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“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.

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“There has been a lot of paternalism about direct-care staff – the notion that they are not really adults,” says Anna Ortigara. “People wonder: Are they really capable of being in a lead role? Can they be trusted to make good decisions? Are they capable of self-direction?”

Instead of these questions, Ortigara believes, we should ask ourselves: “How can we possibly think we are going to improve long term care without involving frontline workers? We need them at the table in order to achieve cultural transformation – and why wouldn’t we want them at the table?”

A Chicago-area nurse with a master’s degree in gerontological nursing and over a quarter of a century’s experience in long-term care, during which she has created pioneering curricula for training and supporting direct-care workers, Ortigara has a passion for improving job and care quality. She also has a talent for asking Socratic questions about what keeps us from making more progress. Read the full story

“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.”

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”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. Read the full story

”In a way, the whole long-term care system is upside down,” says Celia Berdes, PhD, a gerontologist and sociologist at Northwestern University and director of research at Presbyterian Homes in Evanston, Illinois. ”The things that are the most important are the least valued, and the things that are the least important are the most valued.”

”All that care we’re giving is not documented in a chart, so it’s invisible. And it’s hard to distinguish between those who practice care in a caring way and those who do not. We’re not evaluated in those terms, except anecdotally — ‘Mrs. So-and-So really loves you.’ But that’s not part of the bureaucratic machine of care: It isn’t quantified, it isn’t measured, it isn’t valued, in some way. An aide is never asked to write down, ‘Today I was a friend to this resident.’ Yet that may be the most important thing anyone in that nursing home did that day — better than anything the nurses could do, better than anything the DON could do, better than anything a doctor could do.”

Berdes may work at a university, but she hasn’t forgotten what she learned from her years as a nursing assistant, an activities director, and an assistant administrator in nursing homes. Her research documents and attempts to measure those crucial but invisible parts of the long-term care process — the things that either facilitate or impede the delivery of true quality care. Read the full story

Here’s the latest in PHI’s Long-Term Care Expert Interview Series spotlighting issues and trends affecting direct-care workers.

When Josh Wiener talks, people listen. So it’s good news for everyone who’s working to improve direct-care jobs that Wiener talks a lot about the looming shortage of direct-care workers. The growing care gap, he says, is ”the elephant in the room” whenever people are talking about providing or reforming long-term care in the U.S.

Wiener, who got his bachelor’s degree from the University of Chicago and his masters and doctorate degrees at Harvard, all in sociology, has worked for the Health Care Financing Administration, the Urban Institute, and the Brookings Institution, among other influential institutions. He is currently a senior fellow and the program director for aging, disability and long-term care at RTI International. The author of eight books and more than 100 articles about long-term care, Medicaid, health reform, and related topics, he often advises state and federal policymakers on issues concerning aging, disability, and long-term care. In a recent interview with PHI, he explained why he has been warning those policymakers that they need to pay more heed to the growing care gap and how to close it.

The problem

”It seems to me that a lot of the discussions about improving the quality of care or changing the delivery system start with the assumption that we will have workers who can provide services, and I think the long-range demographics are such that that’s not clear at all,” he says. ”In 2005 there will be close to 35 people aged 25 to 64 for every person aged 85 and older, but by 2050 that ratio falls to about 15. So we’re going to have to get a much higher proportion of the overall workforce into long-term care than we are now, and given the pay, the benefits, and the overall structure of the job, we’re not very likely to be able to do that.

”That raises a lot of questions. Are we not going to provide the services? Are we going to put the old people on the ice floe and send them off? Are we going to find some kind of technological substitute? While I’m not quite as skeptical about the future of technology in this area as I was in the past, long-term care is basically a hands-on, person-to-person kind of job, and it’s not clear how technology is going to significantly substitute for people.” Read the full story