The Broken System





On CNA Edge, we sometimes describe long-term care as a “broken system.” I’m guessing that most caregivers who have been in the business for any length of time have a general idea of what we mean by that. They nod their heads, shrug their shoulders and go back to work. It’s just the way it is.

But, really… what do we mean by “a broken system?” I think we can look at three major areas.

First, the average workload for direct care workers often makes it difficult to meet even minimum care standards. Recently, I conducted an informal poll in one of the CNA Facebook groups, asking this question: “Do you feel that your facility has enough staff working direct care to consistently meet the goals stated in the resident care plans?” About three hundred caregivers responded. Two people said “yes.” The rest gave various versions – sometimes colorful and emphatic versions – of “no.” While this was not a scientific poll in any way, it is still supportive evidence for what most caregivers take as an obvious truth.

Second, despite some efforts to integrate caregivers into the decision making process, long-term care still relies heavily on hierarchical relationships. However one wants to sugarcoat it, caregivers remain on the bottom of the pyramid. While there is nothing wrong with this traditional organizational model per se, in long-term care it fails in one significant respect: it does not address the deep communication gap that exists between those who set the parameters of care on one side and those who are expected to work within those parameters on the other. On the other side of the gap, the primary focus is on words and the manner in which words are used for professional and public consumption. On the caregiver side, it’s about action. It’s about how one interacts with a resident physically and emotionally within the context of care. The higher up you go in a hierarchy, the further those in authority are removed from that context and upward communication loses its meaning. In effect, we maintain two parallel realities with each having its own set of priorities.

Third, whether it’s a matter of maintaining a well-organized routine, fiscal constraints or legal considerations, the needs of the facility all too often trump the needs of those who live there. While large organizations are able to centralize services and provide an efficient way of utilizing resources, this comes at the price of limiting flexibility. When facilities discourage workers to proceed according to their own discretion and do not trust their ability to apply common sense and act according to the spirit of the rules rather than to their letter, the needs and desires of individual residents are often considered unreasonable or simply neglected. The purpose of a long-term care facility is to return as much as is reasonably possible to a resident’s life what disease and circumstance have taken away. In the name of efficiency, we routinely work against that purpose.

To be sure, all these areas have improved over the course of the last 30 years. We’re getting better at it, but the progress has been uneven and there is no doubt that there is still a long way to go. The question becomes, where are we going? That is, from a caregiver’s perspective what does a system that’s not broken actually look like?

I’ll give you my take on that in my post next Friday.

2 thoughts on “The Broken System

  1. Carolyn

    Thank you for writing this blog. I love reading it everyday as it reminds me why I do what I do. I am a former CNA. I worked home care, long term care and then acute care. I then went to nursing school and completed a PhD to do research to improve not just the quality of care in long term care but the quality of the system (i.e. work environment, culture). I am currentlly doing a study interviewing CNAs in nursing homes about their experiences at work with bullying, culture, patient care… essentially about what makes the system broken and how to fix it. It has me wanting to design a new care delivery system in nursing homes and research its effectiveness. First change in this new system would be more staff/smaller patient ratios. And in this new care delilvery system the CNA would have more role autonomy – like a care liason – responsible for direct care but also they will use their valuable intimate knowledge about the residents likes, dislikes, needs and goals to contribute to the care planning with other members of the team (RNs, LPNs, PT, etc) then have a role in monitoring progress on the care plan. The idea would be to make the relationships among the healthcare team more reciprocal than hierarchical. I am curious to read others ideas about what a ‘not broken system’ would be. I may incorporate some of them into my new-care-delivery-system-model-in-progress.

    1. Yang Post author

      Thank you for your interest in the blog, Carolyn. I’m curious about how your approach would differ from Greenhouse Project homes. I think it’s a good model, but I’m wondering how much of it could be successfully applied to larger facilities. In any case, whatever the approach, lower ratios have to be part of the solution.


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