Elder abuse is something that occurs in the United States more frequently than many of us know.  According to Elder Abuse Daily in 2010, there are almost 6 million elder abuse cases every year.  This estimate demonstrates a growth since the American Psychological Association reported in 1999 that an average of over 2.1 million elder abuse cases occur every year.

According to the U.S. Administration on Aging, elder abuse is the, “knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult.”  The administration states that these are the common abuse types:

1. Physical Abuse is the infliction of “physical pain or injury on a senior, e.g. slapping, bruising, or restraining by physical or chemical means.”
2. Sexual Abuse is the “non-consensual sexual contact of any kind.”
3. Neglect is “the failure by those responsible to provide food, shelter, health care, or protection for a vulnerable elder.”
4. Exploitation is “the illegal taking, misuse, or concealment of funds, property, or assets of a senior for someone else’s benefit.”
5. Emotional Abuse is the infliction of “mental pain, anguish, or distress on an elder person through verbal or nonverbal acts, e.g. humiliating, intimidating, or threatening.”
6. Abandonment is the “desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person.”

According to the National Institute of Justice (NIJ), emotional abuse, financial abuse, and neglect are the most prevalent of all elder abuses.

Unfortunately, elder abuse is not a crime commonly reported.  The National Center on Elder Abuse estimates that 83 percent of elder abuse cases never get reported.  According to a 2009 NIJ research report, the majority of the elderly’s abusers are people they know.  Through surveys, the NIJ found that the elderly are most likely to underrepresent abuses:

• That happened more than a year ago.
• That they did not report them to the police.
• If the abuser was not a stranger.

Sadly, the unwillingness of the elderly to properly represent or report these abuses is detrimental; the majority of elders surveyed by the NIJ had been abused over a year ago, had not reported the abuse to police, and knew their abuser/s.

How to Protect the Elderly from Abuse

In order to protect your elderly loved one from abuse, you must:

1. Ensure he/she is in a quality elder care program.
2. Do research.
3. Ask the elder care facilities that you visit for their state survey reports.
4. Visit, inspect, and ask questions.
5. Ensure that your chosen facility has a proper staff-resident ratio. According to the Health and Human Services (HHS), 90 percent of nursing homes are understaffed. Nursing home staffs spend less than 3 hours total with residents each day (HHS) despite about 4 hours being what the government and expert recommendation for patient care each day.
6. Check on your loved one frequently.Visit your loved one as much as possible to ensure he/she is receiving sufficient senior care.
7. Physically check your loved one for signs of abuse. A list of abuse symptoms can be found on the NIJ website.
8. Know your loved one’s rights as a resident. You can view these rights on the website below or by asking your loved one’s care facility for a copy of your state’s “Resident’s Bill of Rights.”

About the Author: Amber Paley is a guest blogger and article writer specializing in elder abuse prevention. Amber spends much of her professional life writing about abuse in nursing homes.

Photo credit: pedrosimoes7

During my research on assisted living communities and elder care, I met a woman whom I consider to be the model activities director. Her name is Terri Glimcher and she is the Life Enrichment Coordinator for Emeritus Senior Living. In addition to her duties at Oak Park Assisted Living in Clermont, Florida, she also serves as a trainer for many other local communities. If her techniques were universally adopted, this chapter would be completely unnecessary.

I’ve spoken to Terri several times during the course of my research, as she is a true expert in her field. She gets it!

To reword our discussion would not serve her great work justice, so I’ve included the entire transcript of our discussion.

RYAN: Thanks for spending the time with me, Terri. The work you’ve done at Emeritus has been amazing.
TERRI: Thanks for the kind words.
RYAN: Let’s go ahead and get started. What is your role at the company?
TERRI: I am the Life Enrichment Coordinator for Summerville at Oak Park Assisted Living, an Emeritus Senior Living property in Clermont Florida. I am also on the marketing team here at Oak Park.
RYAN: Sounds like a lot of hats! Being a marketing guy from a previous life I know what you’re going through. I’d like to focus on the activities portion of your responsibilities. Would that be okay?
TERRI: Sure.

RYAN: What is the role of “activities” in an assisted living environment?
TERRI: Great question! Activities play a very important role in assisted living. It is very important to keep the mind and body challenged and stimulated throughout the day. More importantly, however, is the socialization that comes with activities. It is very important for your loved one to feel connected in their new residence. Activities will help to do this. Activities also help the resident continue to enjoy many things they used to do. This consistency helps with the overall transition to assisted living.

RYAN: That makes a lot of sense. I know it was tough for my mom to transition to assisted living, because she was so active before.
TERRI: What did she do?
RYAN: She was involved in women’s club, some charities and card parties with her lady friends. She missed all that when she got into assisted living, as she remembered what is was like before her stroke.
TERRI: That sounds tough.

RYAN: It was. Anyway, let me ask you another question. What do most assisted living communities do wrong with regard to activities?
TERRI: I only know from many that I have observed that they do not meet the needs of ALL residents. They focus on the mainstream population and often have activities that people with special needs such as physical, visual or hearing cannot participate in. In my community, we make sure that adaptive equipment is in place so that all residents can participate in any activity.
RYAN: That great to hear…
TERRI: I also firmly believe that the residents should have choices in their schedule, which is why a resident council should be in place. This is their home and activities should be available at all times for residents to participate in as a group or individually. That piece lacks in many communities. Another important factor is that the assisted living community should be connected to the local community. Many times residents feel isolated because their whole world revolves around the community. The community is very open to seniors and it is a great way to keep them connected.

RYAN: Your approach sounds really unique. What have you planned that is unique?
TERRI: I really believe that most of my activities are unique in that age never plays a role in what I plan. We are always involved in a community service project of some kind. My knitting class made baby hats for the neonatal unit at our local hospital. We donated 150 hats. They were also involved in the Give a Kid a Backpack Program here. The residents hand-craft a beautiful teddy bear to go in each backpack received by the children. We have made soldier caps that were sent to Iraq, we raised money for breast cancer awareness and many more. Seniors enjoy giving back. They feel a part of a bigger picture.

RYAN: That’s really amazing. This is the kind of thing that probably makes a big difference to the residents. It seems like having a purpose is often missing for many of the assisted living residents I’ve met.
TERRI: Absolutely. In talking with the residents, I learned that not working and not having responsibilities was the hardest part for them. In hearing that, I came up with a list of jobs within our building and held a huge job fair for the residents. Each resident who wanted a job came down dressed up, filled out an application for the position, and was interviewed by me. This gave them a chance to tell me about their former careers and what it was like to work when they were growing up. It was wonderful. They all got the jobs they applied for — floral committee, taking statistics, welcome committee, sending get well cards, watering plants etc. I can tell you that for three years, every one of them has taken their job very seriously. We are a family here, and it takes a family to make it work. They receive $100.00 a week funny money and shop at our General Store.

TERRI: I also started the Bridging the Generations program with all the local high schools. This is ongoing for three years now. The high school kids come to Oak Park and are paired up with the residents. They do projects together, cook together, etc. We celebrate holidays with the students. I bring the residents into the high school so that students learn about the aging process. The students play their instruments for the residents and work on their science fair projects with them. The residents are truly mentors for these students. We have been recognized by the Orlando Sentinel many times for outstanding programs here. One of our greatest activities was “Biker Day” at Oak Park. A local merchant brought their Harley’s to Oak Park. Each resident dressed up in leathers with headbands and posed for pictures on the bikes. We sent pictures to the families saying “And you thought your loved one was at home knitting!” We got a huge response of laughter from all involved. It was a blast!

RYAN: (Laughs) That sounds incredible. You really owe yourself a pat on the back for such great work! Can you please send me a picture of Biker Day? That sounds awesome!
TERRI: Sure, no problem.
RYAN: So, in your opinion, how have the residents benefited from those unique activities?
TERRI: The residents feel a part of the community. They truly see that they make a difference. They are loved and respected by so many people in this community. The merchants come here to do activities with them. The local florist does flower arranging, Home Depot does workshops with them, Ritters Frozen Custard makes sundaes here, and we have a merchant that sets up a fruit stand in our lobby with fresh fruits and veggies that the residents can choose at no charge. They feel very connected. It’s not just being part of their residence, but still maintaining a sense of community. That is important factor in maintaining good emotional health.

RYAN: Very cool. How do you mix physical and cognitive activities?
TERRI: I do a lot of physical and cognitive activities. I run a cooking class. We have measuring, kneading, peeling, cutting, those are all good ways to combined both physical and cognitive. We bowl and golf both in the community and out. The residents keep the score. We play twister with word games. Scavenger hunts, walking club, following a map to the destination. Most of the activities have both components as a part of it.
RYAN: I really appreciate your spending so much time with me. I am learning so much. I have a couple more questions if that is okay?
TERRI: Sure, happy to spend the time with someone who’s so passionate about it.

RYAN: Thanks! Ok, so what would you recommend from an activities perspective to readers evaluating assisted living communities?
TERRI: I think it’s very important to ask a lot of questions. You want to make sure that there are activities going on all day that include, physical activities, crafts that include a product that the residents can take to their rooms, outings, and cognitive activities. You want your loved one to be able to make choices in his or her schedule. A big component is to find out how they will help your family member connect when they first come in to the community. “What can you do to help my mom or dad connect if they do not want to come out of their room?” You should also make sure that there are outings outside of the community and that there is community involvement consistently. If people are sitting in the lobby with no activity, chances are that is the way it will be when your loved one lives there. Look for resident participation – talk to the residents. They are the best indicators of what truly goes on in the assisted living community. They will tell you if they are active or not. Stimulation is very important. If you don’t use all your faculties, you begin to lose them. Make sure each and every part of your loved one is being challenged daily.

RYAN: Last question. Do you have any other advice for the readers?
TERRI: Take the time to look around at different communities. Talk to residents; request a report from the Department on Aging for the state survey of the community. You can request it from the community as well. They have to show it to you. That is the law. This will give you the information on any violations the community has had. It covers resident care as well as dietary issues. This is an important piece of information to have. There are agencies that are able to help with the cost of assisted living. If you are a spouse of a veteran or a veteran yourself, there are ways to receive help. Look in to all options before making your decision. Remember, this is your family member’s home. It should not have a community feel but the feel of being home.

Terri’s activities plan is not the norm, although I wish it were. However, it should serve as an example of the kinds of things available to your loved one.

Unfortunately, many assisted living communities follow our typical day example rather than the fine example Terri has described. Do not be lazy about finding a community with good activities. It is a major social and emotional outlet for your loved one.

Photo credit: visual.dichotomy

Before Mom got sick, she was an active lady. By active, I don’t mean she walked every morning. Rather, she was involved in almost every woman’s club in town, dedicated time to fundraising and countless local charities and took a deep level of interest in her family’s lives.

I vividly recall the first community I visited. As the admissions director walked me through the amenities during the tour, I drifted thinking about whether my mom would be bored there. I asked the admissions director what their most unique activity was. She responded: “armchair exercises.”

She proudly told me about the activity and suggested that I stay 30 minutes for the start of the next session. I was intrigued, so I stayed.

Slowly a few residents arrived, most of them with the help of a community caregiver and a wheelchair. Once seated in a semi-circle, the activities coordinator began walking the residents through a number of arm and leg motions.

The concept was solid. The problem: the activities director either didn’t notice or didn’t care that the residents weren’t participating. Many residents had a scowl on the face, evidence of the fact that they did not want to be there. Others went through the motions as best they could.

I remember thinking to myself when I left the community: armchair exercise is not an activity!

The point of my story is not to be sarcastic, but rather to illustrate something important. Activities represent an important part of your loved one’s day. They should be engaging both physically and mentally.

Being physically active can prevent and help treat many of the most common chronic medical conditions associated with old age. Physical activity is one of the most important steps older adults can take to maintain physical and mental health and quality of life. Yet today, more than 60% of older adults are inactive – and this number is probably much higher for residents of assisted living communities. Many are sedentary, physically unfit, and experience disability from chronic medical conditions as they age.

Community administration and staff members hear many reasons from residents as to why they are not active:

• It’sboring.
• It doesn’t feel good.
• It makes my arthritic joints hurt.
• It takes too much time.

However, they need physical activity more today than they care to admit. In fact, without physical exercise they will continue to suffer the loss of strength and stamina.

Walking groups and physical activity programs can help residents become and remain active.

Strength training is recommended for all adults, but it is a vital link to health for older adults. The reason is that strength training prevents sarcopenia, the muscle deterioration that comes with aging, and also helps maintain bone mass. “Stronger people have better health outcomes,” noted Dr. David Buchner, Chief of CDC’s Physical Activity and Health Branch and renowned Gerontologist. However, some elderly people avoid physical activity and become sedentary out of fear of falling and fracturing a bone. Dr. Buchner added that emerging data indicate that physical activity can prevent falls by improving strength, balance, and endurance.

Keeping Young at Heart aerobic activity, which is cardiorespiratory or cardiovascular endurance activity, is also important. It keeps the heart strong, lowers blood pressure, and relieves anxiety and depression. Even when the activities in a program such as this one are too strenuous, older adults can obtain significant health benefits with moderate physical activity, such as walking or gardening.

“We need to make physical activity part of the daily routine for older adults,” said Dr. Buchner. To that end, you should search for a community that has an active, diverse fitness program. Or, should the community you select have less-than-desirable physical activity programs, become instrumental in developing them.

What about Mental Fitness?

A large-scale study of women aged 65 and older found that cognitive decline was least common in those who were most physically active, while a large-scale study of men aged 71 and older found that those who walked less than a quarter of a mile a day were nearly twice as likely to develop dementia as those who walked more than two miles a day.

Basically then, aerobic exercise appears to improve higher cognitive functions (planning, organization and working memory) in the elderly. Another way physical training may help cognitive function in the elderly is by increasing their confidence in their abilities.

A small 14-day study found that those following a memory improvement plan that included memory training, a healthy diet, physical exercise, and stress reduction, showed a better performance on a cognitive measure controlled by this brain region, and participants reported that they felt their memory had improved.

The memory training involved doing brainteasers, crossword puzzles and memory exercises. Diet involved eating 5 small meals daily (to prevent fluctuations in blood glucose levels) that were rich in omega-3 fats, low-glycemic index carbohydrates (e.g., whole grains) and anti-oxidants. Physical exercise involved brisk walking and stretching, and stress reduction involved stretching and relaxation exercises.

Photo credit: brad montgomery

Assistive technology (AT) is defined as any item, piece of equipment, or product system that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. It can be almost no-tech items like canes, dressing sticks, effortless can openers, or low-tech, like rolling walkers, walk-in bathtubs, height-adjustable kitchen countertops for wheelchairs, automatic shut-off faucets and stoves,  etc. Examples of high-tech items include: voice activated microwaves, stair-lift chairs, stair-climbing wheelchairs, smart home monitoring systems, remote health monitoring machines, or robot-nurses.

Assistive Technology Improves Quality of Life

Assistive Technology helps seniors maintain their efficacy, independence, and a sense of control over their lives. Assistive Technology is not a new concept, walking aids like the cane or wheelchair have been around for centuries; but there is an enormous need for new and innovative products that improve the quality of life the aging population. Assistive technology can make up for the shrinking number of caregivers and the skyrocketing institutional care costs. The number of adult caregivers for each person needing care is shrinking thus we need assistive technology to supplement personal care. In 1990 there were 11 caregivers for every 1 older adult. By 2050, the ratio of caregivers to older adults will be one to one. Assistive technology prolongs aging in place thus curbing institutional care costs that can cost about 70,000 a year.

Microsoft Health Vault: An Online Database of Personal Health Records.

Microsoft Health Vault is an emerging technology which empowers consumers to control their personal health records. This technology allows consumers to organize and store their health information in one place, to access their health records whenever and wherever they want to (which is particularly useful in an emergency), and to learn from data to help them make informed decisions. Microsoft HealthVault is free to consumers and it has compatible remote monitoring devices, such as blood pressure monitor, glucose meter, pedometer, and weight scale. These tools allow consumers to upload vital sign data to HealthVault to share with caregivers and care providers.

For more information please visit   www.healthvault.com

If looking for an assistive device for you or a loved one, AssistiveTech.net is a website that finds and compares over 22,000 assistive devices and links people to vendors’ websites to purchase merchandize. Simply go to www.assistivetech.net

Note: The previous definitions and statistics were provided by personal correspondence with Dr Echo Chang lead researcher of the first Microsoft HealthVault study at California State University, Fullerton.

About the Author: Ryan Malone is the founder of Inside Elder Care and author of the By Families, For Families Guide to Assisted Living. He regularly speaks and advises families about how to improve their aging loved one’s quality of life. Ryan is also the president of SmartBug Media, a content marketing agency that helps companies increase leads, customers and influence. You can read more from Ryan on the SmartBug Media blog or follow him on Twitter.

There are many consumer advocacy groups both on a state and national level whose mission is to protect the rights and benefits of seniors or anyone who requires long-term care.  They are:

Health Information, Counseling, and Advocacy Program (HICAP): An independent resource established by the California Department of Aging that provides free counseling and advice about Medicare and healthcare insurance options to senior citizens.  To find counseling services in your area go to: www.cahealthadvocates.org/HICAP/

The Consumer Consortium on Assisted Living (CCAL): A national nonprofit organization dedicated to addressing the needs and rights of assisted living patients, their families and their caregivers. CCAL assists consumers with education about their choices for assisted living environments.  www.ccal.org

American Health Care Association (AHCA): The nation’s largest association of long term and post-acute care providers.  They advocate for quality care and services for frail, elderly and disabled Americans. Their mission is to improve service and administration of nursing homes. www.ahcancal.org

California Advocates for Nursing Home Reform (CANHR): A statewide nonprofit 501(c)(3) advocacy organization, is committed to improving the choices, care and quality of life for long term care patients. Their mission is to educate and support consumers and advocates regarding their legal rights and be a voice long term care reform and humane alternatives to institutionalization.  www.canhr.org/

The National Consumer Voice for Quality Long Term Care (NCCNHR):  Formerly the National Citizens’ Coalition for Nursing Home Reform, NCCNHR is a national nonprofit organization of consumers and advocates dedicated to improving care for residents of nursing homes and other long-term care facilities.  www.nccnhr.org/

Long-Term Care Ombudsman: An ombudsman is an advocate for residents of nursing homes, board and care homes and assisted living facilities. They provide information about how to find a facility and what to do to get quality care. Under the federal Older Americans Act, every state is required to have an Ombudsman Program that addresses complaints and advocates for improvements in the long-term care system. To locate state agencies and citizen advocacy groups by state:  http://www.ltcombudsman.org/ombudsman

To find additional U.S. government information regarding senior consumers, go to http://www.usa.gov/Topics/Seniors/Consumer.shtml

Photo credit: ktylerconk

Whether you are a family member trying to choose the right home care company for your loved one, or you are a provider interviewing potential applicants, background checking is critical.

Eldercare abuse comes in many forms: financial, emotional and physical.  Being proactive about the selecting a home care provider can help you avoid worry, heartache and financial and potential legal action.

Example: Check-Cashing Fraud

Within months of hiring an in-home caregiver for her two aging parents, a woman in San Diego was notified by the Sheriff’s Department that the caregiver had opened 30 credit card accounts in the parent’s name and purchased three vehicles worth $50,000 with those credit cards. In addition, the caregiver had also convinced the elderly couple to provide her with power of attorney and then managed to have them sign over ownership of their house, valued at $650,000.  Further investigation of the individual revealed she had prior convictions for check-cashing fraud 10 years ago.  However, the background check only covered the prior 7 years of criminal history.

Knowing your home care provider does background checks is just the beginning. Not all background checks are the same and not all companies exclude potentially dangerous applicants based on the same criteria.

Questions to Ask Your Home Care Provider

• How many years back in the person’s history does the check cover?
• Does the check reflect both criminal and civil records?
• Does the company check licensing status across state jurisdictions?
• Are credit reports run?
• Are Department of Motor Vehicles records obtained?
• Are gaps in employment history verified?
• Do they make the phone calls to references or are they outsourced?
• Is evidence of education provided and confirmed?
• What criteria does the company use to deny employment?  What offenses are tolerated?

Choose the provider with the most stringent background checking protocol.  If the provider cannot answer these questions, find another provider.

New Federal Database of Dangerous Caregivers

More than two decades ago, Congress demanded that a national database be available for hospitals to check for disciplinary actions taken throughout the country against nurses, pharmacists, psychologists and other licensed health professionals.   The database became available as of March 1^st but there is some skepticism regarding the thoroughness and accuracy of the records.  When the information on this federal list was compared to the individual state records, they did not match up.  The reason for this inconsistency is due to the fact that some states filed incomplete records.

Although both the state and federal agencies continue to push for strong regulations of home care providers, you need to take an active role in making sure the right questions are being asked and the screening process is up to your standards.

Photo: ivers

BRING THIS QUESTIONNAIRE TO YOUR NEXT ELDERCARE FACILITY TOUR

1. How does the staff interact with the residents?   Is there an overall climate of respect?
2. Does the staff look content?   Are they rushed or irritated?
3. Do they address the residents by their names?   Calling an elder “honey” or “sweetie” is not acceptable, unless that is the resident’s preferred nickname.
4. How much training has the staff received?   Ask to see the training logs.  Do they have some measure of competency showing that not only did staff attend a training session, they actually understood the material?   Pressure ulcer prevention, elder abuse education and dementia care are essentials that all staff should master.
5. How is training delivered?  Is it lecture or computer-based “PowerPoint”?  Is there a hands-on or a multimedia computer program that brings life to the training sessions?
6. What is the staff turnover rate in the facility?   Is it more than 30% per year?  More than 50%?  How does this compare to other facilities in the region?
7. Is there potential for good employees to move up the ladder?  How does good work get rewarded?

Until grassroots movements, like the Pioneer network or innovative business models, such as the Eden Alternative, spread throughout the country, the condition of eldercare in facilities will remain relatively unchanged and highly variable.    There is hope on the horizon however.  Person-centered care that is promoted by these “culture change” movements DO make a difference.

A key component of this change includes creative and innovate ways to train nursing home staff.   Reports in the medical literature show that interactive video staff training can increase training compliance by 300%, increase staff satisfaction by 200%, and reduce pressure ulcers by 75%. (1) What’s more, e-learning is becoming more accessible than ever, with many companies providing this type of training through the Web. Instead of being mandated to train for hours at a time, staff can take a couple minutes out of their busy day to complete a lesson. If they have access to a computer at home, they can sign in and work on training there. It gives the learner the freedom to chose, which has shown increased retention of knowledge and higher job satisfaction.

When choosing a nursing home, remember that the most important aspect of your decision are the people inside. Do not be shy about asking for the employee training processes.  Just like a surgeon has their medical degree framed on the wall, or a police officer wears a badge, or a driver has a license, so too should nursing homes show that their staff has been properly trained. Unfortunately, no agency has taken on this burden, so you must be the judge of how well the staff is ready to deal with your loved one.  Be sure that the facility where you place your loved one is using the most modern and innovative solutions for staff training, since this has been clinically proven to reduce staff turnover and greatly improve the quality of care.

If you wish to learn more about the cutting edge in staff education AND family education, visit www.foxlearningsystems.com

About the Author: Debra Fox is the CEO of Fox Learning Systems and a long-time veteran of elder care staff training.  A former television anchor, Debra pioneered the use of interactive documentary techniques to improve training and elder care quality.

Sources:

1. Rosen, J., Mittal, V., Degenholtz, H., Castle, N., Mulsant, B. H., Hulland, S. et al. (2006b). Ability, Incentives, and Management Feedback: Organizational Change to Reduce Pressure Ulcers in a Nursing Home. Journal of the American Medical Directors Association, 7, 141-146.
   

Why is poor training such an important issue?   Is there any evidence that effective training would improve quality of care for the residents?  A recent study reported a 70% reduction in pressure ulcers when staff were properly trained and given incentives to perform better. (1,2)  Other studies have shown a direct effect on resident care or safety as a result of education on reduction of restraints without increasing injuries. (3,4) In addition, researchers also found reduced resident aggression through staff behavioral training as well as the ability to use behavioral interventions with aggressive residents. (5)

In her book Dancing with Rose, journalist Lauren Kessler goes “under cover” as a CNA in a nursing home for one year. She describes her first day as follows: “After a sobering mini-lecture about all the reasons we could get fired, we are led to the meeting room [...] where two inch thick packets of material await us. [The administrator] told us that we will start with the first document in the packet, the Employee Orientation Manual [...] each of us reading a page”. (6)  This training session lasted for almost 6 hours and the next day was her “on-the-job training”. Ms. Kessler and other trainees were tasked with waking, changing diapers, toileting, shaving, showering and transporting 11 Alzheimer’s patients to breakfast. All of this in fewer than two hours makes for a near super-human task. But they got the job done, without the deserved praise, because it was what they were expected to do. (7)

Although Kessler’s story provides merely anecdotal evidence as to the daily lives of CNAs, her experience has been retold by countless CNAs. At the University of Pittsburgh, the Center for Health and Care Work convened a series of focus groups of CNAs with the goal to determine what factors lead to staff turnover and staff retention. (8)   The focus groups were stratified to consist of either CNAs who had established relatively long tenure in their workplace of at least three years, or CNAs who switched jobs at least twice in the last three years.   Ironically, neither the low pay nor long hours were cited as the most important factors in determining whether or not to stay.  The dominant theme of the “leavers” focus group was the lack of respect.  Specifically, “leavers” described the supervisors’ expectations of unrealistic workloads and the lack of rewards or recognition for good work as the frustrating components of their job.  Inadequate training, work related injuries, and physical or verbal assault by the residents were also cited as reasons for leaving. (9)

There is no question as to why the staff turnover rate is so high. A better question to ask is; why do some CNAs end up staying? After all, these individuals could find work at a fast food restaurant for similar pay. What separated the “stayers” from the “leavers” was a feeling of being needed by the residents. Those who felt they were being “called” to service were much more likely to stay. Many felt they became patient advocates and developed good rapport with the elderly.

It is important to understand the different motivations for the “stayers” and the “leavers”.  A work climate that recognizes the dedication and special care the staff provide will reinforce retention.   Assuring an atmosphere of respect is more difficult to achieve.  This would include assuring proper staffing and adequate training and supervision.

About the Author: Debra Fox is the CEO of Fox Learning Systems and a long-time veteran of elder care staff training.  A former television anchor, Debra pioneered the use of interactive documentary techniques to improve training and elder care quality.

Sources:

1. Rosen, J., Mittal, V., Degenholtz, H. B., Castle, N. G., Mulsant, B. H., Nace, D. et al. (2006a). Pressure Ulcer Prevention in Black and White Nursing Home Residents:: A QI Initiative of Enhanced Ability, Incentives, and Management Feedback. Adv.Skin Wound.Care, 19, 262-269.
2. Rosen, J., Mittal, V., Degenholtz, H., Castle, N., Mulsant, B. H., Hulland, S. et al. (2006b). Ability, Incentives, and Management Feedback: Organizational Change to Reduce Pressure Ulcers in a Nursing Home. Journal of the American Medical Directors Association, 7, 141-146.
3. Capezuti, E., Evan, L., Strumpf, N., & Maislin, G. (1996). Physical Restraint Use and Falls in Nursing Home Residents. Journal of American Geriatric Society, 44(6), 627-633.
4. Capezuti, E., Stumpf, N. E., Evans, L. K., Grisso, J. A., & Maislin, G. (1998). The relationship between physical restraint removal and falls and injuries among nursing home residents. Journals of Gerontology.Series A, Biological Sciences & Medical Sciences., 53(1), 47-52.
5. Oh, H., Hur, M. H., & Eom, M. (2005). Development and analysis of the effects of caregiver training program on aggressive behavior in elders with cognitive impairment. Taehan Kanho.Hakhoe.Chi, 35, 745-753.
6. Kessler, L. (2007). Dancing With Rose; Finding Life in the Land of Alzheimers . New York : Viking.
7. Ibid.
8. Rosen, J. (2008, December 2). Getting to the Bottom of CNA Turnover. Retrieved from McKnight Long Term Care: http://www.mcknights.com/Getting-to-the-bottom-of-CNA-turnover/article/121691/
9. Ibid.

The statistics do not bode well for those working in nursing homes.   The direct care workers   are usually the lowest paid workers in the healthcare industry.(1)  The Bureau of Labor Statistics estimates CNA salaries ranging from $7.78 to $12.80 per hour.(2)   Unmarried minority women with at least one dependent child comprise a healthy cross-section of the profession.(3)  CNAs thus have built-in family stressors such as financial worries, finding daycare and caring for sick children. Multiply this with on-the-job stress due to long hours, frequent overtime, lack of respect, little time off and generally poor training; it is easy to see why staff turnover is so high.  The opportunities for career growth of direct care staff are limited when looking at their average education. CNAs usually have a high school diploma but their education most likely stopped there.(4)

CNAs in nursing homes are required to receive certification training prior to starting their first job.   This varies by state, but typically, somewhere in the neighborhood of 80 – 100 hours of training are required.  There is no requirement for refresher courses to maintain certification, but by federal law (OBRA 1987), all CNAs in nursing homes must complete 12 hours of continuing education annually and demonstrate “competency”.   Each of the state’s Department of Health monitors this (supposedly), and many have mandated specific annual trainings, such as fire and safety, infection control, and dementia care.   It is the continuing education (C.E.) that is necessary to maintain skills, develop new skills, and learn new information.

For assisted living and home health agencies, continuing education requirements are even more variable, with some states mandating higher requirements than others.   Even in nursing homes where C.E. is mandated, the quality of education is generally poor and documentation of learning or mastery is typically absent.  Facilities focus on maintaining compliance with the state regulations, rather than actually improving the skills of their staff.  Continuing education is generally instituted in a way that is incompatible with adult learning theory.   Adults learn best when the information is presented in a way that is relevant, and resonates with an emotional note.  In contrast, nursing home education is typically “repeat and recite”.  In some facilities, administrators give packets containing hundreds of pages of dense information and expect the staff to read it cover to cover.    Published accounts of CNAs’ ratings of their training experience suggest that traditional nursing home continuing education is lacking in content and style.  There are multiple problems in providing the necessary education to nursing home staff.  Educators with the background and knowledge to teach on all of the diverse topics and skills needed to care for the elderly are not readily available.(5)   Furthermore, this workforce provides around the clock shifts so lectures or training sessions cannot be delivered to all employees simultaneously.  Repeat lectures by the same lecturer, or worse yet, videotape sessions of the lecture further strip the educational experience of emotional impact and relevance.  Studies have shown that CNA satisfaction with traditional training is poor(6)  and compliance with traditional (lecture or video) modalities of training are below 35%, even when mandated by the administrations.(7)

About the Author: Debra Fox is the CEO of Fox Learning Systems and a long-time veteran of elder care staff training.  A former television anchor, Debra pioneered the use of interactive documentary techniques to improve training and elder care quality.

Sources:

1. Farida K. Ejaz, L. S. (2008). The Impact of Stress and Support on Direct Care Workers Job Satisfaction. The Gerontological Society of America.
2. Nursing, Psyciatric and Home Health Aides. (2006). Retrieved from The Bureau of Labor Statistics : http://www.bls.gov/oco/ocos165.htm#earnings
3. Farida K. Ejaz, L. S. (2008). The Impact of Stress and Support on Direct Care Workers Job Satisfaction. The Gerontological Society of America.
4. Nursing, Psyciatric and Home Health Aides. (2006). Retrieved from The Bureau of Labor Statistics : http://www.bls.gov/oco/ocos165.htm#earnings
5. Stoecklin, M. T., Haan, M. N., Beck, J., Frank, J., Weaver, K., & Francis, D. (1998). Job responsibilities and educational needs of staff developers in long-term care. Annals of Long-Term Care, 6, 122-129.
6. Mercer, S. O., Heacock, P., Beck, C., &  (1993). Nurse’s aides in nursing homes: perceptions of training, work loads, racism, and abuse issues. Journal of Gerontological Social Work, 21, 95-112.
7. Banazak, D. A., Mickus, M., Averill, M., & Colenda, C. C. (2000). Herding Cats: Barriers to Implementing a Nurse Aide Educational Program. Annals of Long-Term Care, 8(10), 68-71.

It makes sense to check out the décor before sending a loved one to a long term care (LTC) facility.   Maybe even try the food in the cafeteria, check the comfort level provided in the beds, observe the cleanliness of the bathrooms, and determine whether the lighting is appropriate. Yet the most important aspect of LTC does not come from the outward appearances but from the caregivers.

In nursing homes, these caregivers, commonly referred to as CNAs (Certified Nursing Assistants) can independently affect the quality of your loved-ones care. They are the individuals who monitor daily health, dress and undress, bathe, feed and clean up after residents. These direct care workers spend the most time with your family member.  Yet this highly stressful job comes with some of the lowest pay in the healthcare field, limited training, and very few tangible benefits.  It is no small wonder that CNAs and other LTC workers turnover at an alarming rate, sometimes at 100% per year, costing the industry $4.1 billion annually.(1,2)

For the consumer, staff retention and turnover rates might not register as the most important issue regarding LTC home placement. Even if the consumer is aware of the importance of CNA abilities, it still might be hard to look for the red flags. This paper will discuss what to look for in a LTC facility regarding an atmosphere of respect among the staff and expectations of training and competency.  Finally, consumers need to inquire about the staff retention and turnover, as these factors are related to the quality of care provided.(3)

About the Author: Debra Fox is the CEO of Fox Learning Systems and a long-time veteran of elder care staff training.  A former television anchor, Debra pioneered the use of interactive documentary techniques to improve training and elder care quality.

Sources:

1. Mary Forrest, C. B. (1990). Nursing Homes: The Complete Guide. New York : Facts on File.
2. Nurse Aid Training. Washington : Department of Health and Human Services.
3. Rosen, J., Mittal, V., Degenholtz, H., Castle, N., Mulsant, B. H., Hulland, S. et al. (2006b). Ability, Incentives, and Management Feedback: Organizational Change to Reduce Pressure Ulcers in a Nursing Home. Journal of the American Medical Directors Association, 7, 141-146.