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Making direct care more appealing

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The care needs of an aging population and the low pay of some of those tasked with fulfilling those needs intersected in a documentary airing last night on HBO.

“Paycheck to Paycheck: The Life and Times of Katrina Gilbert” follows the financial and other struggles of a 30-year-old single mother of three making $9.49 an hour as a certified nursing assistant (CNA) in a Tennessee extended care facility. (If you missed it last night, the documentary is available online at no charge through March 24 on, and YouTube and also will be televised again on HBO and HBO2 several times through the end of the month.)

“Even nurses say a CNA’s job is the backbone to the nursing field,” Gilbert says as the camera shows her performing the various duties of her position. As much as she enjoys the work and the residents she helps care for, “I don’t want to be a CNA for the rest of my life,” she says, later adding, “It wears you out. It wears your body down. I feel like I’m 60 years old.” She plans to return to school to further her career in healthcare.

The film is just one part of a multiplatform initiative, The Shriver Report: A Woman’s Nation Pushes Back from the Brink, conducted in partnership with the Center for American Progress. The focus of the effort is not healthcare, but poverty, especially as it relates to working women and their families. Nonetheless, healthcare figures prominently in the issue, not only because the documentary’s subject is employed in long-term care but also because of the challenges Gilbert faces related to paying for doctors’ appointments and prescriptions and the effects that those challenges have had on her life.

“Katrina’s story is typical of the nation’s more than four million direct-care workers—nursing assistants, home health aides and personal care aides,” Paraprofessional Healthcare Institute President Jodi Sturgeon wrote in a related blog. “These workers provide 70 to 80 percent of hands-on, long-term care to elders and people with disabilities living in nursing homes, assisted living facilities, community settings and their homes. Direct-care workers like Katrina are the invaluable backbone of our nation’s long-term care system, yet they earn poverty-level wages.”

Those aren’t surprising words to hear from the head of an organization that has a goal of promoting fair pay for those in the direct care workforce. As Sturgeon also points out, however, Americans need to figure out how to address the issues that drive direct care workers to depend on Medicaid, food stamps and subsidized child care—and drive them to look elsewhere for employment at the precise point in time when our country’s growing older population needs them more than ever. The U.S. Department of Labor predicts that demand for direct-care workers will increase by 37 percent over the next 10 years, Sturgeon notes.


Lois Bowers

Lois Bowers


Lois A. Bowers was senior editor of Long-Term Living from 2013-2015.



The government could mandate more staff per resident. In other words, right now, most nursing homes provide 3.0 hours per resident, which means that a hallway of 20 residents or elderly people in a nursing home has a total of 60 hours per day to take care of bathing, dressing, feeding, provide activities, and exercising programs, not to mention helping them with bathroom duties. Most elderly people need assistance from at least one person, if not two people. That means one nurse and two eight-hour people for the a.m. hours and one and one-half people and a nurse for p.m. hours and one nurse and one certified nurse aide for night shift hours. This is not enough people to properly care for our frail elderly. We are loosing good, loyal nurses and certified nurse aides by alarming numbers everyday. The pay is very low for what is expected of them. In acute care, you will see typically one charge nurse and one aide for every three to four people. In long-term care, you will see one nurse for 20 to 35 people and one certified nurse aide for every 12 to 15 people. Nursing home staff need help desperately. They work like horses to take care of our dementia and physically and mentally disabled people, and they do it for low pay and not a lot of recognition for what they do. You only see the negative printed about the very few who ruin it for all.

Dear Sarah: Thank you very much for your comment. It’s such important work for many reasons. I hope documentaries such as this one increase the public’s knowledge of the issues so that change can occur.

What about the role of government and their low reimbursement? Providers would pay more if they could.

Thank you for your feedback, Timothy. As you suggest, it's a complicated issue, and many entities will need to come together for solutions.

Facilities need to listen to staff concerns.

Thanks for your comment. I agree that listening could help staff morale and satisfaction.

Unity is a key component. I also think some of the required in-services should cover financing for direct care because of the wages they earn. Most of the turnovers I see are not because of the amount they earn, but because of the environment--not concerning the residents, but co-workers and administration. Appreciation is important.

Thank you for the comment, Jessica. I agree--entities can be stronger when people feel as if they are working toward a common goal.