Abstract
This article tracks the changing roles of certified nursing assistants (CNAs) as they transition from a traditional nursing home setting to a “deinstitutionalized” care setting called the Green House. The Green House concept, developed by William Thomas, MD and based on the Eden Alternative paradigm, emphasizes autonomy, dignity, privacy, and reciprocal relationships between residents and staff. This qualitative work focuses on how CNAs (called “shabazim” in the Green House) negotiated the transition from traditional nursing home to the Green House model. Interview, focus group, and participant observation data before and after the transition to the Green Houses reveal that in the traditional nursing home environment, informants report that resident-CNA interactions tend to be rushed, detached, and adversarial, whereas in the Green House care environment, interdependency and stronger ties are promoted. Shabazim report diminished guilt and enhanced sense of empowerment in their new role.
A social movement in long-term care, the Green House, is gaining momentum in the United States. Conceived by William Thomas, MD, a self-described “nursing home abolitionist,” and social gerontologist Judith Rabig, the movement focuses on a small-house model of long-term care centered on elder vitality, respect, autonomy, and dignity (Thomas, 2003). This movement is about structural and cultural changes surrounding long-term care resulting in a skilled nursing alternative to the traditional nursing home. Unlike a traditional nursing home with a hospital-like feel, Green Houses are described as “deinstutionalized” caregiving facilities. They are ranch-style homes, or small, self-contained houses that house 12 or fewer residents. They feature private rooms and full bathrooms, allowing for elder privacy and personality (elders decorate their own rooms). Each house has shared family-style communal spaces, including a hearth, dining area, and full kitchen. As of March 2010, there were 79 Green Houses in 14 states, and an additional 132 are being constructed in another 12 states (LaPorte, 2010). The Green House project, initially inspired by European care models, currently only exists in the United States.
The Green House model is based on a number of humanistic guiding principles that together represent the “culture change” in long-term care (Koren, 2010). These principles include supporting dignity, autonomy, comfort, choice, privacy, and security of residents; offering meaningful activities and promoting maximum functional abilities of residents; fostering emotional and spiritual well-being; and recognizing, encouraging, and valuing the individuality of elders and staff, and the reciprocal relationships that emerge in this unique context of care (Koren, 2010; Rabig, Thomas, Kane, Cutler, & McAlily, 2006; The Green House Project, n.d.; Thomas, 2003). The use of terms such as elder and elderhood among those affiliated with the Green House movement refers directly to a newly respected life stage. Previous research (Kane et al., 2007) reveals positive health and quality of life outcomes for elder residents living in Green Houses.
A Green House is a skilled nursing facility. Certified nursing assistants (CNAs), direct care workers who are licensed by states, are central figures in these care environments. They play the role of “universal workers,” attending to food preparation, laundry, personal care, habilitation (growth and opportunity), and general promotion of older peoples’ quality of life. CNAs are always on-site with the residents, whereas nurses, physicians, therapists, and other professionals comprise a visiting clinical support team. Unlike in the traditional nursing home environment, where CNAs are at the bottom of the care hierarchy, in Green Houses they are the ones ultimately responsible for meeting residents’ needs on a daily basis. Nurses, who were at the center of the traditional care model, now serve in a visiting and consultative capacity. Two hundred hours of training in culinary arts, dementia care, and habilitation cements this role change, and prepares CNAs to play the role of “shabazim,” or “the midwives of a new elderhood.” This is a considerable role shift for these workers. Traditionally, CNA positions are low-paid, low-status jobs characterized by high turnover rates (Dawson, 2007). In the Green House, the Shabazim role has elevated importance, and CNA pay rates have shifted upward.
This research gives voice to a group of CNAs-turned-Shabazim at the 50th Green House site in the United States located in upstate New York. Qualitative data were collected as a high-rise, 209-bed nursing home transitioned to a residential community made up of 16 Green Houses. This Green House site is representative of others across the United States in its structure and guiding philosophy, however it differs slightly in its size and scope of care, including 16 free-standing houses, each with 12 residents. Anecdotal evidence (e.g., Kalb, Juarez, & Morris, 2005; Wallace, 2006) and unpublished studies (e.g., Bowers & Nolet, 2009; Sharkey, Hudak, & Horn, 2009) exist that document how the Green House care model impacts the work experience of CNAs. This research addresses a gap in the literature. It is based on systematic data collection characterized by prolonged engagement during the transition from traditional nursing home to Green House and gives voice to the CNA experience in the process of nursing home culture change.
Method
Using a phenomenological perspective, qualitative data were collected during the 2-year transition period discussed above (2008-2010). Triangulation of methods were employed, including a mixture of interviews (n = 6) with CNAs, residents (n = 2); four focus groups with CNAs (size of groups ranged from 3 to 11); and participant observation during Shabazim training and in the houses to better understand the experiences of CNAs and this new context of care.
This analysis focuses on CNAs who worked in the nursing home while attending Green House training and those who were new to the role of Shabazim. We spoke with 20 of approximately 250 CNAs who were being trained to staff Green Houses during this transition period. The guiding research questions that informed our qualitative data collection focused on caregiver work satisfaction and perceived quality of care in the context of both care environments. Interview and focus group data were transcribed verbatim and detailed field notes were kept. Data were analyzed for emergent themes vis-à-vis the research questions in an iterative fashion, and peer debriefing was utilized to address trustworthiness of data interpretations. The research was approved by Colgate University Institutional Review Board.
Results
The analysis revealed five emergent themes central to the CNAs’ experience as they transitioned into their Shabazim role: (a) a sense of empowerment in the context of shifting hierarchies, (b) a more enabling work environment (c) enhanced control of time/space, (d) stronger elder-caregiver ties, and (e) diminished guilt and stress in their work.
First, CNAs working in Green Houses report a sense of job empowerment. For example, Jean and Jessica are both experienced CNAs in long-term care contexts who were interviewed in the first few weeks of their employment as Shabazim. Both describe moving from the bottom of the occupational hierarchy to a more central role. Hourly pay rates, responsibilities, and general levels of respect shift to fit this new model of care. CNAs say they experience this shift in terms of their own “value” and “expertise,” and a sense of empowerment as they become involved in all aspects of the residents’ lives.
We are changing roles with the nurses, taking over a lot of their responsibilities. So dietary used to do meal planning; now we will do it. We will sit with them for meals, we’ll be with them during their baths … We also do more activities with the elders. So we are going to be more of their main focus, not the nurses. The nurses are there for back-up.
[In the Green House] our expertise is valued. I take care of my people, like I do with my family at home. We’re the experts, we’re on the frontlines with them. We know them so much better because we do the hands-on work, and if someone is in trouble it comes back to us, because we’re the first responders on the scene.
These quotes, emerging in an occupational honeymoon period, emphasize CNA expertise, value, and power in the Green House model. The Green House training is designed to prepare CNAs, nurses, and support staff for these shifts in expertise as well as to instill a teamwork-ethic.
That said, Jean and Jessica portend potential long-term conflicts in the context of such dramatic shifts in power, such as insecurity among CNAs to play the role of expert, or tension between CNAs and support staff (including nurses).
Second, CNAs report that work environment itself, particularly the pacing of the work, is markedly different from a nursing home environment. For example, Kayla and Jane report being able to focus on habilitation (opportunity and growth) in a slower-paced care environment. This replaces the “half-steps,” and band-aid solutions that reinforce a sense of learned helplessness among the residents and caregivers in the nursing home environment.
In the nursing home it is a rush and your head spins and you get a headache. People take half-steps (like ignoring mouth-care or washing without applying ointment) and that doesn’t do anyone any good. Pretty soon you are going to be in that bed and you will want the whole step.
With less residents there will be a little more time to spend with each elder. And that’s important because this is a family house and its like raising a family. They see us every day, and they see their family maybe once a week, or month, or year. We are here for them when they are happy and when they are sad. We hold their hands when they are passing and we laugh with them and cry with them. Their happiness is our goal. This is their home, and we help them feel like they matter.
Kayla and Jane, at different points in the Green House transition, point to the importance of work environment in the carework context. Kayla is still working in the nursing home and experiencing first-hand the daily constraints of a long-term care work environment. Jane, now a Shabaz, emphasizes how she is newly enabled in a Green House context, with less residents, more time, and a home-like care environment.
The change in work environment allows for CNAs experience better control of time and space. Lisa and Jane report how a house with 12 residents can be less daunting than a hall of 20, and this small group allows for more flexibility to attend to residents’ preferences.
There are people who get up at 4 am and you can actually associate with them and cook them breakfast, and you’re not having 20 residents to keep track of.
In a year’s time some of them are going to come a long way. With less people we can be more hands-on and give them time and tasks and this will make them feel better, like they are part of something and they are going to live a longer and happier life. Even today I see Ellen out talking to people—she is usually in her room watching television. So already you see a difference.
These quotes exemplify how providing an environment where the primary caregivers can be flexible and creative in meeting older adults’ needs translates into resident empowerment.
The Green House also allows for the possibility of stronger elder-caregiver ties. Caregivers report a profound sense of meaning attached to their job and appreciate the family-like relationships that form in this care context. They report having time to learn resident’s specific needs, and the sense of fulfillment associated with being able to attend to personalized needs. However, as a result of this increased intimacy, residents’ deaths and dying processes were impactful.
In the Green Houses the family is there. They come regularly. And you learn elder routines and facial expressions. You get to know their little ins and outs. I learned from the wife of another resident that if I put food on one man’s fork and put it down, he would pick it up and eat it. Just simple little things like that.
I get attached to a lot of the residents. Sometimes they say things … they are like angels sending a message to me. I used to spend so much time with this one woman. That was tough when she died; real tough.
Here, Shabazim interviewed in the context of Green House employment, highlight the role of intense emotional caretaking facilitated by the Green House model. On our visit to several Green Houses at the 6-month mark, the emotional impact of death and loss emerged in conversations with staff and residents. Several residents had died during the transition period, and it was clear that caregivers’ grief took new form in this care environment that emphasized community and active engagement with life.
Although grieving may take its toll, CNAs report overall decreased guilt and stress while working in a Green House model of care, largely because they are able to meet residents’ personal needs, and work in caregiver teams that can be accountable to residents. As Shannon notes below, CNAs no longer have to force elder residents to conform to a standardized model of care they may not agree with.
In the Green House I know I’m not gonna feel so bossy; like I’m making decisions for them. So many of the elders get frustrated when you wake them at 7 a.m. But if you don’t have to take that role of forcing them … you can build a stronger relationship. In the nursing home I feel guilty sometimes at the end of the day because I know that this should have been done and this too … And then there is not enough communication with the next shift. But in a house with a teamwork situation it is easier to communicate.
This gig makes me happy every time I go home, you know, I’m tired and its stressful, but at the end of the day I took care of that person to the best of my ability.
Shannon, who has yet to make the full transition to the Shabaz role, anticipates a decrease in guilt over not fully meeting residents’ needs. Jessica, a new Shabaz, validates Shannon’s prediction, emphasizing satisfaction with the scope of care she can offer and accomplish in a daily Green House shift. These interviews suggest that this new care role is both personally and professionally fulfilling.
The five themes elucidated by CNA’s transitioning into a Green House model of care are further validated through observations of daily life in the houses, and through interviews with residents 6 months after moving into the Green Houses. Specifically, the mix of an enabling work/living environment, worker/caregiver autonomy and flexibility, stronger elder-caregiver ties, and diminished caregiver guilt and stress, empowered many residents to start anew, voicing their needs and perspectives and forging new social ties. Older adults spoke of their respect for and growing friendships with Shabazim (as well as other residents) and vice versa. They also spoke of their own personal habilitation and growth; one discussed shedding her shyness and depression in the context of community, and another focused on learning to walk again.
This new model of care is still very much a work in progress. The voices of CNAs reveal how radical the Green House model can be (in contrast to traditional long term models), and therein may lie potential for conflict and problems down the line. Administrators, in the process of assessing the impact of this new model of care, emphasized resident and staff success stories, while dealing with emerging issues including how quickly to fill beds after a resident’s death, how to stave off staff burn-out, and how to continue to reinforce a teamwork ethic among staff. Inevitably, transitions cause stress and unanticipated challenges, but the evidence suggests that the Green House model stands to benefit both residents and professional caregivers in the long term.
Discussion
The Green House model provides a care environment (both structure and culture) that has the potential to empower residents and staff alike. Caregivers report a newfound sense of autonomy and control in the Green House, and this can have dramatic payoffs in terms of quality of care, job satisfaction, and personal and professional fulfillment. Data from focus groups and interviews revealed that throughout the transition, CNAs were excited about and looked forward to filling their new role, some reported mild anticipatory anxiety about the role’s increased responsibility and visibility, but thrived once the transition occurred. The opportunity for enhanced training on elder care, higher pay (at least at this Green House), and more meaningful responsibility provided the context for enhanced connections to their work and those for whom they provided care and increased sense of accomplishment and pride in what they do.
Other research that address health and quality of life outcomes for older adults residing in Green Houses is promising (e.g., Cutler & Kane, 2009; Kane, Lum, Cutler, Degenholtz, & Yu, 2007; Lum, Kane, Cutler, & Yu, 2009), and the current study adds to these positive outcomes by demonstrating that the context of care also matters for frontline, direct care workers. This analysis focused on the period when CNAs were being trained and transitioning to new work roles and environments. These preliminary findings would be further strengthened by long-term data collection and analysis.
Although this research is limited by its small sample size and focus on one Green House, it does provide initial evidence that the culture change in nursing homes stands not only to benefit residents, but the quality of work life among the thousands of direct care workers who care for our elders when families are unable. This work and other research suggest that improving the work lives of CNAs improves the quality of care received by older adults–in the Green House, everyone has a chance to grow.
Footnotes
Acknowledgements
The authors would like to thank the elders, staff, and administration of our Green House for their time, wisdom, and support of this research.
Authors’ Note
This manuscript is based on a presentation delivered at the International Sociological Association in Gothenburg, Sweden, in 2010. Please visit www.thegreenhouseproject.org and 
for more information on the Green House project.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research and/or authorship of this article.