Tag Archives: CNA leadership

Why are CNAs so Poorly Paid?





This week there has been a lot of talk in the media about the movement to raise the minimum wage to $15 an hour.  While most of the attention was focused on fast food workers, advocates for direct care workers took the opportunity to highlight the negative impact that poor wages have upon caregivers and their residents. In a Wednesday article for McKnight’s, Matt Yarnell, the Executive Vice President of SEIU Healthcare Pennsylvania, pointed out that nearly one in six of the state’s nursing home workers are paid so poorly that they are forced to seek public assistance through the Supplemental Nutritional Assistance Program, Medicaid or both.

Yarnell wrote “If we are serious about providing the highest quality care for our residents, then we have to back our rhetoric with action. It means we have to provide living wages to caregivers to cut down on turnover, to not force caregivers to work excessive overtime and double shifts. It is about not forcing workers to have to look to the state for public assistance to provide for their families.”

Why are direct care workers so poorly paid? A common argument points to the low educational requirements necessary to work as a caregiver. Often this point of view comes from within the Long Term Care community itself.

It’s true that the technical skills of a caregiver can be taught relatively quickly. Things like the principles of basic hygiene, taking vitals, infection control practices and proper body mechanics are pretty straightforward and don’t require a lot of advanced study. However, while formal training serves to create a basic necessary skill set, the real education for a caregiver doesn’t begin until he or she starts working with residents and fellow coworkers. The art of caregiving is learned through a combination of practical experience and mentoring from other workers. For those open to it, this is a learning process that can last the duration of one’s caregiving career.

The real value of experienced caregivers cannot not be found in their technical skills – or in anything that formal education could provide. Rather, it is in their capacity to perform well under difficult – often unreasonable – circumstances without losing their basic sense of humanity. It can be found in their ability to engage residents on an emotional level while under the duress of constant time restraints. It can be found in their willingness to support and sometimes lead their fellow coworkers in an environment that lacks adequate formal supervision. It can be found in their desire to serve as an example of how one human being should treat another without regard to roles or circumstance.

Good caregivers have a monetary value to the Long Term Care industry beyond what their technical skills and education can provide. The industry could not exist in its present form without their effort and caring. CNAs are truly the backbone of LTC. And their heavy lifting does not always involve transferring a resident.

The real reasons why caregivers are so underpaid are rather complex and go beyond educational requirements or even greedy nursing home operators. It is a very real social problem with direct implications to the well-being of our elderly and disabled citizens and should be treated as such.  

A Culture of Empowerment




In my last post, I listed the structural elements that enable the Green House Project’s core value of empowered staff to become a reality. In this post, I will begin to tackle the less easily defined dynamics of empowerment.

Whenever we talk about staff empowerment, we need to keep in mind the reason behind it. While the title “shahbaz” denotes respect for the caregiver, it is actually the elders that are being empowered. The Green House model simply recognizes that in order for elders to be empowered, those closest to them and know them best must have the means to facilitate that empowerment.

Obviously, caregivers in traditional institutional settings play a critical role in how a resident experiences life in in long-term care. Both the nature of the work and the manner in which caregivers engage residents guarantee that central role. For many long-term care residents, the quality of their relationships with their caregivers determines the quality of their lives.

However, when it comes to actual power – the ability to make day to day decisions that most directly impact residents and the accountability for those decisions – the traditional model provides the caregiver with a distorted version of power, created more by default than by design. While caregivers report to a unit supervisor, much of their daily routine is conducted without the direct involvement of that supervisor. The nature of the long-term care business demands that a manager’s time and attention be occupied by matters not directly related to the details of daily care. Simply put, a supervisor has limited awareness of what goes on down the halls and in the rooms.

In this vacuum, individual caregivers are compelled to make decisions regarding the use of limited resources – time, especially. How they prioritize these choices is often influenced by an informal, but powerful subculture in which the caregivers with the strongest personalities sent the standards. Sometimes, this actually works well and supervisors even learn to rely on these caregivers to help manage the unit. But all too often, it leads to mistrust and petty bickering among caregivers. The relationship between caregivers and managers is commonly characterized by conflict over authority, self-promotion, stonewalling and manipulation. Good work is not rewarded and poor work is left uncorrected. This is not the kind of “power” that contributes to a meaningful life for residents on a consistent basis.

By providing the Shahbazim with real decision making power, the Green House Model formalizes and expands the caregiver subculture. In doing so, it changes the dynamics of the relationship both among caregivers themselves and between caregivers and the individual charged with holding them accountable, the Guide. Leaders will still emerge within the group, but everyone is expected to grow into leadership roles. Along with the guide and clinical staff, the strongest and most experienced shahbazim are charged with coaching newer staff members into those roles.

Furthermore, the Shahbazim are held accountable in a way that caregivers in a traditional setting are not. While caregivers are always responsible for their individual actions, the ultimate responsibility for what happens on an institutional unit falls on the licensed supervisor. In the Green House Model, the caregivers assume that responsibility. The team is self-managed and while there can be a degree of flexibility in some matters, they have a vested interest in following their own rules and developing a cooperative work environment.

While the Guide expects and encourages the Shahbazim to make decisions, he or she is much more aware and involved with the day to day details of the home than a traditional manager. Not only does this allow the Guide to be effective in the coaching and support roles, it leaves less room for the kind of finger pointing and lack of transparency so prevalent in traditional settings. Issues are more likely to be dealt with directly and in the open. Again, this is aided by the small size of the home compared to large institutional nursing units.

In my next post, I would like to talk about how an empowered staff’s approach to problem solving differs from the approach taken in a traditional institutional setting.

A Flattened Hierarchy




Continuing my exploration of the Green House Project, I will now turn to the second core value of the model, “Empowered Staff.” Empowered staff refers primarily to the workers who provide direct care.

The Green House term for a caregiver is “Shahbaz” (plural: Shahbazim). Shahbaz means “royal falcon” in Persian and is meant to convey a person worthy of respect, someone who is valued. The title is representative of the Green House Model’s investment in and support of the workers closest to the Elders.

The Shahbazim perform the same basic personal care duties as CNAs in a traditional long-term care setting, but along with the new title they are given a significantly expanded role which makes them responsible for the day to day management of the home. They make decisions that would normally be made by supervisors or mid-level managers. These include decisions involving scheduling, food preparation, laundry, housekeeping and care planning. They rotate the leadership roles – typically each quarter – so that each shahbaz takes a turn coordinating each of these functions.

This organizational structure is often characterized as a “flattened hierarchy.”  However, while the homes are operated by self-managed work teams, the Shahbazim do not work unsupported. They report to a “Guide,” an experienced LTC professional with extensive training in coaching skills. The Guide is responsible for providing the team with support, accountability and the resources necessary for the Shahbazim to succeed.

While it would be easy for a caregiver to simply regard the Guide as just another kind of supervisor, the core value of Empowered Staff requires the Guide to leave the day to day problem solving in the hands of the Shahbazim. A Shahbaz must be willing to receive coaching and grow into these new roles. In this sense, empowerment is not simply a matter of delegating responsibility, but it is a process that depends on the personal and professional growth and development of individual caregivers.

How and why this organizational structure works from a caregiver’s perspective will be the subject of upcoming posts.

Two Open Letters






To Potential new hires,

I want you to be responsible for the care, protection and quality of life for a hall full of people with a wide variety of physical and mental illnesses. Make sure they are clean and dry, supervise their gait, and make certain that their oxygen tanks are full and on the appropriate setting. If they have a doctor’s order for TED hose, please make sure they are on in a timely manner.

Because these folks are unwell, they are occasionally combative. We will offer no help to you in these matters, other than suggesting that you get another aid to help, if you can find one. Often, you won’t be able to because we have a bare staff. We are also desperate for help, so many of the people we DO hire are unable to lift and are squeamish about body fluids, so they will not be much help to you. We hope that you are not like that, but if you are, eh. You get what you pay for. Someone will pick up the slack. Someone always does.

We can’t promise that we’ll remember to tell you if your hall partner called out or your shift relief will be late. We are very important and busy people. You can’t expect us to value your time and effort enough to interrupt our own.

You will be covered in any number of body fluids, we will often run short of supplies and expect you to figure it out. As a matter of fact, we pretty much expect you to handle any situation with little or no input from us. Oh! We will make rules and change them without telling you and we will apply them with inconsistency, as we see fit. This applies to both you and the residents. There will be no raises. No benefits and no rewards for doing an excellent job. But there will also be very few consequences for doing terrible job. Life’s a balance. We’ll pay you 9.00 an hour. What do you say?




To Potential new hires,

This job is tough. It is not for everyone. It will break you into a million pieces and teach you how to put yourself back together in ways you never thought possible, if you allow it.

There are facilities with kind, involved supportive management who offer substantial training and ample rewards for good work ethic. There are facilities with relatively calm residents who are not living with severe mental illness. This is not one of them, a fact that over time I have grown to appreciate, oddly enough. When there is no one willing to solve problems, it motivates you to first understand the problem and then figure out how to solve it yourself.

I have learned more about life, love, courage, vulnerability and perseverance than I could have in any other facility. I have explored, hand in hand with my residents, the subculture in which they live. I’ve learned to trust and be trusted. I’ve learned how to speak my truth, and more importantly, to speak theirs.

None of this will pay my bills, and there are times that I am resentful at the lack of pay, and basic lack of respect for what we do; a job that matters deeply to me is dismissed by those who should know better. I don’t wallow in that though, because I believe that WE can change that. If enough of us refuse to allow our pay rate to dictate our level of care, if we use the systems flaws and mismanagement to teach us how to problem solve and lead ourselves rather than embitter us enough to lose our empathy, then we really can make a difference. I believe this in my heart of hearts and truly hope that you will be a part of the solution. It’s easy to be a light in the day. My facility needs lights in the dark.


Your fellow Caregiver

This is Not Acceptable




“You see things; and you say ‘Why?’ But I dream things that never were; and I say ‘Why not?’”         

This George Bernard Shaw quote was put to good use by Robert Kennedy. It is one of my personal favorites and I try to hold the idea close to my heart, especially when work is at its most chaotic and dysfunctional.

 I have never been one to blindly accept the status quo. The notion of living by the motto of “that’s just the way it is” is simply not a possibility. It’s a cop out. It enables us, as individuals, to blindly go through the motions with very little reflection and even less accountability.       

The long-term care system is a perfect example of misplaced acceptance. The standards of care are low. Often, caregivers do not have easy access to charts, we are not informed of changes in the care plan, new residents are brought in with no notice and very little information and we are expected to make it work.  We are short of supplies, short of staff and it appears that the residents are placed last on everyone’s priority list.         

This is the “norm” and barring any catastrophe, it is accepted by the regulatory agencies whose sole purpose is to ensure the proper care for those living in these facilities.             

The systematic allowance of such conditions can be easily seen by viewing the lists of penalties for violations on your state’s DHSR website. I don’t recommend reading it on a full stomach. It contains information like this: ____  nursing home:  type A violation. Lack of supervision lead to residents elopement of the facility resulting in death. Fine 25,000. Upon appeal, facility paid 10,000…it is a truly horrifying read and it is a long list.       

Hell will freeze over before I accept that there isn’t a better way; a tangible solution. Writing for this blog is one of my ways of fighting back, for both the caregivers and the people for whom we care.     

I write in the hopes of reaching like-minded people who refuse to accept the unacceptable; who refuse to look at a system that allows a 10,000 dollar fine make the preventable death of a human being “ok” without actively trying to change it.  I write for those who would rather fight for the possibility of a better tomorrow than accept the broken reality of today.

The Value of the CNA Voice




There is a school of thought among some professional advocates for CNAs that says caregivers will never fully appreciate the true value of their own work until they have a better understanding of how the business of long-term care works. That, until they recognize their role in the bigger picture, caregivers will never fully grasp how they influence the larger goals of the industry and are thus left to doubt the significance of their work – and their self-worth.

While I’m not prepared to dispute any of that, I will say that in terms of utilizing resources to deliver the best care possible, the converse is far more significant: the business of long-term care can never fully come to grips with its own problems until those who establish policy and enforce standards develop a deeper awareness of what we are all about.

And it’s up to us to tell them.

Before social media, the “CNA Voice” did not have an adequate platform for independent expression. With few exceptions, CNAs were heard only through the filter of the health care hierarchy. The result was a sanitized voice, good for parroting industry buzzwords and contributing to interdisciplinary window dressing, but giving only a glimpse of how we really experience our work.

With social media, direct care workers have been given the opportunity to express themselves more openly, albeit with the caveat that you never know who is watching. The majority of these forums are administrated by caregivers and they accept a far wider range of public expression than is possible within the formal work environment.

While social media gives us a better sense of the CNA Voice, all too often it presents that voice in a fractured and superficial way. That’s just the nature of social media, which promotes interaction and response. What social media doesn’t encourage is the kind of reflection necessary to properly sort out and express that complex and often contradictory blend of thoughts and emotions that make up the inner experience of the caregiver. That is the true source of our voice – and our self-worth.

We can help long-term care understand itself by offering something precious: a dose of reality. And if there is anything that this system obsessed with image needs, it’s a steady dose of reality. Yes, there is much about the “bigger picture” that most of us don’t know. But we are aware of certain truths about long-term care in a way no one else can be. Because outside of the residents themselves, no one knows better than we do how they experience their time in long-term care. In fact, we can’t talk about our experience in a meaningful way without talking about theirs. And that is the real value of our voice.

Everyone Has a Story




This resident does not like for his feet to touch the ground. A bath sheet won’t cut it. Don’t even THINK of bathing him without his shower shoes. There will be hell to pay. 

This resident is afraid of the dark. He sleeps with a bedside lamp.  And you have to watch resident in the room two doors down, because she thinks it’s funny to sneak in and shut the light off.

This resident lost her mother to cancer.  She is a tough cookie and she doesn’t trust others easily, but once I opened up about myself, she began to share her life stories with me. Though she thinks she’s fearless, I know that every rash, every mole, every doctor’s appointment brings back those memories of her mother and she becomes so afraid. She used to refuse to go to her appointments, but once I realized the underlying issue, I was better able to help her walk through her fear.

This resident is smart. Sharp as a tack. Honestly, she is probably smarter than the people who run the facility. She misses nothing. She has lived with Cerebral Palsy her entire life and people seem to think that because of that, there is something wrong with her mind. People who should know better. This breaks her heart and enrages me. I tell her to keep her chin up. The loss is entirely theirs.

This resident is a lifelong bachelor who scraped to put two of his brothers through seminary school. This resident lost her husband at a young age and never emotionally recovered. This resident spent so many years self-medicating his PTSD that he lost everything. This resident was a pioneer for women in the Armed forces and writer.

A caregiver knows more about a resident than anyone else in their lives. More than their doctors, family members, administrators, councilors. By necessity, they have to trust us. We are the faces they see the most. We are their hands in their most vulnerable moments. It is a relationship that requires an incredible amount of trust from both parties.

THIS is at the heart of what we do. It is in no text book. It is not a skill to perform in order to pass the certification test, and yet it is the very skill that allows us to provide a quality of life, to notice when something is “off”, to protect, comfort, safe guard, and care for these people who are living with such difficulties.

Those of us lucky enough to be living outside of institutionalized settings take such simple acts for granted. The ability to be seen and noticed for who we are rather than a diagnosis; the freedom to shower when we choose, to eat whenever we wish, to come and go as we please. 

Imagine, for a moment, if all of those freedoms were ripped away and suddenly you were only seen as a “private pay” or a “two person transfer”; if all anyone knew about you was that you were “difficult and combative”.   Your entire life of dynamic experiences, triumphs and heartbreaks reduced to a three page care plan; the slow and relentless ripping away of your humanity. 

 I don’t know at what point society decided that once a person reaches a certain age or level of disability they no longer have to be treated as PEOPLE if it isn’t cost effective. I only know that it is morally, ethically, fundamentally wrong. We, as caregivers, are in a unique position to stand against this mentality.

Let’s face it. We slip through the cracks. People don’t pay attention to us or how we do our job, unless something goes wrong. There is little leadership and no guidance.  Long term care is a bottom line world. In my experience, if things look alright and appear to go smoothly, the office people don’t concern themselves with the day to day realities on the floor. This used to drive me nuts until I recognized the freedom this actually gives us! They don’t care HOW the job gets done as long as it gets done. I’ve learned what works for my residents and what doesn’t. Most importantly, I’ve learned the value of getting to know those in my care on a personal level; as individuals. 

We are given the gift of reminding our residents every day that we SEE them, that they are valued human beings; that they are bigger than their current situation, more important than their illness, and they truly and genuinely matter. You can’t put a price tag on that. It doesn’t translate well into a bullet on a resume, but it makes all the difference in the world for those for whom we care.  Seeing their humanity will remind us of our own, if we allow it.