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In Direct Care Work, High Passion but Low Pay

April 26, 2021

As communities across the U.S. shifted into lockdowns early in the 2020 coronavirus pandemic, many direct care were unable to see their clients.

“Service stopped for a couple months,” recalled Milta Ayala, a certified nursing assistant (CNA) and home health aide in New Jersey. Her clients’ families didn’t want to risk exposing loved ones to people they didn’t live with. “That was hard. I had to stay home not knowing how I was going to take care of my patients.”

But Ayala, like a number of workers interviewed for PHI’s Direct Care Worker Story Project over the last year, didn’t let the disruption in her employment break her connection with clients. “I still called them almost every day to ask how they were doing.”

Ayala’s coworker, Maria Marerro, had a similar experience.

“The beginning of the pandemic, of course, was hard. Everybody was scared. I understand that,” Marerro told PHI. “I was in communication with my clients even though they didn’t allow me to go to work.”


It wasn’t a requirement of Ayala’s and Marerro’s roles as home health aides that they reach out to clients while home care services were suspended. They also weren’t compensated for making these calls. But each of them saw maintaining connection as critical to their clients’ wellbeing during a traumatic time.

“I kept in communication, explaining, trying to convince them: I’m taking care of myself,” said Marerro. “That way, I can take care of them later.”

The responsibility that Ayala and Marerro feel to their clients, and their interest in sustaining aspects of their work while unemployed, is not uncommon among direct care workers. Commitment to a job that extends beyond the bounds of its pay or prescribed duties is sometimes called “passion. Direct care workers will describe their commitment to clients as a “calling” or otherwise refer to the intangible benefits of positively affecting others.

The high levels of passion associated with direct care work are not unique—they have been observed in professions as diverse as teaching, journalism, and software development—and recognized as part of the “heroism” demonstrated by frontline health care workers during the coronavirus pandemic. However, the concept of heroism in long-term care largely ignores the fact that its jobs are not valued at the level they deserve.

From left to right: Milta Ayala and Maria Marerro, direct care workers at HomeCare Options in Totowa, NJ.


What distinguishes direct care from many of the occupations noted above is the markedly low pay its workers receive. Median wages for this workforce are just $12.80 per hour nationwide. Direct care jobs are also often characterized by part-time hours; unstable schedules; little or no access to benefits; and insufficient training, supervision, and support. While its work may be high-passion, direct care inversely offers a low-quality job.

“The salary that you make during the year is so low that when you get unemployment it’s not enough even for buying food during the week,” said Marerro when describing the three months she was unable to work with her clients. “This is something that you need to love to do it. I mean, if you work for money, forget about it.”

Several workers interviewed by PHI suggested that doing work they find meaningful can help offset the challenges of poor job quality—but also that they shouldn’t have to choose between the two.

High levels of passion can actually make workers more vulnerable to exploitation; studies show that knowing a worker receives intangible benefits from their labor makes it more likely for others to justify their low wages or unfair treatment. Exploitation, unfortunately, has been intrinsic to direct care work: many aspects of its poor job quality stem from eras when the expectation of providing unpaid domestic labor was legitimized by racist and sexist ideas. More recently, a complex funding and regulatory system has made challenges in direct care seem intractable, allowing exploitative working conditions to persist.

Musa Manneh, a hospice care CNA in North Carolina.

“I wish we would make more money because it is really hard for people to go through this emotionally,” said Musa Manneh, a hospice care CNA in North Carolina who frequently supports clients and their family members through the last months of a client’s life. Manneh is grateful to feel valued and supported by his employer, though he acknowledges its ability to pay him is limited by insufficient insurance reimbursement rates.

“We still like what we do. The blessings we count more than the money, even though we need money for our bills. If you want to follow the money, you are not going to work, you are going to [leave the field].”


Manneh, Marrero, and Ayala each have more than 18 years of experience as direct care workers. While turnover in this sector is notoriously high, they are among a significant segment of the workforce who stay long-term. Few recent studies have looked at workers’ retention in the direct care field overall (as opposed to tenure at a single employer). However, national survey data from the mid-2000s show that 35 percent of nursing assistants and 50 percent of home health aides had been in their occupations for 11 years or more. Among the 32 interviewees in PHI’s Direct Care Worker Story Project, average tenure is 12 years. These workers have made a career of direct care, in most cases without a living wage or promotion to recognize their expertise.

The ability for a worker to stay in direct care—or in any field—shouldn’t depend on whether they can prioritize passion above compensation. Neither new hires nor those with several years of experience deserve to be mired in poverty-level pay. But until meaningful job quality improvements reach direct care workers, many will.


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