“Most of the people that get into this work are women, and they have kids,” says Patti Green of her fellow direct-care workers. “A lot of them are single. They need to earn a decent hourly rate of pay, and they need to have health insurance.”

“That would attract more people, and then if they had the good screening and training we could weed out those that don’t really have a heart for it.”

“They listened to me – I was kind of surprised”
A natural leader, Green has become an expert on the state of direct-care work in America by running what amount to online break rooms for direct-care workers. Nursing Assistant Resources on the Web, the blog she started 10 years ago and now runs with the help of two other direct-care workers, is a trove of free articles, thoughtful blog posts, FAQs, and useful links. And at NursingAssistant@yahoogroups.com, the online community Green launched around the same time and still moderates, 750-plus members engage in a lively exchange of ideas, asking questions, venting frustrations, and offering each other affirmation and support.

Green found her voice as an advocate at the nursing home where she first worked as a licensed nursing assistant (the title her state, New Hampshire, gives to certified nursing assistants.) “Everyone was always writing the aides up for everything. Nobody was giving them a chance,” she says. “I told the nurses: ‘Knock it off, don’t get involved in all the aides’ little fights. Let them work it out themselves.’ They listened to me – I was kind of surprised.

“So I started getting involved online, and I saw that was happening everywhere. It’s a national problem – actually international. I heard all these stories from aides about how they were being treated, but instead of speaking up for themselves they would just quit. That’s not right either; you can’t just lose all the aides. They have to learn how to speak up and say, ‘Look, I’m not going to put up with it.’”

“I’ve always said nurses make terrible managers”
A lot of the frustrations Green heard about then – and still does – stem from a lack of effective supervision. “A lot of times, in nursing homes, there is no good manager,” she says. “What I see happening a lot is managers adding more duties to the aides’ already overwhelming list of things, and aides getting in trouble for not meeting expectations that can never be met.

“I’ve always said nurses make terrible managers. They don’t get enough training in that. And it shows on the units. You have high turnover, you got frustrated aides, low morale, frustrated nurses, frustrated housekeepers – frustrated everybody. They’re overworked, overwhelmed. Then they all start bickering with each other, and it just gets nasty.”

Making a career of direct-care work
Green worked for two or three years at a nursing home, and for another year or so at an assisted living facility for people with dementia. But she’s spent most of her career where she is now: at a group home for developmentally delayed children and young adults with brain injuries.

A few years ago, she toyed with the idea of becoming a nurse, getting admitted to a school and signing up for classes. But she decided against it. “I’ve seen what happens to people who go into nursing,” she says. “They go in with these high ideals and turn into nasty people – especially in long-term care. It’s not what I want.”

But sticking with direct-care work has its down side too. The main problem? “The money isn’t great.”

It’s also frustrating that experienced aides like Green have so few opportunities to increase their pay without leaving the field. “If you want to better yourself, you have to become either a med tech or a nurse,” she says.” They’ll always say that, too, which is annoying: ‘Why don’t you become a nurse?’”

The answer to that question is that she loves the up close and personal nature of direct-care work, what Green calls “helping people, trying to take care of someone who’s way less fortunate than you.”

Her current employer’s low, three-to-one resident-to-staff ratio and policy of consistent assignments let her do her job right, getting close to the people she assists. “You know all their little ins and outs,” she says. “You know when they’re not feeling good, before anyone else knows it. You can anticipate problems and how they’re going to react.”

Green also likes the fact that her employer practices what industry jargon calls empowerment. “We have a lot of responsibility; we do everything,” she says of herself and her fellow LNAs.

R-E-S-P-E-C-T
Gaining the respect of the people she works with has never been a problem for Green, but she sees the problems caused by the general lack of respect for nursing assistants – and the people they care for.

“I see it with the new aides. The nurses treat them really badly,” she says. “I also see other people disrespecting aides. Sometimes it’s the doctors. It can be families, therapy people, activities people. It’s not a good feeling to get, that they just don’t respect your choice of career.

“People should know that aides are very skilled, that the work they do is very valuable and takes a lot of patience, compassion, and skill – a lot of skill. We’re the ones that do the turning, the lifting, the ambulating, the bathing, the feeding, the dressing. Those aren’t just stupid little things. Those are skills. Plus just monitoring the residents – checking their vital signs, their weight, making sure they’re drinking enough. And holding their hands. That’s what keeps a lot of CNAs in this work: their relationships with the residents.”

It doesn’t help that those residents tend not to be very highly valued by society either. “I think a lot of this problem stems from an overall disrespect for elderly people,” says Green.

Green also thinks a lot of people ignore the problems of long-term care because they’re not affected by them. “Only 1.8 million people are in nursing homes,” she says. “That’s about 9 percent of the elderly people in the United States.”

“How many bad apples can we afford?”
When she started her online work, Green was surprised to learn how many people wind up in this job who don’t belong there. “I didn’t know the problems people were having with coworkers who were lazy, just there for the money. That kind of shocked me, to know that there were bad eggs among us,” she says.

“We’re always going to have the bad apples, but how many bad apples can we afford? We could cut down the ratio if we make the pay, benefits, hours better. If that doesn’t happen, nothing’s going to get better. But it’s also really pretty easy to become an aide. I think there should be more screening.”

Green sees a need for “more education and exposure to what the work is really all about” before people are hired. “I don’t think a lot of people know what they’re getting into. A lot of these girls think it’s going to be a quick way to make a buck, and it’s really a hard way to make a cheap buck.”

And new employees need more help if they’re struggling. “If they’re not doing well, we have to figure out how to help them,” she says. “And then, if they still aren’t improving even with the help, we have to get them out. Some people just aren’t meant to do this kind of work, and they may not realize it. Or they may feel stuck, like they have no other job to go into.”

Hope for the future
“I notice that a lot of people put a lot of hope into politics as the thing that’s going to save everybody, and I just don’t see that happening,” says Green. “It doesn’t matter who’s going to be president; they’re not going to be able to change all this.”

She does see hope in the aging of the baby boomers, since she’s sure they won’t tolerate business as usual in long-term care.

Green is also encouraged by the improvements she sees in public attitudes toward nursing assistants. “There’s more awareness,” she says. “Especially in the last three or four years, people seem to have a lot more empathy. If they hear about a nursing home being sued, their first thought doesn’t seem to be: ‘Oh, those terrible aides.’”

The Olmstead-inspired moves by states to “get people out of nursing homes, move them back into their homes, their children’s homes, less restrictive assisted living settings, and so on” is another trend Green finds encouraging. “If that really takes root, I think nursing homes are going to go right out,” she says.

“I see the baby boomers as people who aren’t going to like nursing homes, but they might like a smaller group home setting. They might like this culture change movement. I would really like to see that happen.”

Interview by Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org

Part of PHI’s Expert Interview Series.