Category Archives: wages

60 Caregiver Issues: Whose Issues Will We Hear?




In his recent post Yang brought our attention to PHI’s campaign to educate the public about caregiver issues, and gave us a link to their introductory video.  In that video PHI posed these questions:   

1. How can we ensure caregivers get the training they need?

2. How can we keep care affordable to families? 

3. What data is needed to help policyholders take action? 

While these are important questions, if you ask caregivers themselves why some are leaving the field and others wouldn’t think of entering it, they’ll no doubt raise a different set of issues.  At nearly every conference or webinar I attend I ask about staff-to-resident ratios and caregiver wages.  Usually there is no reply, as if I were speaking from some parallel universe and couldn’t be heard.  If there is a reply it’s on the lines of “Yes, we know.  But it’s complicated.  These things take time. You can’t expect things to change overnight.” 

Yes, there is a shortage of caregivers.  And yes, good care isn’t affordable.  In fact good care can’t be bought.  By that I mean whatever you might be paying, either for in-home care ($20/ hour? $40?) or for care in a long-term care home of some sort ($6,000-10,000/ month), the more care the person needs as health declines, the wider the gap between the person’s needs and the quality of care the person actually receives.   

Everyone is selling solutions like workshops and videos and toolkits and new business models to long-term care administrators or home healthcare systems’ owners.  Some groups are advocating on a state or even national level and some gains have been won.  But from the outcomes I’d say that a lot of the effort is wheel-spinning.  (An increase in the NYC minimum wage for home care workers to $15/hour by 2021??)   Today’s aides have rare luck if they earn $15 an hour and have a regular 40-hour work week.  An aide may have six to ten residents/patients to care for, and many of those will suffer from dementia and/or be unable to walk alone safely or even support themselves standing.  (Yes, I know I’m a broken record…)  Do you know what it’s like to try to wash, toilet, transfer these residents several times a shift, and keep them from falling the rest of the time?  (If not, go back and read CNA Edge.)  This is before we even begin to provide enrichment a la ‘person-centered care.’   

I want the whole healthcare industry – including those championing reform — to acknowledge what the biggest issues are for caregivers: our obscenely low wages and our outrageously onerous, even unsafe, working conditions.  These organizations don’t yet tackle caregivers’ most urgent needs: a living wage, safe work conditions, and a work environment that supports person entered care.  We need to ask them, What are you doing about these issues and what can we CNAs do to support you in this?  

When Malcolm X called for a change in Americans’ attitudes on race and was told that such changes (culture change, if you will) take generations, he reminded us of this: At the beginning of World War II Germany became our enemy and Russia became our ally.  But when the war ended we, America, saw Germany as our ally and Russia as our enemy.  That attitude-change didn’t take even one generation.  The healthcare industry needs an attitude adjustment.  It is not okay for long-term care operators or owners of home healthcare agencies to charge exorbitant fees to clients and return a too-small fraction of these fees as wages to their direct-care workers, while management and professional staff and consultants are handsomely compensated.  It is not okay to hire employees unless you train them in the skills they need to work with the elderly frail, starting with English language skills.  It’s not okay for the industry to tolerate poor work ethics: last-minute callouts; texting while on duty; and most of all, failure to interact with residents in a way that says to them “I love being with you.  Thank you for letting me be part of your life.” 

There are thousands of followers of CNA Edge.  As Yang exhorted us, we need to support PHI in their effort to educate the public about caregiver issues.  Let’s ensure that when they frames their 60 Issues, they don’t airbrush our issues out of the picture they’re drawing.

The Issue of Low Wages in Direct Care




When we talk about low wages for direct care workers, it’s important not to confuse two separate issues. The first has to do with our personal satisfaction regarding the work, best summed up by the regularly repeated phrase: “It’s not about the money.” The second issue is about the impact of low wages on the quality of care and on the workers who provide it.

Many caregivers will tell you that they experience significant emotional benefits from the work. They find meaning and fulfillment in making an immediate and real difference in the lives of other people. However, personal satisfaction with the “work” doesn’t always mean contentment with the “job.” The work we find so fulfilling is only one aspect of the job, which also includes things like wages and the work environment.

For some caregivers, the emotional benefits outweigh all other considerations. They find the work so deeply meaningful that they are willing to endure the impact that low wages and difficult work environments have on their lives. It is a noble sentiment.

While the sentiment is genuine, it is also a highly personal one. Meaning is not so much found as created and how we create meaning in our lives is an intensely individual enterprise. It is not something one person can do for another; the most we can do is accept and respect another person’s sense of what brings meaning to his or her life.

It is not a contradiction to accept and even admire the notion that caregiving “is not about the money” on the one hand while condemning low wages and poor working environments on the other. The former is about the choices and perspective of individual caregivers, the latter is about a bigger picture.

Low wages is a major contributing factor to high turnover rates for direct care workers. This has a profound effect on the continuity and quality of care. In her May 5th blog post “Addressing the Difficult Issue of Money,” Paraprofessional Health Care Institute’s (PHI) National Director of Coaching & Consulting Services, Susan Misiorski, sums it up thusly:

“Low wages for direct-care workers has a trickle-down effect on the elders and people with disabilities for whom they provide care. We know that care continuity correlates strongly with care quality, but low wages encourage high turnover rates. Organizations that continually must hire — and train — new staff members likely aren’t providing the best possible care.”

Beyond quality and continuity problems, the issue of low wages has wider social implications. Since wages and benefits in long-term care are impacted by inadequate government reimbursement rates, the issue of low wages is a matter of social policy and a true reflection of the value society places upon direct care work. Misiorski tells us that 22% of direct care workers fall below the poverty line and 43% live in households that rely on some form of public benefits. The very people we depend on to provide quality care often struggle to take care of themselves and their own families. Does it really make any sense to tell workers how much you value what they do and then expect them to live near or below the poverty line?

Yes, we want workers to be properly motivated. But expecting to be compensated fairly for what you do does not equal a lack of compassion. We are all motivated by different things and genuine compassion is expressed through action, not good intentions. While we can admire the notion that “it’s not about the money,” we must reject the idea that caregivers who express concern about their wages don’t belong in the business. We lose too many good workers that way.

It Ain’t About the Money, Honey




$2.83. That is the balance of my checking account. Two dollars and eighty-three cents to last me for the next five days. I checked it repeatedly, as if money would magically appear if only I willed it…It didn’t.

“Well, Alice, rent is paid. Nothing is going to be shut off this month, you have plenty of ramen, cereal and milk that is only mildly questionable”, I thought to myself as I laced up my sneakers, strapped on my back pack and headed out to work.

I always chuckle to myself when I hear other caregivers say that someone is only in this field “for the paycheck”.  WHAT paycheck? Honestly, you could make more money and have more room for advancement and growth in the fast food industry than in the long term care system. Anyone who takes on this gig hoping for a lucrative future either has bad business sense or is delusional.

Our world is not the neat confines of the office. Our language is not the detached, clinical observations of the doctors or nurses who visit occasionally. No. Our place is on the floor, with the people. Hands on.

It is a gritty, raw, deeply emotional reality filled with equal amounts of devastating loss and bodily fluids. It requires a unique skill-set; an adaptability and stamina that few are able to maintain for long periods of time. If done well, this job will break your heart every day. If done correctly, it will test your limits in every way. It is not for everyone.

So why are there “bad” caregivers? Why do some seem to phone it in? My best answer, in the most simplistic of terms, is that it is an emotionally, physically, mentally exhausting job that usually goes unappreciated by those in charge. Often, the only incentive we have is to not get fired. We are underpaid and overworked by people who do not understand what we do. Many caregivers burn out because they cannot see past that wall.

Well then, what makes “good” caregivers? Simply put, they do not give up. They do not let the deeply flawed system define them. They reach down and discover their own personal reasons for their commitment to this field and hold on to it when everything else seems to fall apart. They find their own leadership and they never stop learning and growing. It is an emotionally fulfilling, physically challenging and mentally stimulating job that never goes unappreciated by those for whom we care. Even if they don’t or can’t say so. The truth is in the moments and the moments on the floor are abundant.

As for this caregiver, I never lose sight of the fact that having money and being rich are not synonymous. I do not underestimate the value in what we do or the depth it has added to my life. For me, it far outweighs the difficulties we have to face in order to do it.

Good, bad or indifferent, it isn’t about the money. It’s about the perspective. We make an impact on the lives of other human beings, sometimes breaking ourselves in the process. There is no way to put a price tag on that; no adequate way to measure the give and take required to do this job the way it should be done. I only know that it is so very worthwhile.  $2.83 in my checking account and I wouldn’t trade places with an heiress.

Wages and Compassion




The issue of low pay comes up frequently on the CNA Facebook pages. While it is widely accepted that caregivers are underpaid, there is a counter theme running through these discussions that can be summed up thusly: “It’s not really about the money, we love what we do.” In and of itself this is a commendable sentiment and without it long-term care could never hope to find and retain enough workers. It’s difficult enough as it is.

Some take it a step further and claim that if you seem too concerned about what you’re getting paid, it’s an indication that you lack compassion and you shouldn’t be working in this field at all. As if compassion isn’t possible without self-sacrifice and that talking about money only taints the nobility of what we’re doing. That in fact, we should feel ashamed to expect more.

I reject that notion. As a CNA, you should never be made to feel ashamed simply because you recognize that you’re underpaid for the work you do. While the work can be fulfilling on a personal level, it has value beyond the emotional benefit you receive from it and you have every right to be compensated accordingly. There is nothing about expressing that opinion that means you’re less compassionate and caring then those who happily accept low pay. And it doesn’t mean that you’re there “just for a paycheck.”

The idea that we must be willing to sacrifice monetarily to keep our motivations pure is actually a form of backdoor egoism. It puts the focus on us and our motivations and intentions. The real value of what we do derives not from what we sacrifice or why we care, but from how the residents experience the care we provide and the quality of our interactions with them.

Some would argue that it is not possible to create quality care and interactions without the “purer” kind of motivation. I submit that there is nobility in working hard to support your family – and yourself – and that things such as a sense of duty, an awareness of the value of the individual and a profound respect for the trust you’ve been given are powerful motivations to excel as a caregiver, quite apart from one’s willingness to struggle with an inadequate income. 

To be sure, there are disaffected caregivers who look at our work according to George Carlin’s dreary dictum: “Most people work just hard enough not to get fired and get paid just enough not to quit.” But it’s a mistake to lump those of us who expect to be paid fairly for an honest day’s work in with those who skate by doing as little as possible.

One problem is that we are confusing two separate issues. Let me put it this way: once I walk through that door to go to work, the residents are going to get the same commitment and same level of care from me whether I’m making $8.00 an hour or $20 an hour, but to get me through that door in the first place is going to take something closer to the $20 then the $8.00. Some high-minded caregivers would regard the second part of that as a kind of blasphemy. 

Some are concerned that higher wages would result in retaining workers who really don’t care that much about the residents. The logic here is baffling. Workers can be dismissed or otherwise disciplined according to their performance regardless of what they’re getting paid. The real problem is that on one end we constantly lose good workers who leave for better wages and on the other end employers are left to hire from a smaller pool of candidates. It’s a bad combination.

The reality is that most caregivers who work in long-term care need every single penny they can get. They give so much of themselves every day and while society can nod and smile and call them angels for the wonderful work they do – or alternatively, demonize them based on media reports – the system they work for does not deem their contributions significant enough to offer adequate compensation. Some are paid just above minimum wage. Many work second jobs or put in several hours of overtime each week just to help make ends meet. “Fortunately,” there is plenty of opportunity for overtime due to a chronic shortage of direct care workers – see the preceding paragraph.

The combined effects of long hours, physical and emotional stress, and financial struggle can wear down a caregiver often making him or her feel used and used up. As if the system regards its front line workers as disposable. That’s the real shame.