Long-term Care, Globalization, and Justice

2 The Plight of Paid Workers in Long-term Care

27 The 500,000 registered nurses (RNs) and licensed practical nurses (LPNs) now working in long-term care in the United States provide direct care as well as care coordination and supervision in high and mid-level management positions (Reinhard and Young 2009). Direct care workers, however, play the most integral role in long-term care, providing up to eight out of every ten hours, or 70 to 80 percent, of paid care for those who are elderly, disabled, and/or suffer from chronic conditions. In 2006, there were more than 3 million direct care workers (Paraprofessional Health Institute 2011). These care workers, also known as paraprofessionals, are employed in a variety of settings. Only 17 percent can be found in hospitals; the rest are in long-term care settings: nursing homes, assisted living facilities, and individual residences (Paraprofessional Health Institute 2011). Depending upon where they work, direct care workers perform a wide range of tasks, including providing assistance with mobility, bathing, dressing, toileting, cooking, eating, housekeeping, shopping , transportation, and with paying bills. Like nursing, this work is highly gendered. Nearly 90 percent of direct care workers are women. More than half are non-white or Hispanic. The field, indeed , is sometimes described as a “minority industry,” for the perCHAPTER TWO The Plight of Paid Workers in Long-term Care 28 long-term care, globalization, and justice centage of minority workers is significantly higher than in the U.S. workforce as a whole (Montgomery, Holley, Deichert, et al. 2005; Wolff and Kasper 2006; Paraprofessional Health Institute 2011). Home health and personal care aides have been identified as being among the fastest-growing occupational groups (U.S. Bureau of Labor Statistics 2007; Paraprofessional Health Institute 2010a). Demand for direct care workers in home settings, already their most common place of employment, is expected to increase for several reasons. Cost containment in health care, the growing complexity and cost of long-term care, and the diminished capacity of family caregivers to meet elders’ needs may all increase the demand. Additionally, as states continue to respond to the U.S. Supreme Court’s 1999 decision, Olmstead v. LC, which held that people with disabilities must receive services in noninstitutional settings whenever possible, the need for such workers will expand. A growing number of them are hired on the gray market (Martin, Lowell, Gozdziak, et al. 2009). While the importance of nurses and direct care workers is indisputable and on the rise, they face a difficult plight. Social Values and Health Policies Around the world, paid care work generally suffers from a poor public image and a lack of social respect (Folbre 2001; Kittay 2001; Miller, Booth, and Mor 2008). Those who care for pay also confront difficult working conditions. Nurses in the United States point to such problems as underinvestment in the health sector, staffing that is insufficient to support quality patient care, increasing hours on the job, rotation between units, centralized decision making that denies them participation (including participation in decision making regarding patient care), inadequate opportunity for continuing education and professional development, and poor compensation (Heinrich 2001; Berliner and Ginzberg 2002; Steinbrook 2002; Institute of Medicine 2003). Many, though by no means all, of these concerns can be attributed to health care restructuring in The Plight of Paid Workers in Long-term Care 29 the United States that was carried out in the 1990s under the rubric of “managed care.” Aimed at “improving efficiency” and reducing costs, managed care called for reducing staffing levels and substituting nurses with less training—such as LPNs and nurse aides— for RNs (Halford, Savage, and Witz 1997; Norrish and Rundall 2001; Weinberg 2003). Frustration with poor working conditions and low morale, in part because of such restructuring measures, are concerns cited by nurses around the world (Allan and Larsen 2003; Gordon 2005; Royal College of Nursing 2007). These problems described by nurses are exponentially greater for direct care workers (Paraprofessional Health Institute 2011). This sector of the health workforce reports high rates of job stress and low satisfaction, even when they recognize the importance of their work (Stacey 2005; Brannon, Barry, Kemper, et al. 2007; Castle, Engberg, Anderson, et al. 2007; McGilton, Hall, and Wodchis et al. 2007). Regarded as “unskilled,” direct care workers enjoy little if any respect in society or in the settings where they work (Bowers , Esmond, and Jacobson 2003; Better Jobs...