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Building a High-Quality Long-term Care Paraprofessional Workforce

Working Conditions


Linda S. Noelker, Ph.D., Senior Vice President of Operations and Research, Benjamin Rose Institute, Cleveland, OH.

Mary Ann Wilner, Ph.D., Director for Health Policy, Paraprofessional Healthcare Institute, Bronx, NY.

Good-quality jobs include:

  • Family wages and benefits.
  • Balanced and safe workloads.
  • Adequate training.
  • Opportunity for advancement and professional development.
  • Support from both the community and employer.

Unfortunately, the working conditions for the long-term care (LTC) paraprofessional workforce lack many of these qualities.

Wages for LTC paraprofessionals average between $6.50 and $8.00 per hour. Most paraprofessionals work below the Federal poverty level and often hold more than one job. The majority of these workers are either not offered health insurance by their employer or the premiums are unaffordable.

Turnover rates for paraprofessionals are highest in the first 3 to 6 months of employment. This is due, in part, to inadequate training and support. Classroom teaching often does not resemble on-the-job demands. Also, current clinical training does not adequately prepare paraprofessionals to handle:

  • Challenging clients and families.
  • Interpersonal communications.
  • Problem solving.
  • Critical thinking skills.

Many direct care workers report that their relationship with their supervisor is the main reason why they leave or stay on the job. Good supervision enhances:

  • Retention.
  • Learning.
  • Motivation.
  • Client care.

Although paraprofessionals provide 80-95 percent of the care, few are involved in care planning and quality assurance activities.

Many paraprofessionals often need assistance with:

  • Transportation.
  • Child care.
  • Medical access.
  • General equivalency diploma (GED) and English as a second language (ESL) training.

Assistance with these supports is rarely offered to paraprofessionals by employers and local governments.

Few opportunities exist for paraprofessional career development. Government training and funds have been very limited in most areas. Paraprofessionals often encounter GED and ESL hurdles. The educational and training requirements for LPNs and RNs far exceed the requirements for nursing assistants.

New developments in career advancement and job redesign are emerging. Career advancement programs may include:

  • Job expansion.
  • Organizational reform (such as teamwork, changes in supervision, and new models of caring).
  • Health career paths.

For example:

The Cooperative Health Care Network in New York is comprised of three worker-owned home health agencies, where home health aides can move up to positions such as:

  • Associate trainers.
  • Peer counselors.
  • Coordinators.
  • Clerical staff.
  • Workforce development staff.

Apple Health Care, which has 21 nursing homes in Connecticut, Rhode Island, and Massachusetts, has a certified nursing assistant (CNA) career path offering financial incentives upon completion of sequential levels involving individualized care, improving quality of life, and leadership.

Providence, Mount St. Vincent Nursing Home in Seattle, Washington, redesigned the CNA job and title, now referred to as a resident assistant, who is actively involved in decisionmaking.

Successful strategies for career advancement programs include:

  • Building a strong foundation in training.
  • Building incrementally.
  • Building in necessary supports such as day care, transportation, and counseling.
  • Fostering advancement opportunities in the workplace organization and culture.
  • Developing career ladders.
  • Involving workers on a regular basis.

In addition to strategies initiated by providers, States can be active partners in helping to solve these recruitment and retention problems in home care and nursing homes. According to Dr. Wilner, through legislative or regulatory change or fiscal authorizations, States can:

  • Increase wages for direct care workers.
  • Develop health insurance programs or subsidies for low-wage health workers.
  • Provide training resources and develop training or career ladders.
  • Assist with child care and transportation costs.
  • Provide demonstration funds for pilot programs in wage enhancements.
  • Establish task forces that forge connections between the departments of labor, health, and welfare. All three of these departments directly affect the lives of direct care workers, yet rarely do they synchronize their policies to improve the work lives and well-being of these valuable employees.

Linda Noelker, Ph.D., recently completed an analysis of three research studies that examined issues related to improving work settings and job outcomes for nursing assistants (NA) in skilled nursing facilities (SNFs). The analysis looked at:

  • The demographics of the NAs in this research.
  • Their reported major sources of stress.
  • How the stressors affected their job satisfaction and well-being. The analysis also made recommendations to alleviate the stress and improve working conditions.

According to Dr. Noelker's analysis, job-related sources of stress for NAs included:

  • Scheduling problems.
  • Training issues.
  • Treatment by the supervisor.

The main sources of job dissatisfaction included:

  • Low wages.
  • Mishandling of employee complaints.
  • Lack of promotion opportunity.
  • Lack of benefits.

Decreased physical and emotional health were also recognized. Off-the-job stresses, such as family and financial worries, can also contribute worker dissatisfaction.

Recommendations for improving the retention and health of NAs included:

  • Managing stress and improving employee health through health screening, stress management, and counseling.
  • Improved education and training through additional training hours, including dementia care.
  • Improved supervision regarding communication, recognition, and team-building skills.
  • Improvements in administration and management, such as establishing career ladders and creating a "family friendly" work environment that provides onsite child care and flex-time.


Paraprofessional Healthcare Institute. Direct-Care Health Workers: The unnecessary crisis in Long-term care. Washington, DC: Aspen Institute. September 2000.

Noelker LS. The backbone of the long-term care workforce. Generations 2001 Spr;XXV(1)85-91.

Noelker LS, Ejaz FK. Improving work settings and job outcomes for nursing assistants in skilled nursing facilities. Final Report. Cleveland (OH): The Benjamin Rose Institute, 2001 Sum.

Van Kleuen A, Wilner MA. Who will care for mother tomorrow? Journal of Aging and Social Policy 2000;11(2/3):115-26.

Wilner MA. On the front lines of health care. Health Progress. The Catholic Health Association of the United States. 1999 Jan-Feb.

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