Registered nurses are a vital component in our health care model. Direct care workers who provide care to elders and disabled people are also crucial to our health care system. But there are significant differences in the two occupational categories and those differences may shed light on recognition of direct care workers and their role in health care.
Nursing is an accepted part of the health care system. There are Boards of Nursing in each state. Curriculum standards and scope of practice are well established for nurses. To become RNs, students must pass a national licensing exam after completing a 2-year ADN degree or 4-year B.S. degree.
It wasn’t always that way. In the mid 1800s, nurses received little or no formal training. They got their training on the job, just as many direct care workers do today. By the late 1800s, nursing gained more legitimacy as an emerging profession. This was largely because of the influence of the English nurse Florence Nightingale and the American nurse Clara Barton. Nurses began to receive formal training in 2-year training courses provided by hospitals. There were as yet no commonly accepted professional standards, so the quality and content of courses varied considerably. Graduates were qualified to work in the homes of the sick. (For the first 50 years of nursing in America, nursing was provided mainly in the home setting.)
Now that nursing is so widely accepted, it may seem surprising to remember that as a profession it went through stages in which its value was not recognized, its scope of practice was not developed and standardized training and examination was not expected.
Direct care workers today face many of the challenges that the nursing profession did. Although personal and home care aides are in the top fastest-growing occupations in the country, direct care workers are not widely recognized or included as part of the health care system. It’s almost as if they are invisible, even though they are in high demand.
“It has only been in the last 10 years that direct care workers have been required to have any training,” said Marion Karpinski RN. “One of the reasons I founded Medifecta Healthcare Training and developed the 40-hour Personal Care Attendant Training Program was to provide standardized training for direct care workers in the home setting.”
Training Varies Widely
Training regulations for direct care workers vary widely from state to state; many states still have no training requirements. Some states require less than 10 hours of training. Wyoming for example requires a minimum of 8 hours of training for homemakers. Illinois requires 8 hours of training for home services workers, but provides a long list of topics to be covered. A pending bill in California would require 5 hours of training for home care aides.
Some states require more hours of training. For example, Massachusetts requires 40 hours of training for homemakers and 60 hours for personal care workers. Arkansas requires a minimum of 40 hours for personal care aides. Florida, New Mexico and Wisconsin all require 40 hours of training.
“Some states require 75 or more hours of training for in-home care providers,” said Ms. Karpinski, who has reviewed many states’ training requirements. “Do we really need a CNA level of training for in-home care providers or are we just creating another obstacle to meeting the huge demand for care providers for our elders and disabled? I believe that a well-organized 40-hour training program in care and communication skills is sufficient to prepare care providers with the skills and confidence they need to provide quality home care. Let’s make training accessible and available to more people in order to have enough qualified care providers in our communities,” said Ms. Karpinski.
States may require a specific number of hours of training, but leave topics unspecified. Or they may specify training topics, but not indicate how much time should be spent on each topic. These broad variations and omissions regarding training are not only confusing; they represent increased danger to the health and safety of elders and the direct care workers who care for them.
Job Titles for Direct Care Workers Vary, Too
Job titles for various types of direct care workers vary from state to state. Homemaker companion, home health aide, personal care aide and unlicensed assistive personnel are some of the titles used for these workers. Imagine what it would be like if nurses were known by different job titles in each state, or if their scope of practice or training varied widely from state to state. That is the current situation with direct care workers.
A Hodge Podge of Agency Licensing
Unlike the standardized licensing required for many types of health care organizations, there is no standardized licensing for agencies that employ direct care workers to provide nonmedical care. Laws requiring background checks for agency owners also vary widely. In many states, you can open a private duty agency with only a business license.
Angil Tarach-Ritchey RN, a geriatric care manager who owns a Visiting Angels nonmedical care agency in Michigan, favors licensing. As she recently commented, “Anyone in the state of Michigan can open a private duty home care agency for $20 or $30 and a business license. You don’t need to have any formal education, experience or training. You can hire anyone to provide care, and not be required to train them or even background check them, because there are NO regulations,” said Tarach-Richey.
Currently, 27 states require licensure for private duty agencies. Licensure bills are pending in Hawaii, California, Michigan and Arizona.
What Does the Future Hold?
Will direct care workers be acknowledged and included within the healthcare system as a profession? Can we find, train and retain enough direct care workers to fill the critical and growing need? How can we provide a living wage and benefits to direct care workers, making that high-demand work more attractive to job seekers? Can we look forward to nationally recognized training standards for various levels of direct care workers? Will licensure be required for home care agencies in all states? These are only a few of the questions that remain unanswered.
Gaea Yudron, Medifecta Healthcare Training