Direct Caregiving in Older Adults: How Systems of Care Perpetuate the Grand Challenges and What Social Workers Can Do about It

Background and Purpose:

Direct care workers (DCWs) play pivotal roles in helping older adults maintain quality lives in their homes and communities (Phillips, 2016) by providing personal care and emotional support. DCWs reduce social isolation by providing companionship to people with limited community contact.  DCWs earn low wages, have little training, and experience high turnover rates (Dawson, 2016).  From a grand challenges lens, while DCWs reduce social isolation and advance long and productive lives, they experience extreme economic inequality and lack equal opportunity and justice.  

As the demand for DCWs grows, real wages continue to fall, leading to an unstable workforce. The undervaluation of DCWs threatens older adults in many ways, i.e. caregiver shortages that threaten continuity and quality of care (PHI, 2015). This presentation discusses two DCW qualitative studies, in home care and in nursing homes showing how DCW jobs exacerbate inequality and discuss social work’s role in advancing opportunity and justice.

Study 1: Home Care

Hospice addresses the physical, psychosocial, and spiritual needs for those with a terminal illness and their caregivers. Despite their important role, homecare agencies seldom notify DCWs when patients die, discharge, or transfer between health care settings and may lack clear policies regarding post-transition contact (Staley, Gleason & Boener, 2015). This disregards the benefits of consistent care. This study explored DCWs experience of care transitions in end-of-life care. Findings reveal DCW roles during transitions like live discharge or patient death.

Methods

Individual and focus group interviews were completed (n=24) with DCWs in a Midwestern state. Interviews were recorded, transcribed verbatim, and analyzed through thematic analysis.

Results

DCWs view their role as supportive and meaningful, albeit temporary, and care deeply for their patients. Results suggest DCWs demonstrate emotional resilience with minimal professional guidance. Results reveal inconsistencies in DCW communication with patients and caregivers post-discharge and recommend that agencies provide clearer protocols.

Study 2: Nursing Home

Certified Nursing Assistants (CNAs) are the DCWs that provide the majority of hands on care to nursing home residents (Pennington, Scott, & Maglivy, 2003).  This study explored their experiences in providing care and their perceptions about good care (Kusmaul & Bunting, 2016).  This presentation focuses on recognition of DCW knowledge and DCW roles on interdisciplinary teams.

Methods

Individual interviews were conducted with (n=23) CNAs in a Northeastern state.   Interviews were recorded, transcribed verbatim, and analyzed through content analysis with a phenomenological approach.

Results

The ability of a CNA to systematically improve care depended on the responsiveness of authority figures. However, they were seldom sanctioned members of the care team.  While some facilities paid for professional development in addition to wages, organizational structure was important to both CNAs team role and the level and type of compensation.

Overall Conclusions

Both studies suggest high-quality compassionate care requires greater communication with and decision making by DCWs.  DCWs are integral to our healthcare system.  With growing concerns about an adequate labor force to care for older adults, to truly address social inequality, social workers must advocate for both low-wage workers and vulnerable clients.