Nursing Assistant Training Part 2: Clinical

ImageThis is the second in a three-part series written by Evan Chartier, a Colgate student spending his summer training to be a nursing assistant (CNA) and preparing to write about this for his senior thesis.

Most of us know that with age comes the erasure of summer vacation. I thought so too when I found myself waking up at 5:30 in the morning every day last week to take the first bus, and then a train, and finally a short hike to reach the nursing home where I held my first clinical internship. Where did summer “vacation” go? It was disappearing before my dreary eyes knew what hit them. No more sleeping until 7:30 in the morning, like I did for the classroom portion of my nursing assistant training. The merciless summer sun did not wait, and neither would the resident that I was assigned to assist.

My realization that “summer,” as I had come to know it, was suspended for a week, was unmatched by my realization of what summer meant in the nursing home. My peers and I would arrive at eight o’clock every morning after, for many of us, a two hour or more commute. We would immediately wake our residents, usually with a comment about the beautiful summer weather, and struggle to get them ready before breakfast which was only thirty minutes away. The process looks something like this: gather your supplies, undress your resident, give a bed bath to your resident, change their brief, dress your resident, wash their teeth and/or gums with a toothbrush and/or sponge, place them in a comfortable position, and serve breakfast.

Please recall that I woke up at 5:30 each morning to catch the bus at 6:15. It took me a whole 45 minutes to do a very similar set of procedures to get myself ready for the day. Have you ever tied someone else’s shoe laces? It takes at least twice as much time to do something for someone else as it does to do it on your own and for your self. Although I did get faster as the week progressed, I was never able to complete all of these steps to get my resident ready by 8:30. Yet all of the nursing assistants who were employed at our facility had ten residents in their care, and they are responsible for getting each one of them ready before breakfast. If they are not superheroes, I don’t know who is.

The rest of the day shift is pretty relaxed. Shifts at most nursing homes are either from 7am to 3pm, 3pm to 11pm, or 11pm to 7am, and each of them have their advantages and disadvantages. My internship class was basically in charge of the day shift, so after breakfast we would be able to relax with our residents until lunch. Some of the residents were able to walk or be assisted in a wheelchair; other residents, such as my own, required a complete hoyer lift assist to get out of bed. A hoyer lift is basically a crank or electric-hydraulic device that can help caregivers transfer someone from their bed to a wheelchair without picking them up with brute strength, possibly throwing out their back, dropping the resident, or worse in the process. (Picture the contraption used in the word game hangman, only with a sling on the end of the hook that is placed under the person you want to move). The popular thing to do in our nursing home was to get the residents out of bed and into either the dining room, where there were daily activities, or the T.V. room to watch the news. The residents would stay there usually until after they ate lunch around noon. The nursing assistants would typically record any important observations (such as bowel movements, vital sign measurements, and the percent of each meal eaten by each resident) into their flow sheets while we checked our residents’ briefs to see if it was necessary to change them again. If no additional care was needed we would say goodbye to our residents, take off towards the train, pick up some italian ice, and make the (long) journey back to our homes.

Here is the tough part. A lot of people might think that the previous description of life in this particular nursing home, at least during the day shift when I was present, sounds like a relaxed way to live. All of your meals are brought to you, everything you need is located within the building, and there are plenty of activities and time to relax. What could possibly be missing? It took me a whole week to figure it out.

Over the course of an entire week at the nursing home I did not see a single resident go outside. Not once. It took me a whole week to notice that the residents spent, presumably, the entire day inside. It makes sense, after all, since the nursing assistants have an unbelievable amount of work to do just to get their residents up in the morning. Adding another task on top of their already hectic day would greatly diminish the quality of care that they currently provide. However, as an outdoor enthusiast, I can not imagine how invisible my summer would become if I spent my days inside four walls.

Even as I write this observation I am struggling with how I can reconcile my desire for quality care with my respect and admiration for the nursing assistants and nursing home staff that I encountered in my clinical internship. It is impossibly difficult to balance criticism with commendation. Believe me, the students I worked with were full of criticism. We were taught to change a resident’s brief every two hours, yet we witnessed our residents sitting unchanged for 5 hours or more. While there seems to be a simple answer –change the resident’s brief more often– it is mathematically impossible to change half a dozen briefs every two hours if it takes a half hour to transfer the resident back into their bed using the hoyer lift, undress them, change their brief, redress them, and transfer them back into their wheelchair. We can advocate for a lower nursing assistant to resident ratio, however the rising costs of healthcare in this country would put such care out of reach for many elderly people, not to mention being unrealistic for our struggling federal medical support programs.

In a recent conversation with my research supervisor and adviser, Professor Loe, I was reminded about the Green House Project that promotes a client-centric model of care that emphasizes independence. According to their website, the Green House Project also espouses an “innovative staff model” that “gives residents four times more contact and reduces staff turnover,” both important factors in improving the overall quality of care. The Green House Project demonstrates how the challenges that I faced during my clinical internship are largely due to institutional policy and structure rather than CNAs and individual decisions.

It seems clear to me that change is necessary. I just hope that my research this summer will help me see what change I should advocate for.

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Meika Loe

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