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BY: ELISE NAKHNIKIAN

Ms. Nakhnikian is communications specialist, Paraprofessional Healthcare Institute, Bronx, NY.

To Improve Long-Term Care, We Must Improve Working Conditions for Direct Caregivers

Direct-care workers are caught in a vicious cycle. Inadequate wages and
benefits, poor training, few opportunities for career advancement, and frustrating working conditions all contribute to high turnover and vacancy rates. Workers who already bear heavy burdens are often required, as a result of those high rates, to "work short" or take on more responsibilities than they are prepared for. That added work leads to still more turnover and job vacancies. It also contributes to on-the-job injury rates that are consistently the second — or third-highest of any occupation in the nation. ¹ Job satisfaction vanishes as well, as workers who are pressured to speed up find themselves unable to provide the high-quality care and personal interaction they know their clients deserve.

High turnover and vacancy rates hurt consumers too, because they make it difficult to find reliable, consistent care, and services tailored to particular desires and needs. And they hurt employers, who face high costs for recruiting and training permanent workers and hiring temporary workers. When job vacancies are persistent and severe, employers may even lose income because they are unable to provide enough staff to meet the demand for their services.

Seven Essential Elements
The solution to this vicious cycle isn't easy, but it is pretty simple. To create a stable, well-qualified direct-care workforce large enough to keep pace with a growing need for long-term care and services, employers need to lock into place seven essential elements of a quality direct-care job. The simple part is identifying those seven elements, which are hardly rocket science. We who work at Paraprofessional Healthcare Institute (PHI), Bronx, NY, may have assembled them, but we didn't invent them. And none of the seven is likely to surprise anyone who has ever provided or received long-term care services.

Workers Should Receive Family-Sustaining Wages Almost a fifth of direct-care workers — far more than the national average of 12 to 13 percent of all workers — earn incomes below the poverty level.² About a third of all nursing home and home health aides who are single parents receive food stamps. According to a report written by PHI president Steven L. Dawson and Rick Surpin, president of Independence Care System, a managed care organization that specializes in long-term care:

A reasonable hourly starting wage for a person entrusted with the care of an ill or frail human being should be at least 200 percent of the minimum wage (currently $10.30 per hour total), which is still less than the median hourly wage in the U.S. of a carpet installer ($12.73/hour), auto mechanic ($13.16/hour), or embalmer ($13.55/hour). Additional compensation should be offered for weekend and off-hour shifts, which are essential to providing adequate and safe care to long-term care clients.³

Workers Should Have Affordable Health Insurance and Other Family-Supportive Benefits Many direct-care workers are employed directly by consumers or by small organizations that are unable to offer health insurance. Employees who are offered coverage often cannot afford the premiums or copays. In 1999, one-third of all home care aides and one-quarter of the certified nursing aides (CNAs) working in nursing homes had no health insurance, as compared to the one-sixth of all U.S. workers who did not have it.⁴ Those percentages are probably even higher now, as health insurance becomes even less affordable.

Besides affordable health insurance, CNAs, home care aides, and other direct-care workers also need vacation pay, sick pay, paid holidays, retirement benefits, and family medical leave, in order to balance the work of caring for elders and people with disability with the need to care for their own families.

Workers Should Have Full-Time Hours (if Desired), Stable Work Schedules, and No Mandatory Overtime Balanced workloads that offer full-time employment for those who desire it are healthier and safer for both workers and consumers than overly heavy workloads or workloads that pay less than a worker needs to live on. Yet much of the home care industry is structured on the presumption of part-time work and facility-based workers are often pressured into working unwanted extra shifts. Home care jobs should offer a minimum of 35 hours per week for those seeking full-time employment. Overtime should never be mandatory.

Workers Should Have Opportunities for Advancement To attract and retain dedicated staff members, employers must provide opportunities to develop professionally and to receive increased compensation for increased experience, skills, and responsibilities. Career ladders must be structured in such a way that direct-care workers can advance entering a different profession (becoming a licensed nurse, for example).⁵ Many employers have found peer mentoring to be an attractive career-advancement option because it both supports the new workers who get the mentoring and offers rewards to the experienced staff members who do the mentoring.⁶

Workers Need Training That Helps Them Provide High-Quality, Individualized Care Providing long-term care and personal assistance services requires considerable skill and knowledge. Even so, the federal government requires only 75 hours of training for CNAs and home health aides — and none at all for other types of direct-care workers. All workers should receive entry-level training that reflects current clinical realities and stresses problem-solving, interpersonal skills and communication, as well as specific caregiving skills. In addition, workers need orientation during their first few weeks on the job to help them transfer what they have learned to a specific setting and client base.

Workers Need Supervision That Supports, Encourages, and Guides Them Too often, supervision for direct-care workers is either nonexistent or punitive, when what they need is help in identifying and removing obstacles that keep them from doing their best work. Supervisors should receive training communication, problem-solving, and management skills to help them support workers while holding them accountable.⁷

Workers Need Management Whose Core Value Is Strengthening the Essential Caregiving Relationship between Them and Consumers Long-term care organizations have traditionally been organized around a pyramid-shaped hierarchy, with the administrator or director at the top, the licensed nursing staff and other department heads next, the direct-care workers under them, and the consumers at the bottom.

The Pioneer Network, a coalition of organizations devoted to culture change in long-term care, and other progressive providers are now striving to flatten that hierarchy.⁸ They point out that the purpose of long-term care is to serve consumers, so everything that an organization does should be geared toward supporting its consumers and those closest to them. And the people closest to consumers are their family members and the direct-care workers who provide an estimated 70 percent to 80 percent of their hands-on care.

A Sustained Commitment
As I noted earlier, listing these seven common-sense changes is easy enough, but putting them into effect is not. Most of the seven changes will require the cooperation of the entire long-term care system — especially the state and federal reimbursement systems that pay for the bulk of care and services.

Consumers, workers, employers, and policy makers may agree that the nation needs a stable, well-qualified direct-care workforce in order to deliver high-quality long-term care. But gathering the needed support to make these seven elements the standard rather than the exception will require a sustained commitment. One organization that is focused on that goal is the Direct Care Alliance (DCA), a network of providers, consumers, and workers who are committed to improving the quality of direct-care worker jobs.⁹

Over the long haul, providers can help to stabilize the workforce by joining forces with other long-term care stakeholders — through groups like the DCA — to increase the allocation of public resources to this essential public service.

In the meantime, they can become "employers of choice," a strategy that incorporates many of the seven elements of a high-quality job. As described in Finding and Keeping Direct Care Staff, a joint publication of PHI and CHA,¹⁰ and outlined in "Finding and Keeping Staff" by Steven L. Dawson, Christine Rico, and Julie Trocchio in Health Progress,¹¹ the "employer of choice" model benefits all long-term care stakeholders because it improves quality of care and quality of life for consumers by improving job quality for direct-care workers.

PHI, www.paraprofessional.org, a nonprofit organization based in Bronx, NY, works to strengthen the direct-care workforce within our nation's long-term care system through developing innovative approaches to recruitment, training, and supervision; client-centered caregiving practices; and effective public policy. Its National Clearinghouse on the Direct Care Workforce (www.directcareclearinghouse.org) serves as a resource center.

NOTES

1. U.S. Bureau of Labor Statistics, Lost-Worktime Injuries and Illnesses: Characteristics and Resulting Time Away from Work, Washington, DC, 2003, available at www.bis.gov/news.release/osh2.nr0.htm.
2. Steven L. Dawson and Rick Surpin, Direct-Care Health Workers: The Unnecessary Crisis in Long-Term Care, Aspen Institute Domestic Strategy Group, January 2001, www.directcareclearinghouse.org/download/Aspen.pdf.
3. Dawson and Surpin, p. 22.
4. National Clearinghouse on the Direct Care Workforce, Who Are Direct-Care Workers? Bronx, NY, September 2004. Available at www.directcareclearinghouse.org/download/NCDCW_0904_Fact_Sheet.pdf.
5. For examples of successful career ladders for direct-care workers, visit the National Clearinghouse on the Direct Care Workforce, www.directcareclearinghouse.org; click on "Best Practices," then "Select Category of Practice," and then "Career Advancement."
6. For examples of successful peer mentor programs for direct-care workers, visit the National Clearinghouse on the Direct Care Workforce, www.directcareclearinghouse.org; click on "Best Practices," then "Select Category of Practice," then "Peer-mentoring."
7. For information about a curriculum for supervisors, see Paraprofessional Healthcare Institute, Coaching Supervision: Introductory Skills for Supervisors in Home and Residential Care, Princeton, NJ, 2005, available at www.paraprofessional.org/Sections/resources.htm#tt.
8. See www.pioneernetwork.net.
9. See www.directcarealliance.org.
10. Available online at www.directcareclearinghouse.org/l_art_det.jsp?res_id=59310.
11. Steven L. Dawson, Christine Rico, and Julie Trocchio, "Finding and Keeping Staff," Health Progress, November-December 2001, pp. 61-63, 78

THE "FOUR Ps" SHARPEN COMMUNICATION SKILLS

The Paraprofessional Healthcare Institute (PHI), Bronx, NY, has improved the quality of the training received by direct-care workers employed by its affiliated home care agencies by incorporating a new method of teaching communication skills. Called the "Four Ps," the curriculum uses realistic workplace scenarios and role playing to improve workers' ability to solve conflicts with consumers, family members, supervisors, and co-workers.

The curriculum — which can be integrated into entry-level training, in-services, or peer mentoring programs — breaks problem-solving down into four discrete steps that can be learned through practice, in the same way that an entry-level training program teaches universal precautions or bed making.

The "Four Ps" are:

1. Pull Back. Gain emotional control in a stressful situation. We all know that we don't make the best decisions when we react emotionally to a person or situation. The first step in good communication and problem-solving is to set aside those emotions in order to clearly assess the situation and hear what is being said before responding. Through role playing and other interactive activities, workers learn how to avoid "emotional hooks" that may get in their way and exacerbate an already difficult situation.
2. Paraphrase. Listen actively and ask open-ended questions. Hearing isn't the same as listening. We've all had our attention wander when someone is talking to us, perhaps because their words triggered a memory or thoughts about how to resolve the situation. As our minds drift off, we lose track of what the person is actually saying. In the "Paraphrase" step, direct-care workers learn that active listening is "conscious" listening — which takes practice. Workers learn to give their full attention to a speaker by using techniques such as repeating back what they heard in their own words or asking open-ended questions to clarify the speaker's meaning.
3. Problem Solve. Identify critical facts, brainstorm solutions, consider consequences, and present options to a client or supervisor. We often think we know the best solution to a problem even though we are seeing it from our own perspective only. In the "Problem Solve" step, workers learn to analyze a problem from the multiple perspectives of the parties involved (the consumer's and the employer's, as well as the worker's) and to seek solutions that satisfy multiple needs.
4. Pass It On. Document in writing or communicate with others (e.g., a supervisor, coordinator, or nurse) about the problem, using objective language. In direct-care, documentation is critical. But when is a conversation confidential? When does an issue or problem reach the level that someone besides the worker needs to know about it? In the "Pass It On" step, workers learn what is important to pass on, who to pass the information on to, and how to report without judgment or bias creeping into the communication.

The "Four Ps" is a mnemonic device that reminds learners of the steps they need to go through when faced with a conflict. As everyone in a workplace learns the technique, the language can become part of the culture. From supervisors to frontline workers, co-workers can remind one another to "pull back," "paraphrase," "problem solve," or "pass it on," thereby improving the ability of everyone in the organization to listen, learn, and resolve difficult issues.

Copyright © 2005 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.