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What Staff Are Saying: A Firsthand Report

October 1, 2004
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A professor of communications puts her ear to the door at two facilities by Marian Deutschman, PhD

When you ask nursing home staff about their jobs and ideas for improvement, what do you hear? A few years ago I visited several facilities to glean just such information; I used the Schein methodology (see "Research Methodology"). Data were gathered from observation of routine talk and behaviors, as well as in-depth interviews with key personnel serving as informants. The goal was to identify fresh insights and descriptions of each organization, including the attitudinal supports and barriers experienced by its members. What follows are highlights from two such visits. Noteworthy results from four 3-hour observations at Facility X (a suburban not-for-profit dementia unit with 39 residents in eight private rooms, one deluxe, and 16 doubles): My Visit
The large sign on the wall reads "TODAY IS WEDNESDAY, JULY 19." Everyone on staff is helping serve food. All residents are wearing very large bibs. Nine staff members, including the unit coordinator, are working in the dining area with 27 residents. Residents who need feeding assistance are in another room. An RN is checking food intake and finds that a lot of food is left uneaten. Residents have breakfast, a snack at 10 a.m., lunch, a 2 p.m. snack, evening dinner, and then another snack. The therapy assistant says, "It's too much food." She notices that a resident takes leftover food and scrapes it into a corner of the room. "Maybe she had a cat at one time," the therapy assistant muses.

Residents here have many visitors. Some residents planted vegetables in a beautiful outdoor garden and one, a former land surveyor, takes responsibility for overseeing the garden. Posted activities begin at 10 a.m. and end at 3:30 p.m., but the weekends don't offer any activities other than movies. A sing-along and pet therapy are scheduled once a week. A full-time social worker has been on staff for three months. Her role is defined as helping with families' adjustment, tracking psychotropic drugs, and dealing with depression, among other tasks. However, she did not often participate as a team member during any of my observation periods.

Before a shift ends, CNAs fill out a form reporting on each resident's toileting, behavioral issues, wandering, and other areas of concern. Items in each category define whether a resident has been verbally aggressive, verbally nonaggressive, physically aggressive, or physically nonaggressive. As the CNAs gather to complete their forms, one says she had been at another facility for 12 to 15 years and was offered a 6ó-an-hour raise, while new CNAs were starting at 35ó an hour higher. "It was an insult! I told them they could keep it." Another CNA says she loves it here, even though she has to get up at 4 a.m. for a one-hour commute and another facility is only 30 minutes away. One LPN has worked in nursing homes for 17 years, seven of which have been with this organization, and his wife is a CNA at another facility. They have no children, so for him wages is issue number one and health insurance is number two. A new two-person insurance option (in addition to singles or families) that the facility offers gives him a welcome cost reduction.

A consultant pharmacist reviews medications monthly. She says that behavior documentation includes the CNA daily reports mentioned above, as well as reports done by nursing. Unit staff are given special training to respond to residents' needs appropriately, she says, noting that staff get their positive reinforcement from calm residents and praise from other staff.

There's a rotating list for staff to float among units. "Generally people don't like to float," says one CNA, "and residents don't like floaters either. It gives you a break, but you don't like to get out of routine because everything takes longer, and you can be stuck with the worst assignment." "It's frustrating," adds another, "because you can't find things for the residents. Also, you cooperate differently with different staff." All five CNAs involved in the conversation nod in agreement. Other comments revealing mixed reactions to staff teams: "Working with the same staff has its downside because a lot of people are not doing their jobs." "New staff see things that regulars don't, such as bruises." "Sometimes staff members are watching talk shows or soaps." "This job attracts certain kinds of people-uneducated people who use it as a bridge to something else."

The LPN says he refers some new or prospective staff to Burger King directly because he can tell by their body language that nursing home employment will not work out.

The day shift supervisor keeps information flowing throughout the building. In the staff hierarchy, her position is just below the DON and the assistant DON, and on the same level as the unit coordinator. She deals with staffing issues-if a staff member is not coming in, he or she must call her or the assistant DON at least one hour before work on the day shift and two hours before work on other shifts. The 3-11 shift is the hardest to staff, the supervisor says. One CNA says that particular shift (3-11) "interferes with your whole life, so it's a greater staffing problem."

On my third day of observation, the unit coordinator is extremely frustrated by the lack of activity throughout the unit, and with several activity staff members who appear to be highly disorganized. At 11:30, they have not yet started the scheduled 11 a.m. bowling activity. There is little participation by residents, and staff members are recording scores even though residents can't hear them announced.