I worked for a period of time as a CNA (Certified Nursing Assistant) in an Assisted Living Facility. As a CNA, I was near the bottom of a hierarchically structured business (a “Non-Profit Business). The only layer of authority below mine was that of the Residents. Above me were the nurses, and above them the Director of Nurses, and then the Administrator who answered to the CEO, and then at the top was the Board.
If you didn’t work at this Facility, and just made a visit (as a State Inspector, perhaps?), you probably wouldn’t see how screwed up the system was. It was the Director of Nurses’s opinion that the majority of CNAs were “lazy” and incompetent. She believed that if they were kept under a constant threat of losing their jobs that she could improve the kind of care that the residents received. She was also concerned that the Facility would be shut down by the State if it received another poor or failing report. She feared that the CNA’s incompetence and “laziness” could cost her job – and if fear served as a motivation for her to perform her role, why wouldn’t it motivate the CNA’s as well?
The Administrator administrated by issuing orders. She would make frequent inspections throughout the Facility, and, with a trained eye able to spot events that occurred contrary to her orders, she would loudly demand that someone who happened to be present at the time, do something to bring her world back into the correct order. The Director of Nurses, knowing the impossibility of always matching orders to reality, would at times do her best to hide any evidence of disobedience from the Administrator, sometimes reinterpreting the rules for the CNAs and sometimes providing tips about how to cover the evidence of rule-breaking. The CNAs, under pressure to perform and in fear of their jobs, did their best to hide the evidence of disobedience or noncompliance also. It was a game that to some degree everyone knew about and participated in. Even the Residents, knowing about the rule that forbad them to remove food from the dining room, would nevertheless take food and hide it in their rooms. It was the CNA’s responsibility to search the rooms and remove the food – and try to come up with something to instill fear in the Resident so they wouldn’t break the rule again.
The whole system depended upon fear of consequences in order to control behavior. At the same time, I saw acts of kindness and compassion occur – sometimes requiring that the rules be broken in order to serve the needs of the Residents and fellow workers. I saw that fear was a very poor motivator and that there was an alternative which wasn’t being utilized. I was somewhat immune to the fear in the environment because I wasn’t particularly concerned about being fired. My primary motivation was to serve as best I could (I felt called to serve) – and so I frequently broke the rules. For instance, one rule required that each CNA change the bed linens in the rooms assigned to them according to a written schedule. It was difficult to do what was required in the time allowed without taking shortcuts on other duties. Often there weren’t enough sheets or pillow cases and so decisions would have to be made concerning which Residents would have to continue to sleep on dirty linens. If a bed had been pooped and/or peed in, the first reaction on the part of the CNA often was to take it personnally – as though the Resident had intentionally soiled the linens to make life harder for the CNA – and so the CNA sometimes found ways to retaliate, usually by scolding, condemning, and humiliating the Resident. Wanting to serve, I began helping the other CNAs change the linens on their scheduled days. The chore was accomplished in half the time, it was fun to work together, and the CNAs were able to find time to wash linens. CNAs and Residents were made happier by the teamwork. We also began to work as a team in the dining room and with other duties and acts of kindness and compassion multiplied.
However, the system was still broken. If it was to be fixed, it would require a change in the way authority and power was understood and used. Working as a team, we CNAs had begun to empower one another by working with one another – as partners. But, rather than excercising power WITH us, the Administrator continued exercising power OVER us. Unless the paradigm of authority changed, fear would continue to be an infection that caused everyone to suffer – especially those who had the least power: the Residents.
I tried to talk to the Director of Nurses and had some good discussions with the Administrator about how things could be done differently – but they would dismiss any idea of changing the system and insist that the only changes that needed to be made were in the behaviors of the CNAs.
One of the Shift Nurses was praising me one afternoon, thankful for the positive changes that she noticed. I explained that the changes occurred simply because relationships were changed – from competition, jealousy and fear to mutual caring. I described how such changes could be made throughout the organization if we simply changed the way we used power, and how much more enjoyable the work environment could be – and most of all, I pointed out that the Residents would receive the most benefit from change. Sadly, she just shook her head and said, “It will never happen. This is just the way it is.”