The other day, Josh Wiener, who is one of the nation’s experts on long-term care, presented three papers on certified nursing assistants (CNAs) in nursing homes. Josh and his colleagues at the consulting firm RTI International looked at quality of care, immigration, and injuries. And some of what they found may surprise you. The papers are available here (some may require subscriptions)

The first question they asked was what workforce issues determined quality of care in nursing facilities. Lots of research has identified the problems: worker shortages and high turnover, low wages and few benefits, poor training, and a sometimes-hostile relationship between aides and managers. But which of these problems could be linked to low quality?

Surprsingly, Josh and his colleagues did not find much difference in some of these characteristics between high- and low-quality facilities. For instance, wages didn’t seem to matter much. Neither did staffing levels. But access to health insurance and paid days off did matter and so did a more collegial organizational culture. This last finding suggests that the culture change movement in nursing homes, which attempts to create an environment where aides are given both more authority and responsibility, may be on to something.  

Their second paper looked at immigration, an important issue since about 20 percent of CNAs are foreign-born. Some results were not surprising. For instance, Wiener found only about half of immigrant CNAs reported English as their primary language. And half reported problems communicating with residents. But it turns out that nearly as many (41 percent) native born workers also reported these problems.

Other results were just as interesting. Foriegn-born workers were older, more likely to be married, and better educated than their U.S-born colleagues. Their average wages were about 10 percent higher and while fewer reported getting bonuses or reimbursement for training, more said they got paid holidays and subsidized child care. And immigrants were more likely to work for the highest quality facilities (based on the government’s five-star rating system)

Finally, Josh and his colleagues looked at injuries. Aides have among the highest injury rates of any occupation in the country–the Labor Department reports that almost nine percent were hrt on the job in 2006, the third highest among any occupation in the U.S.

But Josh found many more injuries than were officially reported. He found that nearly 60 percent of nursing home aides reported suffering some injury during the course of the year. While most were back injuries caused by lifting, many others were inflicted by residents (12 percent were a result of bites).

One way to reduce back injuries is through the use of mechanical lifts. Josh found that 88 percent of facilities had these devices available, but only 61 percent of aides said they always used them. The research also found that madatory overtime, inexperience, lack of training, and lack of time to spend with residents all contributed to injury.  

These results are contrversial, espcially some of the conclusions about the relatonship between pay and staffing and quality. But, as with all of Josh’s research, it is worth looking at.