Making Gray Gold: Narratives of Nursing Home Careby Timothy Diamond
This first hand report on the work of nurses and other caregivers in a nursing home is set powerfully in the context of wider political, economic, and cultural forces that shape and constrain the quality of care for America's elderly. Diamond demonstrates in a compelling way the price that business-as-usual policies extract from the elderly as well as those whose
This first hand report on the work of nurses and other caregivers in a nursing home is set powerfully in the context of wider political, economic, and cultural forces that shape and constrain the quality of care for America's elderly. Diamond demonstrates in a compelling way the price that business-as-usual policies extract from the elderly as well as those whose work it is to care for them.
In a society in which some two million people live in 16,000 nursing homes, with their numbers escalating daily, this thought-provoking work demands immediate and widespread attention.
"[An] unnerving portrait of what it's like to work and live in a nursing home. . . . By giving voice to so many unheard residents and workers Diamond has performed an important service for us all."—Diane Cole, New York Newsday
"With Making Gray Gold, Timothy Diamond describes the commodification of long-term care in the most vivid representation in a decade of round-the-clock institutional life. . . . A personal addition to the troublingly impersonal national debate over healthcare reform."—Madonna Harrington Meyer, Contemporary Sociology
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Making Gray Gold
Narratives of Nursing Home Care
By Timothy Diamond
The University of Chicago PressCopyright © 1992 The University of Chicago
All rights reserved.
"Welcome to the Firing Line of Health Care"
The owner of the vocational school stood tall in his three-piece suit on that first night of class, greeting the new recruits to the nursing world with military imagery: "Welcome to the firing line of health care!"
Thirty-six students sat in front of him, all in clean white uniforms, their newly purchased textbooks on the desks, listening intently. We were joining what the owner, the texts, and the teachers continually referred to as the health care team. The school, they said, would teach us our place in that team. "Firing line" in the military means the front lines of battle; here it meant caring for patients. One of the teachers later described the work much as Ina Williams had done in the coffee shop. "Registered nurses," the teacher instructed, "do the paper work nowadays. Your job, at least if you work in a nursing home, as you probably will, will be to deliver the primary care."
The owner, Mr. Cohn, continued his lecture: "You used to be called nurses' aides. In here it's nursing assistants. Things are getting more professional throughout the health care industry. I helped them draft the law. Now nobody works in an extended care facility without a certificate from a course approved by the state Board of Health. There's been a lot of trouble in nursing homes, and some of it is because staff has not been properly trained. We're here to correct that. When you're finished with this course I expect to be able to bounce a quarter on the beds you've made."
Before Mr. Cohn had called the class to attention, the students had milled around, introducing themselves and chatting. It became clear that for most of us being in this particular class was the product of a search for the program that could best fit into our work schedules and budgets. It had meant interviewing at some of the six programs that were available in Chicago. Privately owned schools advertised in the daily papers and beckoned prospective candidates to become health care professionals. Each of the three schools where I interviewed assured me admission, provided I could pay the tuition. At the time, the early 1980s, the fee was $695. This cost did not include the required textbook, uniform, shoes, watch, and thermometer, which added another $200 to the start-up costs. The school I selected had night classes and Saturday clinical training, which was convenient for those who had daytime jobs.
Ms. North, who conducted the interviews, oriented each of us to the program. "Although our school is not responsible for finding you a job," she began, "there are plenty of nursing home jobs out there, and none of you should have any trouble." She went on to describe the state requirement of one hundred hours of theory in the classroom and thirty-six hours of clinical experience.
It was a rushed interview because the waiting room was filled, largely with women of color in their twenties and thirties, and Ms. North seemed anxious to enroll her next candidate. "Do you have any questions?" she asked while closing my file.
I had many questions, but time for just one. "I'm a little uncomfortable being the only man and one of the few white people signing up. Will I be out of place?"
"Not at all," she insisted, "there's need for men in this field." As she talked she walked toward the door and opened it for me, with a quick "Good luck."
On that first night of class Mr. Cohn continued his welcoming remarks with the assurance that this course was no laughing matter, that the days were gone when nursing assistants were considered unprofessional, and that if we did not pass the tests we would fail the course. Glancing around the room, I could feel the typical jitters of a first class session, but in some ways this was more acute than any I had known, for the whole classroom environment was alien to many. To enroll, it was not necessary to have graduated from high school, and later it became clear that some of the students had not. Some were foreign-born, as was evident from their speech. The people in the classroom were mostly black, though not all American; some were Spanish-speaking, and a few were of Asian origin. It was a class of women, except for three men: one eighteen and white, one mid-thirties and black, the other mid-thirties and white—me. Most students were working at another job during the day, pursuing at night this second career with its virtual guarantee of a job.
"We like to think we're the best in the market," Mr. Cohn noted in concluding his welcoming lecture. "The allied health industry, as we call it in the school business, is the third largest industry in the country, worth over $225 billion. Now, before I dismiss you for tonight, are there any questions?"
Tense silence reigned for a long ten seconds. It was broken by the African-American woman who had seemed least intimidated by his presentation. She asked point-blank, "Are we going to have to deal with dead people?"
Mr. Cohn's military bearing crumpled somewhat, but while the class shared a muted release of laughter, he had time to think of an answer. After clearing his throat, he said, "The job of nursing assistant pushes personal care to the limit. Our teachers are all highly trained registered nurses. You can go into that with them." With that he told us to read the first chapter of the text and dismissed the class.
The textbook, Being a Nursing Assistant, introduced us to the work in a different tone, less military and businesslike. The dominant motif of the first section was health care professionalism. Like other manuals in the field, almost all of which are written by nurses with graduate degrees, it began with a cordial greeting: "Welcome to being a nursing assistant ... a very special job, one you can take much pride in. You will be helping people and making your community a better place to live."
After introducing some of the tasks and procedures that nursing assistants perform, the chapter outlined some basic personal qualities required on the job, especially dependability, accuracy, confidentiality, and good personal hygiene. It concluded with a section called "climbing the career ladder." A pyramid graph showed a bar for each step, with nursing assistants at the bottom. Students were advised to work as nursing assistants for a while, then go on to study to become licensed practical nurses (LPNs). After another year of work, they could begin schooling in a registered nurse program to obtain a diploma. Then, after a year of work as RNs, they might enroll in college for a B.S. in nursing, beyond that work for an M.A., and eventually return to graduate school in pursuit of a doctorate.
To suggest that this career ladder was beyond the reach of most of the students in that classroom would be an understatement of great magnitude. Many expressed a combination of pride and anxiety at having achieved their present enrollment. This career ladder would extend from these first days of nursing assistant class through as many as seventeen years, considerably longer than the training required of most physicians.
The tensions generated by the introductory lecture and these ideas of career professionalism were reflected in our conversations as we waited for the second class to get under way. Yet within the next half hour they seemed to dissolve. Mrs. Bonderoid, our teacher, saw to that. A registered nurse and nurse practitioner, an African-American woman of about fifty, she must have understood a lot about classroom jitters and about who was sitting in front of her as well. "What this work is going to take," she instructed, "is a lot of mother's wit." "Mother's wit," she said, not "mother wit," which connotes native intelligence irrespective of gender. She was talking about maternal feelings and skills.
The room was nearly filled with mothers, as I later learned, but even the others could tell that some notion had just been introduced that relaxed the tension. The subject matter had been put into a framework more familiar than military metaphors or the promise of professionalism. Able now to inquire about the work from their own base of experience, several students came alive with questions. Beverly Miller, for example, asked again, "Do we have to deal with dead people?"
On this night the answer was different. After a moment of reflection, Mrs. Bonderoid leaned over her podium to get closer to the class and spoke softly and slowly, "You have to look into a patient's eyes as much as you can, and learn to get the signals from there. You have to make that contact, especially when they're dying. It makes it easier for you that way, and sometimes for them, too. And whatever you're thinking at the time, say something to them, always keeping in mind that hearing is the last to go. If you've cared for them and they die, they're not just another dead person, they're still your patient."
"Mother's wit," she repeated several times during those first weeks of class, "use it and you'll stay out of trouble." Naturally I failed to share the precise feeling it induced in the mothers in the room, yet her phrase stayed with me all the time I was working in the homes. "A certain kind of just being there," was how Mrs. Bonderoid once defined it.
She herself practiced mother's wit in the classroom to ease the fears fostered by the threat of tests and failure. Still, the threat hovered over the class from first day to last. She was responsible for teaching a curriculum that had been set by the state, as we had been told in our welcoming lecture, and it was more rigorous than some of us had expected.
The theory primarily concerned biology and anatomy. As in any high school or college biology course, we were responsible for memorizing the rudiments of human anatomy and physiology: cells and tissues first, then the skeletal, muscular, gastrointestinal, nervous, excretory, reproductive, respiratory, circulatory, endocrine, and skin systems, their functions and principal organs. This comprised the core of what was meant by theory in the class; biology was the dominant theory in nursing assistants' education. The textbook made the point succinctly: "All cells, tissues, organs, and systems operate together to form a human being."
The Latin- and Greek-derived polysyllabic words proved challenging, even frightening, to many students, just as they do in high school and college biology classes. Yet Mrs. Bonderoid managed to calm most of our fears by reviewing former test questions, and she kept interest high by frequent references to what we were all abundantly eager to experience—contact with patients.
If Mrs. Bonderoid was successful in easing these fears inside the classroom, she had a more difficult time reconciling us to the circumstances that greeted us on beginning our clinical training at the nursing home. Half the class, eighteen students, stood in a circle on that first morning, trying to ward off the smells that rose up to greet us: the cleaning chemicals, the stale urine, the lingering odor of leftover powdered eggs. The first hour we spent half-listening to instructions, half-exchanging pleasantries with the residents who came up to greet us in the hall. One woman in a wheelchair was especially curious and convivial. She appeared to be in her nineties, and though her speech was slurred, she spoke continually, supplementing Mrs. Bonderoid's instructions with her insider's knowledge. "Wait till you see my floor," she chuckled. "You'll get some surprises."
We were assigned to various wards and proceeded with a typical day's work, at the side of a nursing assistant on her job. My assigned instructor, Erma Douglas, pulled at my sleeve as she headed down the hall. "Let's go, fella," she said with a smile. "Today you're the nursing assistant's nursing assistant." On the floor we were assigned to, there were four paid nursing assistants at work, one registered nurse, and one licensed practical nurse. The latter two sat at the nurses' station filling out charts and coordinating our work, and twice during the day they dispensed medications. Forty-seven women and eleven men lived on the floor, in two- and three-person rooms.
Our tasks sounded fairly simple on a first scan through the assignment sheet: assist patients with toileting, make beds, give showers, make notations in the charts for each of these tasks, and prepare to serve lunch. Yet it turned out to be a long, sometimes frightening morning for most of us. We wanted to greet our patients with a smile and a note of good cheer, but since they were strangers, some inarticulate or only partially coherent, many suffering from physically unattractive maladies, it was clear that this was going to take some practice. With some, toileting had to be done while they remained in bed, which meant starting by cleaning someone who had already defecated, perhaps hours earlier. I ran to Mrs. Douglas in fear, hoping she knew some tricks that would make it easier.
"Start with George first. He'll help you," she advised. "Just go in there and pretend he's your father. After a while, when you get to know these folks, you'll find out whose shit stinks and whose don't."
It was some time before I understood what she meant by this graphic phrase, but it became immediately clear that she was right about George Lewis. He helped me through his cleaning, especially with his jokes about being an expert at how it's done. But, when it came time to wheel him to the shower, his mood changed abruptly. It was the middle of winter and the water was not warm. He screamed and struggled with me all through the shower. After going through this sequence with four more people, I was physically and emotionally exhausted, but there was no time for reflection. The charts had to be filled in to certify that these five had been toileted and showered, and before that was half done the lunch trays were arriving.
Back in class the following week, students peppered Mrs. Bonderoid with questions about the work, the people, and the place. Because she had a strict course curriculum that needed addressing, she had to quiet the questions as best as she could. Mostly the students wanted to know how better to perform the tasks that had been so unnerving and how to start conversations with patients. They wanted to know, too, why conditions at the place were as they were, especially why the water was cold. She was prepared to talk about the tasks and how to start conversations, but the conditions of the place, she said, were beyond her control. "You'll work in better places." The subject matter at hand was human physiology, the material for the next examination.
During the classes and the clinical experience, I began taking notes on everything I could, mostly on little squares of paper that fit into my back pocket. I tried to do it unobtrusively—often in the bathroom—but my somewhat frenzied scribbling soon led to the inevitable question.
"What are you doing, Tim, writing a book?" Joanna Santos was the first to ask.
Caught off guard, I responded with a sheepish yes. Shortly thereafter, I decided to tell my classmates, with whom I was becoming increasingly friendly, about my project. It was time, I thought, for a forthright disclosure. So I practiced a little speech and seized a moment before one of the classes to tell everyone that I was a teacher and a scholar and that I hoped to write a book about the work we were doing and about nursing homes.
The rejection I feared did not occur. Instead, most took the disclosure quite casually, saying, "Hey, good luck, Tim" or "Yeah, Tim, keep it up." I was on the financial fringes myself at the time, as they could no doubt see. Perhaps for this reason, or for others, most did not take my announcement with the seriousness that I expected. A friend pointed out that they probably saw me much as they saw Charles Baker, the other mid-thirties man in the class. Charles was an African-American jazz musician who wrote music and, as he said, always carried a tune in his head. They may well have seen both of us as launching a second, safer career, while keeping the first in mind. Whatever they thought, there was enough acceptance so that I could continue taking notes and even be interrupted periodically by students saying, "Hey, don't forget to put this in your book."
As the classes continued, students had more to be concerned about than that one of their members was taking notes. They had notes of their own to take and memorize, and the class was becoming more difficult. The initial awe and excitement of the course gave way to some disgruntlement.
"Why do we have to learn all this biology and take these tests? What's this got to do with the job?" asked Martha Vogel, mother of three, formerly a home health aide.
Charles tossed in an answer to Martha's question before the teacher spoke, one that, while not calming the complaints, cut through them by getting everyone to laugh. "Hey, relax, will yuh?" he said. "What do you expect? This is America. You don't want everybody to know biology, do you? How could anybody get ahead?"
Excerpted from Making Gray Gold by Timothy Diamond. Copyright © 1992 The University of Chicago. Excerpted by permission of The University of Chicago Press.
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