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WORKFORCE ISSUES IN LONG-TERM CARE

The concept of a long-term care workforce is of relatively recent origin. Throughout much of the history of the United States, only a small proportion of the population was old and infirm, and dependent aged persons were almost always cared for by family members. Institutional care was virtually unknown, with the exception of almshouses for the truly isolated and destitute. The professional provision of long-term care as it is known today began with the passage of the Social Security Act in 1935 and solidified with the advent of Medicare and Medicaid in 1965 (Olson).

Since that time, the enormous growth in the number of nursing homes, as well as in home care and community-based services, has produced a large number of individuals who care for older persons who are chronically ill and disabled. The care recipients require assistance for months or years and are very unlikely to return to totally independent living. Although long-term care workers have become essential to society, developments since the 1990s have made work in such settings increasingly challenging. There is now considerable concern, both at the public and at the personal level, about the supply and the caring capacity of long-term care workers.

National challenges

At the beginning of the twenty-first century, recruitment and retention of a committed long-term care workforce has become a serious challenge, and one that is likely to persist for several decades. There are a number of reasons for increasing difficulties in this area.

First, the explosive growth in the elderly population has created an enormous need for long-term care workers. The population age sixty-five and older will expand by eighteen million persons by 2010, from 35.7 million to 53.9 million. The number of elderly persons with functional disabilities will increase in that time by 1.6 million, from 8.8 million to 10.4 million (Congressional Budget Office). The growth in the latter group is particularly critical, because it constitutes the demand for long-term care. Much of the anticipated need for additional frontline workers is due to this increase.

Second, the long-term care population is becoming more disabled and more complex to care for. The emphasis throughout the 1990s on transferring elderly people from acute to long-term care settings has had a major impact on nursing homes in particular. This trend toward earlier discharge means that more residents have acute illnesses from which they have not completely recovered at the time they are transferred to long-term care facilities. One of the results of this trend is that nursing homes are now using technologies that previously were used only in hospitals. The burden of care for this increasingly impaired population falls on long-term care workers.

Third, the labor force as a whole is growing at a slower rate than the elderly population that needs care. When one examines the pool of persons most likely to become long-term care workers, there are good reasons to expect a continuing shortfall in the caregiving workforce. Women are the dominant providers in health care, representing 78 percent of health care positions in the United States in 2000. Most critical, 93 percent of paraprofessionals and 95 percent of nurses are women (Franks and Dawson). Therefore, a meaningful statistic is the relationship between the size of the elderly population (who are likely to need care) and the number of ‘‘traditional’’ caregivers—that is, working-age women. Nationally, this ‘‘caregiver ratio’’ shows a striking trend. In 2001, census data indicate that the caregiver ratio is fifty-eight elderly persons to every one hundred females age twenty-five to fifty-four. In 2025, the ratio will be slightly over ninety-nine elderly persons to one hundred females age twenty-five to fifty-four. This is very likely to lead to increased shortages of long-term care workers (U.S. Bureau of the Census).

Fourth, restrictive immigration policies reduce the labor pool. New immigrants are relied upon heavily in urban areas to fill frontline long-term care positions. However, employment-based legal immigration is largely limited to skilled workers; unskilled workers can wait years for work permits. Coupled with the shortage of younger workers, restricted immigration will result in a limited supply of new workers.

Makeup of the long-term care workforce

There are five major job categories in long-term care.

Certified nursing assistant (CNA). CNAs work under the supervision of the nursing staff, and provide 60 percent or more of the direct care to nursing home residents. CNAs assist residents with activities of daily living, such as eating, bathing, dressing, and transferring from bed to chair. They may provide skin care, take vital signs, and answer residents’ call lights, and are expected to monitor residents’ well-being and report significant changes to nurses.

Home health aides (HHA). HHAs carry out a number of tasks that are similar to those done by CNAs, but do so in an impaired individual’s home, under the supervision of a nurse.

Personal care aides (PCA). PCAs, who are not certified, provide patients with assistance in activities of daily living in their homes. Major tasks include feeding, dressing, and bathing.

Licensed practical (or vocational) nurses (LPN). LPNs must be supervised by a registered nurse, and primarily provide direct care after a training program of between twelve and eighteen months. LPNs often have some supervisory responsibility for CNAs in long-term care.

Registered nurses (RN). RNs can take several types of educational programs that may last different periods of time, but all graduates take the same licensing examination. Some RNs focus on direct care of residents, but most have supervisory responsibilities in the long-term care setting.

Because the major actor in the nursing home setting is the CNA, and because workforce problems center around this job category, this entry focuses most heavily on CNAs.

Characteristics of the long-term care workforce

The National Center for Health Statistics estimated that in 1998, approximately 1,434,000 full-time-equivalent employees (FTEs) worked in nursing homes. Of this number, around 950,000 FTEs were nursing staff: RNs, LPNs, and CNAs. CNAs make up nearly two-thirds of staff who provide nursing services, while RNs account for just 15 percent. This is illustrated as well by the staff-to-bed ratio in nursing homes. CNAs have a staff-to-bed ration of 33.9 per 100 beds, followed by LPNs (10.6) and RNs (7.8). Thus, the world of nursing home care is heavily dominated by paraprofessionals. In home health care, there are approximately 368,000 HHAs.

The need for additional paraprofessional workers in long-term care will increase dramatically by 2010. Among nursing assistants, a 23.8 percent increase is anticipated by 2008, and for home health aides, the growth is expected to be fully 74.5 percent (Bureau of Labor Statistics, ‘‘Health Services’’).

Work as a CNA or HHA at the entry level usually does not require a high school education. CNAs must undergo at least seventy-five hours of training (some states have a higher minimum). The training program typically covers basics of geriatric care, such as nutrition, infection control, and body mechanics, as well as the techniques of personal care. Within four months of employment, the nursing assistant must pass a certification examination. Training for HHAs varies from state to state. For those who work in agencies that receive Medicare funding, a competency test is mandated that covers various areas of resident care. Federal law also suggests a seventy-five-hour training program for HHAs.

Motivation for long-term care work

Studies indicate that long-term care workers frequently derive important satisfaction from their jobs. For example, in a survey of approximately six hundred nursing assistants, respondents were asked why they chose nursing home work (Pillemer). They rated twelve possible reasons that have been found to be important to people in selecting jobs. The most frequently chosen reasons were those that related to the intrinsic worth of the job, and the sense that it was socially valuable and personally fulfilling. Three reasons were selected as important by the highest proportions of respondents: provides opportunity to help others (96 percent), makes respondent feel meaningful (93 percent), and the job is useful to society (84 percent). In addition to these ‘‘other-centered’’ reasons, the next most frequent reasons for working as a CNA had to do with rewarding aspects of the job itself: it offers a lot of contact with others (81 percent), is an interesting job (73 percent), and it gives the chance to do responsible tasks (72 percent).

In addition, frontline jobs in the long-term care field do not require extensive education and training, and are typically available to young people, displaced homemakers, new immigrants, people transitioning from welfare, and other persons with limited work histories. The jobs offer more varied and meaningful work than many positions in the hospitality, construction, and manufacturing industries (which also compete for these employees). Further, especially in home care, the jobs offer a greater level of autonomy than other comparable professions.

Problems in long-term care work

Although many long-term care workers are highly committed to their work and derive satisfaction from it, research has extensively documented the many difficulties of the job. These factors have been found to be related to high rates of perceived job stress and burnout, and lower levels of job satisfaction. In the contemporary tight labor market, these problems lead to high rates of turnover in all positions.

Estimates of turnover of nursing home staff are quite high, with annual CNA turnover at 97 percent, RN turnover at 52.5 percent, and overall staff turnover at 69 percent (Harrington et al.). Although estimates differ, turnover is also a problem in home care. For this reason, understanding and reducing employee turnover in long-term care settings has become a major undertaking for both researchers and practitioners. As in other health care settings, turnover and short staffing have been found to have many negative consequences, including reduced employee efficiency and lower morale among employees who stay on the job (Cohen-Mansfield). More important, such staffing problems lead to decreased quality of care for residents (Wunderlich et al.; Harrington et al.).

The following are some major causes of stress, burnout, dissatisfaction, and turnover among long-term care workers.

Excessive work pressure. In surveys, many nursing assistants say that they routinely do not have enough time to complete their basic tasks. This sense of time pressure takes the enjoyment out of their work. Nursing assistants report that when time is short, they are not able to do more personal, satisfying tasks, such walking with residents, talking to them, helping with grooming, and so forth. As caregiving work is reduced to the most difficult and least gratifying tasks, and staff feel that they do not have time to complete even these tasks, job stress and burnout increase.

Understaffing. Work pressure is exacerbated by chronic understaffing in many long-term care facilities. The pressure caused by staff shortages is very severe, and leads to stress and burnout. Conversely, adequate staffing has been found to be the major factor leading to high staff morale. Wilner (1994) found that a major source of dissatisfaction and stress was working with too few other nursing assistants, or with new staff who were not adequately trained. Nursing assistants were especially anxious about injury to themselves, to the new staff member, and to the residents in these situations.

Problems in supervision. Studies show that problems with supervisors are a major cause of job stress and burnout. Conflicts with supervisors are very stressful to frontline long-term care workers. Helmer and colleagues showed the extent of such dissatisfaction. Their survey of nursing assistants found that 71 percent wished administrators and nurses would show them more respect; only 37 percent felt they received sufficient recognition and appreciation for their work. Further, only 36 percent felt that management made them feel ‘‘in on things.’’

Lack of appropriate training. Despite the view that frontline long-term care work is ‘‘unskilled labor,’’ the job is in fact both technically and interpersonally complex. As noted earlier, the training given to nursing assistants and home health aides is very limited. Further, it focuses almost exclusively on the technical aspects of care, although there is evidence that difficulties in dealing with the psychosocial aspects of nursing home work are causes of stress and burnout.

Wages. Funding for nursing assistants comes primarily from Medicaid and Medicare. In many cases, the wages offered keep some workers near the poverty level. In 1998, the mean hourly wage of CNAs was $8.32, and for HHAs it was $8.17. For the purposes of comparison, in the same year telemarketers earned an average of $9.40 per hour, and elevator operators an average of $14.77 (Bureau of Labor Statistics, 1998). Thus, wages for long-term care workers remain comparatively low, considering the difficult nature of the job. Further, some long-term care providers still do not provide CNAs with health benefits. When such benefits are offered, the premiums the CNAs must pay are often prohibitively high for them to participate.

Injury. It is acknowledged that CNAs are at high risk of injury. Indeed, rates of injury in nursing and personal care homes exceed that of private industry in total by a significant amount. CNAs are particularly prone to injury from heavy lifting (Wunderlich et al.).

Relations with family members

An area of significant research interest is the way in which family members of care recipients relate to long-term care workers. Clearly, cooperation is essential to optimal resident care. However, research indicates that structural barriers to cooperation between the two groups exist. In the most influential theoretical approach to this problem, Eugene Litwak noted fundamental differences between large-scale formal organizations and primary groups, such as families. In nursing homes, the potential for family conflict with staff is heightened because long-term care facilities represent the classic case of a formal institution seeking to take over primary group tasks, and to fit the performance of such tasks into a bureaucratic, routinized, organizational framework.

Consistent with Litwak’s view, one line of research has pointed to discrepancies between staff and family perceptions of appropriate tasks for each group Although studies vary in their estimates of the extent of such differences, it is clear that ambiguity regarding the division of labor between staff and relatives exists, particularly in the performance of nontechnical tasks, and can lead to conflict (Duncan and Morgan).

Even when families relinquish the technical aspects of care to the staff, they nevertheless feel compelled to monitor the quality of service delivery. Stephens and colleagues found that over one-third of relatives reported feeling that they had to remind staff to do things for their resident, and that they needed to tell the staff how to care for the resident.

Research has also identified poor communication between staff and families as an important problem. Many residents, especially those with cognitive impairments, are unable to give accurate, factual information about their experience in the facility. There is often little sharing of detailed information about residents, and families frequently feel that there is no one to whom they can bring their concerns. Further, relatives are sometimes hesitant about offering suggestions and criticism, out of fear that such comments might negatively affect the care provided to the resident. Additional barriers to communication include the fact that staff work under intense time pressure, which limits their availability for conversations with families. In addition, nursing home staff—and nursing assistants in particular—receive little or no training in communication skills (Pillemer et al.).

As a result of these problems, studies have found that both staff and family members were frequently annoyed, and sometimes very angry, during and after interactions with each other. Studies of nursing home staff have shown that problems relating to family members are a major source of stress.

Future directions

To upgrade the quality of the long-term care workforce, and to solve the problems of recruiting and retaining enough qualified workers, several options have been proposed.

Increasing minimum staffing requirements. One solution to staffing problems is to increase the number of caregivers in nursing homes. There is considerable consensus among researchers that higher staffing levels are positively associated with better outcomes for nursing home residents. This is particularly the case with RN staffing, but is also applicable to CNAs. Increasing staffing in nursing homes is likely not only to improve the quality of care but also to benefit staff morale, satisfaction, and retention by reducing the stress of providing care (Harrington et al.).

Increase and upgrade training. Although a body of rigorous evaluation research is lacking, there is evidence that training programs of various kinds improve the performance of CNAs and thus leads to improved outcomes for residents (Beck et al.).

Improve salaries and benefits. Many nursing homes and home health agencies have very devoted, long-term employees. However, some individuals do not consider long-term care work, or leave it after trying it, because the salaries are inadequate. Raising the salaries of workers and improving benefits is now a goal in many states.

Expand the range of roles. A number of experts suggest reexamining the official role of the frontline worker, and expanding what is now a monolithic job category into a career ladder of increasing responsibilities. In particular, new job categories can be developed in the nursing home, ranging from an entry-level resident attendant position, to several categories of CNAs. Workers can then can advance to positions of greater responsibility within the facility.

KARL PILLEMER MARK S. LACHS

See also GERONTOLOGICAL NURSING; HOME CARE AND HOME SERVICES; LONG-TERM CARE; NURSING HOMES.

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