Nursing Home – Kimberly Evon 1995

Nursing Home – Kimberly Evon 1995

Nursing home: an oxymoron. I received a call last June from a registered nurse named Susan. She was so upset that I could hardly comprehend what was being said on the other end of the phone. After she calmed herself for the moment, she began to tell a story so frightening yet so common in the nursing home industry. She was working as a registered nurse at Eldercare Nursing and Rehabilitation Center, a non-union facility in New England. I was familiar with the place because years ago some workers had attempted to organize the facility without success.

She went on to tell me that she had put together a letter to the Department of Public Health which described a handful of atrocities taking place in the home. She and fifteen other workers signed the letter and sent it out in the hope that this regulatory agency which was set up to protect residents’ rights at these facilities would intercede and force a corrective form of action. Some of the complaints listed on the letter included: roaches coming out of the food carts used to serve resident meals, mice seen on patient care floors, no emergency equipment on the premises, lack of basic and necessary supplies like diapers, dressing kits and face cloths needed for daily care and not enough staff to deliver quality care to these residents.

Her hope, like that of so many other workers in these nursing homes, is that someone will do something about the injustices. However, the reality of the matter is Susan and others like her are the answers to the problems. Susan, in turn, was disciplined for writing the letter to the Health department. Where is the justice in that? The other workers who had signed the letter were frightened, and rightfully so, at losing their jobs for speaking out in support of Susan’s actions as well as their own. What was the role of the home’s administrator in all this? He sanctioned the discipline. After all they can’t have workers in their own facility reporting incidences of resident neglect and abuse to the proper authorities. It just doesn’t look good for the home. The irony in all this is that workers as well as managers are obligated by law to report resident abuse or neglect. Unfortunately, those who take this obligation seriously are punished while silence in such matters is rewarded. Such is the normal practice in our nursing home industry.

Background a research. Much of the background and research used as a basis for this ethnography stems from personal experience through strikes, organizing drives and Union Rep work in the nursing home industry. Much of the information is derived from conversations with union and non-union workers in nursing homes and their shared experiences in this particular industry. The population used for this study includes nursing home workers with whom I had the privilege of coordinating a one-day strike; workers from three non-union facilities in which organizing drives have taken place and Fremont Nursing and Retirement Home, a union facility for which I function as the Union Representative.

Other sources for information include my own local union, Hospital Workers’ Union, Local 767, SEIU and SEIU International Union which has been dedicated to a broad scale organizing venture of the nursing home industry across the country through its Dignity and Respect Campaign. Most of the conversations and observations used are from the Fremont Nursing Home. Because it is an organized facility, workers have more freedom and less apprehension in expressing their candid opinions of the workplace, and its accessibility afford me more personal interaction with the workers.

Profits before people. In order to understand the nursing home worker, you must first understand the metamorphosis that has taken place within the nursing home industry. Originally intended as non-profit institutions set up to care for our elderly, nursing homes soon became associated with something more enticing – profits. Priorities included achieving maximum reimbursement with the minimum labor required to meet profit goals. What started off as family-owned facilities soon mushroomed into big corporate chains and conglomerates where the owners discovered that lucrative profits could be made in the health care field. The purpose of nursing homes shifted from health care providers to money-making machines. Medicare and Medicaid reimbursement became the name of the game. In order to achieve profits, companies had to prioritize. Those priorities included achieving maximum reimbursement with the minimum labor required to meet profit goals. This explains the low wages and minimum benefits received by nursing home workers across the country as well as accounting for the eroding levels of staffing provided to deliver “quality” care to its residents. This profiteering mentality has had an adverse impact on the workers as well as the residents of these nursing homes. The impact of this growing industry, based on “profits before people”, has shaped and institutionalized the culture and values of nursing home workers.

The administrator.  Detached from staff issues and conditions. Most nursing homes are structured in the same manner. Ninety-eight percent of the workforce in nursing homes is comprised of women with the exception of the Administrator’s job which is almost always filled by men. The administrator is responsible for overseeing the basic operations of the nursing home. Some of the duties include maintaining the operations of the home within the guidelines of a budget set forth by the owners of the facility; acting as the liaison between the company/owner and the residents’ families and public; supervising the middle management and front line supervisors and implementing policy and procedures within the home. This individual rarely has day-to-day contact with the workforce unless for some specific reason or at someone’s request. By remaining detached from the day-to-day operations of the home, the administrator is able to establish an elusive image and more often than not establish his innocence of matters involving worker issues such as staffing and conditions by putting that responsibility onto his managers for not reporting these problems to him. Administrators in union nursing homes are seen more often than in non-union homes because they are forced into participating in grievance procedures, and they are held more accountable for problems within the home by their workers.

 Director of nursing. Some establish some rapport with the workers. A position primarily filled by women, the Director of Nursing is responsible for overseeing all facets of the nursing department. This includes overseeing floor supervisors, Registered Nurses, Licenses Practical Nurses, Certified Nursing Assistants and any work which directly impacts resident care. They must staff the nursing home according to the nursing budget, ensure that all resident care guidelines set forth by the Health Department are met; handle emergency situations that arise, investigate and report any incidences of resident abuse or neglect, and they are responsible for the actions of the nursing staff. They are also responsible for the hiring and firing of personnel as well as making decisions on disciplinary action. Most Directors of Nursing are hired from the outside and have no particular affinity or personal relationship with the workforce. However, some directors who do stay at one nursing home for a long period of time will establish a certain rapport with the workers.

Floor supervisor. Isn’t worth her salt unless she gets rid of the heels and dress.  Floor supervisors are responsible for supervising the Registered nurses, Licensed Practical nurses and Certified Nursing assistants in their daily care functions. Most floor supervisors are hired from within their nursing homes having once been a staff RN or LPN themselves. They are there to assist and respond to problems on the resident care floors as well as report to the Director of Nursing any problems that may arise that necessitate her attention or judgment. They are the most visible of management staff and tend to be more respected by the workforce because they were once part of that workforce within the home. They also discipline workers and often make decisions including termination of employment. Although most have roles that mainly deal with paperwork and “desk” duties which limit their contribution as nurses, a good floor supervisor will roll up her sleeves and help her nurses with resident care when staffing is low.  Put simply by a Union Chairperson, ” A supervisor isn’t worth her salt unless she gets rid of the heels and dress and puts on a nurses uniform.  Then you know she’s there for you and the residents no matter what.”

RN and LPN. Interchangeable. In nursing homes, registered nurses and licensed practical nurses function on equal levels for the most part. Their differences lie in years of schooling and certain degrees of technical functions which they are licensed to perform. Other than those differences, they are interchangeable for nursing care purposes. They are both responsible for directing the plan of care for each resident which may include on average up to thirty residents each day; administering medication and treatments, keeping the physician informed of any changes in the residents’ status as well as obtaining orders from the doctor, answering questions from family members regarding physical and mental conditions of the resident, making recommendations to other departments such as Dietary, Occupational Therapy and Physical Therapy concerning different facets of a resident’s care which need to be addressed by these personnel and to oversee the nursing care functions of the Certified nursing assistants who work directly under the RNs and LPNs license.

The CNAs see themselves at the bottom of the pecking order.  Certified Nursing Assistants, or CNAs as they are called, are the largest group in the nursing department. They do the majority of direct care on residents in the home. They are responsible for all Activities of Daily Living (ADLs) involving the resident. This includes making sure that the residents assigned to them that day are showered, dressed, shaved, fed and ambulated before 11am just for starters.  It takes a CNA approximately one hour per resident to provide ADLs. Within that time, CNAs must also toilet and turn most patients every two hours, take blood pressures and temperatures as well as any specific needs of that resident. The average CNA assignment includes ten residents for the day. Based on this information alone, it would take ten hours to properly do ADLs on ten patients, and this does not include any other facets of care nor does it account for time after 11 am.

The above listed positions are the major roles within a nursing home and they are also the roles which directly shape the work culture as well as its social structure. Through conversations with various nursing home workers, it became clear just how important the interaction of these roles were in developing the social setting and work culture of nursing homes.

“For Christ’s sake, she could have answered the light in the time it took her to tell me that.” Nursing personnel function in teams of an RN or LPN and three to four CNAs. Each team is assigned a group of residents for daily care. The successful delivery of care relies upon how well these workers function as a team. However, it is never an easy accomplishment. There are many obstacles which get in the way of teamwork. One such obstacle is the perception of each group’s role in the home.

There are starkly different perceptions between licensed staff and aides as to who does the real work and what the responsibilities are. The smoke filled break room is the usual hot spot for venting frustration at Fremont Nursing Home. Here are just a few examples of the hot topics discussed.  CNAs. As one CNA described the situation, “As CNAs we don’t stop. All the nurses do is pass out meds and call doctors for orders. They don’t care that we don’t have enough aides to finish feeding residents or bathing them. All they care about is that the job gets done. It must be nice not to worry about being the one to get it done.” Another aide goes on to say, “I could be in the middle of lifting a patient off the toilet and don’t you know a nurse will come in and ask me to answer a light. For Christ’s sake, she could have answered the light in the time it took her to tell me that. It must be nice not to worry about being the one to get it done.”

Nurses. But the licensed nursing staffs also have their own view. As one nurse explains, “We rely a great deal on the aides to make sure that duties are completed and done correctly.  If there are any mistakes, we are responsible. It is really frustrating when you don’t have enough time yourself to get everything done, and the aide is complaining that they can’t answer a call light or get someone showered while you still have to pass meds on to fifteen more people.” Because there is an established hierarchy, it makes it more difficult to work as a team. Management benefits from making sure that these perceptions flourish. By doing this, workers will more than likely spend more time getting angry at each other instead of getting angry at management with control over the important factors.

High turnover.  An obstacle to teamwork. Teamwork takes effort and time to establish. A factor which affects its success is the high turnover rate in nursing personnel at nursing homes. Specifically, at Fremont, turnover is exceptionally high. One reason is that it is a tourist area. During the summer months, people can make more money working as bartenders, waitresses or shop clerks than they can as nursing home workers. Job hunting is at its peak right after Labor Day at which time nursing homes have an endless number of applicants from which to choose. Also a product of being a tourist site is the housing shortage. Many nursing home workers change residency on a regular basis due to an increasing rental cost for the seasonal areas. When they move away, they often seek employment which is closer to them and more easily accessible for the limited transportation services provided in this region.

 “If you can work in the nursing homes past the age of forty, consider yourself lucky.” Another reason for the high turnover is work related injuries. The nursing home industry has one of the highest rates of work related injuries in the country rising to levels found in the mining and construction industries. Reasons for such increases in injuries are directly related to decreases in staffing levels and lack of training and safety standards. Since last year, there have been forty separate instances of work related injuries at Fremont Nursing Home that only employs 100 workers. Most workers consider it a matter of time before they injure themselves at work, and most have been on Workers’ Compensation at one point in their career. One aide explains. “I’ve worked as a CNA for almost thirty years and I still can’t believe these nursing homes don’t do anything about the safety of workers.  Sometimes I feel that they really don’t care because there are fresh bodies to replace the broken ones.” And another aide: “If you can work in the nursing homes past the age of forty, consider yourself lucky.”

When the best isn’t good enough. One of the biggest obstacles affecting workers ability to function as a team is the role of management. If the management personnel in the nursing home do not set examples to its workforce of values such as teamwork, it is inevitable that the workforce will not value such a concept. To workers, actions speak louder than words. Much of the frustration expressed by nursing home workers is the lack of support that they receive from management. In union and non-union nursing homes, workers express their disappointment and anger at management’s refusal to address problems and advocate for the goals of quality resident care.  “You go to your supervisor to let them know that you need help doing up a resident, and you’re lucky if they nod their head.  You tell them that there’s no way you can get everyone up and fed by lunch time, and they just tell you to get it done.  You’re almost in tears because you know that Mr. Smith has been lying in his own urine for over an hour, and all your supervisors can do is yell at you for not getting to him fast enough. I’m sick and tired of being told to do the best you can, and when your best isn’t good enough, they scream at you.”  And from another nursing home worker, “They’re the ones always talking about teamwork, but they’ll pass right by a room with the light on knowing that everyone else is tied up with their residents. It is really a bitch knowing that you’re the only one who gives a s**t about these people, and management just lets you tear your hair out over it.” These are just a few examples of the obstacles that nursing home workers face in carrying out their roles within the home. If teamwork is accomplished, it is done so in spite of the odds, and more often than not workers take on more responsibility for the residents than the home’s management and administration.

The residents can’t fight for themselves. That’s why we’re going on strike tomorrow. In every nursing home there is a policy and procedure manual which outlines the goals of the home and the rules which define the work. There is also a “mission statement” which states the values embodied by the institution and which outlines those standards of care expected from its workers. But workers soon find out that those words are hollow in meaning and have no relevance in the day-to-day operations of the nursing home. As one worker explains to a group of new workers at her nursing home, actions do speak louder than words, “Everyone has read the mission statement that hangs in every corner of this building. They talk about mercy, dignity, compassion and respect for our residents, but what does that mean? I know you just started, but you need to know the real score. The only people who provide dignity, respect and compassion for the residents are us. This home doesn’t give a damn about the people in there. They just want to make money, and the only way they can do that is by cutting our staffing and paying us peanuts. Not only can’t we provide good care to these residents, we can’t even afford to take care of our own families. And don’t think that management is going to lift a finger to solve the problem because they are the problem. We are the solution, and we’ve got to stick together and fight for these residents because they can’t fight for themselves. That’s why we’re going out on strike tomorrow.”

Forget that stupid manual. Trial by fire. Most new workers go through a trial by fire at nursing homes.  During orientation they may be told of wonderful staffing levels and a lengthy training period, but within a week they find themselves working an assignment alone and taking care of double the number of patients that they expected. The other workers find great amusement in hearing the horrible stories of these new workers and seeing the surprise on their faces as they tell the others about the workload they had. Once the shock is over, senior workers will give the fledglings a more accurate account of how things are run in the home.  An RN in one nursing home said, “The first thing I tell them is to forget that stupid manual- it’s bull****.

Then I teach them what I call basic survival skills. What they have to make sure of is that they do those things that can be missed for the day, like brushing someone’s teeth, shaving; doing nail care and things that can be put aside because of time. It’s really letting them know how the rest of us cut corners when they need to, and management knows about it.” Make no mistake about it, they don’t like having to cut corners.  But without proper resources and staffing, many are faced on a daily basis with cutting corners in order to perform the essential duties of resident care.

 Falsify documents or you could be written up. What makes matters worse is the fact that management often encourages workers not only to cut corners but also to document care that was never given. This is the motivation behind reimbursement. Regardless of whether or not the care was given, workers are told to falsify documents which serve as proof for reimbursement of Medicare and Medicaid, or they will be disciplined for insubordination.  A registered nurse said, “My supervisor told me that I had to document that this cream was applied to this resident’s wound every hour even though I had only managed to give it every two hours because there wasn’t enough staff.  She said that I could be written up if I didn’t document it in his chart. “This is a common practice in nursing homes, and it encourages workers to keep quiet about matters which are not only illegal but which also directly compromises the care of the resident. In unorganized homes, the potential for this occurring is much greater than in union homes. Union workers are much more assertive as advocates for the resident and have little fear of reprisal from management.

“It’s not because workers don’t care.  It’s because it hurts too much to keep caring.”   During a conversation that I had recently with the Fremont Nursing Home Chairperson, I asked her why she thought it was difficult to organize nursing home workers. Cindy responded, “It’s like being in an abusive relationship. If you are told that you are worthless enough times, then you begin to believe it. If you are beaten enough times, you become numb to the pain. It’s like that in a nursing home. It doesn’t take a worker long to realize that management doesn’t care, and when that happens, you stop caring too. After a while, the job becomes more about a paycheck and less about the residents. It’s not because workers don’t care. It’s because it hurts too much to keep caring.” But the very reasons that drive nursing home workers to the level of despair and frustration are the same reasons that motivate them to organize and act.

Solidarity. The core value. For the nursing home worker, a sense of solidarity is highly valued. For non-union workers, solidarity provides them with the compassion and support which they can’t get from management. For the Union workers, solidarity is the key to change. It is the motivation behind turning futility into action. Solidarity is the one value which binds nursing home workers. The solidarity which these workers practice in their workplace will serve as an answer to change that is so desperately needed. This solidarity will be the key to regaining power in their workplace. They will find renewed strength within it. More importantly, they will rediscover the true value of their work through their own collective power.


Reflections of Injustice (2013) 

I was angry and saddened when I read the words I expressed over 18 years ago about the plight of nursing home workers. It brought back memories of such incredibly brave and compassionate women who I had the privilege of working side by side with to build a more fair and just workplace for them and their residents.

I was angry because so little has changed in terms of the injustices that face working men and women today.  As I relived the story I documented back in 1995, I could see the names and faces of workers today reliving the same plight.  This industry along with corporations across the country is never sated in their quest for profits and general largess.  They have fed at the corporate welfare trough for over 30 years while the income gap between the rich and the poor has widened to new depths of economic depravity.

I have been blessed to spend the last 18 years on a journey for economic justice with working families from Georgia, Maryland, DC, Chicago, and presently California.  The challenges are many but the cause is always righteous.  Our time, the 99%, is now.  We have started to see a popular shift .  We are tied together – nursing assistants, janitors, homecare workers, construction workers, librarians, adjunct professors, school teachers, security officers – all workers are realizing that the need to join together and take back our country is now.  We are all victims of a hostile economic takeover by a small group of greedy and self motivated individuals.  But we can be architects of real change. We are capable of achieving the American Dream if we stick together and make the eradication of economic inequality our uniting purpose.

Bio update

I have been working in various capacities for SEIU over the last 18 years.  I am currently with the United Long Term Care Workers, SEIU which represents 180,000 in home care providers and nursing home workers across the state of California.  I have served as the Chief of Staff since 2010 and have been honored to be elected this year as their Secretary-Treasurer.


Iles Minoff received his doctorate in anthropology from Princeton University. He taught at St. Xavier College in the Chicago area and taught a class in the anthropology of work at the George Meany Center for Labor Studies in the 1990s. He worked for the labor movement for 28 years, first with the Human Resources Development Institute in the early 1980s where he worked on retraining programs for displaced workers, and later for Union Privilege where, for over 20 years, he developed benefit safety net programs for union members and their families. He has a wonderful and amazing wife, three great daughters, and two, soon to be three, of the cutest grandchildren on the face of the earth.

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