by Tyra Phipps, Ed.D. (tyra.phipps@gmail.com)

There are not many people who understand the responsibilities of a nursing aide, nor the concept of assisted living.  To draw attention to the matter, PBS aired the Frontline program, Life and Death in Assisted Living on July 30, 2013.  Some nursing aides came forward and complained about working conditions at Emeritus, a national chain of assisted living facilities.  One young aide spoke of fears that kept her awake at night with handling so much medicine.  She was responsible for distributing more than one thousand pills to residents each week and she feared making a mistake.  Emeritus only required her to complete eight hours of training.  The responsibility overwhelmed her.

Another woman in a management role at Emeritus told the story of writing letters and contacting the administration only to have her warnings and complaints ignored.  One family member spoke openly of bedsores on his mother and wishing after her death that he had been a better voice for his mother.  This family sued Emeritus and was awarded more than $22 million.  A physician representing Emeritus talked with a cavalier attitude about the bedsores as merely a part of the aging process.  In contrast, a very sincere woman responsible for filling the rooms in assisted living spoke openly of trying to get a good match of the needs that a resident has with what Emeritus could provide.  She found it very disturbing that Emeritus just wanted the rooms filled and repeatedly told her to fill the rooms.  She felt that she could not do her job with any integrity and left the company.

A startling fact was 67% of the residents residing in assisted living at Emeritus facilities were dementia or Alzheimer’s patients.  The blurb for the program talked about the former football Hall of Famer who drank dish detergent because the cabinet was not locked causing him to suffer a miserable death, and the woman who froze to death outside the building on Christmas.  Throughout the program, there was great effort to give the Emeritus representative equal time and he commented that human error occurs and it is unfortunate.

Is human error really to blame?  Is it more than that?  Eight hour shifts and frequently mandated sixteen hour shifts, lack of training, lack of support, understaffed facilities, and poor management set the stage for serious problems including loss of life.  I reside in assisted living at the Goodwill Retirement Community (GRC) and I have lived here for fourteen months as of this writing (September 2, 2013).  Have I seen anything as drastic as what happened to residents who lived at Emeritus?  Thank goodness, I have not seen anything that heartbreaking.  However, I have known some of the true healthcare heroes.  They are low level, low pay, geriatric nursing assistants and certified nursing assistants who provide one-on-one care to residents.  Women dominate the field of nursing aides.  Many of these nursing aides work so hard during their shifts that they have little time to go to the bathroom, or take a break to eat.  Without much education, their compassion and common sense approach to helping people guides them. 

Assisted living is largely unregulated, but the nursing aide must keep up with certification and licensure.  She must also keep up with training on dispensing medicine and in-service trainning on numerous medical care procedures.  She also has to calmly handle the monthly fire alarm drill, or annual drill for what to do in the event of a hurricane or tornado.  She also needs to know how to deal with power outages even though most assisted living places have generators.  She accompanies residents on what is known as transports.  These are visits to physicians, ophthalmologists, orthopedic surgeons, or dental checkups.  A nursing aide may be assigned by management on her off day to assist with transports.  A nursing aide may be full time with approximately forty hours per week or what is called PRN, a work schedule that is more flexible or part-time.  Regardless of her schedule, the good nursing aides have enormous responsibilities which are unlike the responsibilities of an aide in hospitals or nursing homes.  She is usually the only one on the floor to assist an average of ten to fifteen or more residents.

The nursing aide covers the dining area where residents eat a meal.  She is responsible for setting tables, setting up a hot bar and the cold bar, pouring water, cups of coffee, hot tea, or hot chocolate.  She also serves each person a meal and listens to all of their complaints despite the fact that she is not responsible for the food that comes from dietary (GRC is known for very poor quality of food woefully lacking in variety and nutrition).  It is no simple task to serve residents three meals a day.  Many elderly people need assistance just getting to the dining area.  Geri chairs, wheelchairs, walkers, and canes, along with a condenser or oxygen tank may be used by some residents.  Nursing aides move residents and their equipment to and from the dining areas.  Despite the fact that there is a menu, many elderly residents have difficulty seeing and hearing.  The nursing aide has to repeat what is available to eat over and over again.  With many of the residents, she has to yell and it helps communication if it is the side of a good ear.  She listens carefully and tries to serve the foods that the resident wants to eat.  Not just breakfast, but almost every meal means making toast, getting skim or whole milk from a refrigerator in a separate room, also opening small containers of jelly, peanut butter, butter, and oftentimes cutting up food, and last but not least, feeding.

Then there is bathing residents, assisting with transferring and toileting, cleaning rooms and bathrooms, cleaning hallways in common areas.  Overnight, along with laundry and helping residents who cannot sleep or need medications at night, they clean the areas that are too busy to clean by day.  They also answer every call bell.  On top of all of this, everything comes to a halt when a resident falls.  It is still the primary responsibility of the nursing aide to provide assistance when there is a real calamity whether it is a fall, unexplainable bleeding, outbursts, mechanical problems with the temperature heat or air conditioning, cleanup of any accidents, or assistance with daily living activities which can become increasingly more complicated as the resident ages.

Death looms in these facilities, but with aging most people need a lot of help.  It is the lucky person who lives well beyond age 80 and can stay in his or her own residence.  However, living a long time means needing physical health and care.  The nursing aide is the angel providing comfort at the end of life.  She sometimes has been with the resident for years.  Even though turnover is high among nursing aides, in a short time a good nursing aide gets attached to her residents.  She becomes familiar with their routines and that can mean something as simple as how hot they like their coffee.  She has helped them with fingernails, combing hair, facial hair, dressing, even wiping their tears.  She laughs with them during the day and tucks them in at night.  She is there when no one else shows up.  Her job is demanding and also rewarding with many people saying thank you over and over again.

Despite limited personal funds, it is the nursing aide who brings in a jar of bread-and-butter pickles because residents complain that they never get pickles.  She also finds a way to bake banana nut loaf bread and brings in slices for the residents.  However, aides may not accept anything from a resident.  Nursing aides set the stage for nice birthday parties and meals along with welcoming new grandchildren who come to visit family members in the facility.  She is also there to help grieving family members during the final days of a resident’s life and passing of a loved one.  How do they do it?  There are many who work these jobs in America.  No wonder human error occurs when so much is demanded of one human, the nursing aide.

Are all nursing aides compassionate, caring, and dedicated to helping residents?  Unfortunately, the answer is no.  There is abuse, and negligence which are the most extreme cases.  The most annoying and problematic for residents and nursing staff alike are the aides who do not get work done during their shift.  They about how much they have to do, but they leave the cleaning of a room, laundry, dirty dishes, and common areas not cleaned for the next nursing aide coming on duty.  These types also frequently have an attitude and speak to residents with disrespectful tones.  They are abrupt or curt and appear to be quite hurried in everything they need to do when in fact they lack efficiency, nursing skills, and/or manners.  These impersonal nursing aides oftentimes leave the room of the resident in disarray or fail to pay attention to details like folding blankets, making the bed, or forget to bring in supplies such as toilet paper or soap.  Unfortunately with high turnover rates, management is more interested in covering the shift regardless of the quality of the nursing aide.  Staff and residents alike pay the psychological and emotional price from the additional stress of the incompetent nursing aide.

The constant changing of nursing aides because of turnover, even vacations or trading shifts creates instability within the assisted living unit, or skilled nursing area.  As an example, in just a little over a year I have trained more than thirty women in how to assist me.  That also includes teaching them to be familiar with locations of items in my apartment and how to keep things neat and orderly.  I have also worked with more than 25 women in the bathing area to help me shower.  While it may be nice for a nursing aide to say walk me through this, I find it absolutely exhausting to continue teaching each and every trainee who begins working in assisted living.  In fact, I am not fond of redundancy.  However, it is necessary to repeat the same thing over and over again regarding the way I stand for a pivot to transfer, or which side is dominant, or even how my hand needs help to hold a sonicare toothbrush.

I am fully cognizant of my surroundings and my needs, but what about people who are aging with some dementia?  It creates somewhat of a fear factor for me when I meet a new aide and try to assess her abilities in basic bodily movement and kinesiology.  I wonder if she has a dominant side, or if her legs are going to bend at the knees for a safe transfer, and I try to assess whether or not she is patient with a good attitude.  For me as a professor, it feels like I am working with a group of caring and eager to learn students.  The biggest problem is that communication skills are minimal.  It requires great patience on my part, but I am happy to train new nursing aides in hopes of helping other residents.  The disappointment is that I moved to assisted living in hopes of conserving energy to do exercises, maintain what strength I have with progressing multiple sclerosis and continue to work as a professor teaching all online.  Unfortunately, it did not work out that way.  I believe the lack of stability is difficult not just for me, but for any resident.  The uncertainty of which nursing aide is coming on shift creates anxiety making the environment quite stressful.  One resident called it, “Aggravation.”  Despite screening for new hires, turnover remains a huge problem.

At GRC, applicants are expected to take a nicotine test.  Thank goodness the facility is tobacco free as are most health facilities.  If hired, the health insurance plan for a woman does not cover birth control pills of any kind.  Preventive measures like mammograms are not covered.  This means that the nursing aide concerned about her own health in order to do her best job has to pay out-of-pocket expenses for annual checkups which according to one nursing aide will cost about $300.  Many nursing aides struggle with weight problems and will attest to the fact that the food is so poorly prepared.  What results is eating junk food for quick energy and suffering the consequences.  Nursing aides and residents alike constantly complain about lack of nutritional food.  One nursing aide gained a whopping 79 pounds within her first years of working at GRC.  That may not be just poor quality of food, but the combination of stress and the other factors that lead to overeating.  Can more be done to help the stress of a nursing aide?  Yes, and it is not just at GRC.  Goodwill Retirement Community is Mennonite supported and not-for-profit, unlike Emeritus, which has over $1 billion in stocks on Wall Street.  Organizations at either end of the spectrum have to deal with dire consequences of overworking, underpaying, and taking for granted the work of nursing aides.

The low-level workers have the most contact with patients in hospitals as well as residents in assisted living and nursing facilities.  Their coping mechanisms are to be applauded.  Humor helps everyone.  Even as a patient in a hospital, or undergoing rehabilitation in a nursing home, or residing in assisted living, laughter is the best medicine.  There are definitely healthcare workers with bad attitudes, chips on their shoulders, more problems than anyone has ever heard of in their lifetime, and should not be working in healthcare.  Then again there is the healthcare hero who makes the day enjoyable when she does a happy dance.  It is a one-of-a-kind dance that does not resemble a Chubby Checker twist, or cha-cha, or anything from the disco era.  Yet her own dance is guaranteed to put a smile on the face of a resident.  Another way that a nursing aide cheers up depressed residents is to burst into song as the Dory character in Finding Nemo released in 2003, “Just keep swimming, swimming, swimming.  What do we do?  We swim, swim!”

Along with theatrical talent, a nursing aide helps with flowers, watering plants, decorating or redecorating rooms, which sometimes includes moving heavy furniture despite the fact that she may only weigh 92 pounds.  She makes coffee or sets that up the night before in a resident’s room because at GRC there is only decaffeinated coffee and many residents find that wake-up lack of caffeine unbearable.  She may also put a glass in the freezer so that the water stays cooler for the resident who cannot use the water fountain.   She frequently also completes range of motion exercises with various residents.  She may accompany a resident to an in-house hair appointment, podiatrist appointment, church service, or activities such as bingo or balloon tennis.  Sometimes at the end of a shift, the nursing aide delivers mail or boxes and then proceeds to open those very quickly before giving the report at the end of her shift to the next nursing aide coming on duty.  She laments the fact that she did not have any time for a few more minutes with a resident who just wanted to talk.  A good nursing aide rarely gets to leave at the end of her shift and if she does leave on time, the work and residents are still on her mind.

These are the real healthcare heroes.  The dedicated nursing aides have attended viewings and funerals of people they have helped at the facility.  They shared with family members the happy memory of wishing their grandfather sweet dreams the night before he died or how their father would say, “See you later alligator,” when leaving the dining area in a Geri chair with oxygen.

Horror and More…

Not all nurses are heroes.  By 2020, two serial killers made the headlines.  “Elizabeth Tracy Mae "Bethe" Wettlaufer arrived for her first day of work as a nurse at the Meadow Park nursing home in 2014 with glowing references. She was well liked, they said, a ‘good worker’ who ‘loved to mentor and teach.’  Wettlaufer, 52, has admitted to intentionally injecting eight seniors in her care with fatal overdoses of insulin as she worked at multiple nursing homes and long-term care facilities in Ontario from 2007 to 2016.  The killings shook public confidence in Ontario’s long-term care system.”  This story was reposted in the Washington Post, July 2019.  The second nurse, Reta Mays, who worked at the Louis A. Johnson Veterans Affairs Medical Center in Clarksburg, West Virginia was charged with the deaths of seven patients by injecting them with insulin. Newsweek reported this story on July 14, 2020.

While these stories reveal the criminal element in nursing, there is another pattern of addictive behaviors in the profession.  From Psychology Today, March 2018, “Dependence on alcohol and drugs among nurses, hovers around 10%, a statistic which falls in line with the general population.  There are about four million nurses in America, four times the number of physicians, and these nurses are the backbone of the nation’s healthcare system.”  Drugrehab.com on February 26, 2020, says, “The American Nurses Association estimates one in ten nurses today abuse drugs or alcohol.”  For eighteen years in a row Gallup has Nursing as the most trusted profession in the world, but is it wise to trust a nurse?

These statistics are even more revealing about the current status of the mental and physical well-being of nurses.  In July of 2019, suicide incidents was 11.97 per 100,000 person-years among female nurses and 39.8 per 100,000 among male nurses, both of which were significantly higher compared to women and men in the general population (7.58 and 28.2 per 100,000 person-years, respectively), reported Ms. Judy Davidson, RN, DNP, of the University of California San Diego School of Medicine, and colleagues in Archives of Psychiatric Nursing.

The profession of nursing is trying to do their own critical analysis to find answers for high suicide rates, increasing addiction, and people in the field unfit and dangerous to patients. RNspeak.com posted a description of seven types of nurse.  The Hammock nurse keeps everyone calm when all hell breaks loose on the floor or in the department.  The Poison nurse is someone that no one likes, is difficult to work with, and makes the shift intolerable.  The Grim Reaper is the nurse that when she or he comes on duty, patients near death will not make it to the next shift.  The Lightning nurse is the one who knows what you need before you even ask for it. The Sleeping Beauty cares more about their nap time than what is happening on the shift.  The Einstein’s and the Hawking’s nurses’ types are a walking, talking Google with answers to all questions.  The Boss type is a born leader.  They know how to delegate work, sometimes better than department heads.

There is another study of typology among nurses.  Frequencies of MBTI (Myers Briggs Temperament Inventory) Types Among Nursing Assistants Providing Care to Nursing Home Eligible Individuals is an abstract of work conducted by Cecilia Daub, Johns Hopkins Geriatric Division, Susan M. Friedman, University of Rochester, Kay Cresci, Johns Hopkins University and Rayna Keyser, Johns Hopkins University. A random sample of 319 nurses revealed a preponderance of four Myers Briggs types.  The introverted types were ISTJ and ISFJ, while the extroverted types were ESTJ and ESFJ.  These groups totaled 74.6% of all the types.  There were 115 extroverts and 120 introverts.  The interesting functions are Sensing and Judging that the dominate types had in common.  According to MBTI research, SJ are stabilizers of organizations, but they are resistant to change. SJ types are also highly task orientated.  It is commonly understood from multiple sources in the healthcare field that healthcare workers are task orientated. The Sensing/Judging type may be a nurse in a hurry to get the task done, then move on the next task, and so on.  The Thinking verses Feeling type or T, F maybe a constant source of misunderstanding. Women are not traditionally thinking types, yet the majority of nurses are female. Could it be that the measured temperaments from this small study indicates that there is a big problem with the type of personality choosing the profession of nursing? Is it the mismatch of personality type with demands of the job that leads to increasing addictive behaviors, suicide, and loss of patient lives? Are these the reasons why patient advocates are so important when seeking any kind of health care?

It is likely that everyone will need some kind of medical care during a life time. Currently,almost half of all people who live in nursing homes are 85 years or older. Relatively few residents are younger than 65 years of age. The Centers for Medicare & Medicaid Services report that in 2014, the most recent year for which data are available, the population in age range:7.8% of nursing home residents were 95 years of age or older.

33.8% were 85 to 94 years old.

26.4% were 75 to 84 years old.

16.5% were 65 to 74 years old.