Strengthening Support for Immigrant Direct Care Workers: Recommendations from Experienced Direct Care Workers for People Living with Dementia

Abstract

Immigrant workers comprise 27% of the U.S. direct care workforce, yet their experiences and support needs remain understudied. This study examined direct care workers’ experiences and recommendations for supporting immigrant workers in dementia care settings. Using an explanatory sequential mixed-methods design, 27 direct care workers completed a survey, and 25 completed in-depth interviews. Participants were predominantly female and ethnically diverse, with high job satisfaction despite burnout challenges. Qualitative results revealed three key themes: (1) need for enhanced educational support on dementia care and safety protocols, (2) importance of cultural and language resources, and (3) opportunities for career advancement and improved working conditions. Findings suggest that interventions addressing individual skill development, organizational cultural competency, and policy changes are needed to better support immigrant direct care workers and strengthen the dementia care workforce.

Keywords

caregiving dementia home and community-based care and services mixed methods minority

What This Paper Adds

• Provides recommendations for supporting direct care workers providing dementia care, with a focus on the immigrant workforce and solution-oriented strategies.

• Reveals that direct care workers report high job satisfaction despite experiencing burnout and workplace barriers, highlighting a job quality paradox that warrants further investigation.

Applications of Study Findings

• Facilities can implement dementia-specific training, cross-cultural competency programs, and structured mentorship.

• Policymakers can consider creating geriatric care visa categories and funding dementia certification programs to strengthen the immigrant direct care workforce.

Introduction

According to the Paraprofessional Healthcare Institute (PHI, 2022), most direct care workers are immigrants, women, and people of color. Specifically, more than one in four direct care workers in the United States are immigrants, a proportion that increased from 21% in 2011 to 27% in 2021 (PHI, 2023b). In 2025, approximately 7.2 million Americans aged 65 and older were living with Alzheimer’s dementia (Alzheimer’s, 2025). Thus, there is an urgent need for a more robust and resilient dementia care workforce (Alzheimer’s, 2025), including immigrant direct care workers. Immigrant direct care workers are valuable as they can meet the demands of a diversifying aging population. The number of immigrants living in the United States is projected to grow by 25 million people, rising from 44 million in 2016 to a projected 69 million by 2060 (U.S. Census Bureau, 2020). The growing diversity of older adults requiring care highlights a critical need for care that is culturally concordant. Among the aging population, older adults of color will increase from 23% in 2016 to 45% in 2060, and older adults who are immigrants will increase from 14% to 23% during the same time period (PHI, 2023b). This demographic change underscores the critical role of immigrant direct care workers, whose cultural and linguistic backgrounds uniquely position them to deliver culturally sensitive care. Despite the strengths and contributions of immigrant direct care workers, they are often situated in challenging work situations. They may experience language barriers, as three in 10 immigrant direct care workers report speaking English not well or not at all (PHI, 2023a, p. 9), as well as a lack of legal protections, limited work resources, and cultural differences. In the present study, direct care workers refer to formal paid caregivers, specifically Nursing Assistants, Home Health Aides, and Personal Care Aides. The present study examined recommendations from experienced direct care workers regarding the enhancement of support systems, training, and working conditions for immigrant direct care workers providing care to individuals living with dementia. By centering the perspectives of frontline workers with direct dementia care experience, this research aims to identify evidence-informed, implementable strategies to optimize caregiver well-being and the quality of dementia care.

Background

The direct care workforce is marked by significant gender and racial inequalities (McCall & Scales, 2022). Historically, women, people of color, and immigrants have been concentrated in lower-paying and demanding caregiving positions (Dwyer, 2013; Hodges, 2020). These workers face compounded vulnerabilities, such as language barriers, cultural differences, and sometimes uncertain immigration status, while performing physically and emotionally demanding work (Devine, 2025; Eriksson et al., 2023). The COVID-19 pandemic exacerbated these inequalities through disproportionate infection exposure and economic insecurity (Espinoza, 2022). Despite these challenges, immigrant care workers remain essential to meeting the needs of an aging, diverse U.S. population, underscoring the urgent need to address the barriers they face.

Drawing on the ethics of care (Held, 2006; Noddings, 2013), care work is understood as a morally significant yet undervalued practice that is physically and emotionally demanding. Care work has long been recognized as disproportionately carried out by the most vulnerable and powerless members of society, yet it remains chronically underpaid and undervalued, a pattern that is particularly evident among immigrant workers (Held, 2006; PHI, 2023b; Tronto, 1993). Similarly, Arlie Hochschild’s theory of emotional labor (1983) explains how emotional labor, defined as “the management of feelings to create a publicly observable facial and bodily display” (Hochschild, 2003, p. 7), can heavily impact vulnerable workers and contribute to workplace inequalities. In addition to facing various barriers, including understanding workplace cultural nuances, strengthening language proficiency, and navigating workplace and client relationship dynamics, immigrant workers often lack adequate support (Davis & Smith, 2013; Devine, 2025). As indicated in the direct care workforce data, immigrant workers have experienced various challenges, and during the Coronavirus Disease 2019 (COVID-19) pandemic, they experienced disproportionately added difficulties (CDC, 2020; Scales, 2021; Shippee et al., 2020).

The Current Study

Although a body of research provides information about the inequalities and challenges in the direct care workforce, less is known about recommendations for how to better support immigrant care workers. The present study addressed two research questions: (1) What are the demographic characteristics, job satisfaction, and burnout experiences of direct care workers providing dementia care? and (2) What suggestions do direct care workers have for enhancing support for immigrant workers in dementia care settings? Using a mixed-methods approach that integrated quantitative and qualitative data, the study offers descriptive information on participants’ experiences and insights on their recommendations for better supporting immigrant direct care workers.

Design and Methods

Research Design

Using a mixed-methods approach, the study utilized quantitative surveys and qualitative interviews to understand the experiences of direct care workers and their recommendations for supporting the immigrant workforce in dementia care.

Data Sources and Data Collection Procedures

The study used convenience and purposive sampling, in partnership with a home care agency, to recruit direct care workers aged 18 and older (i.e., Nursing Assistants, Home Health Aides, and Personal Care Aides) in California who had experience working with older adults living with dementia. Twenty-seven participants completed the survey, and 25 of these participants also completed follow-up interviews (two participants did not respond to interview invitations). Participants were recruited from home care agencies and through snowball sampling. For the purposes of this study, a broader framing of immigrant background was used to include participants with direct experience working alongside or as immigrant direct care workers in dementia care settings. Participants with an immigrant background were defined as individuals who were either foreign-born (first-generation) or U.S.-born descendants of immigrants (second-generation or later).

Using an explanatory sequential mixed-methods approach (Creswell & Plano Clark, 2018), the present study invited participants to first respond to a quantitative survey and then invited them to participate in a qualitative interview. Participants who provided consent and completed the study received a $100 online gift card. Data collection occurred between June 2025 and August 2025. This research was approved by the Institutional Review Board. Participants provided informed consent prior to taking part in the study, including explicit consent for the survey and audio-recording of interviews conducted via Zoom or telephone. The survey instrument was developed for this study with some utilization of established scales. It consisted of 28 questions covering sociodemographic characteristics, work history and characteristics, and health. The survey was administered using Qualtrics. After completing the survey, an in-depth, semi-structured interview in English was conducted. The interviews included questions about the work experiences of participants as direct care workers and their suggestions for dementia direct care workers who are immigrants. All transcripts generated through the online transcription service were carefully reviewed and verified for accuracy against the original audio recordings. Any discrepancies or errors in the automated transcription were corrected during this verification process. The average time taken to complete an interview was 45.72 min (SD = 8.09).

Data Analysis

Descriptive statistics were used to supplement the qualitative interview analysis by outlining the demographic and contextual characteristics of the participants. Stata software version 19 was used for the descriptive analyses, and it included frequencies, percentages, means, standard deviations, and ranges to characterize the sample and provide context for the qualitative findings. Interviews were recorded and transcribed using Otter.ai (an online transcription and editing service). The data analysis used the following six steps of thematic analysis developed by Braun and Clarke (2006): (1) familiarizing with the data by reading and re-reading the data, (2) generating initial codes, (3) searching for themes, (4) refining themes, (5) defining and naming themes, and (6) writing of final analysis and report. Analysis was supported by notetaking, journaling, and triangulation with the literature review. Data saturation was reached as recurring patterns emerged across the interviews (for more information, see Supplementary Materials).

Measures

Perceived stress (Cohen et al., 1983) was measured using four items assessing the frequency of experiencing the following in the past month (never = 0, almost never = 1, sometimes = 2, fairly often = 3, very often = 4): (1) Unable to control important things, (2) Confident about ability to handle problems, (3) Things going your way, and (4) Difficulties piling up. Items 2 and 3 were reverse-scored before summing all items to create a total score (theoretical range 0–16), where higher scores indicated higher levels of perceived stress.

Results

Quantitative Results

On average, participants were about 39 years old (SD = 15.19) with a range of 20–74, and over 85% were female. In terms of ethnicity, about 30% of direct care workers identified as Mexican, making this the largest single group. Korean workers comprised the second-largest group at 11%, followed by several groups each representing about 7% of the workforce: Chinese, Egyptian, Filipino, Indigenous Mexican American, and Persian workers. The remaining workers represented various other ethnicities including African American, Iranian, Native American and Spanish, and others, each comprising less than 4% of the sample (Table 1).

Table 1.

Descriptive Statistics from the Survey Responses (N = 27)

Variables	Mean (SD) or %	Range
Age (in years)	38.85 (15.19)	20–74
Gender
Female	23 (85.19%)
Male	4 (14.81%)
Ethnicity
African American	1 (3.70%)
Chinese	2 (7.41%)
Egyptian	2 (7.41%)
Filipino	2 (7.41%)
Indigenous Mexican American	2 (7.41%)
Iranian	1 (3.70%)
Korean	3 (11.11%)
Mexican	8 (29.63%)
Native American and Spanish	1 (3.70%)
Persian	2 (7.41%)
Spanish, Scottish-Irish German	1 (3.70%)
Sub-Saharan African	1 (3.70%)
Taiwanese	1 (3.70%)
Born in the U.S.
Yes	14 (51.85%)
No	13 (48.15%)
Generation status
1st Generation	12 (44.44%)
2nd Generation	11 (40.74%)
3rd + Generation	4 (14.81%)
Years in the U.S.	23.37 (17.45)	2–74
Marital status
Married/cohabitating	10 (37.04%)
Divorced/separated	4 (14.81%)
Never married/engaged/single	13 (48.15%)
Education
Some high school	1 (3.70%)
High school (or GED)	6 (22.22%)
Trade school	2 (7.41%)
Some college	5 (18.52%)
College degree	8 (29.63%)
Advanced degree	3 (11.11%)
Other: Vocational school	1 (3.70%)
Other: Trade school and some college	1 (3.70%)
Employment context
Nursing home (1)	2 (7.41%)
Assisted living community (2)	0
Another home care/home health agency (3)	15 (55.56%)
Privately employed to provide home care (4)	2 (7.41%)
Another type of health care employer (5)	1 (3.70%)
Other (6)	0
3,5,6	1 (3.70%)
3,4	2 (7.41%)
1,3	1 (3.70%)
3,6	1 (3.70%)
2,3	2 (7.41%)
Duration of work as a direct care worker (in months)	47.33 (45.23)	4–204
Job satisfaction
Very dissatisfied	0
Somewhat dissatisfied	2 (7.41%)
Somewhat satisfied	10 (37.04%)
Very satisfied	15 (55.56%)
Burnout
Never	2 (7.41%)
A few times	9 (33.33%)
Once a month	6 (22.22%)
A few times a month	5 (18.52%)
Once a week	3 (11.11%)
A few times a week	2 (7.41%)
Every day	0
Perceived stress	5.37 (2.47)	0–10

Note. SD = standard deviation. Total percentages may not equal 100% due to rounding. For U.S.-born participants, years in the U.S. correspond to their age. Years in the U.S. reported for foreign-born participants (n = 13): mean = 11.77, SD = 11.98, range: 2–45.

Slightly over half of the direct care workers were born in the United States. Approximately 44% were identified as first-generation. The mean time lived in the U.S. was 23 years (SD = 17.45). Those with college-level education (college degree 30% and advanced degree 11%) comprised about 41% of the sample. High school graduates made up 22%, while 19% had some college experience. Over 55% of participants indicated that their primary direct care work experience was with a home care agency, while others worked at nursing homes and other relevant settings. The mean duration of work experience as a direct care worker was 3 years and 11 months. Job satisfaction was high among respondents, with over 55% very satisfied and 37% somewhat satisfied. Only 7% expressed any dissatisfaction (somewhat dissatisfied), with no respondents reporting being very dissatisfied. Despite challenges and workforce improvement suggestions identified in qualitative interviews, the quantitative data revealed remarkably high overall job satisfaction among the direct care workers.

Regarding the question about how often people felt burnt out, about 33% of the respondents said a few times, followed by 22% indicating once a month, and 19% indicating a few times a month. Notably, about 19% of respondents frequently experienced burnout, reporting feeling burnt out once a week or a few times a week.

Qualitative Results

Several themes were identified to support immigrant caregivers of people living with dementia. One of the participants recognized the importance of their roles: “maybe 90% of my co-workers are immigrants. Oh, I don’t see many Native people working as caregivers. Yeah, it’s mostly immigrants. In the first place, [this] is not a job that people want to do” (male, 23 years old).

Theme I: Need for Enhanced Educational Support on Dementia Care and Safety Protocols

Participants indicated that educational training on caregiving and topics on dementia would enhance their skills and expertise. Participants suggested training on dementia, safety protocols (e.g., choking prevention), and other relevant caregiving knowledge.

“Prevent choking from patients when [they] swallowed, or something, at least ... training on language and some opportunities. For immigrant caregivers to be certified to become PCT (patient care technician) ... how to take care of the patient ... so providing some resources so that they have the basics ... It’s not just stay [ing] with the patient, because some [sometimes] like a serious dementia patient, they sometimes swallow something, they get a chock [choked], you know, so they have to know the basic support” (female, 45 years old). One participant also emphasized the need for training specific to people living with dementia (female, 40 years old, participant A).

In addition to obtaining dementia and caregiving knowledge, participants highlighted the importance of practical experience. “Well, if it’s possible for them to understand a little bit of, like, what caregiving is, if they’re new to it, they would be able to get, like, a little bit more of the hands-on training. It would help them a lot” (female, 27 years old). Training resources and self-learning tools can be helpful, but being a caregiver requires hands-on experience. “Training is very, very important, even if it’s an online or a video on YouTube or anything like that, [it] would be helpful” (female, 26 years old, participant A). “[What] really helped me was just keeping up with the training videos, like they just give you the scenarios. And then sometimes, just being on the field” (female, 25 years old, participant A).

One participant also suggested providing financial incentives in the process of learning.

“They can say, all right, we’re going to give you a one-hour course or two-hour course, and we’ll give you an extra $20 or $30 in salary ... So, they can give us courses every 3 months about dementia, about safety, about how to transfer, a reminder, even [if] it is the same thing, you have to do the courses, and you pass the courses, and we’ll give you an extra $50 Amazon gift card or a $50 bonus on your check” (male, 56 years old). These findings suggest that meaningful educational support must combine dementia-specific training and hands-on experience with financial incentives that encourage continued professional development.

Theme II: Importance of Cultural and Language Resources

Participants suggested offering resources and cultural support to help immigrant caregivers for people living with dementia adjust to the new working environment, which could help them provide quality care and continue to do well in their jobs. The following participant highlighted a community resource that could help with communications: “I got my mom into doing caregiving, and she’s an immigrant. She only speaks Spanish as well ... the first time, because the clients did speak English, it was a little hard for her to communicate ... sometimes like community centers ... sometimes at the most job fairs, there’ll be like other like caregiving programs and stuff” (female, 20 years old).

Participants underscored the importance of opportunities to strengthen English language skills. “My company [is] always hiring. I would love to refer my friend to my company, but she doesn’t speak much English… She wants to work, but she has to learn English first … The community college, that’s where I started, when I came to America, yeah, when I went to the ESL (English as a Second Language) class in community colleges” (female, 37 years old). “Language would be the most important thing to take, like English, English courses” (female, 30 years old). Employer-provided ESL programs were also recommended: “You can find ESL programs anywhere. You can even ask your company if they provide ESL programs” (female, 35 years old). Two additional participants (female, 47 years old and female, 26 years old, participant B) emphasized the need for English learning opportunities and additional training and resources to better communicate with patients.

Another participant suggested providing English classes and offering cultural community events. “I know there’re a lot of free English classes that can be taken ... So maybe just ... giving them those direct links to those resources, or even like cultural events, like, [that could] make a community [so] they can also learn the American culture a little bit more ... It would be nice to just give them those resources” (female, 38 years old). English communication and understanding cultural nuances are critical components in interacting with clients. “I’ve had a lot of immigrant co-workers, um, I’ve had a lot of them come to me for help, like, specifically [with] things that they couldn’t express in English, or help with charting, help communicating with a patient, also cultural stuff, like a lot of immigrants would be like, what does this mean when they do this? Or do Americans do [this] ... I think, kind of having, maybe like culturally competent courses for specifically immigrant workers, not for them, but for, but for, actually, not even just for immigrant workers. I think everybody could benefit from a culturally competent course. But I do think that it would be helpful for people that are coming from different cultures, specifically [those] being direct care workers to cultures. They’ve never they’ve never experienced, they’ve never seen” (female, 25 years old, participant B). Participants also identified technology as an innovative approach to addressing language and cultural barriers. “Like a translation thing would be helpful for someone ... from another country, and just training, you know, or directing them to the resource of, like training, because there are, like, some adult schools that help with learning English and stuff like that, I think just directing them that there’s a lot of resources in that that would be helpful, and maybe, like a translation, showing them how to use translation on their phone. But I think the way is to mainly learn the language, because then it’s going to be very hard to work with the client, you know, trying to translate things and be there, because you got to be a little faster. So, I think just learning the language is important person and directing them to the right resource, or just having those resources for, you know, colleagues to learn other languages and cultures” (female, 44 years old). Translation services or apps may be useful as short-term solutions to communication challenges. “At least we have, like, Google Translate” (female, 26 years old, participant A). Another participant noted that translation apps are readily accessible: “Translators, like, you can, you can download [them]” (female, 35 years old). Helping direct care workers understand American culture can support their careers as care workers. “It really helps to avoid miscommunication, misunderstanding, because something, something like [not wanting] to be touched, is in The Americans, maybe most of the American does. They don’t like to be touched sometimes, but in my country ... our culture is different. So it’s really good to have these trainings, or maybe this sharing with each other to avoid miscommunication” (female, 40 years old, participant B). Overall, creating a learning and supportive community was identified as critical to supporting immigrant direct care workers.

In addition to the emphasis on English-related and cultural resources, job security through visa sponsorship emerged as an important concern. “I mean, I’ve got my two daughters [who] are very stressed. They’re crying every day because of the issue that’s happening now, and they’re scared they’re gonna be reported. So, this is one of the scary [things] I think that’s happening now. I already paid [$] 5000 to the lawyer, and nothing happened” (male, 56 years old). Another participant shared the struggle of waiting for a green card: “I came in 5 years ago. I don’t have any my green card yet ... “I’m waiting, I’m waiting, I’m waiting. There’s no help ... And, you know, my kids are not happy because you want to travel. They’re dreaming about to give the agreement to go. Go somewhere to see how Canada looks like, yeah, Mexico, something too close, but because we don’t have the green so who can go anywhere?” (female, 51 years old). The visa sponsorship was noted as making a big difference: “I know one of my friends, she’s Filipino ... she came here ... she really struggled in her country, and thank God, she came through a visa here, yeah, with this caregiving, she confessed that ... these opportunities changed her life” (female, 40 years old, participant B). Participants also emphasized the importance of community resources and ensuring immigrant workers are aware of available support: “[There] a lot of different resources ... [People] being new into the country, or needing resources, financially or emotionally. It’s called LifeSTEPS ... They offered even here at where I live, in the affordable housing for seniors, and they refer them for financial help, emotional help, assistance, you know, and all kinds of things that might have something to do with caregiving as well as resources to help people to refer them ... the caregiving support group helps a lot, because sometimes you think you’re all alone in dealing with it. You’re not all alone dealing with it. And it didn’t cost me a dime to go to that ... So when you say immigrants, ... you [might not] think I’m from an immigrant background. I am, and that’s why I say I understand when you come as an immigrant to this country what challenges you have” (female, 74 years old). Overall, participants emphasized that meaningful cultural and linguistic support must extend beyond the workplace to include community resources and pathways to job security.

Theme III: Opportunities for Career Advancement and Improved Working Conditions

Direct care workers shared the importance of having more opportunities to advance their careers and have better work experiences. Participants discussed the need for more education to develop their knowledge and skills, as well as opportunities to explore their professional interests. One participant shared: “Education and even giving more courses to grow in the company? We have medical technician and we have nursing. I would appreciate being 1 day, a nurse, an assistant nurse ... I want to be able to pay my rent ... I’ll be very glad if I can become an assistant nurse, if I can land at the facility. This is one of my dreams ... I mean, I will be getting double pay, maybe after 5 years or 7 years at the facility. I think, I think I’ll be deserving [of] that” (male, 56 years old). Similarly, another participant emphasized the need for a clear vision and goals for caregivers’ professional future. “Well, one thing for certain is that there is a huge shortage of caregivers. So basically, [there should be] something that makes the work more attractive for people to join in, because the job, [there’s] no bonus. You have no progression ... you won’t get a raise, and there is no higher position [you] could get into. It’s a dead end job. So something that gives you the light of hope ... for me, it’s caregiving–It’s not going to be my ultimate job. Yeah, it’s a setting problem. But for some people who [are] gonna do it for the rest of their lives, and there should be some room for growth, otherwise, what’s the difference between somebody who worked for 2 years and somebody who worked for 10 years? Yeah, if they’re getting paid the same, with no bonus, with no room for growth, then what’s the point? You know?” (male, 23 years old). Participants also noted that financial support for professional development would be helpful: “Free online training or something like that, that would help a lot ... when I was doing the nursing aid, it was only [$500], but now that I was looking at it, it’s up to $2000. Oh, so, you know, like, yeah, it’s that crazy now. So I was like, ‘Oh, who could you know, like, afford that if you don’t have any, you know, means of, like, yeah. So I was like, $2000 for that training is, like, too much already, yeah, but I know some of the like, especially nursing homes, they would provide, like, free training, but they’re gonna have to be employed there” (female, 26 years old, participant A). Together, these perspectives reflect the importance of creating meaningful opportunities for career growth and reducing financial barriers to professional development to better support the immigrant direct care workforce.

Discussion and Implications

Immigrant workers constitute a large segment of the U.S. direct care workforce (Campbell et al., 2021). However, they continue to experience limited learning opportunities and a lack of clear career growth pathways (Sterling et al., 2020). Findings from the present study further indicate that immigrant direct care workers face additional challenges, including inadequate language-related support needed to transition effectively into their caregiving roles. Moreover, the COVID-19 pandemic worsened these conditions by contributing to greater invisibility, elevated health risks, inconsistent resources and support, and increased difficulties managing work and personal life (Sterling et al., 2020).

Participants highlighted the need for enhanced educational support on dementia care and safety protocols. Research indicates that with minimal time and cost investment, practices such as sensory interventions, psychosocial approaches, and systematic care protocols can help address behavioral and psychological symptoms of dementia (Scales et al., 2018). These practices could serve as models for training programs that better equip caregivers supporting people living with dementia and enhance the quality of care provided to care recipients. Without strong evidence on the core knowledge and skills needed for dementia care, developing effective training programs for direct care workers remains a challenge (Spetz et al., 2025).

Previous research indicates that language and cultural barriers can impact care quality and worker confidence (Brooke et al., 2018; Davis & Smith, 2013). Acculturation, the process of adapting to new values, beliefs, and social and cultural systems, can influence the immigrant workers’ mental health and their confidence in performing their jobs (Brooke et al., 2018). Sagbakken et al. (2018) also identified language and cultural barriers as challenges faced by immigrant older adults receiving care. These findings suggest that support should be bidirectional, addressing the needs of both direct care workers and their clients. Participants in the present study went further by proposing specific interventions, including employer-provided ESL instruction, translation technologies, cultural orientation programs, and community-based learning opportunities. This insight is consistent with patient-centered care models that prioritize cultural competence as fundamental to healthcare quality.

Direct care workers expressed their desire for clear career pathways and professional growth opportunities. Participants described direct care work as a “dead end job” with no bonuses, raises, or advancement opportunities, raising critical questions about workforce sustainability. These findings align with research demonstrating that investment in workplace support and career development improves job retention and satisfaction (Brannon et al., 2007; Ejaz et al., 2008; Mittal et al., 2009; Yarbrough et al., 2017).

The three themes identified in this study, enhanced educational support, cultural and language resources, and career advancement opportunities, correspond to gaps documented in prior research.

Limitations

There are several limitations to note in the present study. First, the study data collection was primarily from one state, and direct care worker experiences and caregiving cultures in other regions in the United States may be different; thus, the findings may not be generalizable. Yet, this study offers important insights into the perspectives of direct care workers on the immigrant dementia workforce. Second, the present study included 44% first-generation immigrant dementia direct care workers and 41% were second-generation. Future studies could also explore work experiences by generational status and other intersectionality aspects. Third, the present study revealed a paradox of high job satisfaction despite significant challenges. Further investigation is needed to understand the motivation and resilience of dementia direct care workers. Lastly, employment contexts for participants focused mainly on home care and health agencies, and most of the experiences were focused on one-on-one care and may be different from those of workers in larger group settings.

Implications

The research findings aligned well with the theories discussed in the literature review section and provided opportunities for further investigation into the diverse experiences of direct care workers. Study participants were largely consistent with the national profile of direct care workers in the following areas. Nationally, direct care workers are predominantly female (87%) and people of color (59%); additionally, 27% are immigrants and 53% have a high school education or less (PHI, 2020; Scales, 2021). In the present study, 85% were female, and a lower percentage had a high school education or less (26%), suggesting that the present sample was somewhat more educated than the national average.

The present study findings provide implications for immigration and healthcare workforce policies. Considering the proportion of immigrant care workers (Jun & Grabowski, 2024) and the potential for visa sponsorship to provide a pathway to permanent residency for essential healthcare workers, policy development in this area is warranted. Moreover, reducing the financial barriers to training and increasing the number of ESL programs could help the immigrant dementia care workforce and highlight the need for policy subsidies for these learning resources. At the practice level, integrating structured cultural orientation programs and technology integration can strengthen the cultural competency of caregivers. Mentorship programs and community connections are needed to help immigrant direct care workers navigate workplace and cultural challenges. The financial incentives proposed by participants to facilitate continuing education reflect a nuanced understanding of the economic barriers that care workers commonly encounter. Workforce development policies should address financial barriers by expanding Workforce Innovation and Opportunity Act funding (U.S. Department of Labor, n.d.). Targeted grant programs modeled after California’s In-Home Supportive Services Career Pathways Program, which subsidizes CNA certification and dementia care training costs, can secure caregiver incentives and strengthen the quality of care (Hunt et al., 2023). As about five in 10 direct care workers in California are receiving benefits from public assistance programs, providing economic protection through various incentives is critical (Hunt et al., 2023).

Longitudinal studies on how increased resources impact dementia patient care quality would help assess the effectiveness of strengthened caregiver support. The findings from the present study contribute to expanding understanding of the ethics of care and emotional labor literature by illuminating how immigrant caregivers engage in emotional labor while navigating cultural transitions in the United States.

Conclusions

Through a mixed-methods approach, the present study highlighted dementia direct care workers’ perspectives on what resources and support are needed to help them advance their careers. Despite challenges, the direct care workers demonstrated passion and dedication to their work. Programs and policies that provide learning opportunities, pathways for career advancement, and stable job security can encourage them to continue their work and provide quality care for older adults living with dementia.

Supplemental Material

Supplemental material - Strengthening Support for Immigrant Direct Care Workers: Recommendations from Experienced Direct Care Workers for People Living with Dementia

Supplemental material for Strengthening Support for Immigrant Direct Care Workers: Recommendations from Experienced Direct Care Workers for People Living with Dementia by Yeonjung Jane Lee in Journal of Applied Gerontology

Footnotes

Acknowledgments

This research was made possible by the study participants who generously shared their time and valuable perspectives. The author is grateful to Mark E. Woodsum and his team for their partnership. The author also thanks Dr. Joanne Spetz and her team for their leadership and support through the 2025 AWARD Network Pilot Mini Award Program. Special thanks to Catherine Woodward Calder for coordinating participant compensation.

ORCID iD

Yeonjung Jane Lee

Ethical Considerations

This study was approved by the Institutional Review Board at the University of Hawaiʻi at Mānoa (2025-00230).

Consent to Participate

All participants provided written informed consent prior to participation.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the AWARD Network, a National Institute on Aging (Grant: 1R24AG077014). The views expressed in written materials do not necessarily reflect the official policies of the Department of Health and Human Services (HHS) or the National Institute on Aging. The author is grateful for the support provided by the AWARD Network Pilot Award Program at the University of California, San Francisco.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data from the study are not available due to IRB guidelines.*

Supplemental Material

Supplemental material is available online.

References

Alzheimer’s

Association.

(2025). 2025 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, 21(4), e70235. https://doi.org/10.1002/alz.70235

Brannon

Barry

Kemper

Schreiner

Vasey

(2007). Job perceptions and intent to leave among direct care workers: Evidence from the better jobs better care demonstrations. The Gerontologist, 47(6), 820–829. https://doi.org/10.1093/geront/47.6.820

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa

Brooke

Cronin

Stiell

Ojo

(2018). The intersection of culture in the provision of dementia care: A systematic review. Journal of Clinical Nursing, 27(17–18), 3241–3253. https://doi.org/10.1111/jocn.13999

Campbell

Del Rio Drake

Espinoza

Scales

(2021). Caring for the future: The power and potential of America’s direct care workforce. PHI. https://www.phinational.org/wp-content/uploads/2021/01/Caring-for-the-Future-2021-PHI.pdf

Centers for Disease Control & Prevention (CDC) . (2020). COVID-19 in racial and ethnic minority groups. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racialethnic-minorities.html

Cohen

Kamarck

Mermelstein

(1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385–396. https://doi.org/10.2307/2136404

Creswell

J. W.

Plano Clark

V. L.

(2018). Designing and conducting mixed methods research (3rd ed.). Sage Publications.

Davis

B. H.

Smith

M. K.

(2013). Developing culturally diverse direct caregivers for care work with older adults: Challenges and potential strategies. The Journal of Continuing Education in Nursing, 44(1), 22–30. https://doi.org/10.3928/00220124-20121101-54

10.

Devine

(2025). Immigration and the direct care workforce. https://www.phinational.org/immigration-and-the-direct-care-workforce/

11.

Dwyer

R. E.

(2013). The care economy? Gender, economic restructuring, and job polarization in the U.S. labor market. American Sociological Review, 78(3), 390–416. https://doi.org/10.1177/000312241348719

12.

Ejaz

F. K.

Noelker

L. S.

Menne

H. L.

Bagaka’s

J. G.

(2008). The impact of stress and support on direct care workers’ job satisfaction. The Gerontologist, 48(suppl_1), 60–70. https://doi.org/10.1093/geront/48.supplement_1.60

13.

Eriksson

Jordal

Hjelm

Engström

(2023). Job satisfaction and wellbeing among migrant care workers in nursing homes: An integrative review. Nursing Open, 10(6), 3486–3505. https://doi.org/10.1002/nop2.1611

14.

Espinoza

(2022). The impact of COVID-19 on direct care workers. https://generations.asaging.org/impact-covid-19-direct-care-workers/

15.

Held

(2006). The ethics of care: Personal, political, and global. Oxford University Press.

16.

Hochschild

A. R.

(2003). The managed heart: Commercialization of human feeling (20th anniversary ed.). University of California Press.

17.

Hodges

M. J.

(2020). Intersections on the class escalator: Gender, race, and occupational segregation in paid care work. Sociological Forum, 35(1), 24–49. https://doi.org/10.1111/socf.12566

18.

Hunt

Yeh

Fix

(2023). California’s direct care workforce: Who they are, the work they Do, and why it matters. California health care foundation. https://www.chcf.org/wp-content/uploads/2022/12/CaliforniaDirectCareWorkforce.pdf

19.

Jun

Grabowski

D. C.

(2024). Nursing home staffing: Share of immigrant certified nursing assistants grew as US-born staff numbers fell, 2010–21. Health Affairs, 43(1), 108–117. https://doi.org/10.1377/hlthaff.2023.00881

20.

McCall

Scales

(2022). Direct care worker disparities: Key trends and challenges. https://www.phinational.org/wp-content/uploads/2022/02/Direct-Care-Worker-Disparities-2022-PHI.pdf

21.

Mittal

Rosen

Leana

(2009). A dual-driver model of retention and turnover in the direct care workforce. The Gerontologist, 49(5), 623–634. https://doi.org/10.1093/geront/gnp054

22.

Noddings

(2013). Caring: A relational approach to ethics & moral education (2nd ed., updated). University of California Press. https://doi.org/10.1525/9780520957343

23.

Paraprofessional Healthcare Institute . (2020). Workforce data center. Retrieved from. https://phinational.org/policy-research/workforce-data-center/

24.

Paraprofessional Healthcare Institute . (2022). Direct care workers in the United States: Key facts. Retrieved from. https://www.phinational.org/resource/direct-care-workers-in-the-united-states-key-facts-2/

25.

Paraprofessional Healthcare Institute . (2023a). Bridging the gap. Enhancing support for immigrant direct care workers and meeting long-term care needs. https://www.phinational.org/wp-content/uploads/2023/09/PHI-Bridging-the-Gap-2023.pdf

26.

Paraprofessional Healthcare Institute . (2023b). Immigrants can help ‘Bridge the Gap’ in direct care. https://www.phinational.org/immigrants-can-help-bridge-the-gap-in-direct-care/

27.

Sagbakken

Spilker

R. S.

Nielsen

T. R.

(2018). Dementia and immigrant groups: A qualitative study of challenges related to identifying, assessing, and diagnosing dementia. BMC Health Services Research, 18(1), 910. https://doi.org/10.1186/s12913-018-3720-7

28.

Scales

(2021). It is time to resolve the direct care workforce crisis in long-term care. The Gerontologist, 61(4), 497–504. https://doi.org/10.1093/geront/gnaa116

29.

Scales

Zimmerman

Miller

S. J.

(2018). Evidence-based nonpharmacological practices to address behavioral and psychological symptoms of dementia. Gerontologist, 58(Suppl_1), S88–S102. https://doi.org/10.1093/geront/gnx167

30.

Shippee

T. P.

Akosionu

Woodhouse

Duan

Thao

M. S.

Bowblis

J. R.

(2020). COVID-19 pandemic: Exacerbating racial/ethnic disparities in long-term services and supports. Journal of Aging & Social Policy, 32(4–5), 323–333. https://doi.org/10.1080/08959420.2020.1772004

31.

Spetz

Wagner

L. M.

White

E. M.

Chapman

S. A.

Chiong

Friedman

E. M.

Gerlach

L. B.

Harrison

K. L.

Hunt

L. J.

Lee

Muench

Possin

Sideman

Hickey

J. v. T. S.

Putthinun

Yeh

Sandoval

Rose

Rothstein

Zimmerman

(2025). The National Dementia Workforce Study: Development of questionnaires for home care, assisted living, and nursing home settings. Journal of the American Geriatrics Society, 73(11), 3344–3353. https://doi.org/10.1111/jgs.70048

32.

Sterling

M. R.

Tseng

Poon

Cho

Avgar

A. C.

Kern

L. M.

Ankuda

C. K.

Dell

(2020). Experiences of home health care workers in New York city during the coronavirus disease 2019 pandemic: A qualitative analysis. JAMA Internal Medicine, 180(11), 1453–1459. https://doi.org/10.1001/jamainternmed.2020.3930

33.

Tronto

J. C.

(1993). Moral boundaries: A political argument for an ethic of care. Routledge.

34.

U.S. Census Bureau . (2020). Demographic turning points for the United States: Population projections for 2020 to 2060. https://www.census.gov/content/dam/Census/library/publications/2020/demo/p25-1144.pdf

35.

U.S. Department of Labor . (n.d.). Workforce innovation and opportunity act. https://www.dol.gov/agencies/eta/wioa

36.

Yarbrough

Martin

Alfred

McNeill

(2017). Professional values, job satisfaction, career development, and intent to stay. Nursing ethics, 24(6), 675–685. https://doi.org/10.1177/0969733015623098