As I pursued advanced education in nursing, I transitioned from novice to expert nurse, long-term care (LTC) to acute care, staff nurse to supervisor, and 31-year-old to a 42-year-old. Understandably, during this time, my entire viewpoint changed. Concerned with the working conditions of certified nursing assistants (CNAs), I decided to do my program research project in LTC. While my focus was on CNA work practices around urinary continence care, the CNA interview process quickly highlighted 2 dominant and universal themes of overwork and discouragement. My research focus changed from patient-centered to staff-centered.

CNAs have little or no status in the healthcare community, get little to no respect, and make near poverty wages. In addition, CNAs have very little input into decision making, scheduling, workload, or policy. They are terribly overworked and shoulder an impossible burden on a daily basis. In the LTC setting, the CNA delivers 90% of the care.1

CNAs report that they are taking care of as many as 24 patients a shift. These patients are generally dependent, demented, and can be combative. Because activities of daily living are labor-intensive, there is a large gap between what is required from the CNA and what the CNA is physically able to do. CNAs are rarely able to accomplish all the tasks required in a normal shift and are usually denied overtime to finish their work.

CNAs do not feel that their contributions are recognized or rewarded. They are, in fact, asked to give far more in terms of time and skills than they receive in pay and benefits for doing this work. CNAs feel discouraged by what is required of them and how futile their efforts seem.2 This type of pressure tends to alienate them from the very people to whom they provide care. It is hard to feel a sense of accomplishment if one is exhausted. It is difficult to care about people toward whom one is indifferent.

The definition of quality care changes from year to year and standards are increasingly higher and out of reach. The attempt to document that all care requirements are being met means that the focus falls on documentation and not on providing care. Consequently, it defeats the purpose of regulation. Overregulation has fostered an environment that seems to encourage lying and falsifying documents,3-5 which, in turn, further erodes CNAs' sense of self-worth and efficacy.6 This is a terrible disservice to the vast numbers of CNAs who provide care to our nation's elderly and who, by and large, try very hard to do a good job and to give good care. We need to redefine what the standard of good basic care is and also how to evaluate basic care.

The annual job turnover rate for CNAs in LTC is almost 100%.1,7 It would be nearly impossible to find any LTC administrator who would tell you that he or she has no trouble recruiting or retaining CNA staff. Surprisingly, these are the good years for staffing. The United States is in a period where the percentage of working-age people is at record highs, but starting around 2012, the percentage of the elderly and retired will increase and the percentage of working-age people will start to decline.8 This means there will be more elderly people needing care and a proportionately smaller workforce to provide this care. This demographic shift also means that the healthcare sector will be competing with all other economic sectors for lower skilled workers. However, other market sectors offer jobs to lower skilled workers that pay more, have better benefits, and require less work.1

By fiscal year 2040, federal expenditures for Social Security, Medicare, and Medicaid will account for approximately 16% of the gross domestic product, increased from 7.6% in fiscal year 2000 (compare 0.3% in 1950 and 21.1% projected for 2075).9 Federal Reserve chairman Alan Greenspan stated on February 25, 2004 in his testimony before the House Budget Committee, "This dramatic demographic change is certain to place enormous demands on the national resources-demands we will be unable to meet unless action is taken." He testified that the best way to deal with the exploding deficit is through spending cuts.10

If the LTC staffing issues are not addressed, we will have insufficient numbers of CNAs to care for LTC patients.11 If we fail to provide care to these elderly subacute patients in the LTC setting, these patients, by default, will enter acute care settings via emergency departments across the country, further overloading an already overloaded system. With the federal deficit climbing, there will be little federal money to offset the cost of caring for the uninsured and underinsured that make up the majority of LTC patients. Factoring in an already significant Medicare reimbursement inequity will mean that acute care settings will face record deficits with no federal money to offset the cost of caring for LTC patients in the hospital.

To help address problems with LTC and staffing, CNAs should be able to talk openly about the difficulty in meeting and complying with federal and local standards and regulations without fear of retribution by regulatory agencies or LTC management. Administrators need to involve CNAs to help change policy and introduce new ideas into the system. Having their concerns and solutions heard, acknowledged, addressed, and incorporated into policy reform is one important incentive for CNAs to remain employed as CNAs and entice new workers into this already critically understaffed area. To encourage people to work as CNAs, administrators need to build on what is good and rewarding about the CNA job, addressing parts of the job that need to change to increase morale, and make this an attractive employment option. We need to advocate for vulnerable staff as well as for vulnerable patients. We need to ensure that CNAs, the backbone of the LTC delivery system, are treated with respect and deployed effectively.

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