Introduction: Learning From Those Working Most Intimately with the Residents in Long-term Care

Certified Nursing Assistants (CNAs) are responsible for nearly all of the direct patient care in nursing homes or long-term care facilities in the United States and account for nearly two-thirds of the total staff.

Most nursing homes are for-profit enterprises with an average of 107 beds (Centers for Disease Control and Prevention, 2000). The typical resident is female, widowed, and white with the majority over 85 years of age. CNAs are overwhelmingly female and black or Hispanic, or members of immigrant populations that reflect the ethnic composition of a community. To put it bluntly, the least educated, worst paid members of the long-term health care team provide the majority of care to the most complex patients a health professional could encounter. The work is literally back-breaking as most of the residents in a nursing home need help with the basic physical activities of daily living such as walking, transferring, eating, dressing, and toileting. Many residents also suffer from at least one type of mental disorder such as depression or dementia.

Thus, interacting with this frail dependent population places heavy emotional demands on CNAs. The potential for exasperation and abuse is high under such circumstances and CNAs can react with harsh words or neglect. However, abuse isn't one-sided. Residents can become frustrated and angry when care isn't delivered in the time frame or manner they want which can lead to verbal or even physical abuse directed at CNAs. CNAs comprise a vulnerable group of employees in health care with the highest rate of absenteeism and turnover among all health professionals (Fitzpatrick, 2002; Parsons, et al., 2003). The oversight of CNAs is minimal in most facilities. Their orientation to the facility and the residents is often scant. Their work occurs in relative isolation, generally hidden from public scrutiny. Few researchers have studied the experiences and perceptions of CNAs and attempted to understand their attitudes toward their work and interactions with residents, families, and supervisors. The little research that is available, often the result of observational studies, portrays CNAs' behavior as one of extremes—compassionate care givers or abusers (Foner, 1994). Clearly, there are examples of great kindness demonstrated by CNAs who sometimes serve as surrogate family for residents who are literally alone in the world. As with many roles that cross age, race, and socioeconomic lines, the intimate relationship between CNAs and nursing home residents is far more nuanced than these polar opposite types indicate.

In an attempt to tease out some the subtleties in this relationship, the call for stories for this narrative symposium included this request and these questions:

We would like stories written by nursing assistants that describe their work—what is most rewarding and challenging, and what concerns they have about the care they provide and the care patients need. We are especially interested in stories that give the reader a "back stage view" of the life and work of nursing assistants. We want your true personal story. In writing your story you might want to think about:

• • Do you feel that you make a difference in the lives of patients?

• • What kinds of problems do you face working with residents, families, and other staff?

• • Your job is physically challenging at times. Is it also emotionally or morally hard?

• • Have you ever thought there might be something wrong with how someone was being treated? What can you do when that happens?

• • Is there anything about your job that surprised you when you first started working?

• • What things do you think others would want to know about your work?

Gathering these stories proved a very difficult task. Many CNAs do not have home access to computers and the internet. Several stories came in the form of painstakingly hand-written letters. Most were well written with few or no mistakes in spelling, grammar, or sentence structure. All of these writers were very aware that what they wrote and how it was written would directly reflect on their entire profession. They very much wanted to make sure readers knew that they were...