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Did it take a pandemic for us to notice certified nursing assistants?

They’re the ones holding grandma’s hand while she wonders why no one has visited her. But they’re also the lowest paid and most at risk among health care workers.

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Certified nursing assistants stand during an informational picket outside The Villa at Windsor Park nursing home on Chicago’s South Side on Wednesday, May 6, 2020. Staff at dozens of Illinois nursing homes called off a strike set to begin Friday after the workers’ union reached a tentative deal with nursing home owners that union officials said would help safeguard both staff and residents during the coronavirus pandemic.

Charles Rex Arbogast, Associated Press

SALT LAKE CITY — By the second bite of her chicken nuggets, Julie knew she was in trouble.

The sweet chili and sriracha dipping sauce should have burned her mouth, but she tasted nothing.

She got tested for COVID-19 the next morning, and by day three, had a fever of 101.4 and chills.

The 20-year-old certified nursing assistant wasn’t surprised — she’d been working with COVID-19-positive patients for weeks, yet didn’t get an N95 mask to wear in the Portland, Oregon, nursing home until almost two weeks after returning to work, post-recovery.

“It definitely reinforced that we’re practically second-rate citizens,” she said of those in her profession.

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Out of 1.5 million CNAs nationwide, Julie is one of 566,240 nursing home CNAs giving grandpa his bed bath, helping grandma button her blouse, brushing dad’s teeth and changing mom’s briefs — while trying to avoid catching or spreading a deadly virus that’s hitting older Americans with a vengeance.

And she’s exhausted.

Unlike doctors or nurses in a hospital, long-term care happens out of the limelight, leaving CNAs overlooked, undervalued and even disparaged.

The CNAs interviewed for this story spoke on condition they be identified by first names only for fear of retribution from their employers.

“We’re not thinking about them enough,” says Linda Edelman, associate professor and director of the Utah Geriatric Education Consortium at the University of Utah College of Nursing. “We just need to recognize what a hard job they have right now, and how hard they’re working.”

One encouraging step is the new Coronavirus Commission on Safety and Quality in Nursing Homes — an independent committee of 25 experts looking to improve nursing homes.

And for what’s likely the first time, CNAs are in the conversation.

Lori Porter, CEO of National Association of Health Care Assistants, the professional association for CNAs, is on the committee with talking points ready: wage increases ($16 per hour minimum with a path to $22), education and empowerment during a pandemic, and a national recruiting/image campaign to clarify not all CNAs want to be nurses.

“This country has to make CNAs a profession that is lifted up, recognized and respected on par with nurses and doctors,” she said. “When you’ve taken care of someone for weeks, months and years, that’s a relationship. And it’s a relationship that should be admired by everyone.”

Care professionals

In addition to bathing, dressing, toileting and feeding — 90% of all direct patient care — CNAs are also the ones holding the hands of crying residents who can’t understand why no one is coming to see them.

“The CNA role in America is critical,” says Porter. “The families of the residents don’t go ask the nurse in charge about how daddy’s eating or sleeping or how grandma’s pooping. They ask their CNA, their expert. The problem is, until you become a family member, you never know how important they are.”

Most people also don’t realize how vulnerable CNAs are, said Robyn Stone, senior vice president for research at LeadingAge, the association of nonprofit providers of aging services.

CNAs are 91% female, frequently single moms with young children who often work two or more jobs to make ends meet, says Stone. The average CNA wage is $14.77 an hour.

More than 37% of CNAs receive some type of public assistance, and 15% are below the federal poverty level — compared to 7% of all U.S. workers, according to data from PHI, a nonprofit research and consulting firm that aims to improve the quality of direct care jobs.

About a quarter of CNAs are immigrants, and a large proportion are nonwhite, says Stone, meaning they’re at even greater risk during this pandemic, which is disproportionately affecting people of color.

Instead of calling CNAs “low-wage workers,” Stone prefers the title, “care professionals who are paid low wages.” It takes significant skill to care for a medically fragile population that is increasingly demented. Yet, she says CNAs — especially those who choose to work in nursing homes, not hospitals — remain undervalued.

Working conditions

Seth Movsovitz puts it more bluntly: “CNAs are the doormats of the health care system, yet they are the backbone at the same time.”

Movsovitz, a Florida home-care agency owner and CNAs’ “biggest fan,” explains a major problem is poor staffing, which leads to injuries and employee burnout.

Older Americans increasingly want to age in place or move to assisted living communities. Yet those who can’t afford those options end up in nursing homes, which are predominantly funded by Medicaid and Medicare — the lowest payers for long-term care.

As a result, nursing home revenues keep dropping, says Stephen Campbell, data and policy analyst at PHI. And without federal staffing requirements for CNAs, many facilities control costs through small staff and no professional development, says Stone.

Heavy caseloads and pandemic stress are pushing many CNAs to their limits.

At least twice a week, Nickey works 16-hour shifts at a long-term care/rehab facility in Virginia, staying late to help fellow CNAs.

She knows two-person lifts are dangerous done solo, but if a resident is soiled and needs to be changed and there’s only one CNA to do it, they take the risk, which is why CNAs are three times more likely to be injured on the job than the typical American worker.

She worries about getting sick — she can’t afford 14 days out of work.

“If we get COVID, we’re irrelevant,” says the 28-year-old single mother of two. “But the reason we caught COVID is from lack of proper COVID-resistant PPE.”

Lack of protection

Thus far, 153,309 nursing home staff have either contracted COVID-19 or suspect they have, and 614 have died, according to Campbell’s analysis of federal data.

For the week of June 21, more than 2,000 nursing homes didn’t have more than a week’s supply of some protective equipment — masks, gowns or gloves, according to Campbell’s analysis. That may even be a “dramatic undercount,” he says, as many facilities haven’t reported yet.

“For nursing assistants in particular, I can’t imagine them feeling anything but disposable if over 100,000 nursing home staff have tested positive ... and still they’re not receiving appropriate protections,” he said.

Yet not every facility is in dire straits.

In Cleveland, Jessica’s long-term care administrators ordered extra personal protective equipment before staffers even needed it, locked down before a state mandate, and pay for weekly staff COVID-19 testing.

“My administrator has always said from the beginning, it’s not a matter of ‘if’ we get it, it’s a matter of ‘when,’” the 31-year-old said. As residents test positive, Jessica will be protected with N95 masks, gowns and eye shields.

Across the country in Idaho, Alison, 42, had that same protective gear in a bag with her name on it.

Yet, when her equipment started disappearing, the shower aide was forced to grab what she could find. At least a dozen times she had to wear someone else’s used, sweat-stained mask and face shield to care for a quarantined resident.

Recently, when a staffer she’d worked closely with tested positive for COVID-19, Alison asked for time off — worried about coming into work. Her request was denied.

“They don’t care about us,” she said. “They don’t care if you’re sick. They’re going to make you work anyway. And if you don’t work, they’re going to fire you. There’s nothing in place to protect us.”

For many CNAs, the greatest insult of the crisis is exclusion from the federal Emergency Paid Sick Leave Act, which provides pay for sick employees or employees caring for sick loved ones.

But essential workers like Julie, Nickey, Jessica and Alison can be denied paid time off because they are so desperately needed on the front lines, said Campbell.

Where they continue to stand.

Sometimes wearing someone else’s mask.