trained professional.  I am a person who chose this career field.  I am a wife, a mother, a daughter, a sister, a neighbor, a voter and a human being.  I am not an angel.

I have a full set of emotions and thoughts that you, the family of the residents I care for, will never see or hear.  You will never hear the cuss words that run silently through my brain as I discover your delirious wife smearing her feces all over her bed, the floor, herself and anything else within arm’s reach.  Instead, I face the task at hand; cleaning up your wife and her room while calmly interacting with her.  You will never hear me sharply respond to your mother’s cruel, untrue words concerning my work methods.  Instead, I redirect the conversation in a quiet, soothing tone.  You will never see the frustration I feel showing on my face when your husband refuses to walk even though he is able to do so.  Instead, I continue to encourage him to keep trying. You will never notice as I slowly inhale and exhale to calm myself after your elderly father just threw his meal tray across the room because the cook accidently gave him juice instead of coffee.  You will never see the tears I cry while I apply ice to my bruised cheek after your aunt, in her dementia, punched me while I changed her urine soaked clothes.  You won’t know the feeling of disgust that runs through my body like an electric shock when your aged, confused uncle grabs my crotch while muttering sexually explicit phrases as I help him out of his bed and into his wheel chair.  No, you family members of the residents we CNAs care for will never really know these things.   You see us working and instead of respecting our professionalism you call us “angels.”

These are not the behaviors of angels; this is a professional CNA in action.  We are trained, licensed and trained some more to be CNAs.  We work very hard to help other people’s family members.  I would much rather hear someone exclaim with pride, “She is one hell of a CNA!” than call me “an angel” any day of the week.  I won’t even feel like puking because I’ll be too busy smiling.

The Value of the CNA Voice




There is a school of thought among some professional advocates for CNAs that says caregivers will never fully appreciate the true value of their own work until they have a better understanding of how the business of long-term care works. That, until they recognize their role in the bigger picture, caregivers will never fully grasp how they influence the larger goals of the industry and are thus left to doubt the significance of their work – and their self-worth.

While I’m not prepared to dispute any of that, I will say that in terms of utilizing resources to deliver the best care possible, the converse is far more significant: the business of long-term care can never fully come to grips with its own problems until those who establish policy and enforce standards develop a deeper awareness of what we are all about.

And it’s up to us to tell them.

Before social media, the “CNA Voice” did not have an adequate platform for independent expression. With few exceptions, CNAs were heard only through the filter of the health care hierarchy. The result was a sanitized voice, good for parroting industry buzzwords and contributing to interdisciplinary window dressing, but giving only a glimpse of how we really experience our work.

With social media, direct care workers have been given the opportunity to express themselves more openly, albeit with the caveat that you never know who is watching. The majority of these forums are administrated by caregivers and they accept a far wider range of public expression than is possible within the formal work environment.

While social media gives us a better sense of the CNA Voice, all too often it presents that voice in a fractured and superficial way. That’s just the nature of social media, which promotes interaction and response. What social media doesn’t encourage is the kind of reflection necessary to properly sort out and express that complex and often contradictory blend of thoughts and emotions that make up the inner experience of the caregiver. That is the true source of our voice – and our self-worth.

We can help long-term care understand itself by offering something precious: a dose of reality. And if there is anything that this system obsessed with image needs, it’s a steady dose of reality. Yes, there is much about the “bigger picture” that most of us don’t know. But we are aware of certain truths about long-term care in a way no one else can be. Because outside of the residents themselves, no one knows better than we do how they experience their time in long-term care. In fact, we can’t talk about our experience in a meaningful way without talking about theirs. And that is the real value of our voice.

Just a CNA?




Edison Terrell

I‘m not “just a CNA,” but I’m not so bothered by people saying that’s what I am. Other people are taking snapshot judgments of my entire life stories and personality based on a glimpse when they say I’m only an aide, and I do that to them, too. It seems like an evolutionary device to tell potential friends from foes, and as we got more sophisticated, a way to determine someone’s value to you, or lack thereof. It’s deeply ingrained in the mind, passed on and perfected by thousands of generations of reinforcement. Something like this won’t go away by arguing with it. That’s literally the opposite but equal side of the thing. On one side is “You’re ‘just’ a CNA,” on the other is “I’m MORE than just a CNA, I do blah blah blah.” I’m not saying I don’t agree with either stance, but we’re just banging hammers here. You’re fighting one mindset with its equal, an unstoppable force meeting an immovable object.

I don’t know what the answer is, but it isn’t this. I honestly think it’s just to let people hate and not to give in. That’s a pill I haven’t swallowed, I’ll totally admit it. One of the reasons I’m going back for a degree is because on some level I believe that “Just a CNA” bullshit. And that’s OK, too, if you have that same thing going on. It’s just your mind. Mind is like a water glass with dirt at the bottom, and this stuff, arguing the merits of what we do, is stirring up the glass, clouding the water. There’s no taking the dirt out, though, it’ll always be there. You just have to notice when your mind get shaken like a paint mixer and understand what comes up is just a reflection of your shook up mind.

That’s a lot easier said than done, of course. I’m still working on this after almost ten years, and I’ll probably wrestle with it for the rest of my life to some degree, but I’ve found it to be the only thing that may provide some relief. I did a lot of soul-searching before I entered healthcare, fell into Zen, and I think some of the lessons like this one might be helpful for everybody, regardless of the path you’re on. The alternative from what I can see is diving hip deep in the fray, getting pushed around by forces you have no control over, people you don’t know judging you, a person they don’t know, and taking swings at everything that moves. What good will that do any of us? No—what good does that do you? Let’s not make this a global issue. Tell me when doing that has benefited you? When have you jumped into an argument like that and walked away not feeling unclean? I want to meet that person. You might feel like you one-upped somebody because you got in a few good remarks that left them sputtering or pissed off, but you still feel ugly and gross walking away, if not ashamed or mad yourself. Is that worth it?

And I know, believe me, the alternative to that sucks, too, just as bad. That guy called you worthless, but you’re supposed to not snap back at them. It becomes a question of whether you’d rather feel dirty and angry or just angry, and have to examine that anger, the stuff that arises with it, and let it come to rest while the other guy is smugly nodding in the corner like he got you. It takes everything not to verbally crank him across the jaw. After a while it starts looking like the only good option, though, even if it’s not the most palatable one.

Let the haters hate. It’s what they do. Just drop both sides, or try to anyway. Cuz otherwise it’s like thinking you can remove a bullet wound by shooting yourself again. That’s my opinion, anyway. I could be totally wrong, I’ll admit that too. 

Figure it Out




It’s pouring. And cold. And the busses aren’t running. Awesome. Figure it out, Alice. Make it work. Ok. I’ll pack my scrubs, walk in street clothes and change at work. Solution!

Third shift did not get up one resident. Not one. I was informed that she wasn’t going to risk harming herself by “lifting. She’s concerned about HER back and couldn’t care less about MINE. Figure it out, Alice. Make it work.

My partner on the floor is late. Or called out. Or maybe no one was scheduled. I don’t know. No one told me and I don’t have time to bitch. There are seven people calling my name. Where are the TED hose?! Missing again. Figure it out, Alice. Make it work.

Prioritize; desperate to desired. Fall risks first, requests for ice last. Breakfast is late. VERY late. Which means showers will be late, my residents will be “off” and my shift will be “off”; that potentially disastrous domino effect that comes from inconsistency.

New resident, ninety-five years old. Sharp as a tack. She came to us from her own home, having successfully lived independently for almost a century. Now she needs help. That’s scary. I know that’s scary. She knows that’s scary. I tell her she’s brave.

“MAKE SURE SHE GETS UP!”, says her family. Says my bosses. She does not want to get up. She refuses. She adamantly-hell-will-freeze-over-first-refuses. Figure it out, Alice. Make it work. I tell them that everything is a negotiation. I tell them she is going to need time to adjust. I tell her we will work together and try again tomorrow.

Buddy, you HAVE stop peeing in cups. I promise, I will do my very best to make sure your brother doesn’t give up. I’ll find your favorite sweat pants, they are around here somewhere. It’s not ok to dump your milk on your roommate because she got to the Rice Krispies first. Poop. So much poop. WHERE ARE MY MEDIUM GLOVES?! Small is useless when my hands are sweaty and large slide right off. Figure it out, Alice. Make it work.

“Alice. Whose drink is this? You KNOW drinks cannot be on the nursing station!”….Pause, Alice. DO NOT say what you are thinking, for once. Deep breath. Do not SAY not only do I not know who’s drink that is, but I don’t care. Why don’t you take that drink and shove it up…

“Nope. I don’t know.” Good! Restraint!

We don’t get paid enough to “figure it out”. There are days that I feel really resentful and get stuck in the “unfairness” of it all. I hate that! I’ve written previously about how I feel about that sort of mentality, but I’m human and am not immune to the occasional case of the “poor me’s”.

Luckily for me, on those days that my mind and emotions rebel and refuse to cooperate, my FEET know exactly what to do. It’s muscle memory. It’s action. They figure it out and make it happen and usually my feelings follow suit. Resilience overcomes defeatism.


Jumping the Gun




Two weeks. It took every bit of two weeks to adjust to the idea that I could embrace a new opportunity that fell into my lap. An opportunity that I didn’t even know that I wanted.

A few months ago, my frustration at the low wages and dysfunction of my current work environment led me to apply for a position in a new facility. A friend of mine was employed there and she had been encouraging me for months to give it a shot. One day, she hand delivered me the application, I filled it out, dropped it off and promptly forgot about it…until they called to set up an interview.

Suddenly, what was a fleeting notion became very, very real. My first thoughts were about my folks. I’ve been caring for them for nearly 7 years! I BLEW THE WHISTLE in order to save them from terrible owners and cold showers! How can I just ABANDON them?! How can I just walk away from my co-workers; the good ones who trudge forward through the challenges? Can I actually put my own needs for a decent working wage and benefits above their needs for quality care and consistency from a caregiver they trust? It was a maelstrom of conflicting and deeply held thoughts and emotions.

Thanks to the support of friends and family, I slowly came around and warmed up to the idea. Friends said that I’ve EARNED this chance, that I’ve worked very hard and it is an opportunity to love some new people. They said I can visit my folks and it’s time to try something new, to not have to struggle quite so much financially to do what I love.

By interview day, I was equally torn between the excitement of a new opportunity and the heartbreak of leaving my current folks, but I had reached the conclusion that it will always be heartbreaking to move on for me. I am a person who invests my heart fully, but just because it is difficult doesn’t mean it’s not the right choice.

I left the interview elated. They all but showed me in writing that I had the job. I was open and honest, I made eye contact and smiled. I had the perfectly pressured hand shake. I even wore jewelry. I spoke with passion and humor about why I love being a direct care worker. I NAILED it.

The next few days went by in a blur of work and outside commitments. In between activities, I would find myself planning for a life on third shift; my mind leaping ahead, despite my best efforts to not put the cart before the horse. The facility is huge and beautiful. Two more dollars an hour means less Ramen noodles. I was even planning out a visitation schedule so my folks would know that I’m still a part of their lives and what I would put in my written two week notice to my current employers.

So you can imagine my surprise when I got a call saying that they are sorry, but they went in another direction. I was completely dumbfounded. Somehow, I managed to thank them for their time before the wave of crushing disappointment washed over me. That’s when the “what ifs” kicked in, quickly followed by the “whys”. What if I’m no good at this? Why don’t they want me? What if my flaws are all anyone ever sees? Why did they lead me to think I had the job? What if I always have to struggle so much? Don’t they KNOW the emotional roller coaster this has been?

After a few glorious hours of reveling in my own misery and boohooing, I stopped, took a deep breath and reassessed the situation. The whys and what ifs do not matter. It is what it is. I owe myself more than picking myself apart because I didn’t get a job. And no, of course they didn’t know the emotional roller coaster I was on. Even if they did, it is not their responsibility to tip toe around it. Plus, I have a job; a job that I love despite the dysfunction. The pay is pathetic but money follows purpose.

For whatever reason, it’s simply not time for me to leave yet. There is joy that I still get to be there for my folks. I’ve been making it so far and Ramen noodles can actually be tasty if you doctor them up a bit. It was both a humbling and eye opening experience. I know now that when the time comes, I will be able to move on, as difficult as it may be, but part of me is very grateful that the time isn’t today.