What to Look For in Staff Training Part 2: The Plight of CNAs

The statistics do not bode well for those working in nursing homes.   The direct care workers   are usually the lowest paid workers in the healthcare industry.(1)  The Bureau of Labor Statistics estimates CNA salaries ranging from $7.78 to $12.80 per hour.(2)   Unmarried minority women with at least one dependent child comprise a healthy cross-section of the profession.(3)  CNAs thus have built-in family stressors such as financial worries, finding daycare and caring for sick children. Multiply this with on-the-job stress due to long hours, frequent overtime, lack of respect, little time off and generally poor training; it is easy to see why staff turnover is so high.  The opportunities for career growth of direct care staff are limited when looking at their average education. CNAs usually have a high school diploma but their education most likely stopped there.(4)

CNAs in nursing homes are required to receive certification training prior to starting their first job.   This varies by state, but typically, somewhere in the neighborhood of 80 – 100 hours of training are required.  There is no requirement for refresher courses to maintain certification, but by federal law (OBRA 1987), all CNAs in nursing homes must complete 12 hours of continuing education annually and demonstrate “competency”.   Each of the state’s Department of Health monitors this (supposedly), and many have mandated specific annual trainings, such as fire and safety, infection control, and dementia care.   It is the continuing education (C.E.) that is necessary to maintain skills, develop new skills, and learn new information.

For assisted living and home health agencies, continuing education requirements are even more variable, with some states mandating higher requirements than others.   Even in nursing homes where C.E. is mandated, the quality of education is generally poor and documentation of learning or mastery is typically absent.  Facilities focus on maintaining compliance with the state regulations, rather than actually improving the skills of their staff.  Continuing education is generally instituted in a way that is incompatible with adult learning theory.   Adults learn best when the information is presented in a way that is relevant, and resonates with an emotional note.  In contrast, nursing home education is typically “repeat and recite”.  In some facilities, administrators give packets containing hundreds of pages of dense information and expect the staff to read it cover to cover.    Published accounts of CNAs’ ratings of their training experience suggest that traditional nursing home continuing education is lacking in content and style.  There are multiple problems in providing the necessary education to nursing home staff.  Educators with the background and knowledge to teach on all of the diverse topics and skills needed to care for the elderly are not readily available.(5)   Furthermore, this workforce provides around the clock shifts so lectures or training sessions cannot be delivered to all employees simultaneously.  Repeat lectures by the same lecturer, or worse yet, videotape sessions of the lecture further strip the educational experience of emotional impact and relevance.  Studies have shown that CNA satisfaction with traditional training is poor(6)  and compliance with traditional (lecture or video) modalities of training are below 35%, even when mandated by the administrations.(7)

About the Author: Debra Fox is the CEO of Fox Learning Systems and a long-time veteran of elder care staff training.  A former television anchor, Debra pioneered the use of interactive documentary techniques to improve training and elder care quality.


  1. Farida K. Ejaz, L. S. (2008). The Impact of Stress and Support on Direct Care Workers Job Satisfaction. The Gerontological Society of America.
  2. Nursing, Psyciatric and Home Health Aides. (2006). Retrieved from The Bureau of Labor Statistics : http://www.bls.gov/oco/ocos165.htm#earnings
  3. Farida K. Ejaz, L. S. (2008). The Impact of Stress and Support on Direct Care Workers Job Satisfaction. The Gerontological Society of America.
  4. Nursing, Psyciatric and Home Health Aides. (2006). Retrieved from The Bureau of Labor Statistics : http://www.bls.gov/oco/ocos165.htm#earnings
  5. Stoecklin, M. T., Haan, M. N., Beck, J., Frank, J., Weaver, K., & Francis, D. (1998). Job responsibilities and educational needs of staff developers in long-term care. Annals of Long-Term Care, 6, 122-129.
  6. Mercer, S. O., Heacock, P., Beck, C., &  (1993). Nurse’s aides in nursing homes: perceptions of training, work loads, racism, and abuse issues. Journal of Gerontological Social Work, 21, 95-112.
  7. Banazak, D. A., Mickus, M., Averill, M., & Colenda, C. C. (2000). Herding Cats: Barriers to Implementing a Nurse Aide Educational Program. Annals of Long-Term Care, 8(10), 68-71.

  • Vern M.

    The problems with continuing education discussed here are probably found in a great many fields of work, simply because it costs money to get quality training in place. Nursing homes in particular are known to be strapped for cash, but just about any for-profit business these days is trying to pinch pennies too, which means the problem of inadequate direct care worker training will only get worse in the future. For caregivers in these positions, it seems obvious that a boost in their pay (and hopefully respect) would at least motivate them to try and keep their skills current. Personally, I think spending that money on the staff instead of their training is the best solution for a pretty sticky situation.

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