Why Are Direct Care Workers So Crucial and What Can Be Done to Improve their Working Conditions?

Direct care workers (DCWs) provide care to older adults and those with disabilities. The term “DCWs” can be used to refer to different types of healthcare workers in different contexts. For this piece we use the US Department of Labor’s definition of DCWs, which includes home health aides, attendants, personal care aides, and nursing assistants. Despite variations in their care settings—long-term care (LTC), community-based settings, etc.—DCWs typically ensure personal and medical care on a daily or near-daily basis.

With an aging population and a push for shorter hospital stays, demand for DCWs has surged. In the United States, there are currently 4.8 million DCWs; estimates suggest that an additional 9.3 million more workers will be needed by 2031. Yet, the supply remains low, partly due to poor job quality, structural inequities, and challenging working conditions. DCWs are predominantly middle-aged women and people of color, and they often face low wages (median $13.56/hour), irregular hours, and inadequate benefits (about half of DCWs have access to health insurance through the workplace). All of this contributes to high turnover rates. Why are direct care workers so crucial, and what can be done to improve their working conditions?

Long-term Care

In the United States, people over 65 have a 70% chance of needing some form of LTC service. LTC takes place outside of an institution like a hospital, and in these LTC facilities, patients may receive personal assistance, care services or home and community-based services. This enables older or disabled individuals to maintain their independence and participate in family, community, and financial activities. Currently, 10.9 million community residents need LTC, and as Americans age, research suggests an additional 3,000 more nursing homes are needed to meet the country’s demand.

The combination of high demand and an aging population highlights a critical issue within the healthcare system. Significant reforms are urgent. This includes increasing the number of nursing homes and enhancing the services provided in community-based settings. Without these reforms, the healthcare system will struggle to meet the growing needs of the population, compromising the well-being and independence of millions who rely on these essential services.

Job Quality

DCWs face low wages, inadequate training, and limited career advancement opportunities. These factors lead to high turnover rates and a shortage of workers in the sector. A living wage, comprehensive and competency-based training, and clear career pathways will not only help retain current workers but also attract new ones to the field. Additionally, providing consistent scheduling and better benefits, such as paid sick leave and health insurance, will ensure that DCWs can focus on delivering high-quality care without the added stress of financial instability. Improving these aspects of job quality will lead to a more stable and satisfied workforce, ultimately benefiting the patients who rely on their care.

Retention and Turnover

Turnover rates range from 35% for certified nursing assistants (CNAs) in hospitals to over 90% for caregivers in nursing homes. This alarming turnover is driven by low wages that fail to reflect the increasing demand for services, inadequate training, limited opportunities for career advancement, and significant physical and emotional stress. The combination of these factors leads to a cycle of high turnover, which in turn places strain on the remaining staff who must fill in gaps and train new hires, often without adequate support or compensation. This instability threatens the quality and continuity of care provided to patients, compromising their health outcomes and overall well-being.

In addition to wages, training, and clear career advancement pathways, manageable workloads, benefits such as health insurance and paid sick leave, and a supportive and respectful work environment could significantly enhance job satisfaction and retention rates. Long-term, systemic changes in policy and funding, such as increased Medicaid reimbursement rates to support higher wages and benefits, are crucial to sustaining these improvements.

Safety

DCWs face significant risks of occupational injury, which not only jeopardizes their well-being but also their ability to deliver consistent, high-quality care. Injury rates among DCWs are alarmingly high: nursing assistants experience injury rates more than three times the national average for all workers. The primary causes of these injuries include overexertion from lifting and repositioning clients, as well as violence from clients or animals. These injuries often result in time off work, and most DCWs do not receive pay during their recovery, compounding financial strain and high turnover rates.

To address these issues, it is crucial to implement comprehensive safety training, provide ergonomic equipment like mechanical lifts, and ensure adequate staffing to distribute workloads more evenly. Safer workplaces will enhance job satisfaction and retention, stabilizing the workforce and ensuring better patient care​.

Patient Outcomes

DCW outcomes—job satisfaction, turnover, and emotional well-being—significantly impact patient outcomes. For instance, higher job commitment among CNAs is associated with better quality of life for nursing home residents, while higher turnover rates correlate with increased incidences of pressure ulcers, pain, and urinary tract infections among residents. Additionally, positive emotions at work among home health care staff are linked to successful patient outcomes and reduced pain. Conversely, negative emotions and high turnover among DCWs can lead to poor care conditions and weak patient relationships.

Unionization: A Proposed Solution

Unionization can significantly enhance the quality of DCW jobs by addressing their wages, benefits, and job quality. By forming unions, DCWs can engage in collective bargaining, a process that allows them to negotiate with employers for better wages, comprehensive benefits, and safer working conditions. Research found that unionized DCWs earn about 7.8% more than their non-unionized counterparts. Unions can also advocate for better training programs and career advancement opportunities.

Unionization has substantial benefits for DCWs. Future labor policy should seek to address job quality issues by encouraging collective bargaining. Policymakers should also recognize the systemic disparities faced by a workforce that is predominantly middle-aged, female, and of-color, ensuring that future policies are inclusive and free from discrimination.