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.
- 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.
- Federal regulations state that CNAs who are employed by (or have been offered employment from) a Medicare- or Medicaid-certified nursing facility are not to be charged for their training and testing, and those who are employed by (or receive an offer or employment from) such a facility within 12 months of completing their training program are to be reimbursed for their training and testing costs. However, the study found that many CNAs pay for the training programs and testing themselves.
- Informants emphasized the importance of screening applicants before enrollment in CNA courses. They also emphasized that English as a Second Language courses significantly improve the chances for Spanish-speaking and other immigrant students to successfully complete CNA training and testing.
The results of the study suggest a number of recommendations for improving CNA training programs. These recommendations are targeted to federal and state policymakers and training program officials.
- The study points to a need to increase the 75-hour federal minimum requirement to at least 100 to 120 hours, to ensure that CNAs have the training the need to provide good quality care to residents. In addition, improving training may reduce CNA turnover, thereby improving the quality of care and reducing the costs associated with high turnover rates.
- The study indicates a need to increase clinical training to at least 50 to 60 hours.
- The study points to the need for additional resources for training program reviews. Additional resources may allow state practices to become more closely aligned with federal requirements.
- The study identifies a need to increase CNAs’ awareness of federal law regarding reimbursement of CNAs for their training and testing expenses and to penalize facilities that do not reimburse these costs as the law requires. Improved reimbursement of CNAs may help improve recruitment into the profession.
- Better screening of applicants before enrollment in training programs may improve the proportion of students who successfully complete the programs and become CNAs and might also increase CNA retention. Thus, better screening would lead to better care for residents and increase the value of the investments made by nursing facilities, students, and the government in CNA training programs. One part of better screening may be addressing widespread needs in terms of remedial and English as a Second Language courses. At the same time, training programs should consider whether strict English requirements might disqualify too many good workers.
Written by Bernadette Wright, Ph.D., AARP Public Policy Institute
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Public Policy Institute, AARP, 601 E Street, NW, Washington, DC 20049
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