Urban Wire Strategies to Improve the Certified Nursing Assistant Workforce Crisis
Nathan Sick
Display Date

A nurse adjusting an IV bag.

Trouble has been brewing in the certified nursing assistant (CNA) workforce for decades (PDF). Today, it’s fair to call what is currently unfolding in CNA and long-term care (LTC) occupations a crisis.

CNA jobs are a high-demand and growing entry-level health care occupation. CNAs are the backbone of out-of-home elder care, but they’re not paid well (in 2021, their median wage was $14.56 per hour). The profession itself is challenging and hazardous and has limited advancement opportunities—leading to chronic turnover and staffing shortages. Due in part to systemic barriers in education, CNAs are disproportionately likely to be women or people of color, meaning the tough conditions are a serious workforce equity concern.

The pandemic supercharged these problems and added new ones. Many CNAs got sick, and almost a quarter had to work while positive for COVID-19. More than 250,000 LTC employees quit and haven’t returned, and patient outcomes worsened (PDF), with as many as 40,000 additional non-COVID-19 nursing home deaths by November 2020. A Florida survey found 96 percent of nursing homes operating with CNA staffing shortages. Patients were being turned away, and the closure of LTC facilities has been ramping up. In one case, the National Guard was brought in to serve as temporary CNAs.

Many CNAs reached a breaking point or burnout; they reported verbal abuse and a lack of respect or appreciation as some of their top concerns. And economic factors have put further pressure on CNAs, causing many to leave for other industries and others to become higher-paid “travel nurses,” which may also be disrupting the industry.

Last year, the Biden administration, citing declining patient outcomes, announced new 2023 rules that set minimum nursing home staffing requirements, among other changes. One analysis (PDF) estimated an annual cost of $1.7 to $6.5 billion to employ up to 143,000 new CNAs and that filling those positions would be a challenge.

Urban recently helped evaluate the Health Profession Opportunity Grants (HPOG) program, in which we explored CNA training and employment outcomes. Though more research is needed, our findings and several strategies being employed around the country underscore that a multipronged approach that prioritizes pay and career advancement can help improve outcomes for workers, and ultimately, their patients.

CNA training isn’t enough to support workers

The HPOG program provided health care training and supports to people with low incomes, including more than 20,000 CNAs. Our research with the Office of Planning, Research and Evaluation and Abt Associates found the following:

These findings show that simply paying for CNA training isn’t enough to improve their outcomes because the occupation doesn’t pay well and career advancement is hard—even with HPOG’s supports.

What could improve the CNA outlook?

As the CNA crisis has deepened, states, training providers, workforce agencies, and employers have adopted the following strategies to stabilize the CNA workforce:

Compensation increases

  • A least four states have increased nursing home wages, including wages for CNAs, using public funding. Three others adopted temporary pay increases or bonuses.
  • Some LTC employers have raised CNA wages to around $18.00 per hour.
  • A 2022 survey of CNAs suggested that poor benefits were a top reason for why they quit, and better benefits could attract more workers.

Stipends and signing bonuses

Subsidized training and supports

Policy and rules changes

Employer culture and innovations strategies

With the aging population increasing sharply, the CNA conundrum has no clear solution, but a combination of the strategies above—when bolstered by private and public partnerships—could help reverse the mounting closures. Advancing the evidence base by evaluating these strategies can help ensure we’re investing in what works and ultimately alleviating pressure on hospitals, CNAs, desperate families, and patients themselves.


Tune in and subscribe today.

The Urban Institute podcast, Evidence in Action, inspires changemakers to lead with evidence and act with equity. Cohosted by Urban President Sarah Rosen Wartell and Executive Vice President Kimberlyn Leary, every episode features in-depth discussions with experts and leaders on topics ranging from how to advance equity, to designing innovative solutions that achieve community impact, to what it means to practice evidence-based leadership.


Research Areas Workforce
Tags Economic well-being Employment Employment and income data Health care delivery and payment Job markets and labor force Job opportunities Job quality and workplace standards Job training Wages and economic mobility Workers in low-wage jobs
Policy Centers Income and Benefits Policy Center
Related content