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Nursing Assistants Have Training Standards for a Reason

By Kezia Scales, PhD | June 2, 2020

During the first months of the COVID-19 pandemic, the federal government has issued a slate of regulatory actions designed to facilitate the health and long-term care system’s successful response. Among the many changes that have been introduced, at least one has major implications for the direct care workforce in nursing homes: the waiver of training requirements for new nursing assistants.

Ordinarily, new nursing assistants must complete at least 75 hours of entry-level training (or more, depending on their state) and successfully pass a certification exam within four months of being employed. Under the temporary waiver, however, nursing homes can employ nursing assistants who do not meet these requirements—as long as new hires “demonstrate competency in skills and techniques necessary to care for residents’ needs,” according to the Centers for Medicare and Medicaid Services (CMS).

It’s clear that we need to respond immediately to the COVID-19 crisis in nursing homes, but this new waiver raises serious questions about what’s needed in the short term versus what’s best for this sector in the long term. I recently spoke about these issues with Robyn Grant, Director of Public Policy and Advocacy at the National Consumer Voice for Quality Long-Term Care. In this article, we describe some of the key benefits and risks of the CMS waiver and suggest a path forward for its implementation.

More nursing assistants are urgently needed

Prior to COVID-19, nursing homes were already struggling to recruit and retain enough nursing assistants to fill vacant positions and ensure quality care for residents. Pre-pandemic analyses show that nursing assistants on average supported 12 residents per shift, but many cared for 16 or more residents, and a third of nursing homes relied on staffing agencies to fill their staffing shortfalls.

Now these challenges have reached an unprecedented level, as reports from the field suggest that nursing assistants are leaving their jobs in droves—temporarily or for good—due to infection, family responsibilities, stress and fear, and more. In a worst-case scenario, one nursing home had to evacuate residents due to a lack of staff. At the same time, the sector is experiencing increased demand (and facing the risk of further outbreaks) as COVID-19-positive patients are discharged from hospitals to nursing homes with rehabilitative or palliative care needs.

Strategies to rapidly recruit and deploy new nursing assistants are critically needed to relieve pressure on the current workforce while also meeting this increased service demand.

Eliminating training standards poses risks

Bypassing the already minimal training requirements for nursing assistants, however, creates risks for new hires and for nursing home residents.

Nursing assistants care for residents with extensive and complex needs. They must know how to identify and report changes in residents’ health status; to properly turn residents who are immobile; to safely assist those with swallowing difficulties to eat; to minimize distress and related behaviors among those with dementia; and much more. Further, the pandemic has intensified many responsibilities for nursing assistants—infection control is an obvious example, but psychosocial care is another (given the lack of visitors to help meet residents’ needs for social interaction and engagement, among other challenges).

When new hires are not trained to fulfill these responsibilities with confidence and expertise, quality of care and resident emotional well-being will be compromised. Further, insufficient training will increase the risk of future COVID-19 outbreaks (as well as the risk of injury among nursing assistants, and more), which will weaken the workforce all over again.

What should states and providers do?

State policymakers and providers can take steps to maximize the benefits of the training and certification waiver and minimize its considerable risks.

First, in the absence of federal guidance, states enacting this waiver can set clear and strong expectations about how nursing homes should train and assess the competency of temporary nursing assistants. States can create or endorse a temporary nursing assistant training program covering essential content and mandating a minimum number of hours of both didactic instruction and clinical practice under the supervision of a licensed nurse—as South Carolina has done. Second, states can also require that new hires demonstrate competency according to a standardized competency checklist, again under the supervision of a licensed nurse, with the results retained in their employment files. Implemented together, these training and competency requirements will help promote standardization and accountability across nursing homes.

To fill workforce gaps, individual nursing homes should focus on recruiting individuals with robust caregiving experience: family caregivers, nursing assistants with lapsed credentials, and health-care workers trained in other countries are all prime candidates. Even when hiring temporary nursing assistants, nursing homes should also strive to provide a thorough onboarding process, as well as ongoing peer mentoring and coaching supervision for new hires. Going further, nursing homes can also consider creating a new role for temporary nursing assistants. In their tailored role, these temporary workers could be explicitly tasked with supporting the work of existing, experienced nursing assistants, without being asked to take on responsibilities that exceed their training and skills.

Finally, keep it temporary

For years, advocates have called for more stringent training and staffing requirements in nursing homes, with limited success. The same federal training requirements for nursing assistants have been in place since 1987, despite rising acuity among residents, persistent care quality concerns, and clear evidence of the need for higher training standards. Likewise, notwithstanding the evidence on staffing standards, nursing homes are still not required to maintain a minimum ratio of nursing assistants to residents.

When the national emergency declaration is lifted and this waiver expires, the long-term care sector will need to examine what we’ve learned about addressing workforce challenges—but we should not allow stop-gap measures introduced during the pandemic to become permanent. Any lasting changes to training and staffing requirements for nursing homes—including policies to retain temporary nursing assistants in the workforce beyond the pandemic—should be expert-led, evidence-based, and carefully designed to support a stronger workforce and better quality of care.

Kezia Scales, PhD
About The Author

Kezia Scales, PhD

Director of Policy Research
Kezia Scales oversees PHI’s national research strategies to effectively study the direct care workforce and its relationship to long-term care, providing an evidence base to inform public policies on this critical workforce.
Contributing Authors
Robyn Grant, Director of Public Policy and Advocacy, National Consumer Voice for Quality Long-Term Care
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