S2E5: Why Are Nursing Assistant Jobs Overlooked?

Nursing assistants are the eyes and ears of nursing homes, where many people receive 24-hour skilled care when they can no longer support themselves. As the COVID-19 pandemic tragically reinforced, our society has neglected nursing homes and nursing assistants for decades.

In this episode, host Robert Espinoza speaks with Dr. Kezia Scales, Vice President of Research and Evaluation at PHI. They discuss nursing assistants' responsibilities and pressures, how quality care and jobs are linked, and transformative solutions.

Robert Espinoza: What would happen to families everywhere if more than 5 million direct care and childcare workers in this country were to vanish overnight? Welcome to Season 2 of A Question of Care, a podcast that explores this question through different viewpoints and topics. I'm your host, Robert Espinoza, a national expert and frequent speaker on aging, long-term care, and the workforce. In this episode, we'll put focus on the critical role of nursing assistants with one of my former colleagues and someone I highly respect as an authority on this subject, Dr. Kezia Scales.

Kezia Scales: My name is Kezia Scales, and I am the Vice President of Research and Evaluation for PHI.

Robert Espinoza: Kezia, you and I had the joy of working together for almost 10 years in an organization called PHI, and I'm curious if you can share for our listeners, what is PHI and what is your role there?

Kezia Scales: Sure. PHI is a national organization that focuses entirely on promoting quality jobs for direct care workers as the foundation of quality care for older adults and people with disabilities across care settings. And, in my role, I am really privileged to lead a team of researchers that supports PHI’s commitment to building the evidence base on both policies and practical interventions that improve job quality for direct care workers, that elevate this essential workforce, and maximize their contributions to quality care.

Robert Espinoza: We're talking today about the role of nursing assistants who are so critical in nursing homes around the country. I'm wondering if you can help our audience understand: what exactly is a nursing assistant, or CNA, as they're often referred to?

Kezia Scales: So, to take one step up, when I talk about the direct care workforce overall, I'm talking about personal care aides, home health aides, and nursing assistants. Those are the three main segments of this workforce according to formal occupational definitions. So, nursing assistants, who are also known as certified nursing assistants, or often just CNAs, are direct care workers who primarily work in nursing homes.

They care for people who are in nursing homes for short-term rehab stays, like after surgery, for example, and those who are living there long term. And just to note that there is some variation in the definition of the CNA role from state to state and employer to employer, but all CNAs are subject to certain federal regulations around minimum training hours, and topics, the rules for maintaining their certification, and other requirements.

Robert Espinoza: Can we talk a little bit about the responsibilities of nursing assistants? My own mother lived in a nursing home for about seven years, and I was able to see firsthand the incredible amount of work and responsibilities that these assistants have in any given day or any given week. Can you share a little bit more about those responsibilities?

Kezia Scales: CNAs spend more time with nursing home residents than any other member of the nursing home team, by far. They are the ones who help people get up in the morning. They help with bathing, dressing, mobility, eating, and so much more, all of the essential activities of daily life. And they have responsibilities that are less codified, that may not be necessarily on their task list to check off, but are no less important.

So, I just want to speak to those. For example, their role entails building relationships with nursing home residents like your mom. Getting to know those residents as individuals, learning their histories, their preferences, their values, supporting their social engagement as well, and helping offset loneliness and social isolation. And also critically observing residents' well-being, and recognizing and reporting any changes that they see, often quite subtle changes that may need clinical intervention.

That's why CNAs are often referred to as “the eyes and ears” of the care team. And, of course, on top of all that, CNAs are building and managing relationships with each other and with resident family members, both close and far, and others on the care team. There's so much more that goes into the CNA role than is generally recognized.

Robert Espinoza: Those are really important responsibilities, and quite a few of them. In terms of demographics, who is the typical nursing assistant?

Kezia Scales: Well, consistent with the caregiving workforce overall, the typical nursing assistant is a woman of color in her middle years, around 40. Also, about 20% of nursing assistants were born outside the United States. So, as I think you've talked about on this podcast before, immigrants are a critical segment of the workforce as well.

Also, to note, many nursing assistants also have their own caregiving responsibilities outside of work. So, over a third of CNAs have kids at home, and about one in five care for an older family member as well. I think those are important data points to elevate as we consider the care economy more broadly and what's needed to ensure that everyone can get the care they need.

Robert Espinoza: I'm curious about what makes a nursing assistant successful in this important role. What are the key qualities and skills that make a successful nursing assistant?

Kezia Scales: That's a great question, and I would like to answer with a brief kind of biographical note, which is that I've been conducting research on the direct care workforce in long-term care for many years now. But I started this work with ethnographic research, which is a type of research that involves the researcher taking part in whatever context they're studying. And, for me, studying direct care, that meant training and working as a nursing assistant as part of the caregiving team to learn what it takes to do this work.

And that was such an incredible opportunity to both experience and observe the challenges and the rewards of this work alongside other CNAs. And it's that rich, firsthand experience that serves as my touch point. It's what I always come back to when I'm talking about the complexity and value of this work, and, to come back to your question, the qualities and skills that it requires. So what I would say is that, first of all, there's not one way to be a successful CNA. I have seen, as I'm sure you have, very different people with very different approaches and interpersonal styles thrive in this work. But I would say that, no matter what, the work certainly requires solid technical skills to deliver safe quality care.

And the other side of that coin: the ability to adapt, to personalize the delivery of care to each individual on a daily basis, sometimes on a moment-to-moment basis. Also, the ability to communicate effectively, to be patient, usually under significant time pressure, and to be able to manage the boundaries of this work, to avoid burnout.

In other words, I think a key skill in this work is being able to care enough but not too much. And I'm sure we'll talk about this more, but I do want to emphasize as well that success as a nursing assistant is not just about individual fit with this type of work, by far. It's also about the structures and conditions of the work. It's about having sufficient training, and enough time, and a supportive supervisor, and decent compensation, and the ability to take time off, and so much more.

Robert Espinoza: And we'll definitely be talking about some of those challenges that are shaping the extent to which nursing assistants can succeed in these roles. You mentioned research, which is so important for us in terms of understanding their experiences as nursing assistants, and the kinds of barriers that we need to address. And, in fact, the research you've led at PHI shows that the total number of nursing assistants working in nursing homes has steadily declined over the last decade. So, in 2012, there were more than 620,000 nursing assistants. Yet that number dropped to 447,000 by 2022. Why is that? Why the decline?

Kezia Scales: I would say there's a combination of reasons. First and foremost, the majority of people do prefer to age and receive services in place, meaning they want to stay in their own homes and communities, if possible, even as their needs change. And public policy has increasingly, if slowly, supported that preference over the last several decades, through what's known as rebalancing, whereby more public funding, and that's largely Medicaid dollars, because Medicaid is the largest payer of long-term care, more of that public funding has shifted to home and community-based services. So, more and more people are receiving care at home rather than in nursing homes, and that means we have more direct care workforce demand on the home care side than on the nursing home side.

So, in other words, we're seeing massive growth in the home care workforce, even as the nursing home workforce is shrinking somewhat. And then, of course, the COVID-19 pandemic accelerated that trend as nursing homes were suddenly incredibly dangerous places to live and to work. And so, the nursing home sector contracted further and more rapidly in the last several years.

But I also want to say that to sort of shift the frame back, there are still nearly 450,000 nursing assistants in nursing homes supporting over a million people with often extensive care needs. So, there is still imperative to focus on nursing homes to ensure that these are places where people can live and work with dignity and optimal well-being.

Robert Espinoza: Absolutely, and I'm glad you referenced the impact that the COVID-19 pandemic had on nursing homes. And I think, for many people in this country, it might have been the first time that they thought about this sector and those challenges. I want to talk about the importance of focusing on those challenges, and your research has also shown some of the most significant barriers that are facing nursing assistants both on the job and in their daily lives. What are some of those challenges?

Kezia Scales: Well, I could spend a long time answering this question, but I think the overarching challenge is the mismatch between the demands of this work and the way that we value the work. So, I'll briefly talk that through. On the one hand, the work itself can be incredibly rewarding, but it is also incredibly demanding, physically, emotionally. There really is, I don't think, ever an easy day, a relaxed day as a nursing assistant.

You are constantly on your feet and on the move. You are managing extensive care needs across a diverse group of residents, many with communication barriers or behaviors that are challenging. I think you're pretty much guaranteed, as a CNA, to fall short of the level of care that you would like to provide to every resident because of time pressure and staffing shortages. But, on the other hand, we have thus far failed to adequately recognize and value this work and how important and difficult it is. So, like for all direct care workers, CNA wages are persistently low, hovering around a median wage of about $17 per hour at last count. That's not in most places a competitive or even a livable wage.

Employment benefits are often lacking as well, like paid time off, retirement savings plans, in some cases, even health insurance is out of reach for CNAs. Also, respect and meaningful inclusion in the interdisciplinary care team tends to be inadequate. I was in the airport recently, and I overheard a flight attendant talking about her previous work as a CNA, and she was talking about how CNAs just don't get listened to, even though they're the ones who know the residents best. That's such a familiar story, but one that we haven't yet overcome.

Robert Espinoza: I appreciate that you brought up this issue that nursing assistants often aren't listened to. They often sometimes get blamed for the challenges with the nursing homes. You and I were working together during the COVID-19 pandemic, and I remember nursing homes became ground zero for the devastating pandemic when it first started, and many reporters who contacted us wanted to know: why was that? Why was it that nursing homes were disproportionately impacted, why so many residents were dying?

And we both remember when reporters became specifically interested in discussing how nursing assistants might be transmitting the virus from one home to another, and the implication there was a little bit that they were to blame. What did this moment, and that story angle, in particular, tell us about how the public understands nursing assistants?

Kezia Scales: Yeah. That framing, that story angle that we saw, echoed what I often heard from nursing assistants themselves in my earlier research, which was that we don't get seen until something goes wrong, and then we get the blame. And I think that's what happened in those first waves of the pandemic. The outbreaks were so devastating, and there was such desperation to understand how they were happening and how they could be prevented or, at least, mitigated, and there was a kind of default to implicitly, as you say, blaming nursing assistants.

And yes, part of the story was that CNAs work multiple jobs, and traveling between jobs increased the risk of transmission. But it seems like we were only hearing that part of the story without reference to the reasons why nursing assistants have to work multiple jobs to make ends meet, and without reference to their lack of sufficient PPE on the job or in between their jobs,. And without reference to the fact that they were carrying the impossible burden of trying not to spread the virus to their residents or to their own families, while also needing to be able to keep food on the table and a roof over their heads.

Robert Espinoza: In season one of A Question of Care, Howard Gluckman describes how nursing assistants, as part of a direct care workforce, often have some of the highest injury rates in this country. And, in fact, your research at PHI has shown that they are nearly eight times more likely to experience workplace injuries than the typical US worker. Why is that?

Kezia Scales: That's a shocking statistic, isn't it? Nursing assistants have always experienced disproportionate risks of workplace injuries compared to American workers overall, and that risk just skyrocketed in the pandemic because COVID-19 counts as a workplace injury in the nursing home context. That's why nursing home jobs were referred to as the most dangerous jobs in America at that time.

But aside from COVID-19, nursing assistants are highly at risk, particularly of musculoskeletal strains and tears due to all of the non-stop bending, and lifting and pivoting, and catching that they do throughout every shift. Also slips, trips and falls are another leading source of injury for CNAs. And all of these risks are exacerbated by often inadequate safety training, sometimes limited access to assistive devices that are needed like Hoyer lifts, and also insufficient staffing, just not enough people on shift to make sure that care can be delivered carefully and safely.

Robert Espinoza: And these are challenges that are often faced by a workforce that's comprised, primarily, of women, people of color, and immigrants. They're supporting low-income older adults and people with disabilities. Together, they are some of the most marginalized populations in this country. How does this demographic reality affect how nursing assistants are treated?

Kezia Scales: I would start actually by adding one further element of marginalization, which is that nursing assistants also work the physical margins of our communities, in nursing homes, behind closed doors, in places where most people don't go or don't even see until they or a loved one needs that level of care. All of these compounding factors make it an uphill battle for nursing assistants to be seen and recognized, and for their jobs to be improved through better wages, better benefits, better training, and so on.

And these challenges are deeply entrenched in structural sexism, racism, ageism, disableism, and classism in our country. But, at the same time, it's important to say that there is a lot of effort underway right now to improve conditions for those who give and receive care. So, the marginalization that you described is all too real, but it's not inevitable or intrinsic to the care economy. It can be made visible, and it can be overcome.

Robert Espinoza: Thanks for sharing that, and I do want to circle back to some of those solutions. I wanted to ask you a question that's central to this season of A Question of Care, which is that we're asking all of our guests to paint a picture for us of what our society would look like if we had no care workers. And relevant to this conversation: how do you think society would change if there were no nursing assistants?

Kezia Scales: That's a nuanced question, I think, because, on the one hand, if there were fewer nursing assistants, that could mean that more people are being supported in their preferred location, at home, maybe, or in a less clinical congregate setting, and that could be a positive development. But, on the other hand, nursing homes hold an important place, a critical place, in our caregiving landscape. Some people have such complex needs that can only really be supported by a group of dedicated staff 24/7.

What happens to them if there are no nursing assistants and no nursing homes? Some people find more opportunity to build community and connection in the nursing home than in their own isolated homes; what happens to them? And without nursing homes, without nursing assistants, what happens to family caregivers? How much do they have to compromise their own health and financial well-being to help their family members? I would say that nursing homes should not be the only option, but they need to be an option.

Robert Espinoza: I want to circle back to this question of: what are the interventions and solutions that are needed to strengthen the nursing assistant workforce and create a better world for nursing home residents and for families overall. In your opinion, what are the types of policies that are needed to transform the nursing assistant workforce?

Kezia Scales: So, I'm going to come right out and say the new nursing home staffing rule put out by CMS is one of the policy interventions that can and will help. Until now, there has never been a specific minimum staffing level required in nursing homes, but now there is. And it's not going to be easy to implement, but we will never have quality jobs and quality care without sufficient levels of staffing, so we've got to try. Public policy can also support better compensation for nursing assistants, which is critically needed.

The new rule from CMS that I just mentioned also requires states to report how much of their Medicaid nursing home dollars go to staff compensation, and that's an important step toward establishing whether public funds are being appropriately spent, and moreover, whether or not the amount of funds is sufficient or it needs to increase to ensure livable and competitive compensation.

There are also policy options for directly increasing CNAs wages, like setting wage floors, or wage pass-throughs, or incentivizing nursing home employers to make workforce investments. And then, there are broader policies like paid sick leave, and paid family and medical leave, and earned income tax credits, and better childcare benefits, and more supportive immigration policies, all of which can help ensure that nursing assistants can keep going in this important work.

Robert Espinoza: Last season, Dr. David Grabowski from Harvard Medical School talked about the importance of transforming the overall nursing home sector. And he talked about the importance of creating person-centered environments that felt more like homes and less like hospitals, and all the conditions that would need to be in place to create that reality, which we don't have right now. Has your research or experience at PHI uncovered any promising workforce interventions related to training or advancement in this workforce?

Kezia Scales: Yes, definitely. There's a lot to say about training and advancement opportunities for this workforce. What I'd really like to elevate in particular is PHI’s and other partners' efforts to test advanced roles for CNAs and other direct care workers because a key challenge in the sector is that once you become a CNA, sometimes that's it. There are so few career development opportunities unless you go back to school to train as a nurse, or a social worker, or for another role. And that's not necessarily a preference or an option for many.

But there are now important efforts underway to craft advanced roles for CNAs that leverage their unique skill set and allow for increased responsibility and earning potential without requiring them to go back to school or leave direct care. So, as just one example. PHI partnered with a large health system to develop and test a transition specialist role for CNAs, whereby the transition specialist is trained to specifically support individuals as they move from hospital, to the nursing home for rehab, and then back home. The CNA in this advanced role helps ensure care continuity across these sort of vulnerable points of transition and mitigate the risk of avoidable rehospitalization. A lot of advanced role models for CNAs are still being pilot-tested but the evidence is really promising so far, and there's so much opportunity for scaling up and spreading these models.

Robert Espinoza: You mentioned earlier that one of the challenges with nursing assistants and addressing the challenges that face them is that it's a sector that is often invisible, that many people don't visit nursing homes, so they don't see the realities. And I would say that's true about the transition as well that you're speaking about, that not as many people are aware that when a person transitions from a hospital to a nursing home, or from a nursing home to home, that those are incredibly precarious situations that require a good amount of training and support, or something can happen. It can be very dangerous.

Kezia, I want to ask you one last question, which is about dreaming big. If you could wave a magic wand and implement one significant change to support nursing assistants, what would it be?

Kezia Scales: What immediately comes to mind is that I would give everyone the chance to work as a nursing assistant, let's say, for at least a month. There is no better way to understand how hard this work is, and how much it matters, and what needs to change to support better care than being there and doing the work. That would only be a process step rather than a concrete change, so maybe I'm not dreaming big enough. But I believe that one of the biggest barriers to change in nursing homes, it's something that we've been talking about throughout this conversation, one of the biggest barriers to change is lack of awareness and understanding, coming back to the marginalization of this sector and its workforce. So, with my magic wand, I want to build awareness, and then we can all keep working toward transformative change.

Robert Espinoza: Kezia's magic wand wish is brilliant. If everyone could walk in a nursing assistant's shoes, they would realize the skill and patience needed to work successfully in these complex jobs. They would be outraged that these workers toil in poverty with so many residents' lives at stake, and public opinion at large would likely swell in their favor.

Imagine if top-level leaders in government, whether appointed or elected, were required to work a week as a nursing assistant. This experience could give them a first-hand understanding of how these jobs and institutions function. They would witness the conditions of residents, the daily hurdles, and the routine problem-solving requirements of CNAs. They would see the hospital-like settings and the unimaginable understaffing. Would they want to live there if left with no choice? What policy reforms would they propose?

Like Kezia, I also recognize that nursing homes in our current system are the safest option for certain people, and we should ensure that these homes and the jobs they offer are of the highest quality.

However, the North Star as a country is to create robust home and community-based services so we can all age in place and be surrounded by the people and things we love. And we shouldn't forget that, but rather, we should be motivated to work towards it.

Thank you to my guest, Kezia Scales, and to you our listeners. If you enjoyed this episode of A Question of Care, please share it on your social channels and stay tuned for future episodes. This podcast was produced by me, Robert Espinoza, in partnership with Modry Media. Please make sure to rate and review the podcast wherever you're listening.