Many healthcare facilities throughout the country are experiencing a certified nursing assistant (CNA) shortage, conservatively estimated at 200,000 nationwide. Long-term care facilities, in particular, have an attrition rate of 94%. Low wages, lack of recognition and respect, and heavy workloads have been cited as the principal reasons for this.
Because of the magnitude of the CNA shortage and its ramifications, we decided to survey 121 CNAs working the day shift at assisted living and skilled nursing facilities in Utah. We asked questions regarding staffing issues, pay, benefits, reasons for self-termination (when applicable), career satisfaction, and expansion of skills. Here's what we learned.
Resident-to-CNA assignment ratios.Assisted living facilities assigned, on average, 14 residents per CNA. When asked what a “safe and reasonable” resident assignment was, the average number reported was 14 residents. It appears as though an assisted living center staffing equilibrium point has been reached.
Skilled nursing facilities, on the average, assigned 12 residents per CNA. When asked what a safe and reasonable skilled nursing resident assignment was, the average number reported was 8.
Responses to telephone requests to come to work on days off.Twenty percent of assisted living CNAs and 55% of skilled nursing CNAs reported that they would not answer the phone on their days off because they knew they would still be short staffed should they come to work.
Pay, benefits, longevity, and reasons for self-termination.CNAs employed by assisted living facilities reported a starting wage range between $6.00 and $8.50 per hour, with an average starting wage being $8.00 per hour (with medical and dental benefits after 90 days of employment).
CNAs employed at skilled nursing facilities reported a starting pay range between $6.50 and $9.50 per hour, with an average starting wage being $8.50 per hour (with medical and dental benefits after 90 days of employment).
When asked if they thought CNA pay was appropriate for job responsibilities, 33% agreed, and 50% believed that their benefits were acceptable.
It is interesting to note that many skilled nursing facilities offered tuition reimbursement if the CNAs were attending nursing school. This ranged from 50 to 100% of tuition, with a one-year employment commitment postgraduation.
Regardless of facility type, the CNAs with employment longevity appeared to be those with no plans for further education. In our opinion, employers tend to believe that this group of CNAs is the greatest stabilizing force in the field. Although this may be partially correct because these CNAs do not have an immediate desire to leave, or perhaps believe they have limited options because of lack of skills and education, the threat remains that CNAs may leave for employment outside long-term care—jobs that are often less demanding, with equal or better benefits and pay.
The reasons reported for self-terminating a CNA position were wages (60%), work-load (35%), and leaving for college (5%).
CNAs who were pursuing a nursing career consistently reported greater job satisfaction and greater job commitment over all other categories of CNAs. Those who were employed as CNAs but pursuing an education outside of healthcare had the least degree of job satisfaction and would not choose to attend a CNA school again. CNAs with no further plans for education fell in the middle of the two groups, a few percentage points above CNAs pursuing a career outside healthcare, on all questions exploring job satisfaction. Most CNAs, regardless of career goals, reported that they are valued by fellow CNAs and nurses alike.
Expansion of CNA Skills
Views on the expansion of skills were mixed, with 100% of the CNAs pursuing nursing school, 83% of the CNAs not pursuing further education, and 12% of the CNAs pursuing education outside healthcare reporting that they would have greater job satisfaction if their skills were expanded.
Overall, 92% of CNAs believed that expansion of their scope of practice would increase job satisfaction. Ranking skills from the most acceptable expansion of CNA skills to the least acceptable, they were wound care, glucometer and O2 saturation readings, passing routine medications, narcotics administration, and Foley catheter insertion.
The CNA shortage is a growing concern in long-term care, as baby boomers continue to age and more people are diagnosed with Alzheimer's and other debilitating conditions associated with the aging process. The future need for stable, competent staff cannot be ignored. CNAs provide 80 to 90% of hands-on care in facilities. Unless a solution is found to stabilize the CNA workforce, all aspects of resident care will suffer. Possible solutions might include (1) observing and implementing human resources and business strategies encouraging low staff attrition, (2) expansion of the scope of practice for those CNAs who desire the challenge of increased responsibilities, and (3) implementation of a college admission bonus point system for full-time CNA employment before enrollment in nursing, respiratory therapy, occupational therapy, or medical school.
Michelle Snow, RN, MSPH, MSHR, is a Public Health PhD candidate and George L. White, Jr., PhD, MSPH, is Director of the Public Health Program at the University of Utah School of Medicine.
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