“If I had only one sentence, this would be it: Direct support work is a highly skilled job,” says Amy Hewitt.

“It’s not viewed that way by society – or, frankly, by many employers – but not everybody can do this job. You have to be smart; you have to be able to problem solve; you have to be flexible and a quick thinker. You also need patience and empathy and creativity. We’re not going to get anywhere in terms of policy advocacy or getting the supports we need in place without clearly articulating that this is a highly skilled job.”

Hewitt is a senior research associate at the University of Minnesota’s Research and Training Center on Community Living. The center’s mission is to support community living for people with intellectual and developmental disabilities – and that has led to a focus on strengthening and supporting the direct support workforce.

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Update: Jane Gross emailed me on the Fourth of July to enthusiastically invite “your readers — direct care workers, supervisors or anyone else” to contribute to her blog. This is a great opportunity to talk to long-term care consumers and family members about the challenges and rewards and importance of direct-care work. Maybe we can raise a little consciousness, even recruit some valuable allies for the quality care through quality jobs movement. — Elise

A new blog by New York Times health writer Jane Gross (pictured) provides a fascinating window into the world of family caregivers, including their thoughts about direct-care workers.

Gross started the blog after she helped her own mother find care and became a magnet for questions from colleagues at the paper who were in the same position. They all felt as overwhelmed as she had when she first encountered the long-term care system, like sailors trying to navigate the ocean in a rudderless boat (okay, so that’s my metaphor, not hers, but you get the idea.)

Having essentially the same conversation over and over made Gross realize how many people share the same questions and concerns, so she started the blog to provide “a source of information and community for grown children faced with these new responsibilities, for the elderly adjusting to unwelcome limitations and dependency, [for] employers interested in easing the burden, for professionals in the field and for anyone else who wants to chime in.”

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“There’s really no mystery here,” says PHI President Steven Dawson in an interview about solving the staffing problem in long-term care. “It’s a matter of providing a living wage, healthcare coverage, support, and recognition of what these workers do and providing the training they need to do the job well. It’s a matter of political will.”

“The fundamental problem has to do with the industry’s current basic business model of low-investment, high-turnover,” Dawson adds. “It’s based on the assumption that there’s a virtually endless supply of these workers, but I believe that the era of an endless supply of labor is coming to an end…. The approach to dealing with this new era will instead have to be “high-investment” on several fronts.”

The interview was conducted by Richard Peck, editor of Long-Term Living magazine, for the magazine’s website.

Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org

“Nursing administrators who want to promote staff-supportive culture in their facilities should recognize the key role of staff resources,” concludes a study in Journal of Gerontological Nursing, Vol. 34 No. 3. “Efforts to ensure adequate staff resources (in terms of number and mix of staff) might be most effective in facilitating staff-supportive organizational culture.”

“Predictors of Staff-Supportive Organizational Culture in Assisted Living“ (free to subscribers only) is based on a study of 294 staff members in 52 Maryland assisted living facilities.  Most of the workers were nursing assistants. The survey measured employees’ perceptions of teamwork, morale, information flow, involvement, supervision, and quality of meetings.

Staff in facilities licensed to provide higher levels of care rated their organizational culture as significantly more supportive than their peers in facilities providing lower levels of care – maybe because they are generally better staffed, hypothesizes author Elzbieta Sikorska-Simmons.

The second strongest predictor of staff-supportive organizational culture was a facility’s size, with smaller facilities ranked higher. Staff in small facilities were more demographically homogeneous and less structurally segregated (e.g., African-American employees were more likely to occupy professional positions), which leads to more cooperation and a more socially cohesive work environment.

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Nursing homes not only can but must change the way they operate, becoming better places to live and work. Only then will they be able to reduce the epidemic of violence that currently plagues them, according to an article in the Journal of Gerontological Nursing, Vol. 34 No. 3.

CNAs often experience “harassment, threats, and assaults” from residents, and the number of those incidents is probably “seriously underestimated,” according to “Policy Recommendations on the Prevention of Violence in Long-Term Care Facilities.” (The article is free to subscribers only; others must pay.)

Those attacks cause emotional distress, which can lead to more confrontations. “Frustrated and fearful, CNAs’ voices might be louder and their movements rougher, causing residents to respond in an aggressive manner,” notes the report. A vicious cycle of abuse can also occur when, “in retaliation, such aggressive behavior results in staff-to-resident abuse.”

Low reimbursement levels lead to low staffing levels at most nursing homes, which is a major contributing factor, the report says. “CNAs are more apt to deliver care in a rushed, rough, and hurried manner when assigned a large number of residents. A hurried approach is likely to cause residents to become more aggressive, thus increasing the risk of assault.”

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Nursing staff levels and other measures will soon be translated into a five-star rating system for nursing homes by the Centers for Medicare and Medicaid Services, although it is not yet clear how the data will be translated into ratings. CMS is soliciting input into the process during June and July.

In a June 18 press release, CMS called the planned system “ground-breaking,” noting that this is the first time it has ever offered a rating system for any Medicare-funded providers. The agency says the ratings are intended to help residents and their families make “meaningful distinctions between high performing and low performing homes.” The ratings will be posted on the agency’s Nursing Home Compare Web site by the end of this year.

The only nursing staff measure currently on Nursing Home Compare is the number of hours per resident per day. CMS comes up with that estimate by using self-reported data from the homes, calculating the total number of nursing staff per resident day as well as RN, LPN/LVN, and CNA hours per resident day.

But it’s hard to know what to make of those figures with no information about the special needs and acuity levels of each home’s residents – and no way to check on the accuracy of the data to begin with. What’s more, there are no federal minimum nursing staff levels to compare the results to, although some states have their own staffing requirements.

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