Opportunities for enhancement

In Texas, the turnover and vacancy rate for certified nursing assistants (CNAs) in LTC nursing facilities is 87 percent and 13 percent, respectively—the highest in the nation among states similar to ours. A high rate of turnover can result in a disruption in the continuity of care. For the resident, that could have a significant impact on the quality of care received. For the owner of an LTC facility, staffing issues not only impact the quality of services offered, but turnover and vacancy rates can also affect bottom-line operating costs.

To address issues related to the workforce in LTC facilities, Texas Tech University Health Sciences (TTUHSC) Center School of Nursing, in partnership with Sears Methodist Retirement System, Inc., designed a two-part, gold standard approach to improve professionalism and skill level in nurse aides. 


For 30 years, TTUHSC School of Nursing has been training students for careers in clinical nursing as well as to become leaders in the healthcare industry. Through our Center for Innovation in Nursing Education (CINE), the school works to provide leadership in designing and implementing new and exciting nursing education initiatives.

We are fortunate to have not only one of the leading distance education programs in Texas, but also to have physical schools throughout the state, including one in Abilene. At that campus, the School of Nursing serves as the education subcontractor through a $750,000 grant awarded by the U.S. Health Resources and Services Administration (HRSA) to Sears Methodist Retirement System, Inc., a 501(c)(3), nonprofit corporation.

Since opening its first campus in 1966, Sears Methodist has earned a position of leadership in LTC and retirement housing. Today the company serves more than 2,000 residents in eight cities across Texas, several of those in common with TTUHSC.

In addition to having common physical locations, we also both have at our cores a responsibility for enhancing the quality of services to those entrusted to our care. As a result, this project exemplifies the CINE’s mission to develop collaborations with businesses and private industry to bring about solutions to the nursing shortage.


Currently, there are more than a million residents age 65 and older being cared for in more than 36,000 assisted living facilities nationwide. By 2030, the number of those ages 65 or older is expected to be more than 70 million—and the demand for more elder care facilities will also increase.

Having the workforce to care for this growing geriatric population will be essential. The HRSA grant serves to increase the workforce through the training and certification of nursing assistants, and improves advancement opportunities for those now working as CNAs by enhancing critical-thinking skills and leadership qualities.

Even before we began the formal recruiting process for the nurse aide program, we had received more than 100 applications from the Abilene area; this continued to be the norm throughout the first year. Groups of 15 students were selected for each class; those not selected initially were placed on a wait list and considered for subsequent classes.

The need for employment in this area is great: Almost half of those completing the program the first year were out of work or looking to change jobs; 90 percent of them had household incomes of less than $29,999. The per capita household income for the Abilene area is $29,155, significantly lower than the national average of $52,029.

Once selected for the program, the students received formal training through a 75-hour CNA program based on the Texas Curriculum for Nurse Aides in Long Term Care Facilities. The two-week course is taught at Windcrest Alzheimer’s Care Center, a Sears Methodist facility in Abilene, and incorporates offsite instruction at the School of Nursing’s SIM Lab, a high-fidelity simulation training center. 

Enrollment in the program is projected to exceed our three-year target goal of 240 students. Of those completing the nurse aide program, 78 students passed state certification tests on their first attempt, also exceeding our target pass rate of 75 percent.

In addition, Sears Methodist hired many of those who completed the program and received their certification. Representatives from local area hospitals, nursing homes and home health agencies also met with the students to discuss job opportunities.

Historically, CNAs enter the workforce with minimal training and at a minimum wage pay scale. Respondents to a survey by the Texas Department of Health and Human Services, indicated that wage and benefits, work environment and employee recognition were factors that could strongly reduce turnover rate.

Continuing education is a key element in providing in-depth information and experiences that set the course for advancement. The second objective of our gold-standard approach was a career ladder program designed to advance working CNAs into higher levels of the nursing profession.


A strong contributor to the program’s success is the diverse educational experiences provided as a result of collaboration. I’ve been fortunate to work with Vickie Ragsdale, PhD, RN, in directing the nurse aide program, which is based on a model of teaching we use to educate degree-seeking nursing students: hands-on learning, support from mentors and quality instruction.

One of the key components to the students’ training was their time spent working in the nursing school’s simulation center, where students practice clinical skills using high-tech mannequins, without the fear or concerns of harming a real patient. In addition, students seeking nursing degrees worked alongside the CNA students at the center, giving them peer role models. As a result, several of the CNA students have expressed interest in pursuing careers as registered nurses.

As the students successfully completed their training and certification exam and were hired by Sears Methodist, they were partnered with a mentor, which has helped to decrease the stress levels of the new employees. Student autonomy and staff empowerment were considered important concepts incorporated into the program.


The HRSA grant also includes a career ladder component that encourages these students and CNAs already in the field to advance in their nursing careers. Currently, more than 80 students have participated, exceeding our first-year goal of 80 students. The overall target is to have 240 students participate in three years.

To date, the career ladder program has been taught via teleconference at eight Sears Methodist facilities and at three Veterans Administration homes in Texas. These teleconferences have featured presenters from within the Sears Methodist System such as Dr. Dell McKnight, medical director.

Many of the career ladder participants have communicated a sense of empowerment after successfully completing this program. In fact, one student shared how the career ladder experience helped him to solve, in a therapeutic way, a difficult situation with one of the aging residents. The student credited the successful outcome to the tools and resources available that supported a perceived resolution by both the resident and the staff.


We have been extremely pleased with the success and accomplishments achieved during the first year of this project. Going forward, we will work to overcome barriers that were identified, particularly in regard to the career ladder program. We discovered a need for more flexibility in scheduling to accommodate shift variations as well as in delivering content that speaks to the differences in experience levels of those in the program.

As we move into the second year of the grant, our focus also will be to:


  • eliminate health disparities for rural and medically underserved and vulnerable populations;
  • improve quality of geriatric long-term care by enhancing the clinical knowledge, skills, competencies and outcomes of the healthcare workforce; and
  • prepare the nursing assistant and home health aide from underrepresented minority backgrounds for roles in nursing to increase the cultural competency of the workforce in West Texas.



Pearl Merritt, EdD, MSN, MS, RN, is Regional Dean at Abilene for the Texas Tech University Health Sciences Center School of Nursing. She has more than 30 years in the healthcare field, 22 of those in long-term care. Merritt has received numerous awards including the Texas Association Homes and Services for Aging Distinguished Service (2008). For more information, email pearl.merritt@ttuhsc.edu.

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