Issue Brief 3: A Poorly Trained Paraprofessional Workforce
The Problem:
Although the Omnibus Budget Reconciliation Act of 1987 (OBRA) enhanced the training required of CNAs in nursing homes and home health aides in certified home health agencies, Federal regulations for paraprofessional training are inconsistent and still fall short of what is necessary to develop workers with the requisite skills to meet the complex needs of today’s long-term care consumer. Federal healthcare training resources are reserved for the development of professionals (doctors, nurses, etc.); few are directed toward the development of the country’s several million paraprofessional caregivers who work in nursing homes, assisted living facilities and beneficiaries’ homes.
Training is too limited: A higher set of training standards is needed to prepare caregivers for all the services they must deliver to clients — especially now that they are older and sicker and more are suffering from dementia.
Although the Federal government mandates training for nursing home and certain home care workers, the prescribed hours and curricular areas for entry-level training and ongoing skill upgrading are inadequate to prepare workers. Mandated training hours for school crossing guards and cosmetologists, who have less responsibility for personal care, and even dog groomers, are greater than those required by HCFA for entry-level certified nursing assistants or home health aides.
Inadequate supervision: Training is only as useful as the supervision that follows it. If paraprofessionals are not carefully supervised and supported to deliver the quality of care they learned in a good training program, then they lose the competencies they have developed. Good supervision, too, is a skill that must be learned and reinforced. In nursing homes and home care, frontline supervisors are also poorly trained and reimbursed. Their turnover rates are also high, thus impeding the ability of paraprofessionals to do their best work.
Missed core competencies: Mandated curricular areas often focus on discrete clinical tasks, while glossing over the deeper core competencies in interpersonal and communication, clinically-informed problem-solving and decision-making skills that most often guide a competent caregiver in her interactions with clients. As our society becomes increasingly multicultural, frontline paraprofessionals must be trained to work through language and cultural differences with their clients, peers and supervisors. Over time, direct care workers should attain minimum levels of proficiency in reading and writing skills, as well.
Who does the training? OBRA only requires that trainers be “prepared,” but it doesn’t state what preparation is needed or that trainers should be experienced in adult education. And because they often lack the necessary formal training, many CNAs must resort to informally (and in some cases improperly) training one another on-the-job to perform many of their daily tasks. In home care, too, because of inadequate supervision and little opportunity for interaction with other aides, paraprofessionals who have been poorly trained may be delivering improper care.
A changing labor supply: Since most entry-level workers can now find better-paying jobs than those offered by paraprofessional healthcare, the less-skilled job-seekers left behind will require more screening and training than their predecessors. But training standards and mandated curricula have not adjusted to these changes in the composition of the paraprofessional labor supply.
Training not valued as an investment: Because of high worker attrition rates, the healthcare system — in an act of self-fulfilling prophecy — devotes the least possible resources to paraprofessional entry-level training and foregoes developing real competency-upgrading programs for incumbent paraprofessionals who might otherwise become experienced, competent members of the care delivery team.
Incentives for entry-level not ongoing training: Currently, facilities receive reimbursement for the numbers of new recruits in entry-level training, as opposed to those who are given ongoing training to build their competencies. This creates an incentive for turnover and continuous recruitment of new workers and a disincentive for ongoing training that would encourage retention.
Disconnect between healthcare and labor policies: The public healthcare system has left much paraprofessional training to government-funded welfare and workforce development programs directed toward low-income adults. But the new “work first” emphases of Federal welfare and workforce policies are now pulling those systems away from the type of pre-employment skills training that in the past had certified many low-income women for paraprofessional jobs—and Federal healthcare agencies have no plan in place to pick up that slack, or to accept full responsibility for delivering to consumers a well-trained frontline caregiving workforce.
Consequences: Diminished Quality of Care for Beneficiaries
Injuries to consumers: Poor training leads to a higher incidence of abuse, neglect and accidental injuries to patients. With good training, paraprofessionals understand the concepts behind the skills they are learning. For example, they learn the consequences of why a woman with brittle osteoporosis has to be handled carefully, or how a person with Alzheimer’s might react to a certain behavior of the caregiver. Having a foundation of caregiving, communication and problem-solving abilities — and not just a set of rote-based skills — promotes careful and clinically appropriate caregiving and prevents client injuries.
Injuries to caregivers: Poor training leads to a higher incidence of injuries to workers as well. Long-term care paraprofessionals experience significant physical stress and strain that can lead to injuries if they are inadequately trained — or forced to work without proper equipment or assistive staff. CNAs in nursing homes have higher injury rates than coal miners or construction workers. These injury rates add to worker attrition and the overall discontinuity of care suffered by consumers.
Shortages of qualified entry-level workers: Because inadequate resources are devoted to entry-level training or ongoing training, fewer paraprofessionals feel qualified to perform their job or have the opportunity to advance in healthcare. Career mobility opportunities are almost nonexistent. Workers’ frustration at this system leads them to leave jobs in healthcare, thus contributing to further shortages of service providers.
Inadequate care: Because of inadequate pre- and on-going training, many paraprofessionals care for their clients without benefit of experience or formal upgrading instruction. As a result, clients do not receive the best care possible.
We have not made the necessary investment in our healthcare workforce. Paraprofessional healthcare workers have a strong need and desire for ongoing relevant training. Training requirements were minimal ten years ago and are now outdated. Immediate action is needed to bring current training requirements up to a level that enables caregivers to meet the needs of today’s long-term care consumer.
See Also:
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