Like the great TV detective Columbo, Long-Term Living columnist Gary Tetz (Funny You Should Ask) always has one more question. In this bimonthly feature, he talks with long-term care leaders about anything that pops into his mind. He’s as surprised as you are that they’ll speak to him, and apologizes in advance for whatever inanity he might blurt out in the pressure of the moment.

The last time I saw Lori Porter, she was being greeted like a rock star by a few hundred CNAs as she took the stage at a National Association of Geriatric Nursing Assistants (NAGNA) convention. Founded in 1995, the organization she co-created is now called the National Association of Health Care Assistants (NAHCA), and is still seeking to elevate the profession through education, advocacy, and empowerment.

In a 25-year career in long-term care, Lori has been a dietary aide, CNA, nursing home administrator, and operations director. She’s also a nationally known speaker and author of the book, Everything I Learned in Life I Learned in Long-Term Care. I tracked her down at the association’s world headquarters in Joplin, Missouri. The conversation began with an unexpected accusation.

Hey, Gary. How are you?

Doing well, Lori. How are you?

I’m doing fine. Did you just yawn?

No! (Incredulously) Absolutely not.

Oh. I thought you did, and it made me want to.

(The allegation rendered me temporarily mute, but after a moment of awkward silence, I pulled myself together and continued the interrogation.)

So what’s going on at your organization?

I’m sure you’ve caught on that we don’t call ourselves NAGNA anymore. Many of our members are from healthcare settings other than geriatrics, so we started a new corporation called the National Association of Health Care Assistants (NAHCA).

In 2005, we created the Academy of Certified Health Professionals to run all our education certification programs, and now we’re launching our full career ladder virtual campus. It is state-of-the-art online continuing education training that’s never been present in long-term care before. We’re real proud of it.

What’s your main focus right now?

Well, here’s what I know. We’re in deep trouble if we don’t change the culture. It is devastating for long-term care to continue to operate in a desperately seeking workforce mode, but if we recruited 500,000 nurses and nurse aides today, we’d be short again in a month because we don’t have a workforce culture that is welcoming to new people.

The old image of the low man on the totem pole, peon, and butt wiper was born out of an organizational chart that has only one measure of value in long-term care—who is responsible if things go wrong. It perpetuated the idea that one person is more important than another, so I work with facilities to create a value chart where every position is on the same line with equal value.

When I was a CNA, our administrator would get up in front of us and say, “You’re the backbone. We couldn’t run the place without you.” Well, that led us to believe we were the most important, which was a terrible thing to perpetuate. Let dietary stay home a day or two. Let housekeeping all call in at the same time. We find out very quickly just how important every single position is to meeting the residents’ needs.

Why is workforce culture so poor?

Burnout is the number one cause of turnover in our profession, but we don’t pay attention to it. We think it’s just an inherited condition, even though it’s largely caused by the fact that people cannot see the end result of their work. We have a mandatory fire safety in-service every year, but as I’ve often said, we’ll lose far more people to burnout than will ever burn up. When people can see the end result of their work, they know their contribution means something. So that’s the focus of a lot of our programs.

You can take a 40-year-old building or a brand-new Taj Mahal built for culture change, and the old facility will outperform the new building if the workforce culture is as it should be. Because when it’s all said and done, it isn’t the bricks and mortar. It’s the human capital inside.

Any miracle cures for burnout?

Let’s say you’re a 2 p.m.-10 p.m. nursing assistant. Day shift has jumped on the wheel and turned it as fast as they can for their eight hours—getting people up, getting them fed, delivering care, getting them to bed. Then they jump off the wheel and you jump on, turning it for your eight hours. This continues day in and day out, and you never see the final score because it’s never really final. This leads to burnout.

One good way to fight it is to get everyone invested in some other area of the facility. For example, I ask administrators to set up a budget and finance team that might include a couple CNAs and maybe a housekeeper or cook—people who will learn outside their own role what it takes to make long-term care work. Does the administrator really need their financial help? No, not really. But what it does is expand their knowledge base about budgeting, and lets them see that the facility’s not getting rich and paying them little. When they understand that, it’s a step toward creating a workforce culture of mutual respect and understanding.

Maybe that mutual respect would also keep CNAs from watching the parking lot to see what the administrator is driving.

Exactly. You just hit the nail on the head. We have always been about breaking down the us versus them mentality. One of the things that made [co-founder] Lisa Cantrell and I the right people to start this organization is that we were both line staff before we became management. I checked out from my $4.25 job as a nurse aide on a Friday, and started as an administrator on Monday morning. And in the first few months in my new position, I remember thinking over and over, “If I had only known this as a nurse aide.” It made me realize that we often have CNAs, our largest employee group, working out of ignorance and in the dark.

What was your most eye-opening moment as a new administrator?

The budget—how limited the resources were to do the things we all cared so much about. There was just such a thin margin. When I was a CNA, every time I’d go in and say, “Hey, we need a new shower chair,” I’d hear, “Sorry, it isn’t in the budget,” and I’d leave that office thinking all they cared about was money, money, money, not quality. Well, why continue to perpetuate that misconception when all you have to do is sit down and help people understand the budget?

What other misconceptions do CNAs have?

One of the biggest laughs I get in a speech is by telling how, when I wanted to become an administrator, I made a list of things I’d do when I got in charge. I was going to help answer call lights and make beds. I was going to help feed in the dining room, and not just when the state’s there. It always gets a roar of a laugh, because CNAs are still working under the impression that everybody comes out when the state’s there just to try to pull the wool over their eyes.

Sounds like you came into the job like a certain Democratic candidate from Illinois, on a change crusade.

Absolutely. I had high ideals. I really did. I carried a little steno pad in my lab coat pocket, making my list. I wish I had kept the dang thing. I wasn’t going to hire any riffraff, just neat, clean professional people. I was going to have the best facility and survey. I thought seven years as a nursing assistant had taught me everything I needed to know about being an administrator. What I found out was I had a license to be one, and no idea how.

Did you also vow to pay your caregivers better? Was that on your list?

That’s another misnomer that is so paralyzing to our profession. Nurse aides still today, in 2008, think they’re paid what they’re paid because they’re not valued. They have no idea about reimbursement. So once I got in the administrator chair, I never again jumped to the conclusion that the owner was at fault.

Maybe Wal-Mart could pay their people better, but our profession will never have that choice to make. The government will make sure of that. When we still have states that pay more to house a prisoner than they do to take care of an old person, we’ve got problems with funding. My brother owns some motels. He gets 79 bucks a night, and he doesn’t have to toilet or turn anybody. They check in at 3 p.m., they’re out by 11 a.m., and he doesn’t even have to give them a continental breakfast if he doesn’t want to.

For about 30 bucks more, look what we are required to do for a resident? It’s sickening. And if the government doesn’t want to raise reimbursement because they think the owner might get it, why not a direct wage pass-through right to the caregiver?

Speaking of transforming the culture, I’ve been to one of your conferences. Hundreds of CNAs were screaming and waving pom-poms and standing on chairs and dancing around the room. I was genuinely frightened.

(Laugh) But wasn’t it nice to know that we have some very spirited caregivers who are that proud of their profession?

I was worried you were going to get written up for safety violations.

Yeah, well, one year we had a gal fall off the stage backward.

Isn’t all that positive spirit a little misguided? Don’t they realize they work in long-term care and should feel badly about themselves?

(Laugh) Well, we’ve had a long run of that, there’s no doubt, but the residents can only benefit from having an enthusiastic workforce. Nursing assistants are where families get so much of their information—that’s who they know the best, that’s who they ask how mom’s been eating or dad’s been sleeping. But we don’t train them to know how to be experts, or to believe that they are. Many of the things that go wrong in our profession happen because they don’t know their own value.

When it comes to workforce, we don’t have a recruitment problem. We have a retention problem. And that’s because we have to change the existing workforce culture to one of mutual respect and understanding before we can ever maximize the gift of new people.

How’s your crusade to get CNAs to stop calling themselves “butt wipers” going?

It’s really not very hard for them to abandon that once I make an analogy. “If you see yourself as a butt wiper,” I tell them, “you’re reducing your residents to butts. And I know you care more for them than that.”

In terms of the future, are you worried about caregiving robots stealing all the jobs?

(She laughed, but ignored my question.) We have a lot to offer in this profession. Where else could a 17-year-old high school dropout like me have the opportunities I’ve had?

Your early career was a little rocky, right?

It certainly was. I was written up twice as a nurse aide for my negative attitude. I finally saw the light when an older lady I worked with called me out one night when I was being negative in the break room. She said, “I’ve worked here 12 years. How about you?” I said, “Six months, and it’s been the longest six months of my life.” And she said, “Well, it’s been the longest six months of my life, too.”

That’s the night I learned peer power. Those two times management called me into the office did no good. I went back to the break room and started complaining again. But once that woman set me straight, I couldn’t do it anymore. She took my complaining ground away. She said, “This place means something to me. I’m not going to sit in here and listen to you tear it down.”

Gary Tetz

Gary Tetz is multimedia consultant at Consonus Healthcare Services. He was a columnist for I Advance Senior Care / Long-Term Living from 2005-2012.