Who works in nursing homes?  Who are the primary caregivers for elderly patients there?

I offer a reminder that my purpose in writing about nursing homes in the context of my theme of respect for the elderly is not to provide research or statistical analysis on those living or working there but to share my observations from the last 25 years in mostly urban New England settings.  I welcome your nuanced perspectives on the stories I tell and the impressions I offer.

Nursing homes employ a multiplicity of people:  administrators, Registered Nurses (RNs) who serve as nursing supervisors, attending or resident physicians, dietitians, cooks, occupational and physical therapists, psychologists and psychiatrists, activity directors, janitorial and laundry staff, buildings and grounds workers, AND those who provide direct care for the patients – Certified Nursing Assistants (CNAs), or Nursing Assistants (NAs), as they are commonly called.  I am unclear of the difference between these two categories except that one is certified by an accredited training program and the other is apparently not.  The combined job description for CNAs and NAs, as outlined on salary.com, states:

Under the supervision of a Registered Nurse, performs various direct patient care activities in a nursing home environment. Assists patients in dressing or undressing, bathing, or eating. Collects non-invasive body fluid specimens or gathers vital signs but does not start or administer intravenous fluids. Aids physicians and nursing staff members with procedures if needed. May serve and collect food trays, provide for between-meal nourishment, and clean, sterilize, store and prepare other supplies. Documents patient interactions as needed. Requires a high school diploma and certification from an accredited nursing assistant program. Familiar with standard concepts, practices, and procedures within a particular field. Relies on limited experience and judgment to plan and accomplish goals. Performs a variety of tasks. Works under general supervision. A certain degree of creativity and latitude is required. Typically reports to a registered nurse or manager.[1]

And who are the CNAs and NAs? In Northeast urban areas, many are immigrants, often from Caribbean or Latin American countries, predominantly women in early middle age. English is their second language.  I am less knowledgeable about nursing homes in rural settings, but I suspect that the direct caregivers are much like those in the facility in my hometown in Nova Scotia where I worked as a teen: local women (very few men) who elected to pursue technical CNA training in order to be able to work near home for various reasons.  And in Nova Scotia today new immigrants, from a diversity of countries, make up a large sector of nursing home caregivers.

Because English is often the second language of nursing home caregivers, language barriers often contribute to the quality of care provided to patients. I have observed NAs and patients who were extremely frustrated with one another due to language barriers.  It’s hard to describe feelings, both physical and emotional, to a caregiver from another culture who does not speak your language well.  It’s hard to hear instructions or expressions of concern from a caregiver when you may be hard of hearing or unable to decipher an accent.

CNAs and NAs are among the lowest paid employees in our country.  Still, after doing a little research, I’ll have to admit that the information I found suggests that they are not as badly paid as I suspected.  The median annual salary for a CNA in the USA (as of March 31, 2017) is $25,840; for an NA (though no certification is required) it is $28,644.  The hourly wage is between $14-15. In the Boston area the median annual salary is $29,134.[2]  Salaries vary widely depending on a number of factors including the location and size of the facility and education and experience of the aide.  Nursing Assistants in Massachusetts make about $3 per hour above the minimum wage.

The CNAs or NAs are the people who matter most to nursing home patients; they are the employees who are directly responsible for the quality of care that the patients receive.  As caregivers, they interact with their patients multiple times a day, and those patients rely on them for the most basic needs: cleanliness and toileting, food, and movement from place to place.

Nursing Assistants are on the front line day in and day out. They have an extremely difficult and physically demanding job, spending long hours standing, walking, bending, lifting, pushing and carrying.  The conditions in which they work are often “unpleasant.” Incontinence is a common condition for nursing home patients, and the odors are off-putting and even nauseating. How many of us have wondered how baristas at Starbucks get the smell of coffee out of their clothes and nostrils?  Need I say more.

And patients can be difficult.  The elderly can be demanding, angry and even physically, verbally and psychologically abusive to their caregivers.  Sometimes this is due to long-standing personality faults and at other times to the onset of dementia. I have seen patients scream at their caregivers, physically resist care or strike out at aides.  For Nursing Assistants to go home with a black eye at the end of shift is not uncommon.

I fully expect that none of this information will be surprising to the reader.  However, some of the effects of these circumstances may not be so obvious. Repetitive, physically draining, often unpleasant tasks, done day in and day out, for low wages would place a strain on any worker.  And yet, these caregivers are entrusted with the physical and emotional well being of frail, sick, often confused elderly.  How much geriatric psychology are they taught in their CNA programs?  What moral support is offered to them to deal with the daily stress of their jobs?  Do they feel valued?  How do they know that they are doing something vitally important for our society?

We are asking some of the most vulnerable, resource poor, strained individuals in our communities to offer gentle, intimate and consistent care for our beloved elderly family members.  We fail to provide them with the educational, psychological and financial tools to do so.  Do we wonder why the quality of elder care is not excellent?  While the reasons for poor quality care are complex and cannot be reduced to one simple formula, I believe, they reflect our loss of respect for age and for human dignity – our loss of compassion for others and our avoidance of the reality of our own aging and death.

[1]  http://www1.salary.com/Certified-Nursing-Assistant-Salary.html

[2] http://www1.salary.com/Certified-Nursing-Assistant-Nursing-Home-salary.html

4 thoughts on “Nursing Homes: The Caregivers

  1. Hi I love your blog it’s very informational . I myself is a cna I been certifed for 11 years now I have been a caretaker for 19 years. I must say we are definitely under paid and overworked while 25,000 is a not so bad yearly pay and may do great for someone that does not have children or financial disabilities. it’s still not enough for everyone to get by especially the ones with big families like my self the bigger the family the more expenses I suggerst all certified nursing assistant to be there own boss.


  2. Thanks for commenting, Tanasia, and for sharing your perspective as a CNA. $25,000 is definitely not enough for anyone to live on in this modern world. Can you explain a bit more of what you mean by all CNS’s being their own boss?


  3. My wife died from advanced stage Alzheimer’s disease in 2011. She had been at the Androscoggin Home Care and Hospice in Auburn, Maine, for a mere nine days before she died. Her disease was first noticed by my daughter in December 2007. I did not notice nor did I begin to worry until mid-2008. I would like to say we were very lucky in the excellent care she received and the low cost.

    Our internal medicine doctor first labeled her condition as “memory loss”. He prescribed Aricept for her but this had no noticeable effect. She began to lose weight fairly fast during 2010. Because she lost weight so fast our doctor said she could qualify for home care under Medicare. We got an excellent home care nurse who came frequently; I don’t remember how often. We also got a physical therapist for her. I believe these workers were covered under Medicare, although it would only be for a limited time. In terms of finances we were lucky she lost weight so fast. I won’t go through the other difficulties we and she had with her ever worsening disease. But on May 2, 2011 she had a particularly bad night and we were up with her most of the night. My daughter lived next-door to us at the time and she was of constant help. I reported our difficulties to our home care nurse the next morning and about ten minutes later she called back.

    She informed us there was a room available at the Androscoggin Home Care and Hospice and she would recommend my wife be moved there for a few days to see if her medications could be adjusted. An hour or so later a van pulled up to our house and my wife was moved by stretcher into the van. My daughter and I followed the van in my car and a little over an hour later we arrived at the hospice. We had to leave her then and were told by the caretakers later that she was very agitated at first but calmed down after being shown around the facility by wheel chair. I believe her room was free under Medicare for ten days but she lasted only nine. During these few days she became more and more uncommunicative.

    One of us, either my daughter or I or both, visited her every day. Also other members of our family visited her but it was clear she was becoming unresponsive. On the eighth day I decided to stay there for a few days and they made up a bed for me from the couch in her room. That night was the last. A hospice nurse and I stood by her while the nurse gave her morphine and I talked to her constantly telling her how much I loved her. Finally the nurse told me she could not detect a heart beat. The previous few days we had been looking into nursing homes for her because beyond ten days at the hospice the fee would become very high. Well, she spared us that cost by dying on the ninth day.

    To summarize, I feel very lucky she received such great care at such low cost. This didn’t happen in case of my wife’s aunt who many years before had planned to leave my wife over $100,000 only to have it all used up in end of life care costs.


    1. Marden, I am touched that you would share your wife’s and your experience with Androscoggin Home Care and Hospice with me and other readers. It is good to hear of excellent and affordable care options, and I believe that there are a good many of them in certain areas of the country. Your perspective and the information about how payment was covered are helpful. Your description of her death is moving. Thank you.


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