The battle on B Wing: When staff members fight, everyone loses.

When staff members fight, everyone loses

CYNTHIA ELPEAN, FIRST CHARGE NURSE, SECOND FLOOR, STANDS staunchly at her post at the B-wing work station, glaring daggers down the hall. In her sights is Gloria Praiseworthy, who is moving away down the corridor at a full ticked-off stomp. Gloria is the senior CNA on the unit, but at this moment she looks to Ms. Elpean like just another Hells Angel in pink scrubs.

Gloria is doing some ruminating of her own. She veers off course to slam a laundry cart into the wall, wishing with all her heart it was you know who.

Seems there was this red place on resident Aunt Irene's bottom that Gloria saw last week and Swears she mentioned to Ms. Elpean but didn't have time to write down in the CNA notebook. Seems Betty Bacteria, the infection control nurse, found this red place herself the next day and went to Cynthia, and when Cynthia didn't seem to know anything about it, she jumped on her with big ol' "I'm getting a divorce and the surveyors are due" elephant feet. So when Gloria walked up to the desk all cheery 15 minutes later, Cynthia gave her both barrels and they stood there arguing for five long, loud minutes.

As Strother Martin told Paul Newman in the movie Cool Hand Luke, what we got here is a failure to communicate. And the most common place for communication to break down is between the charge nurse and the nursing assistants.

Now, we all know some unit teams that work together like sky and sunshine. But in most facilities, there is at least one unit on one shift that begs for UN intervention. Somebody is angry almost all of the time. People stay frustrated and confused, and morale is in the toilet.

Of course, the folks who suffer most are those that live in the place. You're not going to walk away from a fight at the desk and go into a room all smiles and fool anybody. Personally, I know that when I'm all drawn up and stiff with arthritis I'm not going to want somebody who's boiling with rage transferring me from my bed to a wheelchair. And I'm not going to risk telling you I like blueberry better than strawberry. I'm just not going to bother to eat.

The problem is, direct care staff and their immediate supervisors often have a very poor understanding of one another's perspective. Nursing assistants often do not comprehend the level of personal responsibility felt by nurses in charge of units. They may not appreciate the fact that these nurses have their reputations, sense of professionalism, and careers hinging on correctly following a very full agenda of care directives day after day. And charge nurses often treat nursing assistants as if they were interchangeable robots. They don't seem to recognize that these are people with their own sense of pride and professionalism, whose insights and connection to residents are essential to good care.

That problem is compounded by the communication model we inherited from acute care, with its strict hierarchy and chain of command. You are provided information on a need-to-know basis--and if you don't need to know, you're supposed to shut up. High turnover rates don't help either, since they mean that half the time you don't know who you're dealing with.

So what can we do about it?

We can start by taking the time to listen when a colleague tells us something. In the blur of nonstop activity that characterizes a working day in most nursing homes, that's a tall order--but it's essential. And take the time to write stuff down. If you see or hear something that needs to be followed up on, don't just tell somebody or make a mental note of it; write it down. Your note doesn't have to be elaborate; just something that can trigger your memory.

We also need to treat one another like colleagues, regardless of our job descriptions. In South Carolina, we're talking about getting subacute care nurses and CNAs from different facilities together to design programs that will increase their awareness of each other's responsibilities and missions.

But the solution doesn't have to be that complicated. Things would get better if we just ate lunch together. Too many people cling to the ritual of grouping up at mealtime according to rank and job title. Kick the habit! Sit down with someone you don't usually talk to and talk about residents and care practices, where to go to get your car worked on, or who's got the best deal on used refrigerators. When we get to know one another as people--people who, chances are, share deep-rooted values about caring and personal responsibility--we can begin to build the trust and respect needed to work as a team.

Let's save our fighting energy for the battle to ensure adequate resources for long term care, and to gain recognition for long term care settings as a natural and cherished part of the human community.

William Painter is a long term care consultant and the public policy coordinator for the South Carolina chapters of the Alzheimer's Association.