In Brief: Training Programs for Certified Nursing Assistants

Certified nursing assistants (CNAs) provide most of the care received by nursing home residents. Despite their title, their main role is not to assist nurses, but to assist residents. Although their work is often perceived as “unskilled,” CNAs perform complex and important functions. They help residents with daily activities, measure their vital signs, watch for and report changes in their conditions, and provide companionship and emotional support.

Good quality care for residents and a stable CNA workforce require providing CNAs with the training they need to be well prepared for their jobs. The 1987 Nursing Home Reform Act mandates that CNAs receive a minimum of 75 hours of training. Federal regulations require that a training program must include 16 hours of clinical or “hands-on” training, in which the trainee demonstrates knowledge while performing tasks for an individual under the direct supervision of a nurse. CNA students must complete the training and pass a state certificate exam and skills test within four months of beginning work at a nursing facility. CNAs must also complete 12 hours of in-service or continuing education each year.

About half the states go beyond these minimum federal training requirements. The more rigorous training requirements reflect the concern that the 75-hour federal minimum may not be sufficient to prepare CNAs to provide good care to residents, given that the complexity of caring for nursing home residents has increased since the passage of the 1987 Nursing Home Reform Act.

This Issue Paper adds to the literature on CNA training by examining how many hours of initial training and clinical training are needed. It also examines pre-training screening, remedial education, training in English as a Second Language, and shadowing; CNA testing; and reimbursement of CNAs for their training and testing expenses. It focuses on state nurse aid training programs in 10 states: California, Florida, Maine, Maryland, Massachusetts, Michigan, New York, Pennsylvania, Texas and Wisconsin. Information was gathered by interviews with 55 key informants, including CNAs and CNA students, state officials, experts in CNA training and testing, and state long-term care ombudsmen.

Key Findings

• State regulators have reported difficulties complying with the federal requirement that CNA training programs be reviewed every two years. Because of insufficient survey staff, reviews generally have been delayed or have focused on checking basic items only.
• The study revealed wide variation in the quality of training that CNAs receive. In some states, the actual hours of training the CNAs receive often exceeds the federal and state minimum requirements. In these states, longer programs are often offered largely because program directors do not believe that the required topics can be adequately covered without the additional time. In other states, informants said that most programs provide the minimum or close to the minimum number of hours.
• Informants agreed that 75 hours is insufficient to adequately train CNAs. The majority suggested an increase to between 100 and 120 hours. Informants also generally believed that clinical training should account for a higher proportion of total training time than it does currently. Several informants said that 50 to 60 hours of clinical training was needed, and some said that even more clinical time was needed.
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