Shortage of Nurse Aides, Home Health Aides, and Personal-and-Home-Care Aides Projected

Nurse aides, home health aides, and personal-and-home-care aides are classified as direct care workers. Direct-care workers are paraprofessionals who are trained to assist the elderly and the disabled with assisted daily living (ADL) such as grooming, bathing, and eating.  They are the backbone of the long-term delivery care system (Weiner, Anderson, Khatustsky, & Squillace, 2009).  While physicians and nurses are the primary role players in any healthcare system, the worthiness of the direct-care workers can never be under estimated.  The aging of the American population  more than ever place the importance of direct-care workers, as they are the one who will do the menial jobs of caring for the elderly’s and the incapacitated.  Figures provided by the Bureau of Labor Statistics (BLS) in 2008 came to about three million people who are classified as direct-care workers.  These figures are way below to meet the demands of an expected increase of the aging population.  By the year 2020, there will be more than 19 million to 54 million people of over age 65. Moreover,  the life expectancy for American’s has gone up and the baby boomers who are now in their late 40s and 50s will more than likely see their 85th birthdays and more.

As a consequence of the aging of Americans, there will be a need for 325,000 nurse aides, orderlies, and attendants by 2014.  But retaining and recruiting them is a big challenge and the reasons for high turnover rate in this group of healthcare worker include low wages, few benefits, the toll on physical and emotional strain on workers, and significant risk for on-the-job injuries due to the lifting of patients (Weiner, Anderson, Khatustsky, & Squillace, 2009).

Direct Care Worker Demographics

There is an almost even split among the direct-workers caring for patients at home (42%) and in nursing homes (41%).  The rest (17%) are employed in hospitals (National Research Council, 2008).  A typical direct-care worker is a female (89%), not married, between 25-55 years of age, and with a high school education or less.  In terms of race demographic, 30% are African Americans and 15% are of Hispanic or Latino origin (Bureau of Labor Statistics, 2008).

Job Retention Strategies for Direct Care Workers

The turnover rate for direct-care workers is exceptionally high and remains to be challenging even though policy makers and provider organizations are busy designing efforts to reduce the turnover rate.  High turnover rates and vacant positions create instability in the continuity of resident care and quality.  As mentioned before, the reasons for high turnover rate include low wages, few benefits, the toll on physical and emotional strain on workers, and significant risk for on-the-job injuries due to the lifting of patients. Three possible strategies to retain these workers include: training and career opportunities, increasing the worker’s wages and benefits, and worker empowerment and culture change.

Training and Career Opportunities

It is well known that the training for nurse aides is inadequate including the current levels of educational requirements for certification. Most nurse aide educators agree and poor training is linked to the poor quality being expressed in some nursing homes and the exacerbation of neglect and abuse especially to those patients with dementia.  Recent survey of direct-care workers in different facilities indicates that more than half think the initial training was adequate, 40-45% indicates that further training would help, while 45% think that continuing education will only somewhat help (National Research Council, 2008).  A review of the literature regarding direct-care workers indicates that high level of training results in increased retention (Weiner, Anderson, Khatustsky, & Squillace, 2009).

For the most part, direct-care workers welcome the idea of more training and it shows in the retention rate.  High level of training is positively linked with increased home health workers. Programs like geriatric case-management have shown to be effective in enticing personal aide workers to stay and it also boosts their confidence and job satisfaction.  Moreover, nurse aides who have received continuing education seem to provide better quality of care (National Research Council, 2008; Weiner, Anderson, Khatustsky, & Squillace, 2009).

Increasing the Wages and Workers Benefits

Proposals to increase extrinsic wages and benefits of the job are an overwhelming case for workers to stay.   A study conducted in San Francisco, California showed that a near doubling of wages for home care workers resulted in an increased in the retention rate from 39% to 74% (Weiner, Anderson, Khatustsky, & Squillace, 2009).  OIG (2002) recommended that (National Research Council, 2008, p. 222):

“State Medicaid program should increase pay and fringe benefits for direct-care workers through such measures a wage pass-through, setting wage floors, establishing minimum percentage of service rates directed to direct-care labor costs, and other means.”

Direct care-workers receive low wages and declared as one of the 25 worst jobs in the United States by Forbes Magazine and thus lack the appeal.  This is due to the unpredictable nature of the job, meaning not enough hours for them to earn more even if they wanted to.  An average annual salary for female direct-care workers of $17,228 is about half of what females in general make ($30,441).  Nineteen percent of female direct-care workers live below the poverty line compared to only 8% of females in general (Wright, 2005).

Most of these workers have limited access to health insurance coverage, sick leave, and retirement benefits. Reports indicate that up to 25%  of these workers have no health insurance coverage at all because they work part-time or work independently. As expected female direct-care worker will more than likely to have no health insurance coverage than females in general.  In Los Angeles, the number of uninsured direct-care worker is up to staggering 45% (National Research Council, 2008).

Worker Empowerment and Culture Change

The stigma of being in the lowest level of pay scale affects direct care workers well-being as they often feel underappreciated, not getting enough respect for their knowledge and skills.  They lament the fact that they do not have enough input in the decision making process although they spend the most time with patients.  A number of nursing homes in North Carolina have piloted programs to involve more of their direct-care workers in the decision making process, worker empowerment, autonomy, and respect.  The examples provided by Eden Alternative, the Wellspring Model, the Pioneer Network, and Green House Homes, all nursing homes  have inspired workers resulting in improved quality of care (Weiner, Anderson, Khatustsky, & Squillace, 2009).


This article underscores the importance of direct-care workers in providing care to the elderly and the disabled. The impact of the aging process on the U.S. healthcare system will be mostly felt in the next 50 years as both the population and the healthcare workforce ages. If current utilization of healthcare continues, it is inevitable that the number of skilled healthcare workforce have to expand as well.  There are not very many models out there that can adequately predict the ratio of health care workers to population in a given area.   Chief among the reasons for labor shortage are an aging workforce, diversity disparity, difficulty in retention and recruitment, lack of educational training and career advancement opportunities, low wages and no fringe benefits, and increased workload.

Cesar Aquino is a Cytotechnologist with an MBA in Healthcare Management and currently a PhD candidate in Healthcare Administration

  • Sarah

    I think that our legislature needs to look at this more seriously. I believe that many places are running “short” which only means one thing. That our elderly are the ones that suffer. It is someone’s Grandma or Grandpa. Mother or Father. This is not a job for everyone. It is hard mentally and physically. CNA’s get attached, they become like family. I have been a CNA for 15 years. I disagree with the wages Nursing Homes are able to pay. The long hours that are requested by upper management. This is a subject that needs to become a priority!!