Vulnerable Caregivers: A Comparison of Direct Care Workers’ Health Risks in Skilled Nursing Facilities and Private Homes

This chapter explores variation in direct care workers’ health risks within institutional and home-based settings, according to the demographic composition of workers and the gendered, raced, and citizenship-based expressions of their work roles.

This quantitative intersectional study draws on two nationwide datasets from the US National Center for Long-term Care Statistics, a division of the Centers for Disease Control and Prevention, the National Nursing Assistant Study (NNAS), and National Home Health Aide Survey (NHHAS).

Workplace context was the strongest predictor of workers’ health risks and working conditions. Physical injuries affected more than half of facility-based workers annually compared to less than 10% of home-based workers. Facility-based workers are more likely to report insufficient time for tasks, lower job satisfaction, and less respect and appreciation from patients. Home-based workers may be more likely to experience emotional distress, be offered fewer benefits, but experience fewer injuries, due to the better relative health of their patients and having more time for client care. Women reported more injuries and more time pressure than men across racial and citizenship groups within the same work setting.

There are limitations to the NHHAS and NNAS public-release data file data. We are unable to fully capture citizenship, some racial/ethnic categories, workers over age 65, supervisory workers, facilities with fewer than three residents, and facilities not certified with Medicare or Medicaid. The exclusion of these questions, workers, and contexts is a weakness of the present study.

Analyses draw on data from the first nationally representative sample surveys of home health aides and nursing assistants in the United States. Direct care workers are an important population to capture through intersectional research since care work is done predominantly by multiracial women and immigrants. This research also underscores the importance of workplace contexts in shaping the labor performed and the workers’ experiences.