By: Antoinette 'Toni' Gingerelli (MPP 2022) and Will Mulhern (MPP 2022)
Shortages in the healthcare workforce are a common issue shared by states across the country. The COVID-19 pandemic has made this shortage especially pressing. Two potential strategies for addressing the shortage are to expand the certified nursing assistant (CNA) workforce or to provide CNAs with increased responsibilities and autonomy.
In the Fall of 2020, the Project on Workforce worked in collaboration with the Massachusetts Healthcare Collaborative to identify evidence-based practices that could be utilized in Massachusetts to build this workforce. This research sought to answer two questions: 1) How does Massachusetts compare to other states regarding CNA training rates 2) How have other states developed pathways to higher skill levels for CNAs?
Findings
Our team’s first step was to find the data available on CNA test pass rates and retention. Because of the lack of a centralized data source about certified nursing assistants, our team collected information from state government websites regarding:
minimum training hours
minimum clinical hours
first-time exam pass rates
test administrators
departments overseeing CNA certifications
In order to become a CNA, an individual must enroll in a state-approved training course and pass both a written and clinical test. Our team found that only 9 states and the District of Columbia offered public information about the average pass rate for the written and clinical test in 2019. A summary of the data we collected can be found in the table below.*
**The District of Columbia only did not provide test results disaggregated by test (written and clinical), therefore, they are not included in these calculations.
**This chart is based on the most recently available data: 2018 for Massachusetts and 2019 for all other states.
In every state, test takers scored higher on the written exam than the clinical exam. In 56% of states, including Massachusetts, the clinical exam scores were 15 to 20 percentage points less than written exam scores. Although this is an analysis of a small sample of states, the findings suggest that states may want to assess the effectiveness of the clinical portion of their CNA training programs in order to increase overall pass rates. Focusing on improving pass rates for first-time clinical test-takers may also help address state CNA shortages.
To better understand existing models for pathways to higher skills for CNAs, we conducted a literature review of the existing research on this topic. Our research identified literature highlighting four strategies that may provide pathways to higher skill levels for certified nursing assistants. It is important to note that none of these strategies have been robustly studied or validated using empirical research methods. Much of the literature was based on case studies or one-time programs that had been employed at an individual healthcare facility.
Career ladders: Well-designed career ladders can provide pathways for CNAs to advance their skills and responsibilities. These have been piloted in Massachusetts previously. To be successful, it is important that career ladders connect CNAs with a long-term career path and opportunities for advancement beyond the CNA certification.
Higher skill certifications: Oregon and North Carolina both provide “CNA2” certifications that allow CNAs to take on higher levels of responsibility through completing additional courses and training.
Transitions to acute care: CNAs working in acute care settings may receive higher pay relative to long-term care. Facilities have developed programs to transition CNAs working in long-term care to acute care settings.
Model programs of study: Illinois has implemented model programs of study - combined academic and technical education programs - in a number of high-need career areas, including healthcare. These programs begin in high school and provide students pathways to careers in high-demand fields, incorporating varying levels of certification along the way.
Next Steps
Below are recommendations for addressing the certified nursing assistant shortage and developing career ladders for current CNAs.
Improve centralized data collection and tracking of CNA training
In order to effectively address the shortage and retention rate in many states, including Massachusetts, our team would recommend creating a centralized database for reporting CNA exam pass rates and job retention across states. This could materialize in a regional or a national working group to effectively streamline data collection. A larger sample of states and more accessible data will enable policymakers to better identify trends that may be resulting in the CNA shortage and more effectively address the issue.
Ensure pass rates for state-approved CNA training sites are publicly available
Additionally, our team would recommend that states publish the pass rates for the written and clinical exams for each approved training site. Certified Nursing Assistant training courses, which are required for certification can cost anywhere from $400 to $3,000, in addition to final state examination fees. Given the cost an individual must assume to become certified, states have an obligation to ensure transparency on the return of investment for participating in a state-approved training program. A model for this transparency is Florida which annually reports pass rates for first-time test takers by program.
Research existing models to develop best practices for CNA career pathways
In addition to the absence of a centralized entity for data collection and reporting across states, research on both the impacts of CNA training and empirical evidence for successful training programs is lacking. There are not many proven models for effectively training a CNA workforce that states can confidently adopt to address worker shortages. While the models discussed above provide some options for states to consider when developing workforce programs, they lack the empirical evidence necessary for states to confidently invest in such programs. It is important that the next steps in this field focus on evaluating existing models and establishing best practices that states can follow for CNA career pathways. As with the lack of data collection, a cross-state agency or organization could play a major role in funding this type of research and developing best practices. This could be done by existing workforce development organizations.
The lack of a national consensus on CNA training poses serious issues to data collection and the development of best practices, but these findings are just part of the picture. The low wages and the high turnover of CNAs raise the broader question of whether the certified nursing assistant model is an effective approach to responding to the healthcare worker shortage. Some community colleges have been reluctant to develop CNA programs due to the low wages and generally poor labor force outcomes for CNAs, though the majority of Massachusetts colleges are still offering programs. To address these concerns, it will be vital to establish models that allow CNAs to advance to higher wage roles. Research on the effectiveness of the programs discussed above would be a good step in generating evidence for successful models. The COVID-19 pandemic has highlighted the urgent need for a stronger healthcare workforce in Massachusetts and throughout the country.