A Tough Job Getting Tougher

Thousands of AFSCME members work in nursing homes. It's a demanding career under any circumstance, and a national staffing shortage is making the job even more difficult.

By Clyde Weiss

MANITOWOC, WISCONSIN

In the basement of the Manitowoc Health Care Center, a 116-year-old county nursing home near the western shore of Lake Michigan, Tricia LeMay hands cardboard boxes to six developmentally disabled adults who are in her care. Then she instructs them to tear the boxes apart with their bare hands.

This isn't punishment, and her child-like charges are clearly delighted — if a bit frustrated — by their task. LeMay, a certified nursing assistant (CNA) and steward of Local 1288 (Council 40, which represents more than 6,000 health care workers), explains to a visitor that the nursing home residents "get to use their motor skills and their minds" when they engage in such activities. "They feel a real accomplishment — they're so proud of squashing the boxes."

As if to prove that point, John — a robustly built, middle-aged man wearing a yellow football T-shirt emblazoned with the number 84 — carefully rips at his box. "I did it — look at that!" he proclaims, stunned at his achievement. "What a strong hand I have." Turning to LeMay, he asks, "What did I earn, a dollar?"

"A pizza," she answers.

HAZARDOUS DUTY. LeMay and her colleagues — a staff of about 125 CNAs, registered nurses, licensed practical nurses (LPNs) and nursing assistants (NAs) — also express pride and satisfaction in their jobs. They feel that way despite the comparatively low pay and various hazards that nursing home workers throughout the country face daily. The hazards can include musculoskeletal disorders and repetitive strain injuries caused by lifting patients.

During a typical shift in an average nursing home, for instance, an NA might have to perform eight to 15 lifts per resident, according to the Journal of Healthcare Safety, Compliance & Infection Control. In Wisconsin, however, a "no-lift policy" requires residents to be hoisted with special equipment to reduce the chance of injury to both patient and nurse.

Even with mechanical assistance, "It's hard work," says Barb McCredie, a CNA who has worked at the Manitowoc facility for 25 years. She is also president of Local 1288, which represents most of the employees here, including CNAs, LPNs, dietitians, housekeepers and activities specialists. "Some of our residents are combative, especially the Alzheimer's patients. You don't know when they're going to hit you." It's just a defense mechanism, she quickly adds. "They don't mean it."

More than 18 percent of all nursing home workers are injured or become ill on the job each year, a problem exacerbated by a nationwide staffing shortage that not only threatens workers' health, but also the well-being of the residents. In fact, more than half the nation's 17,000 homes fail to maintain the minimum staffing levels needed to ensure quality care for their residents, according to a July 2000 report by the federal Health Care Financing Administration (HCFA).

The study notes that, not surprisingly, residents are "significantly more likely to have quality-of-care problems" in nursing homes with low staff levels. For instance, bedridden patients need to be turned over every two hours to prevent painful and potentially life-threatening bedsores. Malnutrition and abnormally low weight also rise and fall with staffing ratios.

LIKE FAMILY. Despite rigorous and often dangerous challenges that come with the job, many of the employees of the adequately staffed Manitowoc Health Care Center consider their career choice worthwhile. "I can't wake up fast enough to get here," says nursing assistant Jim Knutson, an activities aide on the developmentally disabled ward. "The pay isn't as good as you would get working in a factory, but it's more rewarding. I know — when the elevator door opens — that people are going to be waiting for me."

Manitowoc's nursing staff views the residents as members of their extended families, and vice-versa. "I have one resident who always says, 'Nancy, I love you, you are my family, you are my girlfriend,'" comments Nancy Becker, a CNA and a member of AFSCME International's Health Care Advisory Committee. "This goes on every morning. They look at you as a friend. They trust you."

Developmentally disabled individuals, who county homes are more likely to get because for-profit facilities consider them difficult and costly, "are touchy-feely kinds of people," observes Knutson. "Their cognitive abilities are basically those of a child, yet they have adult bodies."

Because many of those bodies (and minds) don't work the way they should, they put greater demands on the staff. As Knutson explains his job, for instance, a young man, Dan, suffers a seizure and falls off of his chair in the common hall. While he lies on the floor — unable to move but conscious — Knutson and LPN Barb Peronto kneel beside him, offering calming words while they try to get him to stand up. He soon recovers and Peronto escorts him to his room.

FALLING SHORT. HCFA recommends that nursing homes have enough NAs — the lowest-skilled job category — to provide at least two hours of care daily to each resident. For "optimal care," HCFA says there should be enough NAs to provide nearly three hours.

Unfortunately, more than half of America's nursing homes fail to meet this recommended minimum-staffing level. In addition, HCFA says, nearly a third of nursing homes do not meet the minimum RN standard to guarantee proper resident care.

The federal government has been reluctant to set tough staffing standards. The Nursing Home Reform Act, passed by Congress in 1987, merely requires "sufficient staff" to meet residents' needs. Federal regulations spell it out further, but only require, at minimum, that one RN work eight hours a day, seven days a week, and an LPN to be on duty around the clock. These inadequate mandates apply regardless of the number of residents, however.

At least 37 states have imposed staffing levels that are more stringent than the federal decree. Wisconsin is among the states just now considering such bills.

It's minimum nursing requirement — 2.5 hours of direct care per resident a day — is so low "that I wouldn't put my dog in a facility staffed at that level," says Michael Thomas, administrator of Manitowoc's 199-bed county nursing home.

In Wisconsin and elsewhere, however, owners of for-profit nursing homes (66 percent of all facilities nationwide) and administrators of public nursing homes insist that government staffing mandates won't solve the problem. "They [lawmakers] don't seem to get this," says Thomas in exasperation. "It isn't that we don't want to hire more people: There is just a serious shortage of certified nursing assistants."

Twenty-six CNA positions at his facility are currently unfilled, he notes, "and this is not like a job at McDonald's. We have great benefits, thanks to AFSCME. We pay about $10.35 an hour to start, with plenty of opportunities to pick up overtime, so you can support a family on what a CNA makes here. But we can't fill the jobs."

If Thomas is unable to attract nurses and nursing assistants now, how desperate will the situation become when the bulk of the 76-million-strong baby boom generation enters its golden years? Even if the percentage of elderly requiring nursing home care were reduced by one-third over the next three decades, says a report by the federal Centers for Disease Control and Prevention, they would still need 2 million beds in traditional long-term care facilities, an increase over current levels.

Who is most at risk from the inevitable consequences of this health care crisis? Based on the 1.5 million people who currently live in nursing facilities, the average resident will be female (75 percent), white (89 percent), and over 65 years of age (90 percent). She will probably suffer from disorientation or memory impairment and incontinence, require help in bathing and eating, and some may be totally dependent on assistance.

MORE THAN A JOB. Barb Meister-Rohr, a CNA and member of Local 1288's Executive Board, sits with a small group of residents. She is teaching them to recognize road safety signs, a skill that could save their lives when they venture out — and the exercise stimulates their minds. "I've always felt this is my calling," the former sheriff's deputy reflects. "I don't think everybody is cut out for it, but the majority of people I work with here are genuinely caring people and really want to make a difference in the lives of the less fortunate."

If only there were more like them. Offering higher salaries and better benefits would help to alleviate the staffing shortage. But public and private nursing homes have been hit with a funding shortfall, which of course has a direct impact on staffing levels.

Medicare and Medicaid programs pay for the care of two out of three nursing home residents, yet administrators say the money doesn't cover the homes' expenses. In Wisconsin, Medicaid paid nursing homes $100 million less than the cost of providing resident care in 1999-2000. The consequence: 49 private for-profit nursing homes have filed for bankruptcy.

Although publicly operated facilities like Manitowoc Health Care Center also feel the pinch, they cannot take the bankruptcy route. But 44 of the state's 47 county-owned facilities reported deficits totaling nearly $67 million in fiscal 1998.

"We're running about $11 per day, per resident, short on our Medicaid program [funding]," says administrator Thomas. "That doesn't sound like a lot of money, but it comes out to about a million dollars per year. The problem we have here is that we've reached our tax-levy limit. So the county has decided we're going to downsize" — from 199 beds to 150 or fewer.

Thomas says they've been given two years to accomplish that task. "We're hoping to get to that size through attrition, but we'll have to relocate" some residents to other public facilities if that doesn't work.

He hopes the federal government will appropriate more money to pay the growing expenses of the state's 426 nursing homes. "The only alternative is to start cutting expenses," he says. "That means cutting personnel," which he is loath to do.

UNION MEMBERS REACT. AFSCME and its affiliates are therefore working to alleviate the nursing-home staffing crisis. AFSCME represents more than 250,000 health care workers throughout the country, including doctors, nurses, nurses' aides and food service workers. More than 33,000 are employed in nursing homes and long-term care facilities.

"Our front-line nursing home workers have known for years that staffing is the most important component in providing quality care," Pres. Gerald W. McEntee said in response to a 1999 federal report describing the extent of nursing-home staffing problems. "We hope that the federal government will now find ways to guarantee that long-term care facilities are staffed at safe levels."

AFSCME members are still waiting. The union supports a House bill (introduced last year as H.R. 5166) that would set minimum staffing ratios at adequate levels: for example, one full-time direct-care employee per five patients during the day shift. The bill also would require HCFA to ensure federal reimbursement levels are sufficient to meet those standards.

In Philadelphia, the National Union of Hospital and Health Care Employees (NUHHCE)/AFSCME Local 1199C is taking matters into its own hands. The union has been training CNAs since the late 1980s and will graduate its first class of LPNs in September.

NUHHCE's School of Practical Nursing, open to the public as well as members, is operated under 1199C's Training and Upgrading Fund and financed partly with money negotiated through collective bargaining. "We are providing a vehicle for people to move up a career ladder and to address the nursing shortage," says Cheryl Feldman, coordinator of the training fund's Breslin Learning Center.

Members of Wisconsin's Council 40 are also trying to make a difference. In May, they lobbied their legislators to approve a one-time transfer of Medicaid dollars that would put $40 million into county nursing-home coffers, in addition to their current budget allotment.

In Manitowoc, AFSCME-represented nursing home workers talk about their jobs to audiences at area schools, hoping to attract students to their field. And dedicated people like Nancy Becker continue to speak out on behalf of the residents who cannot speak for themselves.

"The government would like to get out of the nursing home business," says Becker. "They feel you should take care of your loved ones at home. Yet the government is willing to spend money on everything else, from the military to teachers. I support all that 100 percent. But they're forgetting about the human being who's grown up and paid taxes, who has taken care of other people and helped their community. Now it'stheir turn to be taken care of."

They just need more people to do the caretaking.

Editor's note: The names of residents have been changed to protect their privacy.