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:

• Most participants completed entry-level training, but only 6 percent ascended the career ladder.
• Few CNA trainees “stacked” entry-level credentials like phlebotomy and electrocardiogram technician training. Other non-HPOG research has shown this too. Stacking was not tied to higher wages.
• Longer, higher-level trainings than CNA led to higher earnings. But inequities in access to those trainings exist: white participants were more likely to take them than Black or Latinx participants, even when controlling for other factors.
• CNA trainees were employed at a lower rate than higher-level licensed practical nurse (LPN) or registered nurse trainees.
• Entry-level trainees (including CNAs) earned $13.94 per hour, compared with $14.41 per hour for participants who completed no health care training.

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

• The Baltimore Public Health Pathways Program offers a $1,000 per month stipend for CNA trainees with tuition assistance and a guaranteed job upon completion.
• The Georgia CNA Career Pathway Initiative provides 500 stipends of $5,000 each, paid in three milestones (starting training, completing training, and six months of employment).
• Wisconsin’s WisCaregiver Careers offers $500 bonuses after six months of CNA employment.

Subsidized training and supports

• Subsidized CNA training and apprenticeships are available sporadically throughout the country. One example is the Minnesota Next Generation Nursing Assistant Initiative.
• Part-time and flexible trainings encourage career advancement and reduce turnover. For example, Monroe Community College designed a part-time, jobsite LPN course for CNAs.
• HPOG piloted the use of academic supports (such as mentoring), personal and logistical supports (child care or transportation), and employment supports (job search assistance). Our findings showed a positive association between receiving these supports and completing training. The Georgia CNA Career Pathway Initiative also offers supports.
• One employer offered a paid 16-day course with a guaranteed job and four weeks of on-the-job orientation, easing the process of becoming a CNA.
• In 2014 a Massachusetts nursing home implemented a four-step microcredentialing ladder, with up to 50-cent pay increases per step, which, they claimed, reduced CNA turnover.

Policy and rules changes

• Minimum staffing requirements may affect the CNA workforce and are tied to patient outcomes. Florida loosened the criteria for counting staffing hours and reduced required CNA patient hours, which was criticized by patient care advocates.
• Increases to Medicare and Medicaid reimbursement rates are LTC employers’ top priority. The reimbursement structure has changed over the years and varies by state, straining the LTC industry.
• Wage pass-through Medicare/Medicaid rules have been shown to increase wages.
• Volunteers for America allows nurses to cross state lines to work at higher-need facilities, increasing pay and workforce flexibility.
• Some advocate loosening immigration policy to attract CNAs and paying for citizenship application fees. Doing so won’t necessarily improve job quality, however.
• A survey of employers found their second priority was less paperwork. Better employer efficiency could free up funds for paying workers.

Employer culture and innovations strategies

• Employers and employees can create “employee councils” that meet regularly and report their concerns to management.
• Employers can implement strong orientations, regular check-in interviews with employees, employee surveys, and “stay interviews” when a CNA considers leaving.
• Technological investments may reduce injuries (ceiling lifts for patients) or reduce tasks (automated medication dispensers). Algorithmic scheduling or flexible scheduling can improve efficiency and job quality.

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.