Challenges Faced by Nursing Home Direct Care Workers During the COVID-19 Pandemic: A Comparison Across Care Settings

The COVID-19 pandemic has generated awareness of the value of the direct care workforce to provide care in settings serving those most at risk from the disease. However, few studies have gauged the impact of COVID-19 on this workforce and their pandemic-related challenges. The purpose of this study was to examine the challenges and stress experienced by direct care workers (N=1,414) and their perceptions of preparation and quality of employer communication during this health crisis. Nursing home (NH) workers reported separation from family members and understaffing as the top external and work-related challenges. They felt adequately prepared and gave their employers high marks for communicating with them during the pandemic. NH direct care workers were more likely to report increased workload and understaffing as a challenge compared to workers in home and community-based settings. They also experienced a significantly higher number of work-related challenges compared to workers in assisted living.

Direct Care Workers Employed as Medical Aides: Home Health Aides, Nursing Assistants, and Orderlies

Purpose This study describes the differences among direct workers (DCWs) employed as medical aides in three occupations: home health aides, nursing assistants, and orderlies. Design and Methods Data were from the 1% Public Use Microdata Sample (PUMS) of the 2019 American Community Survey (ACS). Logistic regression was used to compare demographic and employment characteristics of DCWs employed as medical aides in three occupations: home health aides, nursing assistants and orderlies. Results Compared to orderlies and psychiatric aides, home health aides are more likely to be foreign born, more likely to be female, less likely to work in institutional settings, less likely to be under age 25, less likely to work year-round full-time, less likely to have more education, and less likely to receive insurance from their employers. Implications: Since 2018, the PUMS of the ACS separates nursing, psychiatric, and home health aides (previously one occupational category) into three: home health aides, nursing assistants, and orderlies. This affords researchers a more precise understanding of this part of the direct care workforce. Home health aides represented more than 2/3 of DCWs employed as medical aides in 2019. Further, these workers are distinct among medical aides. More than nursing assistants and orderlies, home health aides are older, female, underinsured, foreign-born, and with limited education. This reflects both the barriers home health aides face to other occupations and also the preferences of their employers (which include private households). These findings have implications for the recruitment and retention of medical aides across all three occupations.

Influences of Prejudice and Stereotyping in the Direct Care Workforce

Direct Care Workers (DCW; nursing assistants, personal care aides, home health aides) have the most one on one care with sexual and gender minority (SGM) older adults who reside in residential care facilities or use home health services. DCWs make up a vast majority of the healthcare workforce, holding almost five million jobs in 2019, with approximately 70% of the positions held being in residential care facilities. In a qualitative design study, 11 DCWs were interviewed using an open-ended, semi-structured format to describe their perceptions of care provided to SGM older adults in residential care facilities and the home health setting. These results were part of a larger qualitative study which found there were cues of stereotyping and prejudice in DCW narratives toward SGM older adults. The category DCWs’ care and social system referred to characteristics of the DCWs’ work environment and the perspectives, attitudes, and reported care toward SGM older adults and diverse populations. It was determined that there are synergies among SGM older adults’ care and DCW along with DCW workforce issues (short staffed, low wages, lack of health benefits) that may prevent the DCW from being accepting of implicit bias training or culture change within these facilities/agencies. Implications for practice, policy, and future research are discussed.

Grief and Loss During Care Transitions: Experiences of Direct Care Workers

Direct Care Workers (DCW) provide both personal care to patients and emotional support to patients and caregivers in hospice and palliative care. DCWs often develop close ties and are then expected to work with new clients immediately following a care transition, with little or no time to grieve. A qualitative pilot study (n = 24) was conducted to explore the experience of DCWs during care transitions. Data was collected via focus groups and individual interviews. Thematic analysis was used. Results suggest DCWs managed their experiences (n = 19), by anticipating and accepting grief and loss (n = 21), employing personal coping strategies (n = 19), and saying good-bye (n = 15). Relational factors impacted the experience of care transitions (n = 22), including building and maintaining the relationship (n = 14), and the strength of perceived connections (n = 15). Increased organizational support and training to help address grief and loss will better support DCWs and the direct care workforce.

Direct Care Workforce: Where the Boys Really Are

Purpose: This study describes the continued growth of male direct care workers (DCWs) and identifies the occupations with the greatest concentrations of male DCWs by utilizing the expanded information available in the 2018 American Community Survey (ACS). Design and Methods: Data were taken from the 1% Public Use Microdata Sample (PUMS) from the 2018 ACS. Beginning in 2018, the ACS separated the single occupation category nursing, psychiatric, and home health aides into three categories: home health aides, nursing assistants, and orderlies and psychiatric aides. Results: Between 2000 and 2018, the total number of male DCWs in the U.S. increased 118% to 474,925, with more than half (52.6%) in 2018 employed as nursing, psychiatric, and home health aides. Among these 250,139 aides, 62% (154,557) were employed as nursing assistants, 23% (57,126) worked as home health aides, and 15% (38,456) were employed as orderlies and psychiatric aides. However, 60% of all orderlies and psychiatric aides were male; this was the only occupation in the direct care workforce in which men were in the majority. Implications: The majority of male DCWs work as nursing, psychiatric, and home health aides and the new occupation classifications in the ACS reveal that while most work as nursing assistants and home health aides, the one occupation with a majority male workforce was orderlies and psychiatric aides. These findings suggest that the greatest need for male DCWs may be as orderlies and psychiatric aides, occupations in which size and physical strength are important factors.

It Is Time to Resolve the Direct Care Workforce Crisis in Long-Term Care

Nearly 4.6 million direct care workers—including personal care aides, home health aides, and nursing assistants—provide daily support to older adults and people with disabilities across a range of settings in the United States, predominantly in long-term care (LTC). Even as the population grows older and drives up demand for LTC, the sector continues its decades-long struggle to fill direct care positions and stabilize this essential workforce. Recent events and emerging trends have converged, however, to produce new opportunities to address this longstanding workforce crisis, including the unprecedented attention generated by the coronavirus disease 2019 (COVID-19) pandemic and the systemic shifts to managed care and value-based payment in LTC. This Forum article outlines the pressing direct care workforce challenges in LTC before describing these potential levers of change, emphasizing the importance of not just expanding the workforce but also maximizing direct care workers’ contributions to the delivery of high-quality services for a growing and evolving population of LTC consumers.

A Profile of the Assisted Living Direct Care Workforce in the United States

Background and Objectives: The purpose of this article was to develop a profile of direct care workers (DCWs) in assisted living (AL). Research Design and Methods: We used data from 2014 American Community Survey (ACS) to identify the demographic and employment characteristics of AL DCWs. We collected state training requirements for AL DCWs from the administrative rules of state agencies and interviews with state officials. Results: AL DCWs were more likely than other DCWs to be younger, male, White, English speaking, U.S.-born, never married, and to have attended college. Two Affordable Care Act (ACA)–designated training topics (self-care and the role of the personal care aide) were not required in any state. Discussion and Implications: AL has tapped a unique pool of workers (i.e., younger, male as well as female, and with some college education) but needs to address its workforce needs via training, improvements to overall job quality, and the development of career opportunities.