When I was a nurse’s aide at the old Wayland Health Center I almost drowned a patient. It was in one of the big hot tubs. There was a hydraulic seat that raised and lowered the patient into a giant stainless steel whirlpool bath. I was feeling sorry for the guy, a young man with traumatic brain damage whose body was frozen stiff and contracted.
My plan was to set him up in a secure position and check in on him every few minutes. But on the way out of the shower room I looked back and saw him tilting to the right. I fixed him nice and straight and walked to the door. I looked back and saw him tilting to the left. At that point common sense kicked in and I knew I was not leaving that room until I could get another aide to help me get him out of the bath. No harm done, no prison memoir to write.
This was my first health care job in 1986. In the 1980’s there was a lot of blame on families- Americans were heartless ingrates who abandoned elders in nursing homes. My first day as a nurse’s aide I saw how untrue and unfair that was.
The most oppressive factor in the lives of the nursing home residents was age itself. Loss of the ability to physically care for themselves, and even worse, dementia. The physical labor required to keep a person clean and fed when they can’t fend for themselves is staggering and endless, 24/7/365.
Families agonized over the decision to put a parent or spouse in a nursing home, an outcome that nobody wanted. There were patients who never got visitors, but equally there were patients whose spouses came every day at lunchtime, because no one else would patiently and lovingly feed their partner. There were elderly wives who took the bus to visit their husbands. There were children and grandchildren who came evenings and weekends. Patients sometimes went out with family or even stayed with them for a few days.
The Wayland Health Center, now a high end apartment building, was a large nursing home for many years. I was a downwardly mobile RIJC graduate with a background in photofinishing and I got a job there with no healthcare experience. There were always nursing homes listed in the ‘help wanteds’ in the Providence Journal- unsurprising in an occupation that had a turnover rate close to 90%.
I began a 1-week orientation as a nurse’s aide. I fainted when I got my Tuberculin skin test, which wasn’t the most promising start, but soon I was tasked with getting 8 or so elderly and disabled people out of bed and dressed and fed and made presentable.
Wayland had a union. Other than taking dues I never saw any signs of it, but they may have kept the patient load down. Other homes stretched their staff more. Still, it was much harder work than the factories and motel maid jobs I had done before. After 2 weeks of running my legs off I got my first check. I stared at it a few minutes in disbelief that such hard work paid so little.
At that time nurse’s aides weren’t certified. It was a mixed crew. Some of the nurses and aides were kind and conscientious and most were at least getting the job done, but at that wage management wasn’t too choosy. ‘Jane’ the charge nurse, constantly called the patients “lazy and mentally slow.” I was told that her life work was staying sober one day at a time. She was mean to patients and staff. One of the nicest aides had a patient break a hip when transferring to the toilet and was too scared to report it. I don’t know if she was at fault or if the patient was unlucky enough to have a spontaneous fracture, or if anyone investigated the cause of that accident. I never saw that aide again, I don’t know what happened to the patient.
Nurse Jane mostly sat in the nurse’s station smoking. “Posey that patient,” she’d say between puffs. The Posey Company manufactured the restraints we used, and Jane’s method of fall prevention was to tie the patients to chairs.
The tying up was bad, force feeding was worse. Management needed the aides to document that patients were eating at least a minimum percentage of their meals. Some patients didn’t want to eat. We used nagging, manipulation and sometimes we just shoved food into their mouths.
It’s not to my credit that I obeyed these orders. I’ll say in my defense that without a very strong caring ethic the conditions were brutalizing. Everyone knows it’s shameful to leave a person to lie in their own waste, but some of the patients were so far gone in dementia that they would fight the aides who tried to clean them. There are ways to approach confused people and gain their cooperation. It does take training and a stretched, burned-out staff won’t figure it out on their own.
Most of the patients weren’t subjected to the worst of it. In the 80’s there were many people in nursing homes who would be in assisted living or their own homes today. People who could manage some of their own ADL’s (activities of daily living) weren’t discouraged from doing so- less work for us if they ate their own meals and got themselves to the bathroom.
People think that cleaning up incontinent adults is the worst but that’s not true. Caregiving has an inherent worth and dignity because it is necessary work. Each patient was a person of value. There was kindness and an opportunity to make someone’s life better. But kindness was on our own time in work culture of bullying. Nurses to aides, aides to each other and the patients, especially those who were the most vulnerable, at the bottom of the heap.
The relentless pressure to do up the patients fast and adhere to the nursing home routine at all costs was dehumanizing to patients and staff. The turnover was very high. The nursing home was in debt. There are statistics for the dollar cost of high staff turnover but none for the human cost to low-wage workers who suffer abusive conditions that drive them to quit. No measuring the loss to a patient who has little to look forward to but the kindness of an aide who just couldn’t do it anymore.
The day I quit I ratted out Jane to the nursing director, informing her that one of the patients had bedsores.
The nursing home was full of moral hazard and proved to be physically hazardous as well. In February of 1990, 86 year old Birdie Oringel was burned to death in one of the hot tubs. A temporary worker lowered her into a tub full of scalding water. The nursing home had previously been cited for dangerously hot water. And in the crisis the nursing home staff did not give full information to the Fire Department.
“After the caller asked for an ambulance at the Wayland Health Center and gave the address, the dispatcher asked “What’s the matter?”
“We have a patient that is, uhh, unresponsive.” (Providence Journal Archives February 23, 1990 page A-01)
The ambulance technicians found the patient in bed partially covered by a bedsheet and treated her for cardiac arrest, not discovering that she had burns over half her body until they pulled back the sheet. They had to radio for another truck to bring burn sheets.
I see a direct connection between the aide who failed to report a broken hip and the un-named caller who failed to report the burn injury to the rescue. That nursing home was repeatedly cited for deficiencies. You couldn’t work there day after day without being compromised. I was glad I had long since quit.
Rhode Island now requires that nursing assistants be certified. There’s issues with that process but the training is more comprehensive and regulated. You can’t tie patients up any more, restraints require a doctor’s order and have to be temporary and documented. Force feeding is out. Bedsores are no longer considered inevitable. We use catch phrases like ‘patient centered’ which is a long way from how things used to be.
More people are able to stay in their homes now but there will always be a need for a level of care that can’t be provided outside a facility. I’ve seen family caregivers make themselves sick trying. No one can be awake 24 hours a day. Physical disability, even quadriplegia, can sometimes be managed at home, but a person with dementia who needs constant supervision has needs beyond what a family can provide.
Nursing homes are much better than they used to be, more patient-centered. This didn’t happen overnight or just by ‘evolution.’ Atrocious incidents like the death of Birdie Oringel and others spurred calls for reform and more regulation. The demographic bulge of the Baby Boom has changed the ratio of youth to elders and a large proportion of our population will need help in the coming decades. I’m part of the Boom generation that is balancing care of parents with help to children starting out in life.
It’s thanks to Medicare that my generation isn’t going into debt with our parent’s medical bills. It’s thanks to Medicaid that nursing home care is possible for ordinary people and thanks to government regulation and patient’s rights that the quality of care is much better.
Caregiving is honorable and necessary work that many people do very well. Direct patient care can be a first step on a career ladder. It was for me. I worked as an aide on and off in different temp agencies then went on to get an Emergency Medical Technician certification and later to nursing school. After getting my license I worked in several nursing homes and saw much improvement. More people are able to stay at home with some help and the nursing homes are dealing with the challenge of a sicker population. This post is not meant to be an indictment of nursing homes but a warning that we could go back to the bad old days.
The proposed repeal of the Affordable Care Act will result in cuts to the Medicaid that pays for a large and growing proportion of nursing home care. This will inevitably affect quality. Funding cuts combined with de-regulation will reverse the progress we’ve made and set us back to the worst conditions. This comes at a time when the need is increasing. Despite the low reimbursement there are national for-profit nursing home chains that can thrive in a de-regulated, business-first environment.
It used to be said that families heartlessly ‘put their parents in nursing homes’ but we don’t hear this so much now. In the 1980’s society was still getting used to the fact that women were leaving unpaid labor in the home for paying jobs. Now that we don’t have a housewife class it’s more clear that caregiving is work, requires skill, and costs money. Now more of us are connected to someone who is a caregiver or we ourselves are giving care or receiving it.
The rhetoric around repealing the Affordable Care Act is astounding in its callous ignorance- denying our responsibility to one another, ignorant of how the whole system is interconnected- not only our health care system but our whole economy. The health care industry, labor-intensive as it is, is a job-creator. Proposing to cut care from pre-conception to end of life to profit the rich will be sweetened with lower costs for the young and healthy. As long as they don’t need to make a claim.
What we need is a solidarity economy. Instead, we’re told it’s our ‘personal responsibility’ to stay lucky or at least to be rich and well-connected. The very people we depend on to provide the care at less than a living wage will not be able to afford it for themselves.
We’ve been there, this was the old normal. But this time around a bigger proportion of Americans are heading into old age. If we fail to recognize our interconnectedness and debt to our elders the younger generation may just follow our example and leave us to the mercy of the free market. Will we deserve any better?