“I’ve seen a tremendous change in the view of direct-care workers,” says researcher Barbara J. Bowers. “I don’t think you’ll find a lot of people in long-term care any more who say ‘They’re lazy, they’re incompetent, they don’t know anything.’ I think there’s a tremendous amount of respect.
“The trouble is, managers think it’s their job to come up with a solution when there’s a problem, and they don’t think to include the frontline workers. And that’s partly because the workers don’t have any time, because they’re usually worked to death.”
Looking at CNA work like an anthropologist
A professor at the University of Wisconsin in Madison, Bowers has been studying how people live and work in long-term care facilities for nearly three decades.
After earning a master’s degree in nursing and a PhD in sociology, Bowers published her first study of direct-care workers “around 1980,” she says. Few others were researching the workforce at that time. “People were looking at what people did, but not what the experience was like. So I did a field study around 1984 where I looked at the work essentially like an anthropologist, working as a CNA for four months in a nursing home.”
Her report got her known as an expert on CNAs – and that led to requests to help develop screening tools for CNAs. “There was a fair amount of attention at the time, because of the high turnover rates and what people saw as bad care, with developing tools to screen out people who would be bad workers,” she recalls. “A few people asked me to help them develop tools, but I refused. I told them bad workers are really rare, in my experience. Most of the bad things that happen are because of the working environment, not because of bad people.”
She may have been one of the first industry analysts to voice that opinion, Bowers acknowledges, “but I can’t take credit for being brilliant or anything. I’m a sociologist, so my training tells me to look at systems and organizations. I think most of the people who had been looking at this were psychologists who were trained to look at the individual.”
She may be trained to look at systems, but she’s also wired to connect with individuals. The relationships Bowers has formed over the years with individual caregivers help fuel her passion for her work. “I feel a tremendous affection and respect for the people in this industry,” she says. “I don’t think any of them get a lot of resources or respect, whether it’s the directors of nursing or the frontline workers. They’re incredibly hardworking, very competent, very skilled, but they have very little in the way of resources and support. They do the best they can with what they have.”
Listening to the people who do the work
While most academic researchers come up with a theory and then test it, Bowers develops her theories over the course of doing research. “The method I use is developing theory from the people who have the experience,” she says. “We can’t know what the issues are unless we talk to the people who do the work. The only way to know if you’ve got it right is to go to the horse’s mouth.”
So what has she learned about how to improve the quality of life and quality of jobs in long-term care?
Nurture relationships between direct-care workers and the people they care for. “Those relationships are the most important thing to people in long-term care. That I’ve heard from the first day, and hear over and over again,” she says. “We know that, yet we still don’t seem to do much about it. We still don’t even have permanent assignments in lots of places.”
Show more respect for direct-care workers. “I think we need to better understand how to be supportive of CNAs,” she says. “I still hear all the time that CNAs feel like they’re looked down on, scolded publicly, humiliated. The nurses doing that don’t realize they’re doing it at all – they don’t mean to do it. I think they actually have a tremendous amount of respect for CNAs. They just don’t know how to supervise.”
Improve wage, benefits, and staffing ratios. “Certainly we need more staffing and we need more money,” she says. “I don’t know if we need any more studies to tell us people would be happier if they got paid better and they got better benefits – we just need to do something about it.”
Give CNAs more control over their work. “I don’t know if we know enough about how to better organize the work so CNAs can get more control over their work flow, so they can do what they know they need to do.” Hiring enough people is part of it, she says, but that’s not the only factor. “It’s also things like how they’re supervised, how they’re trained.”
Nurturing relationships
Bowers described one promising direction for training in a recent study by psychologist Louis Medvene, who looked at the quality of CNA/resident relationships. “This work was based on earlier research that explored the quality of marital relationships. Using the same theory to look at CNAs and residents, he found a similar pattern with nursing home staff, that is, that people tend to see someone they like in more complex ways and people they don’t like as much less complex: we see them as having only have a few attributes,” she explains. “And if you teach CNAs who don’t see residents in very complex terms to see more complexity in them, they actually like them more. It’s a fascinating look at how we might be able to build relationship training into educational programs.”
Medvene’s finding also addresses a challenge that’s central to the work CNAs do – the fact that they often care for people who would be difficult for most people to relate to. “Someone who’s not continent, who’s combative, who can’t talk, who can’t walk – we often see someone like that as barely even a human being,” says Bowers.
Learning by teaching
In addition to her teaching and research, Bowers conducts trainings herself. Recently, she has teamed up with Robyn Stone of the Institute for the Future of Aging Services to teach leadership development to CNAs and delegation, supervision, and staff development skills to nurse managers. Although she clearly loves all aspects of her job, training caregivers may be one of her favorite parts. “It’s so wonderful to just meet with these people,” she says. “They’re a wonderful group.”
Besides, training them keeps her in touch with their day-to-day concerns – and for Bowers, that’s what it’s all about. “Makes your research better,” she says.
Part of PHI’s Expert Interview Series.
I am glad to know that their are others out there that are looking at how LTC workers are treated compared to acute care workers. I was a CNA in LTC for 3 years before getting my nursing license and working as a LVN for 3 years. I then was promoted to ADON, making me direct supervisor of the CNA staff which is what I wanted to do. When I took over the job we had 10 FT CNA’s working for us, but only because that was their only skill and they needed the paycheck, they would have been the first to tell you that. I worked closely with the staff we had and with the input of the CNA’s themselves, after a years time we doubled our amount of FT staff, had a great PT crew and even a PRN pool to draw from. We turned the workplace into a fabulous environment for all departments, we involved the residents, increased the educational opportunities, etc. The facility I was in was owned by the hospital, the nurses there constantly said, “How can you work there?”, “I would never work in LTC,” etc… After they got wind of waht we were doing at the care center and how much are staffing had improved they started asking me to come to the hospital to promote the same thing…unfortunately I never got the chance because my family relocated. LTC nurses and nursing staff do not get the recognition they deserve, the job is difficult, especially for the CNA. I would love to give my ideas to anyone interested.
I’m great at my job, I just don’t like how people look down at what I do. From my employer to the relitives of the people I care for. Makes me angry at their stupidity.
I am a CNA in LTC. I have been doing this work for 16 plus years and I have heard all kinds of comments made about this line of work. Most comments are always “What does she know. She’s only a nurse aide not a nurse.” That may be true but I know more about my residents than most nurses do. We do lack respect and that is why I am working so hard to help develope Pennsylvania’s Direct Care Worker Association. If we work together as a team we can prove to everyone that we are professionals and deserve respect and credit for the hard work we do. Everyone who is a direct care worker needs to get involved and help us improve our jobs and earn the respect we deserve.
iam retired nursing assisant. i worked mainly at a hospital, medical, surgical units ortho units and mostly pediatrics, was pulled to ob, retired working onconology and pulmary units. at one time i did private care. i also worked nursing hiomes for two years and at a group home for handicap childern. i,am so glad some one is trying to get a group together, to give us more respect. i preferred, doing basic care, careing for peple doing their wishes and what needed to be done. i have worked with many nurses and have seen them go down hill. i feel alot of them are in for the money, and lack respect for nursing helpers no matter what that is at any given time. i was hard worker, taught by my older parents. that prove to be a very good quility, for me as aworker.
I am a cna for 16 years,with all my experience at different fracilityI can voice my opinion and say that the CNA’S are the most important worker in any LTC facility. we are the one to notify the nurse of changes in patients condition, always in direct care of the patient,I think we CNA’S should be more recognised for the great job that we do instead of being look down at times.
The lack of respect for direct-care workers is such a huge issue. I was encouraged to hear Barbara saying that the long-term care nurses she talks now respect nursing assistants, even if they often don’t know how to show it. But it’s also clear — and she talks about this too — how much much anger and frustration nursing assistants still deal with due to the disrespect they encounter daily. Has anyone out there been in a situation where they felt disrespected and found a way to get some satisfaction? If so, how did you do it?
I remind the nurses that the job I do is one they would prefer not to do…and without me, and my skills, resident/patient care would suffer. I also remind them that those who chose to be CNA’s as a career are not bad people, are not unmotivated or otherwise lacking in some desire to improve. Some of us simply like hands on caregiving. I don’t give respect automatically; it must be earned. I also don’t expect anyone to respect me without that being earned.
I do agree that the job of a CNA or PCW is a thankless job. I started out as a CNA and have felt all of the things that have been reported here. I have, however also experienced the other end of the spectrum as an Administrator and having to address the human resource issues that arise with front line staff. I think that both aspects are extrememly difficult as CNA’s deserve better pay and many smaller companies can not afford to pay super wages or even offer benefits. I have also experienced building better relationships between administration and front line workers as well as between workers and clients. There are a number of problems with this as well; when the staff are “friends” with Administration they have a difficult time accepting direction or having the level of respect that they are supposed to, when the staff are “friends” with clients they cross professional boundaries by doing something nice for one client but not the rest. As far as training is concerned, I believe that you can teach but only to the extent in which people are capable of learning. (Example: I teach Fire Safety many times a year and there are always a number of CNA’s or PCW’s that do not pass the test. I always offer assitance if someone has a learning disability or has difficulty taking tests.) I believe there are always 2 sides to the story and I do understand both sides of it. I feel that some people are made to take care of people and others are not. If someone is doing it for the wrong reasons – to get a pay check or because they feel they can not do anything else, I sure would hope that they have enough confidence or pride in themselves to pursue something else as this may not be the right thing for them. Long Term Care definitely takes a special kind of person and I commend all of you out there who work as CNA’s or PCW’s or any other capacity. In an ideal world you would be making more than others who do less work and get paid much better.
Amen Bonnie.
In this work we do have far too many who are in it for the paycheck and nothing else. Management loves them because they work tons of overtime and complain little. But their ability to truly care and do good work is overlooked…the quantity is more important than the quality.
You speak of Management and front line staff being “friends”- yes, it’s a big problem. What is worse though is the floor nurse and her buddy aides. They go out after work together; they hang out on weekends off…and the nurse never sees her buddy’s work ethics and poor performance everyone else bears witness too…on a daily basis. Morale breaker big time.
To the response posted by Rebecca Huffman – she stated she would love to share her ideas with anyone who would like to hear them –
I would love to hear them !! anyway you can put me in contact with her?
I’ve been doing pt care for quite a while. I started out as a care giver, and then went ahead and got my CNA license because I knew that this was something that I wanted to continue for a very long time. I love the hands on care, and I love knowing that I am making a difference in somebodies life. Thats the part that I love. I’m not in it for the paycheck, b/c if I were, I most certainly would not be where I’m at right now.
As for the nurses, what a lot of them don’t realize is, CNA’s have not been around forever. There once was a time, when the Nurse had to do the job that we Nurse Aids are doing. They used to be the ones who put them on the bed pan, dressed them, fed them, cleaned, showered, bathed, them, kept them happy, got them out of bed, etc etc, it seems as if maybe the nursing programs have gone down hill somewhat since the Nurse Aids have come about, b/c they don’t know what it is to do what used to be referred to as Nursing Care. I believe that maybe its time that these Nurses have to step back into our shoes for a while so that they can see exactly what we do, and go through on a daily basis.
To me, the best nurses were CNA’s first. Those are the ones that treat us with respect, and care, and know exactly what we are going through, and those are the ones that will jump in and lend a hand.
I think that maybe it should be required for a RN or an LPN to have to be a CNA for about 2 years before they are allowed to start taking any kind of a Nursing class.
I do get asked a lot, why don’t you go to school and get your nursing license, well, to tell you the truth, I do plan on that someday. I plan on that when My body can’t handle the stress of being a CNA any longer. I know that I won’t be able to do this kind of work forever, but while I can, I will treasure every moment of it. This may sound funny, but I will treasure every time I need to change a brief, or dump a urinal, I will treasure holding a residents hand when they are scared and forget where they are, I will forever treasure getting to be in the room as their spirit is leaving the room, knowing that I was able to give them the comfort of knowing that they are not alone during their last moments of life. I will forever treasure them, b/c without them, we wouldn’t really be here now. Without them, society would not be the same. They need us, the same way we needed them. I will forever be grateful knowing that I was there for them, the way they were once there with us.
I too think cna’s should get paid well with benefits; we do a job well skilled to our capability, we established professionalism with the client and charge nurses,lvn etc…we are there when pt become ill more we are the first to report any and all symptoms when noted. Yes,cna’s have hard work from cleaning a stomy, to a colonscopy we do it all, even vitals.. I am a cna and now going to school for medical assistant,also Lvn I have two more months for med assist. I am very lucky i enjoy what i do and do it well> I tell every nurse assistant out in the world, take it farther because you will be so skilled in every field and when time comes you will reap the rewards and remember the people you took care of as a token of appreciations.
This is to Brandi. Your reply really touched me. I recently lost my father while he was a resident in a nursing home. I live out of town and did not get there in time before he passed. There were two CNA’s with my father at the time of his passing, each holding a hand of his. I was so grateful that he was not alone as this was my biggest fear. I was so sad not being able to get there in time but it was comforting to know there were kind and caring people with him because he was the best father a child could ask for and he deserved nothing but the best. You sound like a wonderful person yourself- very giving and caring. You should be proud of the work that you do- you are making a wonderful difference in this world.
WELL I HAVE SOME LEARNING DISABILITIES I AM SLOW WHEN IT COME TO READING WRITING AND SPELLING .When i take a test i seem to fail because it takes me to long i have taking the test to be place for the cna classes but i failed because i did not finish it in time . they said i was on a 4 grade reading level my heart broke but i do not want to give up because iam slow. All in grade SCHOOL I HAD A HARD TIME AND HIGH SCHOOL WAS BASICE CLASS. SO I NOW WORK AS A PCA PLEASE HELP ME WORK ON GETTING MY CNA THANK YOU JOY. I WORK ONE ON ONE WITH A LADY IN HER 90S