With the
population growing along with the seniorities living longer, nursing homes are
becoming high in demand as most families are unable to take care of the aging
parents due to work. The roles of the nurses and the aides are becoming more
and more important as many seniors become dependent on them. As someone who has
volunteered at a nursing home for over two years and having a grandparent
living in a nursing home, I have become curious about the behind-the-scenes of
the nursing homes. I noticed how the people who work in these nursing homes are
often taken lightly with their jobs. They are not as appreciated for their work
for the disabled or the sick despite all the stress and difficulties coming
from many different factors. For a deeper understanding, I have chosen this
book. In the ethnography, “The Caregiving Dilemma” by Nancy Foner, the author tells
her eight months experience as an nursing aide, which reveals the challenges
the aides face with intensive care residents, pressures from the patients’
families and the aides own families, pressures from their supervisors, and the
bureaucracy that influences the actions of aides’ service for the residents.
Foner starts off with the point of
addressing the nursing home not just as a residence, but a work place. She
began to describe the conditions of the nursing home that she was in, which is
called the Crescent Nursing Home. She then gave an overview of the aides’
shifts, the different occupation roles in the institution, and some of the
scenes of an interaction between the resident and the staff workers. Up to this
point would be something that volunteers or visitors would see when visiting
the nursing home for a day. She then moved on to focusing more in depth of living
the life as a nursing aide as she has immersed herself as one of the staff
members. Majority of the time, the aides’ work are often hindered from giving
the best service that they can give for the residents because of the bureaucratic
regulations that the aides must follow (Foner 3).
There
have been systems of reimbursement that “give nursing homes financial
incentives to accept heavy care patients by considering residents’ illness
level in reimbursement formulas” (Foner 12). The nursing homes would then pick
the patients, which are done by those in the higher positions, which they would
bring. This only caused more work for the aides since they had to handle
numerous high maintenance residents, which was prone for more abuse to the
residents by the workers to vent their frustrations at them. The level of
stress became higher among the aides as residents are more hostile, but they
were reluctant to bring it up because of the “fear of being reported by
patients…whatever the actual frequency of complaints, aides feel that patients
have the power to get them in trouble” (45) and that would be under the
administration’s power to fire the aides if the complaints get worse.
Foner then goes in deeper with the issue of
bureaucratic rules, which the staff in high positions believe that the system
would bring the institution in efficiency, control, and precision. It is “designed
to make staff methodical and disciplined…at the same time, encourage rigid and
inflexible behavior” (Foner 57). On the other hand, as a result of having bureaucracy,
the aides either become insensitive to the patients, meaning there is no sign
of compassion, in order to press on with the scheduled tasks, or it becomes
really difficult or even rule breaking for aides that cannot give up their
compassion for their residents, which often times made the progress slow in the
nursing home. Basically, those who ignored the schedule and the rules, in order
to assist the residents, were considered as the threat to the order. Because of
the risk of getting in trouble, aides sometimes hold in their emotions and
press on with the scheduled work for the day.
Nurses in nursing homes are very
important and are considered as the authority figure for the nursing aides.
However, they were also the ones who were the most “discourage[ing ] humane and
responsible care; some even decidedly, unsympathetic to patients” (77). Therefore,
the tension between the nurses and the aides were present because of the
difference of having a bureaucratic view for the nurses and a personal approach
for the aides, as Foner described. Foner also mentions that aides that do not
receive the respect and space are often time making it unbearable for the aides
to get through their days. As one would would say that it is like getting stuck
in an “iron cage.” However, those that were able to work with a nurse who was more
compassionate and respectful to her aides, even in times of disagreements, the
aides will did not lose their result for the nurses.
Family ties were another great impact
on the aides. When families visited the residents too often, the pressure to do
just as good or better were huge upon the aides. Again, the aides were afraid of
getting a complaint sent to their supervisors. The aides would be directly held
responsible for when family members were displeased with the effort that the
aides may or may not put in. Aside from the residents’ families are the aides’
own families, especially workers who have children or husbands. Mothers were
preoccupied when there were emergencies from a family member, thus giving
poorer service for the residents that the aides are helping.
Analysis
Despite the
author’s strong concrete points explaining about the pressure factors that
would affect the aides’ jobs, along with the circumstances listed above, Foner would
also mention about the impact of the racial and ethnic trait of the aides time
to time, hinting that this was also playing a role. However, I found this to be
a weak point in this ethnography since its justifications were incomplete or
open-ended. For example, in the chapter about patients, Foner quoted, “racial
and ethnic similarity between patients and aides did not lead to better
relations with patients or more sympathetic care” (Foner 45). Also, later in
the book, the issue of race and ethnicity comes up again, “…workers from
different ethnic groups often eat and talk together…family as well as work
concerns draw workers together…” (125). These statements plus other racial
claims affecting aides’ work were not supporting well with the author final
conclusion of the possibility of race and ethnicity to play a role. Unlike the
main issues that she has covered in this ethnography, these statements were not
directly quoted from aides of color or from the residents, but all based on her
observation. It was almost as if the author was trying to place a non-coherent observation
that was not supported well enough as evidence. Foner would often time move on
after briefly mentioning this issue. To back up my claim furthermore through my
experience in a nursing home institution, it was evident that most of the aides
were of color and the staff members in a higher authority were mostly white,
there were no signs of tension between the differences of race. I have seen
plenty of nurses and aides of different ethnicities and race all in the same
dining hall, having a light conversation with each other in between while
feeding the disabled seniors. Perhaps her attempt may have been an indication
of “culturally competent medicine” [which] focuses only on the other side of
the equation” (Borovoy, Hine 18). With a team full of diverse ethnicities and
race, it is possible that there can be a difference in what is acceptable in
medical treatment and care. Thus, the collaboration in helping each other out
could be a problem. However, it would have been better if she were to not
mention about this, but rather have it as a separate study since her focus on
this ethnography was more relevant to the effect of bureaucracy system on the
lower nursing aides. Clearly, more research, a separate study, was needed for a
sufficient and clear explanation to the significance of race of the aides
playing a role in serving for the institution and the residents.
Besides the
issues of race and ethnicity, the ethnography left me an impression of both
sympathy and frustrations of the way the aides, who does most of the work in nursing
homes, treating the residents. While reading this ethnography, my emotions
equated with the author’s reactions to the mentality of the aides and the
choices that they have made, which were at times doing more harm to the
residents in order to save themselves from getting into trouble by the higher
authority. When I volunteered at the nursing home, I remember when some of the
aides would just go past a resident in the hallway, who was asking for help,
but the aide would tell me to continue following her to a different resident,
in which she was in charge. One of the lines that struck me was “They feel
justified, since, officially they are not responsible for others’ patients can
be the ones who suffer” (Foner 135). Although as a rule, the aides were indeed
assigned to take care of residents on specific floors, this did not necessarily
mean to ignore patients when they need the help, even if it wasn’t someone that
she or he was not in charge of. In a way, this bureaucracy system, which tried
to facilitate efficiency for the benefit of the residents, was paradoxically
also harming the resident due to their indifference. It has been known that
this system has been widely used by many nursing homes. This can be issued also
global health because if other countries were to adopt this bureaucratic system,
many patients will be neglected and may get worse in their conditions for not
taking a timely measure.
Conclusion
When thinking about having my
grandfather in a nursing home right now, I wonder how he is treated when my
parents are not there to visit him. Thankfully, the nursing home that he is in
is a much smaller place where the number of seniors only compromise about 10 at
maximum. However in bigger institutes, such as the Crescent Nursing Home or the
nursing home that I volunteered at, it seems that the bureaucratic system is
stronger and the quality of the aides’ treatment to the residents seems to
decline. As more and more aides become subjected to the rules and the
authorities, the fear of losing their jobs comes into their minds before the
compassionate heart to serve the elderly. They become dehumanized and rather
than seeing people with sympathy, the aides start to see the residents as
objects; things that needs to be taken care of quickly and as many as possible
during their shift in order to receive the respect and recognition they need to
promote for full-time staff. Yet, there is a lot of strain and frustrations in
their hearts as well as they struggle the priorities between objectivity and
subjectivity towards these residents who are also mentally unstable. Even the
abuses the aides may get from the residents and/or from their families for not
doing a proper job. If there is not a better solution for a better environment
for the aides, we will not only lose a quality care from them, but also lose
number of workers, which may be detrimental in the future when the populations
of the elderly are increasing even today.
Works Cited
Borovoy, Amy and Hine, Janet. 2008. Managing the Unmanageable: Elderly Russian Jewish Émigrés and the Biomedical Culture of Diabetes Care. Medical Anthropology Quarterly Vol. 22 1-26
Foner, Nancy. The Caregiving Dilemma: Work in an American Nursing Home. Berkeley: University of
California Press, 1995. Internet resource.
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