Angeles, for instance, found that about 45 percent of them were uninsured (Cousineau, 2000). And health insurance is not the only benefit that direct-care workers are less likely to receive. For example, approximately three-fourths of nurse aides in nursing homes and home health settings have no pension benefits (GAO, 2001b).

While concerns about poor wages and lack of benefits are significant, non-financial job characteristics also play a major role in the job satisfaction of direct-care workers (Bowers et al., 2003). Factors that influence job satisfaction include professional growth opportunities, adequate training, rewards for performance, and manageable workloads (Castle et al., 2007; Parsons et al., 2003). Direct-care workers often report that they do not receive enough respect for their knowledge and skills, that they have little discretion or input into care planning (despite being responsible for most of the patient care hours), and that they sense a lack of trust by manage-