R.E.S.P.E.C.T.

Policymaking in Washington sometimes seems to be limited to questions of money. Legislators and agency administrators investigate who is getting more money and who is getting less, they negotiate about how much one interest group should be given and at whose expense. Liberals are accused of throwing money at problems and conservatives are accused of demanding accountability for every penny while allowing their allies to walk away with millions.

The long-term care field is not indifferent to money issues. Providing quality care requires an impressive amount of funding: Long-term care insurance providers estimate the cost at more than $135 billion per year, including both residential and home care services. That's roughly $600 per year for every adult resident of the United States. Out-of-pocket payments and private sources account for only about 40% of this funding, which means that the constant debate in Washington and in state capitols about the public sector's share of long-term care cost is absolutely crucial. It has been less than 10 years since a wave of bankruptcies and near bankruptcies rocked the long-term care field.

The fact remains, however, that this focus on funding is not the dominant issue for the thousands of nurses, nursing assistants, technicians, and other personnel who work in our country's skilled nursing facilities (SNFs). For years, spokespeople for the long-term care industry have repeatedly told legislators and administrators that professional caregivers remain in the field because they enjoy their work and feel a sense of dedication to the people they work with. This description is clearly at odds with the images of greedy managers and indifferent providers that some politicians like to depict in speeches to justify even more regulation and more accountability (and, oddly, lower reimbursements). Now, through the release of a massive nationwide study on work-related attitudes about nursing home employees, the industry can document the truth of many of its claims about the motivations of long-term caregivers.

The study, "2006 National Survey of Nursing Home Workforce Satisfaction," was conducted by My InnerView, an applied research firm founded by Neil Gulsvig, a former SNF administrator. Under the guidance of Associate Professor Leslie A. Grant, PhD, of the University of Minnesota, My InnerView collected data from more than 106,000 staffmembers at nearly 2,000 facilities. Critics may carp that My InnerView's close ties to the American Health Care Association and to individual nursing home chains and facilities weaken the credibility of the survey findings. Additionally, the failure of My InnerView to survey former employees who quit the long-term care field introduces bias: All of the respondents were sufficiently satisfied with their work to be actively working for nursing homes at the time of the survey. On the whole, however, "2006 National Survey" is at least as valid and reliable as comparable workforce satisfaction studies in other industries.

The single best news in the survey is that more than 60% of nursing home employees rate their employment as either good or excellent--a significantly higher level of satisfied workers than in most U.S. work sites. Although nurses and nursing assistants were more likely than other employees to be dissatisfied with working in SNFs, according to the My InnerView study, a slim majority of direct-care staff are satisfied with their work.

Rates of pay enter into the satisfaction equation, but in a surprisingly complicated manner. Nursing assistants are most likely to be unhappy with their salaries, followed closely by other direct-care staff, but salaries do not appear to be a decisive factor in overall work-site satisfaction. At the same time, facilities that offered overall higher rates of pay than the industry average are more likely to maintain higher levels of employee satisfaction. In effect, most employees say that low salaries are not the cause of dissatisfaction, but SNFs with higher pay scales have fewer unhappy staff members.

Cynics might suggest without evidence that the survey respondents were not being completely truthful about their relative lack of interest in higher salaries. A better explanation, however, can be found in direct-care staff's top-rated concerns for improved working conditions. As shown in the table, nurses and nursing assistants agree that high priority should be given to management that cares about employees and listens to them, while nursing assistants place priority on supervisors who appreciate their efforts. Salary rates provide a rough measure of how much management values the employees. In other words, survey respondents tend to value higher salaries because they demonstrate appreciation for the employees rather than because pay itself is the dominant motivating factor.

This should not be a startling finding. Most long-term care in the United States is delivered without pay, by families that donate hundreds of hours of service to caring for elderly or impaired relatives who may not yet qualify for nursing home stays. Perhaps a few of these family members are motivated by expectations of inheritance or other self-centered concerns, but many more are likely to be motivated by the appreciation they receive from helping someone they genuinely like. Given the comparatively low rates of pay available to staff in residential long-term care settings, it appears that many helping professionals have a similar motivation for their own work.

The federal government probably recognized this principle in 1974, when it changed the Fair Labor Standards Act that guarantees minimum wage and maximum hours rules for most employees. Although the 1974 legislation explicitly provided protection for most domestic workers, Congress specifically exempted "any employee employed in domestic service employment to provide companionship services for individuals who (because of age or infirmity) are unable to care for themselves." At the time, Sen. Quentin Burdick (D-N.Dak.) stated that he did not want the exemption for "the professional domestic who does this as a daily living," but expected it to benefit "people who might have an aged father, an aged mother, an infirm father, an infirm mother, and a neighbor comes in and sits with them."

The U.S. Department of Labor repeatedly has considered a reinterpretation that would limit the exemption to "companion" workers who are employed directly by the family of the long-term care patient. Each time, however, the federal government has backed away from this change and continued the policy that places all home healthcare workers in the same "exempt" class as babysitters. The U.S. Supreme Court unanimously ruled in June in Long Island Care at Home, Ltd. v. Coke that the Department of Labor is entitled to continue denying Fair Labor Standards protection to home health aides, effectively implying that people who choose this work are motivated by something other than the prospect of earning the national minimum wage.

The fact that the Supreme Court ruled that home health aides can legally be paid less than almost any other type of worker does not make it a good management practice. Retention and recruitment of competent, caring professional home healthcare workers will not occur if they know that employers do not value them enough to pay the national minimum wage. Similarly, the My InnerView survey's finding that nursing home employees are motivated by factors other than salary does not justify keeping reimbursement rates so low that good employees can't be recruited. The survey already found that nearly one-third of today's nursing home employees have been employed in SNFs for less than two years, implying rapid turnover even among staff who claim to be satisfied with their work. For this reason, My InnerView's analysis concluded that "additional resources will likely be needed to maintain an adequate supply of direct-care workers and ensure its future growth."

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Table. Priority items cited by nursing staff

Nursing Assistants                   Nurses

1. Help with job stress and burnout  1. Help with job stress and burnout
2. Management listens                2. Management listens
3. Management cares                  3. Management cares
4. Supervisor appreciates            4. Training to deal with difficult
                                        residents
5. Adequate equipment/supplies       5. Training to deal with difficult
                                        family members