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CNA John H. Booker
We nursing assistants, home health care aides, personal care attendants and mental health techs - especially those of us who work in assisted living - can be very proud of the efforts of the Assisted Living Workgroup that gave recommendations to the Senate Special Committee on Aging this spring. This coalition of concerned organizations did its best to shed some light on a situation that needs it, gathering recommendations in an extensive report (click here for the report).
Those of us who work in assisted living or have worked there in the past know that things can go wrong and workloads can be overwhelming in that environment just as they can in a nursing home, yet assisted living holds as much promise for workers as it does for residents. I love the assisted living model and would like to see it thrive, but there are a few things I'd like to see changed to make sure it's done right.
A Career Opportunity
One of the many proud moments of my career as a direct-care worker was my first real promotion, a legitimate step up on what I thought would turn out to be a long career ladder. Back in 1979, I was one of a few singled out to be trained as a Qualified Medication Aide (QMA). The first thought of those of us who were chosen was: 'WOW! We are moving up!'
We were enrolled in a community college pilot program that would be tested in a small number of states and facilities around the country. We went to college, all expenses paid, while keeping our present jobs.
Our curriculum was somewhat intimidating, including basic anatomy and physiology, pharmacology and medication administration, psychology, gerontology, and basic math with an introduction to calculus. But my administrator wanted to make sure that we would succeed. She arranged for us to take two more classes: leadership training and English composition, grammar, and writing, which greatly improved my confidence in being able to chart effectively.
Our 12-month program stretched into nearly 16 months of training and pre-training, after which we were certified to pass oral and topical medications in skilled facilities under the supervision of a registered nurse. We believed we were well prepared, and so did everyone concerned.
In preparation for working in assisted living, I started at a skilled nursing unit under the direct supervision of a wise charge nurse. She knew the importance of training, so for six months she checked every medication that I gave and every entry I made into the medical records, making me write it on a blank piece of paper for her to check before entering it.
The next step for me and my QMA colleagues was to become the primary charge person on the night shift posts. Some of us then moved to evening shifts, where we were still allowed to be in charge of passing meds as long as there was a licensed nurse in the building. We didn't have to worry about medication errors because we worked uninterrupted, with few or no patient care responsibilities. We were there just to pass meds and do treatments, with light patient care at times, such as feeding in the dinning room and assisting with transfers or answering call lights when possible. That, along with charting and taking vitals, filled our time, but we never felt stress.
So when I was told that I was going the assisted living unit, I thought 'piece of cake.' If I could succeed on a skilled unit, surely a less stressful, less regulated assisted living unit would be easy to handle.
And so it was - at first. The residents were delightful, and the administration screened new admits carefully, making sure they were good candidates for our beautiful, peaceful community. All residents were ambulatory and able to both feed and dress themselves with the minimum of assistance, and their cognitive skills were good enough so they could recognize and take their medications.
As a result, we didn't need much supervision or oversight. In case of emergency, the medical director and administrator were always accessible by phone. We were drilled in emergency procedures and well organized and, most important of all, we had enough staff - not all the time, but most of the time. Sufficient staffing freed the QMAs to concentrate on passing meds and charting correctly and allowed us to help keep lights answered and to check on residents who needed extra attention.
Then the acuity level of our residents began to climb as the facility began to admit residents who had dementia or used wheelchairs. Soon my co-workers began to leave. They left for various reasons, but the two most predominant were the lack of upward mobility and the increased workload. The amount of work it took to care for residents greatly increased and so did the skills required, yet we got no additional training, and we generally had less staff because of the increased turnover.
As our staff diminished, I became responsible for more patient care duties along with my other responsibilities. Eventually those responsibilities included light housekeeping, laundry, and even some food prep duties, and I often stepped in to help when residents required transferring in and out of wheelchairs, since I knew how to do transfers and few of my coworkers did. I also had to shower a gentlemen who had dementia, although I had no training in special care for people with this condition. I learned the hard way - by being attacked - that people with dementia often hate to be showered, and especially detest having water in their face.
My 'dream position' had become a nightmare. I began to feel used, and I felt unable to ensure that everything was running smoothly without supervision or adequate staff. When it got to the point that disturbed residents were abusing other residents, it became clear to me that I wasn't prepared for this level of care. I had no time to concentrate to prevent med errors or proper charting techniques. My confidence dwindled, and I began to look for ways out.
The next blow was the announcement that all med aides will now have to give insulin injections. We got a crash course on the floor behind the nurses' station and were told we'd be held responsible for any errors.
I resigned, but before I left, I introduced the next QMA to the job. Fresh out of QMA class, she had no registered nurse to take her under her wing and no idea what she was in for. I told her she would be all right if she just took her time, but I knew she wouldn't be able to get enough of that precious element. I could only pray for my former residents.
A Worker's Recommendations
Based on my experience, I would like to add a few recommendations to those proposed by the Assisted Living Workgroup:
1. Create training standards that take into account the acuity level of so many assisted living residents and include dementia care. Give all direct-care workers this training, so they're prepared to provide whatever level of care may be required of them.
2. Provide a structured career ladder for direct-care workers, and strive to provide a living wage and access to affordable healthcare insurance. These building blocks help attract and keep the competent, motivated workforce needed to provide quality care.
3. Create applicant screening standards to avoid hiring people with questionable backgrounds or poor work histories. Criminal background checks and checking with the national abuse registry should be a mandatory part of the process, but they alone are not enough.
4. Create a detailed job description for all workers. Nursing assistants who pass medications should not be laden down with resident care responsibilities.
5. Create aggressive, broad-based programs to recruit high-quality staff. If you can't find enough good workers, maybe it's because you're not looking in the right places. Consider CNAs for the job, especially those with special training in dementia care. Broaden your search to include more men.
John H. Booker is a member of the Direct Care Alliance and the National Urban League Young Professionals as well as president of the National Association for Direct Care Workers of Color.
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