”There needs to be a real shift in terms of the values of our society, in how we regard the people who give this care,” says Constance L. (Connie) Coogle, Ph.D., of our nation’s direct-care workers. ”How do you get a whole society to have a revolutionary change of values?”

”I think maybe you do it the way we’ve been doing it: Start at the ground level and get the supervisors, the administrators, the families, everyone who’s directly connected to see the value of what’s being provided. Then gather the data to make the case for better quality care. That’s when the policy pieces start to change.”

Coogle is an associate professor and associate director for research in the Virginia Center on Aging at Virginia Commonwealth University (VCU). Like her colleague Iris A. Parham, Ph.D., a VCU professor emeritus and the former chair of the university’s department of gerontology, she has been conducting health research for decades.

At first, both researchers focused largely on training for health professionals in gerontology and geriatrics, but lately they’ve broadened that group to include direct-care workers. This year, the two worked with the journal’s regular editor, Pearl Mosher-Ashley, Ph.D. to produce a special issue of Gerontology & Geriatrics Education (Volume 28, Number 2) devoted to direct-care worker training and education.

What we know about direct-care worker education

The idea for the issue sprang from the growing body of in long-term care and home and community-based care that have demonstrated the importance of the direct-care workforce in determining care quality. Studies have also documented the negative effects of the high turnover and vacancy rates, poor training and orientation, and other problems that plague so many long-term care settings — and the positive effects of interventions that help solve those problems.

”We wanted to highlight what education can do in terms of addressing some of these problems,” says Coogle. ”There were a lot of educational projects being studied. What were we finding out from them, in terms of outcomes? Were they really affecting quality of care? Were they improving job satisfaction?”

The bulk of the research in the special issue was done for the Better Jobs Better Care (BJBC) research and demonstration project. ”BJBC was focused on outcomes,” says Coogle. ”They weren’t going to fund any projects that didn’t have very strong evaluation components, and they funded research projects that were structured to say: ‘This is what works and this is how it works and this is what you can expect.’ So we had some good models, and good tools for continuing to collect data.”

The two also wanted to cull through what’s currently known and outline a comprehensive model for direct-care worker training and education. That overview is provided in the issue’s introduction by Robyn Stone, the executive director of the Institute for the Future of Aging Services, which managed BJBC.

”She’s a synthetic thinker, and could really see the thread that ran through the projects,” Coogle notes. ”BJBC started out with some questions about how education and training can be done in the most effective way. Then they looked at the relative value of orientation versus in-service or continuing education programs, and then at creating career ladder opportunities.”

Other interventions described help workers cope with the emotional demands of their work. ”They have all kinds of issues in their own lives, like paying for gas and taking care of the kids, and then they have issues at work with losing people they really cared for,” says Parham. ”It’s about life coaching, life mentoring. Who are you as a person? Where are you in your life? Where are you in your career? How do you deal with your own stress, your own exercise and diet?”

The issue also raises questions about how to individualize training. ”What can we do to maximize the time we spend training to target it to where you are? There are also a lot of commonalities, of course, but there are a lot of individual differences,” Parham points out.

This is what I did in college

Both researchers have a passionate interest in seeing direct-care workers get the respect and recognition they deserve. ”I became more and more invested in this as I became more acquainted with who direct-care workers are and how committed they are, and then look at the way they are too often treated — and how hard it is to get anyone to even think about changes in pay and benefits,” says Coogle.

For Parham, the connection is even more personal. ”That’s what I did in college,” she says. ”Emptied the bedpans, moved people, and so on. I worked in a hospital. It gave me a lot of insight — sort of set me in my direction. I was confused by it. It was so hard; some days I loved it, some days I thought, ‘This is almost too difficult to do.”’

These days, Parham relates to direct-care work primarily through her research and her family. Her mother is assisted by two regular caregivers, each of whom work six hours a day. ”Both of those people are integral members of the family,” she says. ”And seeing the magic that can happen — and the tragedy that can happen — is a motivator for me.”

A crossroads for the aging and disabilities communities

Coogle sees advocating for direct-care workers as ”a crossroads where the aging and disabilities communities can come together. I’d like to see even more working together — involving the area agencies on aging, for instance, with some of the disabilities boards. We need more training, more state funding to address the issue, more federal funding for demonstration grants. If you have a broader presence, you can be more effective in getting things done.”

Getting things done, she believes, means having a public policy framework in mind when deciding what to research in the first place. Citing a set of interviews with researchers published by the Clearinghouse, she says: ”We need to focus on the connection between interventions and outcomes. We need methods that can be replicated. And we need to tie research to public policy. We need research findings disseminated, so we can speak to the people who are going to be making the decisions and affect those decisions.”

Parham would like to see the knowledge gained through research used more in practice as well as policy. ”We have a lot of information on what works and what doesn’t, but we need to get it out there for people to use it, rather than relying on the same old in-services. There are so many direct caregivers out there in need of the new knowledge we now have. When is this going to trickle down to them all?”

Research can also serve a valuable documentary role, helping to make direct-care work visible to those who don’t normally come into contact with it, they point out. ”Many caregivers feel invisible and not highly valued,” Parham notes.

”I wish we could communicate more about the levels of enthusiasm that we found, the capacity for learning, the openness, the willingness to share,” Coogle says. ”I think everybody’s so desperate for hard-core outcomes that we’re not yet at the point where we can give a lot of flavor of what’s being accomplished. I think some qualitative research would help people start to see [direct-care workers] as full individuals.”

We have this giant hurricane coming, and we’re acting like FEMA

”We have this giant hurricane coming, and we’re acting like the old FEMA did two years ago,” Parham warns. ”We have a crisis looming here.

”There are 78 million baby boomers who expect a different kind of care for their parents, for themselves. If they’re going to be cared for at home, someone had better be there to do the caring. And I sure want people who have been trained and are knowledgeable for my mother, for myself, for my husband, for my child.

”This is part of our crisis in health care, but when people talk about health care reform, they seldom talk much about long-term care, let alone about direct-care workers.”

”In gerontology, we always talk about the importance of aging with dignity,” Coogle adds, ”but that’s just not going to be possible unless there’s good quality care. We need to be sure this older population is going to be able to age with dignity. And one of the ways we can do that is to make sure that the people who are providing the care are also accorded a certain amount of dignity.”

Part of PHI’s Expert Interview Series.