Temporary Nurse Aides Need Job Stability and Support

In March 2020, the Centers for Medicare & Medicaid Services (CMS) waived the long-standing training and certification requirements for nursing assistants employed in nursing homes. The CMS waiver—which was part of a slate of actions designed to help nursing homes and other health care providers respond to the looming threat of COVID-19—created a cadre of “temporary nurse aides” who stepped in to fill significant workforce gaps.

A year later, the COVID-19 vaccine is being rolled out, the rate of new infections has declined, and the end of the national public health emergency seems to be in sight. (In long-term care settings, over 4.8 million long-term care residents and staff had received at least one dose of the vaccine as of April 11, and new COVID-19 cases in nursing homes are at their lowest rate since data reporting began last May.)

But an important question remains: what should become of those temporary nurse aides who helped sustain services during arguably the worst crisis the U.S. nursing home industry has ever faced?

The COVID-19 Catastrophe in Nursing Homes

The disproportionate impact of COVID-19 on nursing homes and other residential long-term care settings is well-known. As of last month, according to The New York Times, the virus had infected more than 1.3 million residents and staff in these settings and caused at least 172,000 deaths—more than a third of all COVID-19-related deaths in the U.S.

Driving these statistics was a “circular nightmare” of understaffing and outbreaks. Staffing shortages that predated the pandemic were exacerbated as workers took time off or left their jobs due to infection, to care for their families, because of safety concerns, or for other reasons. (A number of states even turned to the National Guard to help address their most urgent staffing shortages.) In turn, understaffing compromised the delivery of daily care and increased the risk of outbreaks.

Temporary Nurse Aides Help Fill the Gap

The CMS training and certification waiver has provided one way to break this cycle—enabling nursing homes to quickly employ new workers even as in-person training and testing programs have been scaled-back or suspended altogether. The only stipulation in the waiver is that temporary nurse aides “demonstrate competency in skills and techniques necessary to care for residents’ needs.”

Immediately after the waiver was implemented, the American Health Care Association/National Center for Assisted Living (AHCA/NCAL)—which represents long-term and post-acute care providers—launched a free eight-hour online training course for temporary nurse aides. This nominal training program has been adopted by 23 states and DC and, as of February 2021, it has been completed by more than 136,300 trainees.

Unfortunately, beyond these data points, it is impossible to describe the temporary nurse aide workforce. States have adopted the CMS waiver in diverse ways and without any federal tracking or reporting requirements. The Payroll Based Journal, for example—which is how nursing homes report staffing data—does not differentiate temporary nurse aides from certified aides, nor has CMS created any new system to track these workers. We know almost nothing about who they are, where they work, which tasks they perform, or their experiences on the job.

What Happens Next?

The federal government has yet to issue guidance to states or employers for dealing with temporary nurse aides after the CMS waiver expires. But in the meantime, states are already developing their own approaches to retaining these workers in the direct care workforce. For example:

• Pennsylvania adopted the training waiver with the proviso that temporary nurse aides complete the eight-hour AHCA/NCAL training program plus 80 hours of on-the-job training. In December, the state passed legislation allowing temporary nurse aides—who number nearly 4,000 workers in Pennsylvania—to be added to the Nurse Aide Registry as fully certified aides after taking the state examination or via certification from their employers.
• Wisconsin has developed a pathway for temporary nurse aides to become certified via bridge training. During the waiver period, temporary nurse aides have been required to complete just 16 hours of training, but they may now complete an additional 59 hours of training (to reach the federal minimum of 75 hours, rather than Wisconsin’s standard 120 hours) to become certified and placed on the Nurse Aide Registry.
• Georgia allows temporary nurse aides to work after completing just eight hours of online training, two hours of supervised training, and a skills competency checklist—and the state has promised that, once the waiver is lifted, these workers will be allowed to take the state certification exam and enroll in the Nurse Aide Registry without fulfilling any additional requirements.

Like so many aspects of direct care workforce development, these state-by-state approaches vary widely—introducing even more inconsistency into an already fragmented training and certification landscape.

Toward A Middle Ground

In January 2021, a bipartisan bill was introduced in Congress that would create a federally recognized pathway to certification for temporary nurse aides. The Nurses CARE Act of 2021 would make temporary nurse aides eligible for “prolonged work as nurse aides” as long as they have completed at least 80 hours on the job and are certified as competent via a state exam, through an apprenticeship program, or by their employer.

This legislation strikes an important compromise: it acknowledges the timely contribution made by temporary nurse aides, their value to the workforce, and their on-the-job experience, while also establishing national minimum standards for their certification.

On-the-job training can be a valuable route to competency, when carefully planned and properly supervised. However, temporary nurse aides have come on board in the most challenging circumstances imaginable: joining an overstretched workforce on the frontlines of a ravaging pandemic. In these conditions, their work-based training has likely been minimal at best. Legislators could amend the Nurses CARE Act to address this reality in two ways: first, by removing nursing home employers from the competency assessment process (avoiding a potential conflict of interest by requiring that competency be assessed only by a state exam or state-appointed assessor); and second, by specifying that temporary nurse aides must receive supplemental (and clearly documented) training to fill any assessed gaps in competency.

As well as establishing standards for temporary nurse aides’ retention, the federal government should commission and fund a rapid study of this workforce to learn as much as possible about its size, profile, experiences, and impact. The findings from this research could inform immediate efforts to bridge training and competency gaps for temporary nurse aides as well as address ongoing recruitment and retention approaches and plan for future emergency workforce responses. This research should be folded into a broader, much-needed national reckoning of the full impact of COVID-19 in nursing homes.

No matter what, any national or state-level solution to the temporary nurse aide question should be understood as a necessary but short-term compromise—and should not be leveraged to erode the long-standing and hard-won training and competency standards for nursing assistants in nursing homes. These minimum standards are critically needed to prepare nursing assistants for their challenging role, reinforce the value of this essential workforce, and support quality care for nursing home residents. Indeed, the tragic lessons learned during the COVID-19 pandemic should propel us toward more stringent—not more lenient—staffing and job quality regulatory standards in nursing homes in the future.