Nursing home leaders have routinely pointed to staffing shortages as a top operational challenge, even in the years leading up to the COVID-19 pandemic. Now, the public health emergency has even further exacerbated the hiring challenges operators face.
Those challenges were quantified recently in a Health Affairs study that examined pre-pandemic payroll-based journal (PBJ) data to assess turnover at U.S. nursing homes. Using data from more than 15,000 facilities from 2017 to 2018, researchers found that the average turnover for certified nursing assistants (CNAs) was 129.1%.
The COVID-19 pandemic also highlighted the shortcomings of the current nursing home staffing model, which requires frontline staff like CNAs to care for large numbers of vulnerable patients for minimum wages. In a Congressional hearing held last summer, one CNA was adamant that staffing shortages were a problem well before the pandemic, telling representatives that “the only thing COVID did was rip the doors open.”
That means that investment in the CNA profession is paramount to addressing the issue, as numerous operators, advocates and CNAs themselves agreed in a virtual March on Washington event held last month.
On a macro level, that means the entire approach to CNA training will have to be re-examined, according to Victoria Randle, the CEO and founder of CNA training consulting firm The Secret Cocktail. She got her start in health care as a CNA and opened a CNA school in 2015.
During the CNA March on Washington, she pointed to the Nursing Home Reform Act of 1987 as the root of many of the industry’s current training obstacles.
“For over 30 years, our federal government has been regulating CNA training and education under the Nursing Home Reform Act,” she said during the April march. “It was very helpful in the beginning, but now it is very outdated, and we need to revamp it immediately.”
Nursing homes might be wise to take a page from their home health and home care rivals when it comes to CNA recruiting, Randle told SNN. Speaking from her own experience, she said nursing homes are missing recruiting opportunities by not contacting CNA schools.
“The only people that were actively coming to me when I had my CNA school – and the same, I feel, with my clients – [were] home care agencies,” she said. “Now, they are on it. They will come to you as soon as they see that you’re open, they’ll come and speak to your students on graduation day, they’ll do any and everything for recruits. You see them all the time. Nursing homes – you never see them.”
Temporary nurse aides will not solve shortages
Staffing shortages in nursing homes seem to cry out for a solution, such as the Section 1135 waivers issued by Centers for Medicare & Medicaid Services (CMS) at the start of the pandemic. They allowed nursing homes to make longer-term use of temporary workers.
Specifically, they waived rules that previously prohibited SNFs from employing anyone for more than four months unless they met specific training and certification requirements.
Under the waiver, individuals still had to be competent to provide nursing and nursing related-services, but the certification and training restrictions were removed “to assist in potential staffing shortages seen with the COVID-19 pandemic,” according to the agency.
But Randle argued that temporary nurse aides are not a sustainable solution to the pervasive CNA shortages that plague nursing homes. For one thing, the aides do not receive the supervision that they should.
“They don’t get to really follow someone around and learn the ropes,” she told SNN. “They are put out there on their own, and they’re just learning as they go. That is dangerous.”
For Randle, the low retention numbers one major operator cited are telling enough: Kennett Square, Pa.-based Genesis HealthCare, one of the largest nursing home operators in the U.S., hired more than 600 TNAs over the course of the pandemic, with 319 still working, according to the company’s vice president of workforce development.
But even before the pandemic, CNA training and certification was outdated, Randle said. She pointed to The Omnibus Budget Reconciliation Act of 1987 – which included the Nursing Home Reform Act – and its specific regulation related to nurse aide training and education.
The federal laws surrounding CNA education are the issue, because those laws were looped into the nursing home law, Randle said. One of the reasons for shortages of CNAs is that the federal law requires that only registered nurses (RNs) with long-term care experience can oversee a CNA program.
“The training of nurse aides must be performed by or under the general supervision of a registered nurse who possesses a minimum of two years of nursing experience, at least one year of which must be in the provision of long-term care facility services,” the regulation states specifically.
This is one of the most significant barriers, since “there’s not many RNs that have ever set foot in nursing homes,” Randle said. But she also pointed to the fact that different states have different definitions of *”nurse,” so while some states might allow licensed practical nurses to teach CNA programs, another might only allow RNs to conduct that teaching.
Nursing homes can start their own CNA programs, and it’s typically a much easier process than for an individual trying to launch a CNA school, Randle noted. While it’s not clear how many facilities offer such programs, she said many nursing homes have begun to reach out to her more recently and over the course of the pandemic, asking if she could connect them with CNA schools.
“Of course I’m happy to do so,” she said. “But I would always ask them: Is there any reason why you’re not starting your own CNA program? It would just behoove you to do it, why are you not? And the answer was always: We don’t have the time. We don’t have the funding. We don’t have the person. … But if they did have their own program, they would be reimbursed for every CNA that they teach that gets hired.”
Improving the pipeline by improving the job
Another problem is mandated ratios, with instructor-to-student ratio requirements for CNA programs that do not exist for nursing programs, Randle said. While the ratios vary by state, the caps mean that not enough CNAs are graduating to fill the job openings that exist. For nursing homes, that translates to incredibly heavy patient caseloads for each CNA, she told SNN, sometimes as many as 30 to 40 patients per CNA.
This contributes significantly to the shortage of CNAs for nursing homes in particular, Randle noted.
“A lot of CNAs, … they’ll do a nursing home for a year or two, and they’ll get sick of it,” she said. “And they will opt to do personal or private care, where they have one-on-one care, because that’s what they got into it for. Anyone getting into this business is getting into it because they want to make a difference. … You’ve got to do that for $10 an hour.”
The hourly wage for CNAs, of course, is another significant factor that has to be addressed, and one stakeholder with financing relationships spanning multiple nursing homes over decades is taking steps to address that. The immediate focus of the program his company is helping launch is training.
Specifically, the nonprofit Jack and Nancy Dwyer Workforce Development Program aims to provide training for the CNA and geriatric nursing assistant (GNA) positions, as well as entry-level jobs, in effect introducing people in need of work to the CNA profession and facilitating their training. CFG Bank contributed $1 million to launch the program, in addition to donating $1 million to the nonprofit Living Classrooms in Baltimore, which will train students, according to a press release announcing the program.
But the program would go beyond training by finding the graduates new jobs and hiring case managers to remain in touch with the graduates so they can transition successfully into their new career, Jack Dwyer, owner and chairman of the board of CFG Bank, told SNN.
“If we can create the jobs, and then have some stability in the jobs, it’ll be rewarding for everybody: our industry and people that are stuck with unemployment,” he said.
He envisions a runway for workers who graduate through the workforce development program to continue their education, with some of the funds from the grants going to scholarships and education so CNAs could advance through the health care ranks if they so choose. Though the program is still working out some of its targets – it was announced in the middle of April – the ultimate goal may be to train 50 to 100 people on a quarterly basis, Dwyer said, though he was also clear the program is still in the early stages.
As part of that process, he is in touch with the nursing homes and assisted living facilities in the Baltimore area where he has relationships, with the goal of telling them about the training program, and getting a sense of what the facility might be able to offer graduates in terms of wages and benefits.
And while it won’t happen overnight, he’s hopeful that the program could eventually spur some wage competition and improve the hourly rate for direct care workers in the area.
“These are people that are doing really hard jobs, and taking care of frail elderly people, and they have to be paid a good wage,” Dwyer said. “We could go on for a long time talking about reimbursements in nursing homes, because of the Medicare/Medicaid program, and there’s limitations, and states set guidelines for how many CNAs are in the building. There’s a lot of factors that go into this, but at the end of the day, greater pay will help retain people at your building.”
*An earlier version of this story used the term “registered nurse” rather than “nurse. SNN regrets the error.