Tag Archives: problems in long-term care

The Caregiver Shortage and Immigration

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

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

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

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

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

 

Beneath the Surface

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Alice
The longer I am in this field the more I realize that in order to truly change the culture of Long Term Care, we must change the way those who are living within the system are viewed. Regulations can be changed. Environments can be improved upon. Staffing levels can be reasonable, but until society begins to see through the physical disabilities and age to the person underneath, such changes, though important and well meaning, is like treating the symptoms rather than curing the disease. This point has become so much clearer to me since I began working in private care.
As an independent caregiver, I have the freedom to do the job as I see fit within very wide margins. Being pretty terrible at setting work boundaries, I find myself in many roles throughout each shift; CNA, housekeeper, family confidant, driver, personal shopper, cook…the list goes on and on and each shift brings new surprises. There is only one client and yet for me it’s every bit as challenging as working in a facility. Working one on one with my client has opened my eyes to how people view those living with disabilities outside of the four walls of a facility. Sometimes, it’s not very pretty.
My client loves baubles. She loves bright colors, and make up and having her hair done professionally. Her appearance matters to her. It always has. Religiously, once a month she goes to a particular salon and has her hair washed, colored and styled. She has been doing this with the same stylist for five years. Now, this particular stylist knows that my client suffered an immediate and life altering change to her health sixteen years ago. She sees the effort it takes for her to transfer from her wheelchair to the shampoo chair and back again. She knows that on my clients tougher days, when it takes all she has to get dressed, it is the idea of her beauty days that pushes her through that pain. I’ve told her that myself.
It’s a splurge. It’s not a cheap salon and this hair stylist is always tipped well. Getting beautified is one of the few good things that has remained a constant from the time before my client fell ill. It takes her more effort, but it is well worth it. So you can imagine my fury when I received a call from my co-worker informing me that this hair stylist would no longer be taking appointments from my client because she was fifteen minutes late. This hair stylist to whom my client had formed an attachment, despite what I considered to be her snarky attitude, who had NO problem gushing over her tips and taking her money, was put out. She did not bother to tell this to my client. No. She told it to my co-worker who, like myself, does not have the heart to tell her.
Look. I understand that we all have lives and a client being late for an appointment can cause inconveniences to whomever is providing a service but if you are incapable of taking on those with physical challenges, then DON’T TAKE THEM ON. When my client is going to be late for appointments, we call. After so many years, the very least she could have done was have enough respect to have a conversation with her about it.
It was such a clear example of apathy. I realize that it’s not cruelty that causes such slights, but the damage done from it is the same. It’s an example of the self-centeredness that we all have within us in one form or another. Even those who are closest to my client are subconsciously guilty of this thinking. How much is my client going to slow them down if they take her with them? Is there room in the car to pack all of her necessities? Is it worth the effort when she will be so exhausted the next day?…they see all the obstacles and none of the opportunities and in so doing, they diminish her humanity and reduce her to little more than “person with disability”.
I look at people through the lens of a caregiver. There is not a single person on the face of this earth who doesn’t have obstacles or challenges. Most have the luxury of wearing them on the inside. The downside to that is that too often, they forget those wounds exist and begin to convince themselves that they are a part of a group lucky enough to be normal. Allow me to disabuse those of you in that category of that notion. There is no normal. It’s imaginary. The only thing that separates you from those in my care is circumstance or age.
If I had to pick one lesson that I would like people to learn from my posts, it would be this: We are all human. Separating yourself from the way you view those in our care may make you feel safer or more comfortable but you do yourselves a disservice. One day, you will age out too, if you’re lucky enough to maintain your health. Ask yourself this: How would you want to be seen? As an “invalid”? A burden? As someone who has “outlived usefulness? As a bed filled to keep census up? As a cause? As part of a group to be pitied?…I wouldn’t. I would want to be seen as a person first. As Alice. And I would hope that all of those who were fighting for my rights would take the time to actually ask me my opinion of the system and what I think would be an improvement. I would hope my loved ones would see me before my disability and I would hope that an overpaid hair stylist would have the decency to tell me to my face that she no longer wants to do my hair.

“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.  

See No Evil, Hear No Evil … Fix No Evil

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Minstrel

As aging impacts physical and cognitive health, many of us will eventually live in long-term care homes.  Thanks to poor standards of care, most people dread this prospect.  To improve care, experts advocate a person-centered model of care as an alternative to the traditional medical model.  Moving from one care model to the other calls for culture change.  Last year I visited the website of a leading culture change organization for information on their annual conference.  It was discouraging to see that among their many events, none included one of the critical elements of culture change, CNAs: our workloads, wages, and caregiving standards.  Hour after hour, day in and day out, CNAs are key caregivers.  Without us, there can be no culture change.  Yet CNAs aren’t heard.  Here is one CNA voice.

I first became familiar with LTC homes when a family member needed care.  I explored many places to find him a good home, then visited him frequently.  Since then I’ve worked in LTC homes and gone into others as a hospice volunteer.  When my uncle moved to a memory care home, I saw the aides who cared for him as angels: they did for my uncle and the other residents what we family members no longer could.  They did this with magical skill and saintly kindness.  And for wages that were obscenely sub-standard.  I was enormously grateful to them.  But in these years of being in and out of long-term care homes, this is what I’ve also seen: aides who sit talking to each other or texting while residents sleep in front of TVs or sit staring into space, alone.  I’ve seen a resident fall because an aide was busy texting.  Aides spend mealtimes noisily socializing with each other instead of engaging with residents, most of whom (at least in memory units) need some level of assistance.  Some aides announce, by their behavior, “Once she’s bathed and dressed and in the dining room, once he’s fed and toileted: once the ADLs are completed, it’s my time.”  Sometimes instead of interacting with residents, aides simply take time apart to rest.  It’s not that aides are intentionally mean or abusive.  And comradery among aides isn’t a perk; it’s essential.  But on every shift there are failures in attentiveness to residents, failures to engage them in an enriching way, lost opportunities for Creating Moments of Joy, as Jolene Brackey has written. 

Some will object, “Not in OUR facility!  We have awesome aides who go out of their way every day to make life better for residents.”  Yes, aides are often inspirationally caring.  But too frequently the quotidian reality is lackluster care, not the person-centered care promised.  Tellingly, the administrators who dispute this picture are often conspicuous for their absence from the daily fray.

Here’s something else I see: thanks to abysmal wages, many aides work two jobs.  Where I live, starting wages are $9 to $12 an hour.  Self-employed aides can earn more, but have no benefits.  Full-time aides are sometimes scheduled to work only 32 hours a week, to avoid overtime when an aide is asked to work a double shift to cover for someone who calls out at the last minute.  Many aides have children at home to care for.  By the time the aide starts his or her shift, which typically involves caring for six to ten residents, she is already tired in body and spirit.  How can this aide bring to work the physical and emotional energy needed to care for the chronically ill, the elderly frail, the cognitively impaired?  Is this what you want for your parent or spouse, or yourself?

How to improve care?  Administrators provide innovative training programs.  Workshops offer state-of-the-art information and creative care ideas.  Two questions not examined:  1. How do we get aides to buy into culture change and embrace person-centered care, once the trainer leaves?    2. Where do we find the money to increase staffing and pay direct-care workers a living wage, one that honors the physical and emotional demands they meet every day?  

Culture change seems focused primarily on training of direct-care workers and renovations to the physical environment.  A more effective approach might come from a change in what we expect of leadership.  Once upon a time, ‘Management-by-Walking-Around’ was the mantra.  An effective manager was expected to circulate on the factory or office floor, paying attention.  Not spying on employees, not micro-managing, but noticing things.  Sensing conflicts and stresses before these undermine performance.  Offering feedback when needed.  In care homes, how often do you see someone on hand whose role is to encourage, compliment, coach or critique?  To see that necessary supplies are on hand.  To offer an on-the-spot performance suggestion, transforming a moment of poor care into an opportunity to reinforce good care skills, per Teepa Snow’s  coaching model.  And at times, with a chronic slacker, to go down the road of discipline.  How much do managers engage with direct-care workers? 

Today’s code word for good care is engagement: aides need to engage with residents.  If administrators aren’t modeling this by meaningful interactions with direct-care workers, will aides believe that engagement is to be the ethos in their workplace?

We can’t improve what we don’t see.  If administrators don’t see the problems, it might be because they are buried in ‘CYA’ paperwork, medication management, marketing efforts, and time-stealing meetings.  Sometimes their offices are in some distant realm of the facility.  Culture-changing organizations might hire a clerk for paperwork and scheduling, freeing the front-line manager for a more constructive presence among staff.  Give this manager a mandate to convert ‘person-centered care’ from a slogan to a fact.   

Can LTC homes provide person-centered care, without the personnel?  Staffing levels are egregiously low.  They may meet states’ woeful requirements but we all know they are inadequate to ensure patient safety, let alone the person-centered care everyone espouses.   Inadequate staffing also leads to on-the-job injuries and CNA burnout.  Are any of the culture-change conferences addressing these issues?  Are leaders lobbying for better staffing and better wages for their CNAs?

Ah, wages!   One is tempted to wonder whether managers tolerate poor performance out of guilt or shame for what they pay their aides.  Even compassionate professionals don’t want to mention the issue of wages in public.  It may seem too daunting and discouraging a challenge—and an embarrassment.  Compensation levels reflect the fact that the job doesn’t require high-level academic or technical credentials.  But aides shouldn’t be thought of as unskilled.  Our skills lie in meeting the global needs of residents who are sometimes completely dependent on us.  A good aide needs to excel in kindness, patience, gentleness, flexibility, effective time management, communications creativity, appreciation for the diverse ethnic, racial, religious, cultural backgrounds of those in our care.  We care for residents regardless of their illnesses or diseases.  We don’t need to describe here the physical tasks we perform, sometimes difficult, often unpleasant.  When the person has dementia, the challenges are doubled, tripled.  We’re accountable to employers, to families, and to our residents.  Not everyone is up to the job.  Wages should reflect the importance of this work and the competencies it requires.  We need a mindset conversion among executives who still think it’s acceptable to sustain their LTC organizations by reliance on a bare-boned staff of underpaid workers who need public assistance to supplement their wages.  Care homes charge their CNAs to respect the dignity of residents.  What about respect for the dignity of CNAs, starting with a living wage?

“Where will we get the money to raise wages and increase staffing?” ask horrified LTC operators. The question is valid.  However, it begs the further question: How much are you spending now, and for what?  Until there is budget transparency (another piece of culture change), the industry’s position that these proposals aren’t affordable, isn’t credible or convincing.  Their question should be not the end of the discussion, but the beginning.  Reviewing the content of culture-change workshops, we don’t see these issues on agendas.  No one wants to touch staffing or wage issues.  Could it be that the profit motive plays too big a part in the culture of some LTC organizations? 

This isn’t rocket science: Be as zealous about improving supervision, staffing, and wages as you are about upgrading the chandeliers and countertops and holding conferences.  Put your assets where you claim your values are.  (Make your budget transparent!)  Invite CNAs to be co-leaders in culture change.  Then we might see culture change that leads to transformed care, transformed lives.  

The Great Yoga Pants Debate

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Alice

    Yoga pants. YOGA pants? Poor staffing, supply shortages, low wages, a world full of people who see a disability instead of a person, a world full of people who treat the elderly as if they were disposable, a broken system and a national elder abuse average of one in four but no. She’d rather put an embargo on Yoga pants. Stop muttering to yourself, Alice. You’re alone in your apartment ranting like a lunatic at something you read online. Take a breath.

      It was nothing, really; an innocuous comment on one of the support sites that got me going. The poster commented about a facility that contracts out to her agency that allows their employees to wear yoga pants. She thought it was inappropriate. That was it. So why did slowly work me into a tizzy? Why did it nag at me like a hole in my sock? 

      There is a smug superiority in some of the comments I read that concerns me. If you don’t like yoga pants, work at a facility that doesn’t allow them. Why pull others down in order to boost yourself up? And it happens often. First shift blames second. Hospitals are better than facilities. Home care has higher standards. This caregiver has tattoos and is unprofessional. We pull each other apart over nonsense when in reality, we are ALL running around and sticking our thumbs into the leaky dam as the water comes crashing around us!

      Don’t misunderstand me. I think the fact that we have online groups is great. Many of the questions are insightful and uplifting and funny and it’s wonderful to have sites full of people you’ve never met who all speak the same language. Long term care is a bizarre world and as caregivers we see it through different eyes and relate on a different level. Maybe it’s because I believe in the best of us. Maybe it’s because I know we are better than the powers that be treat us. Maybe it’s because I expect more from us, but for whatever reason, I was really bothered by that comment and could not shake it…but then Yang pointed something out to me. Maybe people resort to that sort of destructive behavior because they feel so powerless over everything else. That stopped me in my tracks.

       Let me assure all of you that we are not powerless unless we allow ourselves to be. We have choices! We can advocate in so many ways, big and small. We can be kind to the new co-worker. We can speak our truth to our employers. We can volunteer or start a support group, or write for a blog, or join the Alzheimer’s association. Most importantly, with our united actions, we can start a much needed conversation about changes that need to be made in the system from our own perspective as well as those for whom we care. 

    It’s not that we are “entitled” to a living wage. It’s that we’ve EARNED it. We have earned the right to safe work places and proper supplies. We have earned the right to be treated with respect and we have earned the right to be heard. We will never get to the real issues if we allow ourselves to stay stuck in a mindset where another person’s pants choice is of grave concern. Margaret Mead said never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has. Isn’t it time to get started

Let’s Prove Them Wrong

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Alice

    We have received some wonderful and articulate emails from a reader who posed this question:  How do we make life better NOW for those living with dementia? She went on to explain how advocacy is what drives the flow of funding and most of the funding is going towards finding a cure for Alzheimer’s disease. While vitally important, it does nothing to help those currently living with the disease in the long term care communities. Who is speaking up for them? Who us speaking up for us?

       The frustration is that here on our level, there is little meaningful conversation of such things. We are expected to show up and take what is dished out. We don’t do it for the money, they say. It’s just a “stop-gap” job. If they were smart, they would have furthered their education. Treat someone as disposable for long enough and they begin to feel disposable; begin to act disposable. Is that what we want? Disposable people caring for the most vulnerable section of our society in their hour of greatest need?

      Or maybe it’s an indication of something deeper. They treat us as disposable because on some level they feel that those within our care are disposable. They have aged out. They no longer contribute to our society. Wisdom, experience, history, dignity are not valued commodities in this fast paced world of “me first and the give me! give me! mentality. Old, sick people barely make the priority list and those of us who care for them don’t make the list at all.

      No one SAYS that of course. I have never once seen a bumper sticker that reads Old People Suck and yet the situation in which many seniors and people with disabilities are forced to live is heartbreaking. There is no other word for it. They devalue them and by doing so they devalue us. And I’ve got news for you, folks…we allow it. Hell, sometimes we encourage it by our own behavior.

      One in four seniors will suffer from elder abuse. I’m no statistician, but I would say there is a probable correlation between quality of care and treatment of the work force. One in four. The injuries caregivers suffer on the job is sky rocketing. Again, this is supposition, but I would say exhaustion due to being forced to pull double shifts or multiple jobs to barely make ends meet would contribute to this. The standards for certification is low, the wages are low, the work is difficult, and the turnover is high. Why, why, why would ANYONE choose this quagmire? Because someone has to. Because those of us in the know have a moral obligation to do everything we can to be a part of the solution. Because it’s a battle worth fighting.

         How do we make life better NOW for those living with dementia? For all of those living with a disability that requires care? I have no idea. I’m winging it. I give the best possible care to my client. I write for this blog. I notice lonely people and try to make them less lonely. That’s the only way I know to make any difference that counts. I’ll tell you this though, the most meaningful changes are going to begin with us or not at all. They think we’re disposable. Let’s prove them wrong.       

Embracing the Moment

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Alice

When I was green and just starting in this field, a resident informed me that youth was wasted on the young. At the time I dismissed it as just something that elderly people say. It took a while before I realized how wrong I was.

      I did notice how little it took for my residents to be truly grateful. With short staffing and terrible patient ratios, it sometimes feels like all we hear are complaints. On the days where the routine on the floor is disrupted, it can feel impossible to please anyone, but that’s as a collective. Individually, their requests were perfectly reasonable.

       On the floor, a request for a cup of coffee is trumped by a resident who is a fall risk’s urgent need to use the restroom. A request for an extra pillow will have to come after taking vitals. We are constantly prioritizing the needs that have to be met and something always falls by the wayside.

       In such a setting, forgetting a cup of coffee seems a forgivable offense, but then again you would be hard pressed to get me going in the morning without my coffee. I had a freak out just the other day because I didn’t realize I had run out. Coffee is a vital part of my daily routine and my whole day is thrown off without it. Is a day without coffee a “forgivable offense” to me? Not so much. Furthermore, the sheer joy and gratitude I’ve seen a simple cup of coffee with two creams delivered in a timely manner bring a resident is downright humbling. I don’t even notice my coffee until I run out.

      The ability to be fully in the moment is a gift that comes in the beginning and end of our days. It’s true that I have countless stories of residents who flew off the handle over some innocent mistake but I have just as many stories of residents who were deeply moved by moments that I take completely for granted. They don’t just drink their coffee on automatic pilot. They SAVOR it.

      I waste so much time worrying and fretting over imaginary scenarios in my head. I have wished away shifts and boring dates. I have missed opportunities right in front of my face because I wasn’t paying attention; countless moments wasted. It is through working with those who have a lifetime of experience that I learned this.

     What would they give to have the moments that I so carelessly wish away? To have the ability and freedom to come and go as they choose? I am still not great at being in the moment, but I am learning. It takes practice. Now every morning I make it a point to stop and savor my coffee. It’s a good start.

Horizontal Violence Among Direct Care Workers

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Yang

In my last post, I suggested that there may be something about the Long Term Care work environment that makes conflict among caregivers almost inevitable. Some – or perhaps even most – of the behaviors associated with this conflict could be described as “horizontal violence.”

Horizontal violence is a form of hostile and aggressive behavior exhibited by individuals or groups toward others within the same peer group. It is usually not a physical kind of violence, but relies more on emotional and social pressure. It includes a wide range of negative behaviors, both overt and covert. Examples include such things as direct verbal abuse, belittling gestures, threats, intimidation, gossip, “humorous” put-downs, sarcastic comments, social exclusion, nitpicking, ignoring legitimate concerns, withholding support, and slurs based on race, ethnicity, religion, physical appearance, gender or sexual orientation. In a word: bullying.

The thing that makes horizontal violence “a thing” is not a big list of nasty behaviors. These can happen anywhere and for a lot of different reasons. Horizontal violence is a phenomenon that occurs within oppressed groups. That is, groups of people who do not feel as though they have the means to adequately address the most significant problems and issues associated with their group. Some respond to this sense of powerlessness by becoming submissive and exhibiting learned helplessness. Others respond by adopting feelings and attitudes of superiority over others within their group. In a sense, both are coping mechanisms, characterized by inappropriate and self-defeating behaviors.

If a sense of powerlessness is at the heart of what it means to be an oppressed group, than direct care workers certainly qualify. Overworked, underpaid, and unsupported, LTC caregivers generally do not believe that they have the means to independently create the kind of fundamental change that would address these issues in a meaningful way. You either accept “that’s just the way it is” and learn to do what you can with what you have – or you leave.

At the bottom of the LTC hierarchy, the caregiver brand of horizontal violence plays out in one of two ways. The first way is the classic division of Older Workers vs. Newer Workers. This divide is typical in nursing in general and most of the literature I’ve come across regarding horizontal violence has to do with career RNs, but it applies just as well to nursing assistants.

New workers enter the field with a set of expectations of what caregiving is all about and are soon disillusioned by the reality of what they witness on the units. If they are unable to adapt to “the way things really are,” the more experienced caregivers have ways of putting them in their place. Newer workers are regarded as both naïve and judgmental – and perhaps even threatening – because they base their impressions of experienced workers on unrealistic expectations.  They often become victims of horizontal violence, not fully comprehending why they are being mistreated.

The second situation is created by the absence of adequate and appropriate involvement of management in the typical LTC work environment. The formal rules and standards are enforced inconsistently, sometimes capriciously, depending more on personality and circumstance, such as inspections or any other time the facility is under public scrutiny. Good workers go unnoticed and poor workers go uncorrected.

By default, caregivers are left to fill the vacuum and develop their own norms and standards. These can be very different from facility to facility and even from unit to unit within the same facility. To one degree or another, they are informally enforced by the strongest personalities among the established caregivers.  In the best circumstances these norms and standards are communicated through example and positive leadership, but often they are enforced by various forms of horizontal violence.

Caregivers frustrated by their inability to formally address the larger problems of the Long Term Care workplace find an outlet by dominating their coworkers. Others simply acquiesce, doing their best to keep to themselves as they struggle to find a balance between the official standards, pressure from their workgroup, and their own sense of right and wrong.

In my next post, I will share my take on how we as caregivers should approach the problem of horizontal violence in the LTC workplace.

For more information on horizontal violence:

http://www.nursingassistants.net/horizontal-violence/

http://www.cnaboard.com/2010/useful-cna-information/certified-nursing-assistants-and-horizontal-violence-in-the-workplace.html

https://www.birthinternational.com/articles/midwifery/69-horizontal-violence-in-the-workplace

The Moral Authority of Caregivers

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Yang

Even in the worst work environments caregivers have the opportunity to make an immediate and positive impact on how residents experience life in long-term care. So much of what our elders experience depends upon the quality of the interactions we have with them. Whatever our difficulties, we are ultimately responsible for the manner in which we approach and respond to our residents. At the same time, how we conduct ourselves as caregivers has significance that can go beyond our ability to impact the immediate environment.

Caregiving is a practical art. Our role involves us in the details of the daily routines of our residents, but not necessarily in the larger issues of Long Term Care. While we are profoundly affected by things like poor staffing ratios, direct care staff turnover and disconnected management, the conventional wisdom among caregivers is that we simply don’t have the authority to do much about those things and the only option we really have is accept things as they are or find a different place – or field – to work.

Meanwhile, we leave the larger problems to those who we believe have the real power: the administrators, regulators, legislators and assorted LTC professionals. However, no one has greater awareness than direct care workers of how chronic understaffing and turnover rates actually impact the care and well-being of individual residents on a day to day basis. We know what it looks like and we know what it feels like to our residents in a very real way. We can give these problems texture and a real sense of the human cost. Our experience in the trenches of Long Term Care provides us with a unique perspective, a perspective that is very much needed if Long Term Care is ever to truly come to grips with its problems.

While caregivers lack formal authority, we can still influence those who do have formal authority. Our real world experience gives us something valuable to say. Our capacity to convince others that what we have to say is valid depends on our moral authority. But if we are not doing everything we can as caregivers to improve the immediate environment of our residents, then why should anyone listen to us about the bigger problems? By taking responsibility for our own behavior and conducting ourselves according to what we know by reason is right – in spite of difficult circumstances – we provide the basis for our moral authority.

And with that, we cannot be ignored.

The Power of Caregivers

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Yang

In her December 2 post on CNA Edge “Quality of Life is a Precious Gift, Alice distilled the true meaning of a caregiver’s work into one fundamental principle: “Improving the quality of life for those around us.” While the idea may seem obvious, how we go about living up to it is anything but easy, given the typical long term care work environment.

We all know the list. It’s an environment where caregivers are overworked and underpaid, overwhelmed and undersupported. It’s an environment that features disconnected management and rules that make little sense at the caregiver’s level. It’s an environment where mistrust and dissension among staff is common.  It’s an environment that breeds cynicism and futility.

While we can’t ignore the negative aspects our work environment, how we respond to them is entirely up to us. Even in the worst of circumstances, we can always do something to improve how our elders experience their time with us. In fact, doing so is a kind of moral imperative – something that we know by reason is the right thing to do and a far more powerful and consistent motivator for ethical behavior than the directives and admonishments issued by those above us in the LTC hierarchy.

Alice’s “simple idea” is more than just about doing the right thing. It provides us with a standard of behavior that we can cling to amidst the chaos. Or as Alice put it:

“For me, realizing that truth has brought me great peace. It simplifies it. I don’t have to fix, save, diagnose, manipulate, or perpetuate any negativity. My job is to make life as positive as possible and to preserve the dignity as much as possible for those in my care.”

By persistently returning to that simple idea, we make a conscious choice to liberate ourselves from the drift into despair.

May makes a similar point in her post “Soap and Thought”:

“Sometimes it’s too much, being a CNA. There’s too much stress, too much everything until I think I just can’t take it anymore. Days when I want to tear out my hair; shifts when I want to leave and not come back. The problem, I’ve come to realize, is that the bad things are the big things; the skyscraper problems that draw our eyes and threaten our strength. The good things, well, they’re quiet, understated. Things like washing my hands with a resident that is special to me.”

We need these “quiet, understated” moments. And do so our residents. These moments are as significant as the bigger issues that plague us. In some sense, they are more real. 

The common thread between these two posts is that despite the difficulties, we are not powerless. For Alice, it’s a simple idea. For May, it’s a simple act. As we proceed through our daily routines, we may not be able to directly address the larger problems, but we do have the ability to alter our immediate environment. And our immediate work environment is a big part of our residents’ living environment. In that we find our true source of power.

None of this is to suggest that direct care workers will never play a major role in making fundamental change in the Long Term Care system. In fact, it really can’t be done without us. But to play that role effectively, we must never stray too far from what really gives us our strength.  I’ll explore that idea in my next post.