Essential Long-Term Care Workers Commonly Hold Second Jobs and Double- or Triple-Duty Caregiving Roles.

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Long-term care (LTC) facilities are particularly dangerous places for the spread of COVID-19 given that they house vulnerable high-risk populations. Transmission-based precautions to protect residents, employees, and families alike must account for potential risks posed by LTC workers' second jobs and unpaid care work. This observational study describes the prevalence of their (1) second jobs, and (2) unpaid care work for dependent children and/or adult relatives (double- and triple-duty caregiving) overall and by occupational group (registered nurses [RNs], licensed practical nurses [LPNs], or certified nursing assistants [CNAs]).


A descriptive secondary analysis of data collected as part of the final wave of the Work, Family and Health Study.


Thirty nursing home facilities located throughout the northeastern United States.


A subset of 958 essential facility-based LTC workers involved in direct patient care.


We present information on LTC workers' demographic characteristics, health, features of their LTC occupation, additional paid work, wages, and double- or triple-duty caregiving roles.


Most LTC workers were CNAs, followed by LPNs and RNs. Overall, more than 70% of these workers agreed or strongly agreed with this statement: "When you are sick, you still feel obligated to come into work." One-sixth had a second job, where they worked an average of 20 hours per week, and more than 60% held double- or triple-duty caregiving roles. Additional paid work and unpaid care work characteristics did not significantly differ by occupational group, although the prevalence of second jobs was highest and accompanying work hours were longest among CNAs.


LTC workers commonly hold second jobs along with double- and triple-duty caregiving roles. To slow the spread of COVID-19, both the paid and unpaid activities of these employees warrant consideration in the identification of appropriate clinical, policy, and informal supports. J Am Geriatr Soc 68:1657-1660, 2020.





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Van Houtven, Courtney Harold, Nicole DePasquale and Norma B Coe (2020). Essential Long-Term Care Workers Commonly Hold Second Jobs and Double- or Triple-Duty Caregiving Roles. Journal of the American Geriatrics Society, 68(8). pp. 1657–1660. 10.1111/jgs.16509 Retrieved from

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Van Houtven

Courtney Harold Van Houtven

Professor in Population Health Sciences

Dr. Courtney Van Houtven is a Professor in The Department of Population Health Science, Duke University School of Medicine and Duke-Margolis Center for Health Policy. She is also a Research Career Scientist in The Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System. Dr. Van Houtven’s aging and economics research interests encompass long-term care financing, intra-household decision-making, unpaid family and friend care, and home- and community-based services. She examines how family caregiving affects health care utilization, expenditures, health and work outcomes of care recipients and caregivers. She is also interested in understanding how best to support family caregivers to optimize caregiver and care recipient outcomes.

Dr. Van Houtven  is co-PI on the QUERI Program Project, “Optimizing Function and Independence”, in which her caregiver skills training program developed as an RCT in VA, now called Caregivers FIRST, has been implemented at 125 VA sites nationally. The team will evaluate how intensification of an implementation strategy changes adoption. She directs the VA-CARES Evaluation Center, which evaluates the VA’s Caregiver Support Program. She leads a mixed methods R01 study as PI from the National Institute on Aging that will assess the value of "home time" for persons living with dementia and their caregivers (RF1 AG072364).

Areas of expertise: Health Services Research and Health Economics


Nicole DePasquale

Assistant Professor in Medicine

Nicole DePasquale, PhD, is an Assistant Professor in Medicine in the Division of General Internal Medicine at the Duke University School of Medicine. She earned her PhD in Human Development and Family Studies from the Pennsylvania State University (2017), MSPH from the Johns Hopkins Bloomberg School of Public Health (2011), and BA in Communication with minors in Psychology and Sociology from Rutgers University (2010). Her research addresses questions about health, well-being, and multiple role management in the context of middle and late adulthood, with the ultimate aim of informing intervention efforts. She addresses these questions through two lines of research that utilize quantitative and qualitative methodology. One line examines the ways in which patients with chronic kidney disease and their family care partners work together to self-manage the disease and the impact dyadic self-management has on their health both as individuals and as a unit. The second line examines the work/nonwork interface of long-term care employees with family caregiving roles, or double- and triple-duty caregivers. Recent research includes patient-family discussions about living-donor kidney transplantation, decisional conflict regarding kidney failure treatment modalities, and the work and nonwork benefits of family-supportive supervisor behavior among double- and triple-duty caregiving men.

In April 2021, Dr. DePasquale received a K01 Career Development Award from NIA to fund her research project, “Supporting Patients and Care Partners to Manage Chronic Kidney Disease Together,” or The Shared Kidney Care Study. The Shared Kidney Care Study examine ways in which older adult-family care partner dyads appraise and manage CKD together and the impact dyadic management has on their health and well-being as individuals and as a whole. A year later, she became a 2022-2024 Pilot and Exploratory Studies Award (PESC) Scholar at the Duke Claude D. Pepper Older Americans Independence Center (Duke OAIC). The award, which begins on July 1, will fund her pilot study project, “Individual and Dyadic Factors Associated with Older Dialysis Patients’ Physical Resilience.” This pilot project serves as an add-on component to the Shared Kidney Care Study and expands the parent study’s existing strengths by adding a new and unique focus on physical resilience. It will examine how kidney failure dyads work together (or not) to maintain, regain, or optimize older patients’ physical function amid dialysis initiation and its negative downstream effects for patients and family care partners alike.

Dr. DePasquale is the recipient of the Springer Early Career Achievement Award in Research on Adult Development and Aging from Division 20: Adult Development & Aging of the American Psychological Association (APA). Prior to this, she secured a NIA-sponsored National Research Service Award (F31) to support her dissertation on the sleep implications of double- and triple-duty care, for which she received the Doctoral Dissertation Award in the Psychology of Aging from Division 20 of APA. She was also an NIA Butler-Williams Scholar. Since 2017, she has served in a leadership position for APA Division 20’s Early Career Task Force and was responsible for launching the Division’s Special Interest Groups (SIGs) initiative. Currently, she is assisting with projects on the NIA/NIH CARE IDEAS R01 study examining outcomes among persons with cognitive impairment and their family care partners.

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