Nursing Homes: The Caregivers


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, 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.