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Poor Quality Nursing Assistant Jobs Undermine Care in America’s Nursing Homes

April 12, 2016

Wages Insufficient to Attract and Retain Workers, According to PHI Report —

Poor quality nursing home jobs are preventing residents from receiving the high-quality care they deserve, a new PHI report argues.

Raise the Floor: Quality Nursing Home Care Depends on Quality Jobs outlines the case for improving jobs for the 650,000 nursing assistants employed by the nation's 15,000-plus nursing homes. These workers — who are 91 percent female, 35 percent African American, and 20 percent foreign-born — provide the majority of hands-on assistance that allows nursing home residents to live with dignity and as much independence as possible.

As the report explains, nursing assistant jobs are characterized by low wages; erratic, often part-time schedules; limited support from supervisors; and little chance to advance professionally. Hourly wages, which have decreased by seven percent over the last 10 years when adjusted for inflation, average just $11.51 per hour; the yearly median wage is $19,000. Less than half the workforce reports working regular full-time hours throughout the year, while more than half report working overtime hours during the same period.

Nursing assistant jobs are also characterized by high rates of workforce injuries, comparable to those of police officers and construction workers. Injury rates are three-and-a-half times those of the average U.S. worker, and musculoskeletal injuries are five times as high.

Consequently, the nursing assistant workforce is profoundly unstable. Average yearly turnover rates top 50 percent and are growing along with staff vacancies.

"Increasingly, employers report that they cannot recruit sufficient numbers of qualified workers," says Jodi M. Sturgeon, president of PHI. "Nursing homes deliver an indispensable service, providing support to individuals who cannot live safely in their homes. Ensuring quality jobs for nursing assistants is essential to improving the quality of care in these long-term care settings."

The situation is becoming more urgent because of the growing "care gap." Our nation is rapidly aging, with the population over 80 expected to triple by 2050. Currently, we have 7 adults in the caregiving generations — mid-forties to mid-sixties — for every adult over 80. But by mid-century that ratio drops to 3:1. This will increase pressure on long-term services and supports — but the number of working age women is barely increasing, making it hard to fill nursing assistant jobs if quality is not improved.

A workforce of well-trained, experienced caregivers is impossible to build unless caregiving jobs are more highly valued, the report argues. Nursing assistants need better wages, but also jobs that offer sufficient training, on-the-job support, and opportunities to grow, learn, and advance professionally.

"We need to see nursing assistants as important assets to quality care," Sturgeon says, "not as an expense to be managed. Employers need to invest in training, supportive supervision, and career paths to keep experienced workers on the job."

To support that investment, PHI calls for Medicaid reimbursements to cover the true cost of labor. Raise the Floor argues for increases in rates to be tied directly to wages and benefits of nursing assistants and other low-wage support staff. The paper also makes the case for updating training requirements, which have not kept up with increases in acuity and behavioral health issues among today's nursing home residents. Alzheimer's disease and other dementias affect half of today's nursing home residents.

As nursing assistant Maribel Rodriquez from Waterbury, CT says of her work, "It's hard physically, mentally, and emotionally. To be successful, you need to be prepared for what you can control, but more importantly, you need to be prepared for what you cannot control."

Raise the Floor makes the case for providing nursing assistants with the resources they need to succeed at their jobs. Quality jobs are essential to building a stable, skilled workforce prepared to provide care for today's nursing home residents — and the growing numbers of elders who will need care and support in the coming decades.

Raise the Floor was produced by PHI with support from the W.K. Kellogg Foundation.

For more information, visit the PHI website at:

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PHI (Paraprofessional Healthcare Institute) works to transform eldercare and disability services. We foster dignity, respect, and independence — for all who receive care, and all who provide it. The nation's leading authority on the direct-care workforce, PHI promotes quality direct-care jobs as the foundation for quality care (

Karen Kahn, PHI Director of Communications; 978-740-9844

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