MARIETTA, Ohio -- She had made it as far as the career school's parking lot for the December training class and the February class, only to drive away each time in a tangle of anxiety and self-doubt. Now it was March, and here Tereza Sedgwick came again: dressed in the mandatory class uniform of red-and-black scrubs, a lit cigarette dangling in her fingers out the busted window of her '88 Plymouth. She parked in the lot and watched a procession of unemployed workers enter the school building in southeastern Ohio, trying to will herself to join them.
On her lap sat the textbook for the school's monthly nurse aide class, which she had finished reading two weeks early, filling the margins with handwritten notes.
"Most stable job ever!" read one.
"A world of opportunity," read another.
She had been awake the night before until 2 a.m. with a nervous stomach, and now she reached for a Xanax and swallowed it with the last of her Sprite. How long had it been since she entered a classroom? How many times in life could she summon the courage to start over? She was a few weeks shy of turning 30 -- a single mother on the verge of eviction, with a 5-year-old son and a part-time job at McDonald's. The run of failure that she so far had blamed on external forces -- bad luck, the Rust Belt, economic collapse -- was threatening to become internal, a self-definition she would carry forward into what she called "my actual, this-is-really-who-I-am adulthood."
"A NEW CAREER and a NEW YOU in just 75 classroom hours," a brochure for the nurse aide class had promised, and it was transformation she was after.
She grabbed her textbook and walked toward the career center, a concrete building set amid the rolling farmland of Marietta. It was the oldest city in the state, 14,000 people pressed against the Ohio River, and its survival had always depended on reinvention: from agriculture to coal, from manufacturing to service industries. Now, two-thirds of the region's available jobs related to health care, and Tereza walked into a classroom cluttered with wheelchairs, portable toilets and hospital beds. There were seven other people in the room -- all starting over in the tenuous, low-wage recovery of 2014, in which job retraining was no longer a qualification but a prerequisite, and careers were chosen based not on preference but on prescriptions of economic need.
"Welcome. Each one of you has made a great choice by coming here," said the teacher, Diane Morris, as she surveyed her students for the first time. There were five women and two men, ranging in age from 19 to 50. Morris asked them to introduce themselves and explain their interest in the class.
"I was told by my mom, 'Get a job or move out,' " said one, a laid-off factory worker. "The only job openings I saw were in this."
"This is my second go-round in this class," said another, a former cafeteria worker. "I'm just trying to pass."
Morris turned to Tereza, who was twirling a pencil through the blonde highlights in her bangs. She knew little about health care beyond its abundant job openings, and she had difficulty with math and a phobia about needles. But she had gone three years without full-time work, and she liked the idea of caring for people. She had a framed picture of her son attached to her key chain and tattoos on her arms symbolizing peace and love. Maybe in this career, she thought, compassion and eagerness would be qualification enough.
"I'm getting desperate, to be honest," she told her classmates. "I need something good to happen. I'm hoping this might be it."
Her hope was placed in the fastest-growing job in America -- a cornerstone of the recovery, what government economists referred to as "the opportunity point" in the greatest economy in the world. It was changing bedpans, pushing wheelchairs, cleaning catheters and brushing teeth. Pay was just better than minimum wage. Burnout rates were among the highest of any career.
This was how the economy looked from the bottom up in 2014: the fastest-growing job was also among the hardest, and the place of opportunity was in fact the place of last resort.
"What Does It Mean To Be A Nurse Aide?" read the cover of the first class handout, and Tereza flipped the page to see a series of charts. The number of Americans age 65 or older was expected to double by 2050, to more than 84 million. That meant double the nursing homes, double the hospice personnel and double the home health agencies.
"Need: Urgent," the handout read.
"Necessary work experience: None."
"Necessary skills: None."
Underneath the charts Tereza saw a series of pictures that showed a smiling young woman feeding, washing, and checking the vital signs of an elderly patient. "This is basically what I already do for my son," Tereza said, feeling encouraged, and then she flipped to the next page, which listed signs of "caregiver stress" that nurse aides sometimes experience in their first year of work: Tension headaches. Teeth grinding. Reckless driving. Apathy. Depression. Fits of anger.
"On the way home from work, try to focus on one good thing that occurred during the day," the handout suggested.
Tereza closed the pamphlet and followed her classmates to a sink at the back of the room for their first lesson, a tutorial on hand washing. One student rolled his eyes and another played chess on her cellphone, but Tereza jotted notes. The proper hand wash involved 15 distinct skills, Morris said. Each skill would be graded as part of a test the next morning. Their two-week course consisted of one week in the classroom and another spent working at a nursing home. Students needed an average grade of 80 percent to pass the class and receive their state certification. "If you get to that point, you'll have a job for as long as you want it," Morris told them as she dried her hands.
"Congratulations on joining the health care movement," she said.
It had never occurred to Tereza that she would be congratulated, because nothing that brought her into the class had seemed like an accomplishment, or even a choice.
The past several years had amounted to a steady accumulation of losses -- her layoff from a furniture factory; the expiration of her unemployment insurance after 66 weeks; the eviction from her one-bedroom apartment; the loss of her cable TV, her cellphone and 50 pounds to stress. She had stayed at friends' houses with her son, Sebastian, and worked whatever hours the local McDonald's would give her. But before long she had exhausted her savings and her friends' patience, so she moved into the only house she could afford, an abandoned farm building with meager heat and sporadic electricity.
Only then had she gone to her mother to ask for help. And only then had her mother, Carol, who had spent the past decade helping, offered one final lifeline. Yes, she would allow Sebastian to live with her for two weeks so Tereza could focus exclusively on passing the nurse aide class. Yes, she would lend Tereza the $600 enrollment fee out of Sebastian's college account.
"Your 5-year-old is paying for this," Carol had told her, in case the stakes weren't already clear enough. "If you fail, you're failing him."
Tereza had never been apart from Sebastian for more than a few days. He was her Valentine's Day baby, the one happy result of an abusive relationship, and she had his birth date tattooed across the back of her neck. But now, after her first day of class, she dropped him off with a small duffel bag at her mother's house. Carol was inside, already sorting through classified advertisements for nurse aide jobs. "You should start applying for some of these tomorrow," she told Tereza.
"I haven't even passed the class yet," Tereza said.
"You will," Carol said.
"How do you figure?" Tereza said. "Haven't you been watching me these last 10 years?"
Carol's optimism came from her own experience a generation before, when she had been a little like Tereza -- adrift a decade after high school, spending everything she earned waiting tables, wanting better. She had enrolled in a career school and taken its most popular class, Introduction to Computers, and soon she was writing code, programming and graduating from college.
It was the early 1980s, the beginning of the tech boom, and it felt to Carol like life was all promise, everything hers to take. She accepted a job at General Electric and bought a three-story house on the Ohio River. She wanted a daughter, so she searched international adoption catalogs until she found a picture of a 6-year-old girl at an orphanage in Brazil. The girl stared straight into the camera with beautiful, searching eyes and a weary grin. Here was someone with whom Carol could share so much possibility. She purchased a plane ticket to Rio, submitted the adoption paperwork and brought the girl home.
All these years later, that girl was still searching, still weary, and Carol had spent a lifetime trying to help her fulfill the promise that once seemed so ensured. But where Carol had seen a world made up of things to take, Tereza was mostly preoccupied with hanging on -- to jobs that never lasted, to men who never lasted, to the bottom rung of a middle class that wasn't lasting, either.
Carol had bought Tereza a car, lent her money and finally introduced her to the Marietta career school. "This is the kind of place where I got started," she had told Tereza, encouraging her to follow suit by also signing up for her generation's version of the most popular class. It wasn't computers, and it wasn't the tech boom. But it was something.
"This could be your start," Carol said now, walking with Sebastian back into her house.
Tereza said goodbye to her son and drove alone to the place she was starting from -- out of the city, off the highway, over a hill and onto a 35-acre farm owned by a guy she had known in high school. The Plymouth rattled over the potholed dirt road, and the engine belched smoke whenever she took it over 50, but somehow the car still ran. "Tough like me," she said, patting her hand against the dashboard. She drove past a farmhouse and parked in front of a small wooden building that her high school classmate had lent to her for free. Three cow skulls hung on a tree near the door, and the porch smelled like the goats and alpacas that had been there before.
Her mom hated to visit the place, but Tereza didn't mind it. There was a horse to ride and a lake to swim in. She had strung Christmas lights in Sebastian's bedroom and taped eight rolls of car-themed wrapping paper into an oval on his ceiling. Maybe if she turned his room into a racetrack, she thought, he would never notice the flies or the leaking roof.
The latest problem was that her classmate wanted the building back, and he had cut off the water to make the point. Tereza and Sebastian were showering at friends' houses and going to the bathroom outside, and now she began to worry about something else: Her hand-washing test. It was the next day. How could she practice?
She walked to a neighbor's and filled gallon jugs with water, carrying them back into a house where nothing was simple. She tipped a jug onto the counter so water ran over her hands, and then she began to follow the steps she had written in her notes.
"Rinse until no longer contaminated."
Their exams covered hand washing, hair care, making a bed and bathroom etiquette -- two or sometimes three tests each day, 50 questions per test. By the time the students reached the last exam of their first week, emptying a urinary bag, they had begun to seek distractions. One drummed heavy-metal songs with his fingers against the desk. Another sank into a wheelchair used for training and tried to fall asleep. "Wake me up when I'm in a different career," he said.
When Morris scanned her students during lectures, eager for eye contact, only Tereza looked up from her incessant note-taking. "I hear you," she said, again and again, although her exam grades had begun to suggest otherwise: 67, 91, 82, 68. She completed additional homework for extra credit. She continued to wear her mandatory uniform even after other students had gone to sweatpants and torn baseball hats. She dutifully kept a list in her notebook of vocabulary terms: "voiding" rather than peeing; "incontinent garments" instead of diapers.
Not until late in the first week, during a lesson about "catastrophic outbursts," did Tereza stop writing long enough to truly listen. And what she heard made her worry about the realities of the vocabulary words she had collected in her notebook.
"Some of these elderly patients can get violent sometimes," Morris said, explaining that dementia patients often tried to rip off her glasses.
"And necklaces," said a student named Tiffany Riggs, who had worked as a nurse aide before but was taking the class again because her nursing college required it. "I had a woman who tried to flat-out strangle me. She hated me."
"When that happens, try stepping out of the room and coming back to reintroduce yourself," Morris said. "If they have dementia, they might forget they were even upset."
"It's just a matter of how much you can take," Tiffany said.
"And having the self-control not to fight back," Morris said. "That's a hard thing at $10 an hour."
"$10 an hour?" Tiffany said. "No way. I never heard of anybody making more than $9."
Morris gave the students a 20-minute lunch break, and Tereza walked outside carrying a bag of Funyuns and a pack of cigarettes. "What am I doing here?" she wondered. She thought about going to the front office and asking for a refund. In 35 minutes she could be at her mom's house, lying with Sebastian and escaping into cartoons. She tried to light a cigarette, but her hand was shaking. "Damn it," she said, and she started to cry. She felt a hand on her back and turned to see one of her classmates standing ready with a lighter. It was Tracy Doll, a mother of two from West Virginia. "Tell me what's wrong, honey," she said.
"It's probably fail or quit, so I'm going to quit," Tereza said.
Tracy reached into her car for a bologna sandwich and handed Tereza half. She was 44 years old and she knew what it felt like to fail and to quit, which was why she was setting her alarm for 4 each morning to drive 75 miles through the mountains to class, hoping a graduation certificate might help her reclaim something of herself.
She had withered within a bad marriage for a decade until her husband grew audacious enough to move his latest in a series of girlfriends into the family house, and Tracy, with no place else to go, consented to move into that girlfriend's unoccupied trailer. "The old switcheroo," Tracy had called it then, and in the trade she forfeited her husband, her self-esteem and the respect of her 17-year-old daughter.
Now, each day in class, Tracy was taking cellphone pictures of her test scores -- 100, 92, 97 -- and sending them to her daughter, who was suddenly responding to her mother's texts more quickly. "So freaking proud!" she had responded once, and Tracy had held up her phone to show the message to the entire class.
"Let me ask you something," she said now, to Tereza. "Do you have any regrets? 'Cause I have a lot."
"Yeah. About a million."
"Do you want quitting this class to be another?"
Tereza didn't answer, and Tracy stepped closer. "Nobody is here because they dreamed of doing this," she said. "I know that. We had struggles. We lost our place, so now this is the place we got. You have to start looking at that as an opportunity."
"I'm looking at it as bathing people, cleaning them up," Tereza said.
Tracy checked her watch. Their break was over. The teacher was about to hand out another test. "It's all about mindset," she said, turning toward the school. "You coming?"
Tereza shook her head and lit another cigarette. She took a long drag and watched the smoke spill from her mouth.
"How am I ever going to do this job?" she said, but then she stamped out the cigarette and headed back to class.
A few days later, as the second week of class began, Tereza walked inside a nursing home for the first time. She had tucked an anti-anxiety pill into her pocket and tied her hair into a bun. She put on surgical gloves and pinned a name tag to the breast of her rewashed scrubs.
"Welcome to the most desirable nursing facility in the Ohio River Valley," Karen Metz, the training supervisor, said to the students during their initial tour. She explained that their job for the next week was to act as "guardian angels" for the 86 residents of Harmar Place -- to bathe and feed them, to keep them comfortable and calm.
"If you're lucky, these are the things you'll soon be getting paid to do," Metz said, knowing that Harmar Place itself had three openings, at $8.35 an hour.
She told the students their first task would also be the most simple: delivering and feeding breakfast. She handed Tereza a plastic tray loaded with cereal, bananas and yogurt and directed her to a room at the end of the hallway, pulling back a curtain to reveal a woman lying flat on the mattress, her face turned to the wall. "Advanced dementia," Metz explained before handing Tereza a spoon. "See if you can get her to have about five bites."
"Like, spoon-feed it to her?" Tereza asked.
"By myself? Right now?"
"Find me if you have questions," Metz said, turning toward the door.
Tereza stood for a moment and studied the woman who had been put under her care, her first patient. She looked about 90, with short gray hair, a checkered nightgown and dark sunglasses wrapped around her eyes. A stuffed animal was tucked under her arm. "Is it OK if I feed you?" Tereza said, because the class textbook instructed to always ask. The patient didn't respond, so Tereza repeated herself louder. "Hi there! This is my first time. We'll do it together, OK? You and me!"
Still nothing, so Tereza leaned closer to the bed. "Are you OK?" she asked. She looked at the breakfast tray and noticed a small notecard labeled "Resident Medical Notes," tucked behind the cereal. "Eyesight limited," it read. "Hearing limited." "Communication limited."
"Still you and me," Tereza said as she placed two pillows behind the patient's back and began to peel a banana. She mashed it using the back of a fork, remembering how she had done the same for her son in his first year. She dipped a spoon into the mush and scooped up a bite with no lumps or seeds and held it under the patient's nose. Nothing. Tereza opened and closed her own mouth, mimicking eating. "Can you just try it?" she said, whispering this time. "Please?"
She counted to 10 and pulled away the fork. Her hand was trembling. Sweat ran down the bridge of her nose. Was it bad to force a patient to eat? Was it worse to leave her hungry? She had been inside a nursing facility for 30 minutes, and already she was failing. She started toward the hallway to ask for help, but then she remembered a lesson from the first day of class, about how some patients responded best to touch. She picked up the patient's hand and rubbed her wrinkled fingers, drawing circles on the inside of her palm. "Here's your breakfast," she said, almost singing it this time. "It's so good. It's so, so good." She raised the fork again. She flexed her forearm to keep her hand from shaking. She closed her eyes. "Please, God," she said.
The resident opened her mouth. Her lips closed around the spoon. She swallowed.
Four bites to go.
"OK, great job! What an eater!" Tereza said.
The key to treating patients, Metz had explained that morning, was to know their "stress triggers." One dementia patient at Harmar Place got scared by his reflection, so the staff taped construction paper over his window. Another woman, the mother of nine, felt most comfortable holding a baby, so she walked the halls of the Alzheimer's ward rocking a plastic doll. One woke up every morning and asked if it was Thursday, because that was the day her son took her out for fried chicken.
Now Tereza looked around the room for clues that might reveal something about this woman in the bed. There were no family pictures on the walls, no souvenirs on the desk. The only decoration Tereza could find was a Valentine's Day card face down in a stack of papers. "Oh, isn't this nice," Tereza said, propping the card upright, displaying it on the windowsill. She looked inside for the inscription. "From the Harmar Place staff," it read.
Tereza reached again for the fork. "You're doing great," she said, guiding more banana to woman's mouth. "Breathe. Bite. Breathe. Bite. Breathe. Bite," she said. Again the patient opened her mouth. Again her lips closed around the spoon.
Three bites left.
Tereza hurried in another. Two to go.
She reached down and removed the patient's sunglasses. Her skin was frail and her cheeks were almost translucent. "Now I can see you better," Tereza said, and for a moment what she saw was something of herself. She knew what it was like to be fragile. To be alone.
Tereza had not spoken a word of English when she left Brazil with a blonde stranger from Ohio who would become her mother, and she had kicked and screamed as they boarded the plane. During her difficult first year in the United States, she sometimes thought about the last words she had heard in Portuguese, from a priest at the orphanage. "Can't you see this is good luck?" the priest had told her. "America."
She mashed more banana and loaded it onto the spoon. One bite left. "Terrific," she said. "Really terrific."
She looked out the window and fanned herself with a plastic plate. How long had this breakfast lasted? Fifteen minutes? An hour? She could see a bench out there, and birds, and a maple tree with sunlight shining through its newly green leaves. "I would kill for a cigarette," she said. Why did it feel so hot in this room? Why was it so hard to breathe? "Almost done," she said. "Almost almost almost done." She filled the spoon one last time. She rubbed the patient's palm. She coaxed in another bite.
"Five!" she said, standing up to stretch her back. In two hours, she would come back to feed this patient a snack. In three and a half hours, she would be back again for lunch.
She took out a pen and wrote a note on the patient's chart.
"Five bites," she wrote. "Great breakfast!"
After a few days at the nursing home, Tereza had become the only student whom patients requested by name. She asked to hear the stories behind family pictures on their walls, and she remembered who liked ice cream and who preferred pudding. A Harmar Place supervisor began following her during rounds with a clipboard, evaluating her for a full-time position. "She's green," the supervisor said. "But she's learning."
Tereza, though, was still preoccupied with all she didn't know. What was the code again to unlock the linen closet? Was that high-pitched noise a routine call button or an emergency alarm? "Why can't I ever locate a pulse?" she said, one day, searching the wrist of a motionless resident for so long she began to wonder if he might be dead. "Is it possible?" she said. "Dead?" The patient opened his eyes. "No," he said. "Not possible."
She returned home each night with sore legs and bloodshot eyes, but she could never stop thinking about the job long enough to rest. Her skin reeked of antiseptic. She stayed awake and imagined the patients alone in their rooms, the medical equipment blinking in the dark, the hallways quiet. She wondered what beds she might find empty when she returned in the morning.
"I can't wait to be done," she said a few days before graduation as she began to fill out a Harmar Place job application. She sped through the form until she reached the last line. "Requested start date," it read, and she left question blank. She put the application in the glove box of her car, to complete another day. She started extending her smoke breaks from three minutes to five, and then from five to 10, until her supervisors wondered where she had gone.
"There isn't a Florence Nightingale in the bunch," said Morris, the classroom teacher, when she visited the nursing home one morning to observe the students' work. One had forgotten to wear gloves during a bed bath, risking infection for the patient. Another had been soaked by urine while cleaning a catheter and then stormed off, leaving the patient unattended.
None of them were fully prepared. Of that much Morris was sure. "We crammed six months of work into 75 hours," she said, and she had spent the last days wondering whom this training system served. The students, who would make $8 an hour in jobs they weren't prepared for? Their future employers, who would be hiring novice workers? The 72 million aging Americans, who would spend their last years living through these caretakers' mistakes?
"What can I do?" Morris said, and she had already made up her mind. She had another class to teach in a few days, and then another after that. America's elderly needed caretakers. America's unemployed needed jobs.
She passed the student who had forgotten to wear his gloves.
She passed the student who had stormed out on a resident.
She passed Tracy with a grade of 103.5 percent, and Tracy took photos of her certificate and called her daughter, who answered on the first ring. "You won't believe this," Tracy told her.
And she passed Tereza, just barely, giving her the absolute minimum score necessary to graduate: 80 percent, buoyed significantly by extra credit.
"I made it?" Tereza asked.
"You did," Morris said.
"So, I can use this to go out and get a job?" Tereza said.
"You can," Morris said.
Tereza stared at her certificate, looking from her printed name to her grade, from her name to her grade.
"Did I deserve this, or did you, like, give it to me?" she asked.
"What do you think?" Morris said, gathering up her papers, heading toward the door.
"I don't know," Tereza said, and by the time she looked up she was alone in the room.
Her mother, Carol, wanted to celebrate. "Please?" she asked, so Tereza agreed to meet her at Golden Corral. Carol had spent the afternoon calling relatives to tell them about Tereza's graduation, and she raised her water glass to offer a toast. "The health care field is so great," she said. "To new beginnings. To you, for making us all so proud."
Tereza wondered if her mother's exuberance was partly for show -- an attempt at generosity, maybe, or desperation to see her daughter claim some small piece of the promise she remembered from long ago. Either way, Tereza decided her version of generosity would be to let the moment last. She set her graduation certificate on the table. She raised her own glass to meet her mother's. "Thanks for everything," she said.
"You really did it," Carol said. "You passed."
"Thanks," Tereza said, even though what she was thinking to herself was, so did everybody else.
"You learned a new career in two weeks!" Carol said. "And all these years you've been saying you can't learn."
"I guess this time I got it," Tereza said, but in fact she was thinking about the 80 percent and all of that extra credit.
"And you'll be making good money."
"Uh-huh," she said, remembering the teacher's advice on the last day, about how to answer questions on job applications about salary requirements by writing either "Flexible" or "Minimum Wage."
"And you're going to be taking care of people, making their lives better."
"Uh-huh," she said again, thinking about the patient she had fed that morning, a man with dementia who, after eating a few bites of mashed peas, gently placed his trembling hand on her wrist and said he would shove the spoon down her throat if she fed him one more bite.
"You're on a great track," Carol said.
Tereza nodded, but she couldn't stop thinking about where that track led. Even if she got a job and worked full time, her income would still qualify her for food stamps. She would still be unable to afford her own apartment. She would likely burn out before she saved up any money. Within a year, most nurse aides return to the ranks of the unemployed, back into the economic churn, choosing uncertainty over the one certain career in a low-wage recovery.
Carol stood from the table and handed Tereza back her class certificate. "Hang this up somewhere, OK?" she said, and Tereza drove home with Sebastian and took the certificate inside. She placed it on a shelf above the sink that didn't run, but then changed her mind. She carried it into her bedroom, but what was the point in hanging it where no one else could see it? She brought it back into the living room, where most of her belongings were already packed into garbage bags, ready for an eviction that was only days away.
"Do I really want to look at this thing every day?" she said, pressing her hand against the certificate's edge, feeling its texture against her fingertips.
She was already staring into a future that the certificate foretold. That seemed like more than enough. She tucked the certificate into her textbook and dropped it into a drawer.