Why nursing homes are hellish places

I just found something I wrote last year and thought it was worth posting. Warning: it's very dark!

Nursing homes are hellish places. I can’t speak for every nursing home in the world. I worked in one for 8 months, have been in a few other ones (training, working with clients who lived in nursing homes, etc.), and have been a support worker in various other settings (some of these things are also true in those settings). I think there’s a system in place that causes residents of nursing homes to often be in hellish situations–treated roughly, severely physically neglected, and denied kindness, respect, and freedom at a time in their lives that is likely to be very confusing and painful.

The people who appear to be responsible for this are the staff who work directly with the residents–the aides and charge nurses (LVNs). And these are the easiest people to blame when something bad happens, like a resident getting injured or sick due to neglect. Not only does it seem to be the aide or LVN’s fault, but they’re often from marginalized groups–poor, women, immigrants, POC–so it’s easier for higher ups to project something negative on them. They weren’t empathetic, they’re not kind, they were too lazy to take care of their resident. Due to language or cultural barriers, the aide may not be able to present themselves in the best light or make the best impression. It also is easier to fire or punish this person than to change the system.

However, what’s actually happening is that they’re put in an impossible situation.

They’re paid very little, and aside from the obvious stresses and difficulties of being poor, they may be doing things like picking up extra shifts–so, like, working 24 hours in a row. They might be trying to raise kids, work another job, or be in school at the same time so they may not be sleeping much or at all. Obviously, all this stuff affects how functional someone is and how fast/well they can work.

But there’s the other thing which is that too much work is assigned. Like, when I worked at a nursing home, the minimum required ratio at night was 1 aide to 24 residents. (Often it was like thirtysomething residents–but since that wasn’t actually legal I won’t talk about that.)

So, let’s say 12 of these people aren’t continent and are supposed to be changed every 2 hours, let’s say changing & cleaning someone takes 10 minutes. (Which I’m absolutely sure someone who doesn’t know anything about it would say is SO much longer than it really takes! You should be able to do it in 5 minutes! But also it’s against the law to have diapers and wipes out and visible on a table in someone’s room, they should be away in a drawer. But you should be able to do it in 5 minutes even though you might have to change the person’s bed and clothes. Well…I’m saying 10 minutes. Sorry.)

Anyway, doing that job already takes 2 hours. But also there’s helping people who put on their call light asking for help getting to the bathroom, or for a glass of water or something. So let’s say 3 people do that, the water takes 5 minutes. One person goes to the bathroom and back in 5 minutes. The other person goes to the bathroom and sits there for a long time–you’re supposed to stay with this person because they are a fall risk. (You are responsible if you leave them alone and they fall.) So the whole trip takes 15 minutes. Now we’re at 2 hours and 25 minutes.

Also, someone is confused and is getting out of bed, walking up and down the hall, and walking into other people’s rooms and touching them, which is scaring those people. You realize this is going on, so you go and convince that person to go back to bed. This takes 10 minutes. (Also, the LVN finally comes on the hall–you haven’t seen her all night–and wants to drug the person to keep them from getting up, which I’m pretty sure is illegal, and is definitely a horrible thing to do. But maybe you can see where this kind of decision is coming from.)

We are now at 2 hours and 35 minutes for what was supposed to be 2 hours of work, and our hypothetical self is working without ever taking a break or going to the bathroom or anything. Also, I forgot that you’re supposed to be filling out this computerized chart of what everyone ate and if anyone went to the bathroom, and if so, how much, etc. I don’t really remember how long this takes overall, but let’s say that you do it for 20 minutes during this “2 hour period.” So we’re basically at 3 hours. You are working at a speed that isn’t realistic; you’re also probably exhausted because of your life circumstances that I mentioned earlier; and you are 1 hour behind in your work.

Oh, by the way, pain: getting the nurse (who is stressed & busy) and trying to get her to give a pain pill to someone who is screaming in pain. And, by the way, emotional pain, just kidding. Like, someone is terrified, or miserable. That person is crying. You’d like to go and talk to them and keep them company. Just kidding, it’s 3 people. You’d like to go talk to these people. But you can’t talk to any of them, you don’t have time. But you go talk to one of them.

Then, you hear an alarm going off, indicating that someone who’s a fall risk is walking around, but you’re pretty sure it’s someone who, while she’s technically a fall risk, is always getting up and walking around by herself, but she never falls. So you keep talking to this person who’s upset. The other person falls and is seriously injured. Also, you’re in a lot of trouble.

Basically, the actual circumstances of the job encourage you to not care about people at all–to do a half assed job with the physical act of taking care of people (not cleaning them very well when you change them; just throwing random clothes on them; not brushing their teeth; transferring people in a very fast brusque way that is physically uncomfortable for them), never mind their actual preferences (you’ll help them get to the bathroom when YOU can carve out the time to do that) or God forbid their FEELINGS (how could you possibly have time to just sit and talk with someone?). The job is SET UP LIKE THIS because the workload is not realistic. Meanwhile, the higher ups expect you to get all your work done, AND the things they officially ask of you are like, to be gentle and polite and respect people’s preferences.

So if the aide doesn’t get their work done or is short with people, the higher ups are like, oh they’re a bad aide. (To be clear, I obviously don’t understand why someone would speak cruelly to an old person they’re taking care of. I do understand neglect and roughness in this context–the former of which especially can be really dangerous.)

And the higher ups maybe aren’t evil. I’ve never been one. But when I was an aide, the nurse manager was this very soft spoken lady who seemed very sweet and caring (btw she also came off kind of upper class and seemed to find the working class aides rude and uncaring and stuff) but like…at best, she just didn’t get it! And I’m guessing that the further away you get from the actual situation, the less you get it. And those are the people who set the job up.

Rabbits

When I worked in an institution I was afraid that I secretly liked institutions.

I was afraid that I liked the fact that I had a very specific job, that I would get told off for even trying to plunge a toilet myself instead of calling the person whose job it was to do that. I was afraid I liked all the alarms and call lights that worked in the same way, the small number of kinds of beds where once you knew how to operate a few of them, you knew how to operate them all. I was afraid that I liked every bathroom having the same color washcloth and the same brand of shampoo.

Obviously I am Autistic so on the surface some of this makes sense, but it's also something other than that. I was worried how deep staff infection went and worried that scheduled lives had started to seem normal to me.

I've been working in "home care" for a few weeks now and it's definitely hard for me to have to do stuff other than physical support when I have trouble cooking and cleaning for myself. But it's incredibly worth it.

I don't think I had really thought about the distinctness that a person's own home has. Not just the space but the way they do things, and how their ways and the space interact.

I love messy rooms full of dirty dishes, tables of grandmotherly objects like wind-up Easter rabbits and Christmas trees that are up all year. I love obsessively organized rooms too, with labels on everything. I love getting to work with someone who hasn't been moved across the long term care hall to a different room with a different stranger, but is living in the house where she raised her kids.

I feel very cheesy describing it this way but it does feel like my function is to be part of the machinery that helps someone keep being themselves, and that's really exciting.

"Would it kill staff to ever show the slightest bit of respect or compassion to their euphemisms?"

This is the opening line to a lot of my mental post drafts but pretty much all of the drafts are just different stories about my adventures working at a nursing home, at which I am going to work for 24 more hours before I move to California, where I am considering working in a gas station, or maybe becoming a professional Pokemon trainer, but most importantly not touching this kind of work with a ten foot pole for the rest of my life.

We'll see how long I can keep that up.

My mom asked me what kind of jobs I was thinking about applying for in California and I didn't know how to explain why I might not want to work as an aide anymore. When the average person hears that you work in a nursing home or with disabled people, their reaction is to think of you as a nice person and, I think, even gentle, which is more important to me. It seems like such a departure for me to explain why my inclination for support work actually feels like one of my worst qualities, and how I feel like if I was a braver, more adaptable, or just more ethical person, I would dive into a completely different line of work and never come back.

I think even a lot of people who would consider themselves fairly "radical" or social justice-y wouldn't understand why I feel like there is a huge push toward unethical behavior in a lot of support jobs. If someone isn't familiar with it it is easy to tell me I'm worrying about nothing and I should just feel proud of what a good person I am for working in a nursing home.

I tried to explain to my mom by telling her something small. People who work on the night shift are assigned to get two or three residents up and dressed by the time we leave, which is about seven. Sometimes we're supposed to shower them too. According to the rules, we're supposed to start get-ups "no earlier than 5:30," but this is one of the rules that no one will care if you break, and in fact it could even be considered a good thing.

If someone has to leave early, they will have their residents dressed by five or six, sitting in the hall in their wheelchairs. Some of the residents quietly push themselves around by their feet, but most of them just sleep sitting up. Some aides will just get their residents that early every day so they can get other work done after. If someone is working a double night shift and day shift, then they might just get all the residents on the hall up starting during the night shift, so they will have more work done early.

This is a decision that no one I work with would ever question, because you are getting your work done by the time it's supposed to be done. The day shift aides would probably even be pleased by a night shift aide doing this, because the person would be able to get more small things done on the hall before they leave. Basically a night shift aide who gets people up really early is seen as a competent worker who organizes their shift in a way that works for them.

You might be wondering what I think is so wrong with getting people up early. I mean I admit that in the grand scheme of things it's not exactly abusive and sleeping in a chair isn't going to kill someone, but to me it really shows how we don't put the comfort of our residents first or focus on what they want. I wouldn't mind if I had to get up and sleep in a chair in my clothes sometimes, but having someone get me out of bed to do this on a regular basis would be pretty annoying, especially if it was because they saw me as a task to get out of the way and not a person to be supported.

Anyway, I basically told my mom that this was something that my coworkers saw as a normal and harmless thing to do and it was an example of why I might not want to be an aide anymore. My mom told me that I was "very kind" but I should think about the practical reasons why people would have to get their residents up early. It is hard for me when people have to tell me I'm "kind" just because I am trying to think from the perspective of people I have a lot of control over, especially because it seems like a lot of people think that part of being competent or just being an adult is thinking about things only from your perspective and the perspective of people who have power over you.

What are restraints?

A lot of staff people talk about restraints like they are not the greatest thing, but it seems like they don't understand what is wrong with them. I am not an expert but this is just how I feel.

I think a lot of people feel like restraints are bad because they are scary-looking. To be honest a lot of people don't even seem to feel that much(1), but anyway. Some people and places are "restraint-free." They believe in being gentle. The question is: is gentleness restraint-free?

I have always been told stuff like, ask someone what shirt they want to wear not whether they want to get dressed(2). Make statements about what's happening, don't ask questions. The idea is that if you do this the idea of disagreeing with what you're doing won't even enter the person's head. Which is supposed to be the ideal thing--no conflict. But these "tricks"--presented as innocently as advice on how to transfer someone--are intended to keep a person from making decisions about their own life that might be inconvenient to you. Is this extremely different from physically making it so the person can't move?

Picture a staff person who reacts with complete sweetness and friendliness to a resident who's trying to do something like get up when he is supposed to be asleep. The staff person distracts the resident with conversation while gently guiding him back to his bed, and it seems that she has successfully caused him to forget what he had planned to do.

I can't think of any supervisor I know who would watch this interaction and not come away thinking, "wow, what a good staff person." The person is avoiding conflict and keeping the resident (apparently) calm and happy, while still efficiently controlling him. The supervisor might even think that this is a staff person who really cares about her residents because she is so "gentle" and didn't do anything that came off as angry or aggressive.

But what is actually caring about not allowing someone to make a choice, and not even having enough respect to tell them what you're doing? Is it caring to try to trick someone to the point that they won't even know what is going on? (If someone has a disability like dementia, is it really going to help them keep skills as long as possible if you are trying to control them by making them confused?)

There are other things that aren't always recognized as restraints, like failing to offer someone the support they need to do something you don't agree with. But I feel like these this are sometimes recognized as restraints. Like in Ohio, leaving someone in a locked wheelchair is a restraint, which seems to be along the right lines. (Chairs are not though, which is weird since at least some people could unlock a wheelchair.)

I feel like the idea is that it's bad to do something that would look immediately abusive at a glance or look like someone's stereotype of a restraint. Merely being controlling isn't recognized as wrong and the implications and affects of trying to manipulative someone into doing what you want are not considered.

(1)In my nurse aide class, we were told that while we would be shown how to put someone in restraints, we didn't need to learn how to do it because it was no longer on the state test. As part of the class we were taught and tested on lots of things that could be considered attitudes or ethics, like "don't try to convert residents to your religion" or "be willing to listen to a resident talk about their problems." Our various teachers, who were nurses, would give us advice from their experiences about how to treat residents properly.

But absolutely no subjective comments were ever made about restraints and why they were no longer on the state test. No one even said, "it's better not to use restraints" or the most basic thing in support of more facilities being restraint-free.

When one of our teachers put a student in a restraint to show us, everyone just watched like it was normal. Except one girl was really creeped out. She said, "I have a friend who can't stand being held still and if you did that to her she would go crazy. Anyone would go crazy if you did that to them. It's wrong." She said this almost to herself, not like she expected a response, and no one gave her one.

(2)When I described this "trick," Pancho Ruiz suggested that it could work not because the person has actually been kept from considering other options, but because assuming consent like this would be sufficiently scary to stop the person from disagreeing with staff.

    Sorry to just write about my job. But I have to admit I don’t have time to think about being disabled, but I am the enemy and I guess writing about my time as the enemy can possibly be educational to others. I feel really screwed as a support worker who wants to do ethical work but also is a non-driver, because the less institutional a setting is, the more likely they are to only hire people who drive. But I am still finding myself thinking that when I move in a few months, I’ll do anything to work somewhere that’s not an institution, I don’t care what it takes.

    Caregiver burnout is seriously the weirdest idea I’ve ever heard of, since I’ve never in my life had a staff job where the people I supported (all supposedly “heavy” populations to work with) have actually been difficult. I mean, there has been a very small minority of people who are tough to work with for different reasons, but probably less than in the general population. 99% of stress in my staff jobs has always come from being asked to perform contradictory tasks, or being asked to do things that I think are wrong. The stress always comes from cutting corners and compromising, being afraid that the thing I skipped to get something else done will turn out to be really important, or being guilty because either I did something that I know was wrong, or I did something that someone else might think is wrong. If I’m stressed about something related to the people I support, it is usually because I know I’m starting to see them with less ordinary human compassion. They’re becoming pipes.

    But really I just want to tell you about some advice I got the other week.

2

    I used to work 8-hour shifts (11 pm to 7 am). I’m really glad I started out that way, because a night shift is definitely the most mellow it ever gets at the place I work. For the last hour or two of the shift you are helping people get dressed and showered, but until then, the job basically consists of helping someone if they wake up and want to go to the bathroom, and doing things like emptying catheter bags which you can do on your own schedule.

    Last month I started working 12-hour shifts (7 pm to 7 am) which means that the first four hours of my shift are about ten times busier than I’m used to. If the person who worked 3 pm to 7 pm got a fair amount of work done, I have to put maybe 10 people in bed in 3 or 4 hours, which is fine. Other times I have 14 people, which doesn’t work out for me so well.

    Two weeks ago, one of the night nurses showed up for work at 11 and noticed that I still had one resident left to put in bed. The nurse--let’s call her Anna--is a few years older than me and maybe six years ago, before she was a nurse, she worked here as an aide. It was her first job as an aide, just like me.

    Anna approached me later that night and said, “I noticed that someone was still up when I got here. You should really have everyone in bed by ten.”

    I tried to say that I’ve had trouble putting people to bed fast because I don’t have much experience working with these residents in the daytime and I don’t know what kind of lifts they need, or even things like if they have dentures. I tried to ask for a guideline on how many residents I should put to bed in an hour.

    Instead she suggested that I start at the top of the hall and put the residents of the first room to bed first. If I continued in that order, she said, I would be able to get things done faster. She started to do an impression of how she used to talk to residents when she first started working: “‘Hi, I’m Anna, I’ll be your aide tonight. Would you like to go to bed? Well, what time would you like to go to bed? Okay, I’ll come back then.’ And I would be on my hall at 10:30 wondering why everyone else was finished. You have to have a way of doing things and do it in that order.”

    “I guess some people will always say they don’t want to go to bed, if you ask them,” I said.

    “That’s right. And other people will be sitting in their doors calling, ‘Honey, put me to bed.’ But you have a lot to do, and they understand that. So just get in there and start at the top of the hall and go to the end. I bet by the time I see you next week you’ll be a pro.”

    I have my own thoughts about the content of what she was saying, but my main reaction in the moment was that it was nice of Anna to offer me advice, and that she had done a good job presenting that advice in a way that didn’t make me feel like there was something wrong with me. When she came back on the hall later, I thanked her for what she had said.

    Now she said, “I know it’s hard, because in your aide class, they tell you to ask everyone what they want. And you’re a sweet person--don’t change that--but you have a lot to do.”

3

    Despite all the obviously messed up things about support work it is hard for me to imagine doing a different kind of work, because the people I end up supporting almost always turn out to be really great. Or maybe it’s just the kind of relationship fostered by that work, that I end up seeing the best side of people. Either way it is a job where all the big frustrations end up being totally made up for by mundane details.

    The more I like my residents though the more I just wish I was working for them. I want to do what they want, not put them where someone else decided they should be at a certain time. This is such an obvious aspect of institutional settings that I wouldn’t even say it is what this post is about, although if you have not worked or lived in a nursing home, I guess now you know more about it. (This blog explains things a lot better than I could.)

    Anyway, what struck me about Anna’s advice isn’t that you’re not really supposed to ask people what they want. I have been learning that since the first day my State Tested Nurse Aide class ventured out of our classroom and into clinicals at a nearby nursing home. At the end of clinicals, my classmates talked while we were filling out the sheet of skills we had practiced--brushing teeth, changing diapers, passing trays. Everyone noticed that unlike our role-plays in class, which we always started by asking the imaginary resident what she wanted, in clinicals we were expected to do as many skills as we could unless the resident actually yelled at us and fought us (and even then we were supposed to give it a good try.)

    The thing is though that when my classmates noticed this, they just thought it was the difference between official standards and the way things work in real life, like it's easier not to lift people in the way that is officially supposed to be better for your back. They weren’t upset that we were supposed to be coercing people into doing things they didn’t want.

    This is also what struck me about what Anna said to me. She felt like if I was just exposed to the idea of not asking people what they want, I could just start doing it. She assumed that I was asking people what they wanted because it’s what I had learned in class, or because I was “sweet”--that it was a habit that came with my temperament, like saying please and thank you. It didn’t occur to her that I might be making an informed choice because I thought it was the right thing to do.

    I didn’t finish How Indistinguishability Got Its Groove Back and I don’t know if I will.  But this kind of ties into it. Basically I feel that most people who work with vulnerable populations, and/or people with disabilities, don’t seem to come into their job with a sense of ethics or power dynamics or the potential for abuse, and no one works to instill it in them. This doesn’t mean that most people in these jobs are awful people or that they commit a lot of abuse, but I think that there would be a lot less abuse and people with disabilities would have better lives if someone just thought these ideas were important.

Hospice

Say it with me, I work in a nursing home. And while I don't consider nursing homes for old people to be the same as institutions for young PWDs (there is a big difference between going into a setting like this at the end of your life, and doing so as a young person often at the cost of pursuing the things that most people your age get to pursue), I do think I am learning about institutions and why they just aren't the best thing for anyone--at least not with staff ratios that are so badly suited for people's support needs.

This is obvious, but institutions create "behaviors." They create people who are demanding or mean or angry. A person who likes to go to the bathroom frequently isn't a bad person if they can go to the bathroom independently or if they have an aide at their house whose job is to take them to the bathroom whenever they want. But if the person shares an aide with 20 other people, she becomes "the person who always wants to go the bathroom and doesn't even fucking do anything in there" because of the effect that her quite innocent and harmless personality has on an already overwhelmed aide.

And the big thing is, some people don't want to sleep at night. They want to get up. They want help getting up and going somewhere. I clearly cannot provide this help. They get mad. I start thinking to myself, "why won't they just chill out and watch TV in bed," when the person wants something totally normal that I would probably be asking for sometimes if I lived in a nursing home.

There are various ways of dealing with this situation, but recently I was introduced to the idea of pretending that someone is about to die so they can get hospice services. This means that the nearby hospital associated with us will send an aide just for that resident, to stay with them and do everything they want. I guess when you're about to die you deserve to have all your whims followed even when you have support needs, whereas other people with support needs just have to suck it up and take what help people have time to give them.

I'm not saying this is exactly a lie since we probably do have to convince people that the person could die in 6 months. But it's not like this happens to everyone who might theoretically die in 6 months, because some people don't care or wouldn't get that much out of having their own aide. It happens to people who need/want way more support than we can give them. They are the people who are suddenly like, "you guys he's about to die, he needs to be on hospice!"

This is probably not that interesting but I just thought it was kind of a funny and not very subtle way of dealing with shortcomings of institutions.