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Unsung Heroes, Who are Nursing Home CNAs? The SeniorScape™

More than 600,000 certified nursing aides are employed in the over 15,000 U.S. nursing homes. They provide assistance for approximately 1.4 million people. Despite the advent of more families and individuals opting to receive care in their homes or the homes of their loved ones, nursing homes continue to play an important role in long-term care for individuals who require 24-hour care and support.

An integral part of the job responsibility of the certified nurse aides

is transferring and lifting residents, many of whom because of their significant physical or cognitive impairments are unable to participate when those tasks

are being performed. This result in a staggering rate of injury: 3.5 times more frequent than the typical American worker in other professions.

A large portion of their work is devoted to assisting with personal care needs

known as activities of daily living (dressing, bathing, feeding). These tasks are considered menial and custodial, which may be one reason those who are in these positions are

treated poorly.

The salary for the nursing assistant job is generally reimbursed through Medicare and Medicaid funding. This amounts to approximately $116 billion annually. Cuts in reimbursement most always affect the salaries of these workers. They are paid low wages; the median hourly wage is $11.87, with a median annual income

of $19,000.

Compared to 25% of a Black or African American U.S. workforce, over 30% of certified nurse aides are Black or African American and 25% are foreign born, although it is

worth noting that 90% are citizens of the United States. Fifty percent of nursing assistants have only a high school education. Because the education, experience, and training requirements for the position of nursing assistant are limited, it is an easy and accessible point of entry for many new immigrants, especially for those new immigrants who have limited or poor language skills. This affects their ability to find gainful

employment in other areas.

Nursing aides outnumber other employees in the nursing home by 30%. They have more time with residents than any other care worker; they perform 90% of the

hands-on care 24 hours a day. They have limited training or education yet are required to make nuanced observations about residents. (i.e., changes in mood, skin color, mental state, bodily functions, temperature, and appetite) These oftentimes subtle changes can be indicative of a brewing or actual change incondition, which are ultimately reported up the command chain to nurses and doctors. These are changes that someone knows only when spending a significant amount of time with a person. Though it is not considered a medical assessment, it is an assessment of sorts.

Certified nurse aides should be valued for the important role they serve in the life of the nursing home resident, without whom the nursing home would not be viable. They also go by other names; certified nursing assistants, nursing attendants, nursing aides, and

nursing care attendants. I prefer to refer to these valuable healthcare workers as

certified nursing assistants as their role consists of a real-time, hands-on

assist to a registered or licensed practical nurse. Their observations are critical

and often the basis on which care decisions are made.

I can recall countless times when I’ve asked a nurse about a resident only

to hear them say, “I don’t know, ask the CNA.” In the over 50 nursing homes in which I’ve worked, I can’t remember seeing a doctor confer with a CNA about a resident’s condition, the person who has experienced and observed this condition first-hand. They rely on the report they receive from a nurse. However, I’ve seen nurses discount the report of a nursing assistant, and have been told by many CNAs, “they don’t listen to us.” It’s almost as if certified nursing assistants are shadow workers, doing the bulk of the word from behind the curtain.

Each year there is a high rate of turnover in nursing home assistants.

This is due in part to the poor rate of pay, the difficulty in the workload, and the

rate of injury. As a whole, the nursing home industry has difficulty filling

positions for these jobs. This is related to the poor quality of the environment and the stresses and strains of the position. Oftentimes, this industry competes for the same workers with the fast-food industry. Rapid growth in the population of older Americans will put even more stress on nursing homes, making it imperative to develop strategies to strengthen and stabilize the workforce.

In the senior living industry, females account for the largest number of the workers, at 89%. Approximately 25% of them are Black, and large numbers have emigrated from other countries. Forty percent are upwards of 50 years of age. The lowest rung of the direct contact workers, the certified nursing assistant, provides 90% of the direct care and has the most frequent contact with patients. Their direct care work consists of backbreaking tasks—helping people who are weak, frail, infirm,

and confused.

While certified nurse assistants have the most contact with nursing home residents and do the lion’s share of the work, they are often scorned, mistreated, undervalued, and underpaid and overlooked. Many are forced to work multiple jobs just to make ends meet.


The home and community-based health care workforce is characterized primarily by females of color. Over the past 10 years, the workforce has grown by 50%, consistent with the shift from care delivered within institutional settings to people remaining in their homes and communities to receive care. In coming years, the rapidly growing population of older adults will dramatically increase the demand for home care workers.

According to the U.S. Census Bureau, by the year 2035, the population over the age of 65 is expected to outnumber the population under the age of 18. As the elder population continues to grow, the needs for caring for older adults will also

grow. By the year 2050, the number of people over the age of 65 will increase by almost 50%, from 47.8 million to 88 million. During that same period, the number of older adults over the age of 85 is expected to triple, from 6.3 million to 19 million.

As one would expect, consistent with an increasing number of people living to more advanced ages, the care needs of that population will also increase. Thus, there will be a proportional increase in the number of health care workers needed to serve

that population.

The ability to maintain a robust health care workforce will remain a challenge consistent with the persisting root causes for the shortages, low wages, poor benefits, poor quality work environments, disrespect, excessive and strenuous workloads, and job requirements.

In many states, employers seeking health care workers are competing with the fast-food industry. The median hourly wage for the home care worker is reported to be

$10.11, and available work fluctuates based on need. Therefore, it may be either part time or, in the case of home care, only a portion of the year. In many cases, the average annual salary is approximately $13,300. Statistics indicate that approximately

25% of health care workers live below the federal poverty line, as compared to 9% of the general U.S. population, and over 50% rely on some form of public assistance to meet their basic living needs. This is the reason many health care workers hold

jobs at multiple agencies or institutions, one of the suspected root causes for the spread of the coronavirus in nursing homes. I’ve personally known of several health care workers living in homeless shelters.

The aforementioned statistics regarding health care worker wages are discouraging. In addition, consider these facts:

• The wages have not kept up with the rate of inflation for over the past 10 years.

• Because of the variable needs, two-thirds of home care workers work part time or only for a portion of the year. Nursing home, skilled nursing, and assisted living

environments require around-the-clock staffing. Home care varies, from a few hours daily or weekly to 24-hour care.

• Twenty-six percent of home health care workers do not have medical insurance. They rely on public health coverage, Medicaid, or Medicare.

Nursing home health care workers, and particularly certified nursing assistants are

undervalued, underappreciated, undertrained, underpaid, which is tantamount

to disrespect.

For both nursing home assistants and home health care workers, a caring and committed relationship is fundamental to ensure quality care. This can only be accomplished when the worker receives high-quality training, a fair living wage, and

the respect they deserve based on the important role they play.

How would any of us feel about remaining in a position under those conditions?

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