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In Brief: Long-Term Care Workers in Five Countries: Issues and Options

Introduction and Purpose

This In Brief summarizes the findings of the AARP Public Policy Institute (PPI) issue paper, Long-Term Care Workers in Five Countries: Issues and Options. According to the U.S. Bureau of Labor Statistics (BLS), the United States will need nearly 900,000 new paraprofessional long-term care workers between 2002 and 2012. This report examines selected aspects of both policy and performance in the long-term care workforce in Denmark, France, the Netherlands, Canada, and Australia. It describes selected aspects of the home care delivery systems that are unique to each country.

The report focuses on frontline workers, including nurse1s aides, personal care workers, personal assistants, and other similar occupational categories as these are understood in other countries. These workers have frequent, usually daily, contact with clients. The countries were selected to complement and contrast with each other and with the United States.

Key Findings

The long-term care workforces in the study countries share many features with one another and with that in the United States. The overwhelming majority of care workers in the study countries are female, and many are aged 45 years and older. Care work is frequently part time and often pays at or near the minimum wage. The comparison of conditions in the study countries yields several major conclusions.

Funding. Funding shortages have led to inadequate staffing and service shortages in Canada, Australia, and the Netherlands. Added funding can probably be usefully spent on pay and benefits, training, and restructuring jobs to create more career paths, provide stable income for employees, and attract both younger workers and men.

Pay and unions. Both Denmark and the Netherlands have relatively high-paid care workers and strong unions, but Denmark has fewer staffing shortages. One difference between the Danish and the Dutch experiences is that Denmark has integrated training with employment, offering aspiring professionals a chance to earn income and gain on-the-job experience as they study, and creating career paths that can reward further training.

Hours. Part-time or temporary work clearly suits some people. However, such jobs are not typically considered "good" jobs by many prospective employees, especially the younger workers many countries want to attract to care work. Workers may be required to work split shifts, with some hours in the morning and some later in the day, and agencies may subdivide shifts even further. Such hours can be particularly punitive for workers who must travel long distances and are not paid for travel time between clients. Experience in the study countries suggests that the care sector1s problems of recruitment and retention can be alleviated by offering guaranteed hours, with adequate wages and benefits.

Training. There may be few alternatives to employer or public sector funding to train care workers. Since care work is generally a low-paid field, prospective employees are unlikely to have or be willing to invest their own funds to acquire needed qualifications. Unless workers acquire these qualifications, however, many may face barriers to employment or limited career paths. To the extent that the qualifications are relevant to job performance, the quality of care will suffer if untrained workers are hired or if they do not receive training after being hired.

The care worker's role in service delivery. Care workers are often not considered members of their clients1 health care and long-term care teams, despite their extensive contact with the client and understanding of the client1s needs. Consequently, the care worker is not included in care planning, which can reduce care workers1 job satisfaction as well as the quality of care.


All five study countries face problems concerning pay, hours, training, and the care worker1s role in service delivery. Adequate pay is the foundation on which workforce improvements must be built, but the experiences of the study countries suggest that other elements are also important. Many care workers put in uncompensated time—in care planning and client-to-client travel, for example—that decreases their effective earnings per hour. Many want full-time jobs, with adequate wages and benefits, rather than part-time or irregular hours.

Training care workers, particularly those who provide home care, becomes more important as medical advances permit more persons with complex needs to live in the community rather than in specialized institutions. Training—whether in the classroom or the workplace—also is necessary to provide the horizontal and vertical career mobility that will keep workers in the profession.

Moreover, the care worker's frontline role needs to be recognized in service delivery. A better paid and better trained workforce will provide better care, which should be the ultimate goal of workforce policies. The findings of this report suggest that improving the economic and professional status of these workers is likely to improve the quality of care as well.


  1. PPI Issue Paper #2004-07, Sophie Korczyk, June 2004

Written by Enid Kassner, AARP Public Policy Institute
July 2004
©2004 AARP
All rights are reserved and content may be reproduced, downloaded, disseminated, or transferred, for single use, or by nonprofit organizations for educational purposes, if correct attribution is made to AARP.
Public Policy Institute, AARP, 601 E Street, NW, Washington, DC 20049

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