Women of Color in a World Apart

An Ethnography of Care Workers and Dementia

Anne Vittoria, Anne K. Vittoria

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9780367370800
• eBook ISBN: 9781000206524
• Topic: Social Sciences
• Subtopic: Nursing
• Index: Social Sciences

Care, whether viewed as acts of civility, acts of compassion and skill, or acts of close personal interaction, is the fundamental process by which society perpetuates and recreates itself. Despite social need and the undeniable benefit of occupations such as Certified Nursing Assistants (CNAs), these workers—mostly female and disproportionally from minority groups—face very low wages, a notable lack of respect, and little public recognition of their abilities. The United States is experiencing what experts call a crisis of care with a current and growing shortage of nurses and CNAs. In U.S. Nursing Centers, the demand for Certified Nursing Assistants, the largest group of employees who operate on the front line of health care, is expected to grow exponentially due to dramatic increases in population aging.

Over the course of a year and a half, Anne K. Vittoria examined the meaning and social construction of care work on an Alzheimer's Pavilion located in a geriatric facility in the mid-western United States. Through in-depth ethnographic research focused on the local culture and logic of care, Vittoria documents that, when given autonomy in their daily work in an institution, CNAs and the LPN Charge Nurse constructed a systematic body of knowledge and created a language of care—forging a "different" model of personal care in resistance to the medical model of care. This book challenges the assumptions of the outside world that low-level workers are alienated from their work and have minimal skills. Paradoxically, the Pavilion is both a refuge and a site of struggle for the CNAs; they desire to create a world that is the antithesis of the world in which they live on the outside. Women of Color in a World Apart provides a public forum for the voices of women of color, the development of concepts, and a practical as well as theoretical language of care that could be transformational in connecting the meanings of care with the organization of care.

1

In Place on the Pavilion

My watch reads 6:40 am. The steps leading into the main lobby of Starrmount Geriatric Center seem higher at this hour as I greet Suzanne at the front desk and sign in. I find it easy to imagine I am in a stately old hotel. The walls of expensive honey brown paneling dressed in plaques convey respectability and a long history. Richly upholstered chairs and traditional sofas dot the perimeter of the expansive lobby. The stillness of the hour is broken by the muffled voices of those opening the gift shop. Waving to Mary who tends the shop, I cross the gleaming parquet floor and head for the stairs to take me down to the Garden Level.

Once on the ground floor, I am taken hostage by the harsh, unforgiving fluorescent lights. I make my way through a narrow corridor of whitewashed cinderblock walls, past the utility and laundry rooms in the lower reaches of social space until I am face-to-face with the Helen Wise Alzheimer’s Pavilion.

I do not know the world I am about to enter this day. Negotiating the panel with the code that grants me physical entrance, I hesitate in the transition space between the larger institutional world and the world of the Pavilion. I remember a family member referring to it as the “preparation space,” a place for the family to ready themselves and to locate their family member in the distance. This funnel-like passageway allows one to view the goings on before entering the public space that contains a kitchen-dining area, living room, and a small nurse’s station. Resident rooms line the right perimeter to complete an L-shaped configuration.

Resident Harriet French sees me and approaches quickly, as I hear the heavy door shut behind me. A wiry woman, her salt and pepper hair tangled, though not fashionably so, she runs, her legs propelling her directly toward me. Without enough arms and understanding to gather her in, I fear she will fall and take me with her, such is her intensity. Harriet is a musician and a former music teacher. With bright eyes and big energy, she greets me though I cannot understand her words. Clad in a red-checkered skirt and red sweater, she has allowed her crisp white blouse to escape her skirt, a hint of the incompleteness of the morning dressing combined with her restlessness and a propensity to disrobe. She grabs my forearm and pulls me toward an imagined destination. The brightness in her eyes turns to unknowable yearning when she looks up at me. As I put my arm around her shoulder I wonder if she has been up all night.

Alighting from the entry, Harriet and I find ourselves in an expansive space with the palest of blue walls. Just as powerfully as she sought me out, Harriet turns away and clasps arms with her friend, Susan. Bodies moving in tandem, they walk away chattering to one another. To my left, natural light pours through sliding glass doors looking out onto an enclosed courtyard, a place affording protection and the potential for pleasure. Residents may amble through quadrants of grass and onto walkways lined with bright pink and white blooms, the last fruits of an Indian summer. In the center is a small fountain, pleasing in its simplicity. Yet, there is no mistaking this courtyard to be private. When Harriet and the other residents walk into the garden they can be watched because the courtyard is encircled by three floors of the institution. The purpose of the building design is to provide visual pleasure but also to provide ample opportunity for surveillance of residents. A comparison with the Panopticon¹ is not out of the question.

I walk past the dining area, which consists of six tables, usually in two rows, end to end. If not aesthetically pleasing, it is nonetheless functional and remarkably clean given its multipurpose use. Just ahead is the residents’ sitting area—a square enclosed by chairs and a television in one corner, an island of blue carpet on a sea of white linoleum. Artwork on a pillar separating the sitting room from the dining areas reminds me of residents gathering to draw with the art therapist on Monday and Thursday mornings. My eyes travel past the large fish tank to the nurses’ station, an alcove tucked away at the farthest point from the entrance, directly across from the sitting area.

Only a few residents are stirring, either the early risers or those who stayed up all night. Miss Ava Reynolds is one of the all-nighters who may remain awake for forty-eight hours after which she collapses and sleeps “like the dead” for a day. The lighting is mellow and sounds are muted with only a hint of activity behind residents’ doors. Martin Lovett, a small, gentle man given to occasional emotional outbursts, is sitting on the blue sofa snoozing. He was in the “big time” in one of the largest cities in the U.S. as a “crackerjack” newscaster, according to his son who is so stunned by his father’s demise he cannot come to see him. The son fears visiting with his father will be so emotionally upsetting that he cannot do his work as a newspaper reporter.

Over my right shoulder comes wafting, “One, two, three, out goes she into the deep blue sea … Softball seven eleven.” Marge Jacobs dances up to me, pausing in her rhyming to respond to my “Good Morning to you.” She continues to move in place, full of energy, expectant, trying to find the words to say what’s on her mind and “doing her little dance” as one CNA calls it. Her legs and head are perfectly synchronized in an up and down motion, jam-packed with bursts of energy. Marge’s presence is electric. I walk back through the sitting area where residents Boris Randolph and David Hogan are on the couch. Mr. Randolph wears his customary hat and jacket and David Hogan sports a colorful long-sleeve shirt. I wave and they wave back.

On this autumn day I look out through the large window wall that frames the courtyard and notice the leaves on the tree in the center seem to have changed color overnight. Resident Paulina Creed is standing next to the sliding glass doors, peering out. Her hands are clasped behind her back in a familiar pose, a little bun poised atop her head, a diminutive, yet hardy figure. She gazes upward at the trees. I walk over:

Anne:Anything exciting going on here this morning?

Paulina:Well no, but it’s fun.

Anne:What did you do that was fun?

Paulina:Well, going out, sitting under the trees, looking at the leaves, watching the birds, and so forth.

Anne:Did you notice that the leaves are turning a color?

Paulina:Oh, I wondered … I think it’s nice that it turned that color. It probably amuses the tree that way too.

Anne:(Hesitating to catch my breath at the cleverness of her response) That’s an interesting observation. We had a couple of cold nights last week.

Paulina:Ohhhhhh … (raising her voice slightly in recognition) Well, you mean … ah … that they’re ah … losing their ability to produce things?

Anne:Right. To produce chlorophyll that makes the leaf green.

Paulina:(With earnest concern) Well, is there anything we can do about it?

Anne:Don’t think so … but they’ll come back next year.

Paulina nods.

In the distance, Charge Nurse Marita and her team of five Certified Nursing Assistants are gathering in the cubby hole that is the nurses’ station.

Marita’s Leadership

LPN Marita Martin lives so near Starrmount Geriatric that she can round the corner from her little house at the end of a cul-de-sac in a working-class neighborhood, shoot across a busy city street, and be there. According to Charge Nurse Marita, in the world of the Helen Wise Alzheimer’s Pavilion, “you have to leave your normal self behind when you walk through the doors.” Marita, who comes out of a background of poverty, sets the tone in the Pavilion. As leader, she is wise and passionate, and prides herself on being attuned to the individual sensibilities of frail residents. Marita worked in a psychiatric setting as a frontline worker before coming to Starrmount and has a learned psychological acumen. All of “her girls,” as she calls them, respect her a great deal even though she gets mad at them sometimes for “sitting around” when they could be thinking of things to do. She tries to build resident morale and works hard at it.

Marita is informed by logic but also sensibility. Her care comes not from a technique that is applied to human objects but from a reservoir within. She is overworked and is a poet of sorts. Marita gave me several of her poems in which she struggles to find and convey a rhythm of effective communication with residents. At any point in the day, she may let down her hair and enfold the residents in spontaneous dancing and singing. She is full of pride for her Mexican heritage but critical of herself for what she thinks are her failures. Her vicarious feelings of pain and questioning are part of a meshing of self-analysis and resident analysis. She has a desire to preserve the dignity of the residents, to have them considered fully “human, inside and outside of the Pavilion.”

CNAs settle in for the morning meeting. Some bodies are large, some are small and space in the alcove is at a premium as they take their place on top of desks, leaning against the file cabinets, shoulder-to-shoulder and hip-to-hip. These women know one another on and off the job. At 7:00 am, yawns punctuate tales of lost sleep and morning migraines but soon give way to figuring out Miss Ava’s morning routine, letting “Boots” (Verna) and Emma sleep-in as an experiment, and collective groaning at medicine choices that may cause Henrietta Stein’s trails of “dreaded” diarrhea. Strong-willed and intelligent, Henrietta tests the mettle of the staff. With a gleam in her eye, CNA Arnella Jackson comments, “I think she does it on purpose, I do, I really do.” Several nod in agreement but try to pass it off good-naturedly.

Arnella’s Insights

Arnella Jackson’s insights come from seven years of observation on the Pavilion. Arnella is characterized by Marita as “the organizer. She can get things done. If she says she is going to do it, she does it. She doesn’t procrastinate.” Arnella has a family to whom she can talk about her work and let off steam. On the one hand she likens the Alzheimer’s residents to “children that like to get your attention and have their own little way of getting it.” On the other hand, she emphasizes, “They are not children and we don’t treat them as children.”

Arnella recognizes many sides of resident behavior and is adept at using metaphors to describe such behavior:

I hate to compare it to this but it’s like when it’s a full moon and the werewolf gets loose and he just goes into a frenzy. Some residents are like that in the afternoon. Some of them become verbally abusive, some of them become physically abusive.

She understands because her grandmother was diagnosed with probable Alzheimer’s disease.

As I watch Arnella throughout her day’s work, she is precise and thorough, moving rhythmically and expeditiously throughout the space. She likes to bring order to situations and laser-like shoots to the source to quell the disorder. The emotional aspect of her work and the amount of patience she must have with the residents are critical elements in her care. When I asked her how many eyes and ears it takes to work in this place, she answered, “Thousands.” She believes she has an ability to intuit what is “going on” with a resident or with a team member. There are times when she is feeling at the end of her rope and as she relates, “I must go to the cooler, smoke a cigarette, and give myself time to come back to my senses.”

Arnella has a sly sense of humor and a steady, usually even temperament; however, she can become very angry when giving me examples of people who come to the Pavilion and disrespect residents. She is dedicated to providing equal treatment to the residents and not “neglecting” anyone.

Everything is relaxed, familiar as the morning meeting begins with Marita perched atop the desk console. “With regard to Ruby, just let her sleep until she gets tired of it.” Resident Ruby Klein has been on the mend from an accident where she fell and broke her pelvis. She is making progress, but slowly. At times, she is disheartened by not being able to walk and by the pain. “Also, let Mary sleep later if she wants,” Marita continues.

We do have to change that mattress. It smells so bad. And Barbara Cole is on a special “cal” (calorie) sheet now because she’s lost too much weight. Well, you know she’s always been a little eater anyway. I tried to explain that to Susan (the head of dietary) but they still have to put the weight down so that State (nursing home regulators) will see that we’re trying to do something. We may want to start her on Great Shakes and just give her that. Why don’t we give it to her at mealtime and in-between and see what happens.

Peering over her glasses, CNA Arnella asks Marita Martin a question that is on everyone’s mind.

“The Great Shakes don’t cause diarrhea, do they?”

At this point the rest of the CNAs are chuckling, making faces and gagging.

“I wondered why you were staring at me,” Marita says laughingly.

“Again, I say, does it cause diarrhea?” Arnella quips, barely suppressing her laugh.

“Yes it does.”

In unison the CNAs groan, “Ohhhhhhh …”

“Marie had ’em yesterday and she made a big mess,” offers CNA Carma Lee. “She cussed me out yesterday. I ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Introduction
• 1 In Place on the Pavilion
• 2 Everyday Ambience and Conflicts
• 3 “Getting into the Resident’s World”
• 4 Shared Meaning and Identity Work
• 5 Co-constructing Trouble
• 6 Defending the Ethic of Care
• 7 “We’re Not A Zoo”
• 8 Local Intelligence
• Conclusion
• Bibliography
• Index