and turnover among these occupations, which can, in turn, lead to poor quality of care for patients.

Much of this chapter focuses on issues concerning direct-care workers in general because there is relatively little data on the group of direct-care workers solely involved in the care of older adults; whenever possible, however, issues related specifically to the care of older adults will be highlighted. The chapter begins with descriptions of direct-care occupations and the basic demographics of the current workforce, followed by an overview of the current state of education and training of these workers. The chapter then discusses challenges to the recruitment and retention of direct-care workers, including financial disincentives and difficulties in work environment. The chapter concludes with an examination of strategies to improve the recruitment and retention of direct-care workers, including enhancing the quality and quantity of basic education and training, increasing overall job satisfaction (including expanding roles and responsibilities), improving economic incentives, and broadening the labor pool. Overall, in order to create a more effective and efficient direct-care workforce, much more needs to be done to educate and train these workers to care for older adults, and much more needs to be done to enhance the quality of these jobs.

DIRECT-CARE OCCUPATIONS

Direct-care workers are often grouped into three categories: nurse aides (also known as nursing assistants); home health aides; and personal- and home-care aides (Harmuth and Dyson, 2005). Forty-two percent of direct-care workers care for patients in the home setting, 41 percent work in nursing homes, and the remaining 17 percent are employed in hospitals (Smith and Baughman, 2007). Table 5-1 provides details about the various types of direct-care workers, including their most common employers, the types of services they provide, and typical supervision requirements.

Nurse Aides and Home Health Aides

The occupation of nurse aide goes by a number of job titles which vary by state, setting, and situation; these titles include certified nursing assistant (CNA), geriatric aide, orderly, and hospital attendant (BLS, 2008c). Nurse aides are employed primarily in nursing homes but also work in other institutional settings, such as hospitals and assisted living facilities. They assist residents with activities of daily living (ADLs), including bathing, dressing, eating, and toileting, and they can perform such clinical tasks as taking blood-pressure readings and, in some states, administering oral medications (Reinhard et al., 2003). These workers have a major role in institutional



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