An Overview of the CNA Shortage
For those considering careers as nurses or certified nursing assistants (CNAs), it is common to hear “there are always jobs available in the field,” in no small part due to a nursing shortage. This article will examine the causes and implications of the shortage of nurses and CNAs, both nationally and in Florida.
Extent of the Shortage and Future Projections
The U.S. Bureau of Labor Statistics reports there are over 1.5 million people employed as nursing assistants, with a projected growth rate of 9% between 2019 and 2029—faster than the rates of most occupations. Most of this projected growth is attributed to the aging population, which is increasing the number of patients requiring care each year. Another contributing factor to the rising need for nurses of all sorts is the rising demand for mandatory safe staffing ratios.
To determine staffing needs, care facilities use a measurement called “hours per patient day” (HPPD) or, by some sources, “hours per resident day” (HPRD). This determines the minimum number of hours of nursing care needed per patient to provide safe and quality care each day. The HPPD is multiplied by the number of patients on a given unit, and staff members should be scheduled accordingly to provide adequate coverage. In 2001, expert panels recommended a minimum of 4.55 HPPD be implemented for long term care and skilled nursing facilities to promote optimum safety and quality of care for residents. Of these hours, 2.8 HPPD were recommended to be provided by CNAs. All states have failed to effectively implement this goal (Figure 1).
Perhaps due to greater population density or the older average age of the population compared to much of the rest of the country, Florida is among 13 states utilizing a greater number of hours of nursing care, reporting a >4.25 HPPD in 2016 (Figure 2). Though better than many other regions, this still falls short of minimum recommendations, and the outlook for Florida’s nursing shortage is alarming. Florida’s nursing home occupancy has increased by 6% increase since 2003. This trend is expected to continue, and it is predicted that the number of CNA jobs in Florida will increase by 17% to keep up with the demand. Despite these predictions, data is showing a decrease in the number of new CNAs graduating (and passing the certification exam) each year in Florida (Figure 3), creating concern about what will happen to the thousands of patients needing CNA care. To properly address this issue, a closer look needs to be taken at what is causing the shortage, how the shortage affects those working as CNAs, and potential solutions to a problem that promises to grow.
Causes of CNA Shortages
A quick job board search reveals how many job opportunities there are statewide (Figure 4), with nearly 700 available CNA positions in the Tampa area alone. Still, there are not enough professionals to fill them. Many factors contribute to this shortage, and all must be considered to formulate realistic solutions. As previously mentioned, one of the greatest contributing elements is the aging population. Currently, Americans over the age of 65 comprise approximately 15% of the population. However, the Population Reference Bureau estimates that number to increase to 24% of the population over the next 40 years. Additionally, the average life expectancy has steadily increased since the 1950s, meaning not only will there be more people utilizing healthcare resources, but the number of years they require care and live-in facilities will be greater as well.
As Americans age, not only will there be more patients needing care, but there will also be more CNAs and nurses leaving the field. As of 2018, 47.5% of nurses were 50 years old or above—and the number of nurses reaching retirement age without new graduates coming in to replace them is expected to grow. In addition to retiring to enjoy the following years, difficulty adapting to increased use of technology in healthcare, a rising risk of work-related injuries, and the long-term toll of a physically demanding job all contribute to older professionals leaving nursing.
On the other end of that spectrum is the consideration of childbearing years. Approximately 92% of nursing assistants employed by nursing homes are women. CNAs often cut their hours to part-time or stop working altogether to accommodate raising children.
The accompanying shortage of licensed nurses has a direct impact on the expectations and strain placed on CNAs as well. Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) who are short-staffed often delegate more tasks to CNAs to free themselves up to complete care within their own job scopes. More patients and tasks contribute to mental and physical fatigue, erode job satisfaction, and eventually lead to burnout. A 2018 study indicates that approximately one-third of nurses experience some level of burnout, and burnout rates may be as high as 50% for CNAs. Burnout can lead to poor job performance and, for many, leaving the profession.
Finally, much of the shortage can be attributed to a bottleneck effect in the education system. There are many more potential students who apply to CNA programs each year than can be accepted, slowing the rate of new graduates and possibly deterring waitlisted students altogether. The low number of nursing educators is the main reason class sizes are kept small. The quality of programs also directly affects the number of new CNAs entering the workforce. Poor certification exam pass rates will not help the supply chain.
Figure 4: CNA Jobs Available
|Region||Available CNA Jobs on Indeed.com|
|West Palm Beach||366|
Effects of the CNA Shortage
The most obvious effect of the shortage of CNAs is the decrease in the quality of care provided to patients. Even the most efficient professional can only do so much during one shift, and if the assigned task list exceeds their capacity, quality of care can suffer. This increases the risk of mistakes and safety breaches and can create feelings of stress and disappointment in oneself. Complaints may also arise from patients or coworkers, adding to strain and job dissatisfaction.
If these toxic issues are not addressed, burnout can develop, and staff members may choose to leave, adding to the shortage and perpetuating the cycle for others. Conversely, they may choose to stay but may inadvertently contribute to a negative work environment due to their own frustration. If the negativity among staff is widespread enough, the quality of care within an entire facility can suffer, creating a stigma about the work of CNAs and branding the profession as rough, sloppy, or uncaring. If a poor imge of CNAs is present in a region, this could deter potential students from becoming CNAs, further perpetuating the shortage and subsequent problems. This vicious cycle is an important reason the shortage must be addressed, and efforts focused on solutions for restoring the quality of care and improving CNA job satisfaction are essential.
Potential Solutions to the Shortage: Accessibility, Quality, and Affordability
One of the first steps toward creating more CNAs is to increase the capacity of the education system. It takes nurses to teach nurses, so incentivizing educators to work for CNA schools (via competitive pay, flexible schedules, or opportunities for professional growth) is an ideal place to start. The quality of education must also be considered, as students must pass the certification exam to gain employment. Administrators for CNA programs should have a thorough understanding of national standards of nursing education, hire expert faculty who can actively engage students, and provide opportunities for individual attention or tutoring for students. If a program is consistently falling short with student retention and first-time exam pass rates, administrators and educators of the program need to take a closer look at their framework, compare it to successful programs, and make changes.
In addition to increasing the availability and quality of education, there is a need to improve the appeal and accessibility of CNA programs to prospective students. Students may be wondering, Why should I become a CNA? or Can I afford CNA training? Both of these questions can be answered through effective program marketing and partnership with financial aid experts.
Recruiters and financial aid staff should be well versed in financial assistance options and help potential students sort through what they may be eligible for. Loans, scholarships, tuition reimbursement options, and free CNA programs are all helpful to know about, particularly for students who may be deterred from CNA training because of cost.
Marketing is also important. CNA programs can be presented as opportunities for great “starter careers” or paths to further healthcare education for students. They can also be promoted to those who currently work in non-clinical settings as new, essential careers they can enter relatively quickly. Third party schools (organizations offering career training to high schoolers) seem to be the most popular option for enrollment (Figure 5) and could benefit greatly from creative marketing. Billboards, radio and localized podcast ads, job fairs, and recruitment events are all great places for CNA schools to advertise.
Interestingly, high school CNA programs had some of the highest exam pass rates but lower enrollment than third party programs according to recent data (Figures 5 and 6). This may indicate high schoolers comprise a potentially beneficial and untapped market. There may be many high school students who are considering careers in healthcare or planning to attend nursing programs, but they are not aware CNA training during high school is available. Job fairs, career counseling, or recruitment events at high schools might increase enrollment in CNA courses. Guidance counselors should also be trained to present this as an option for any student expressing interest in healthcare.
A novel option with the potential to make a big impact is collaboration between healthcare facilities and CNA schools. This tactic has recently been employed in St. Petersburg, where Galen College of Nursing students began attending classes on Northside Hospital’s campus in summer 2019. This integration of learning and clinical settings offers students an opportunity to see healthcare in action. Immersive, hands-on learning may draw the interest of students and prepare them for the transition to the workforce. It also offers invaluable networking opportunities that may open doors to employment and offers the hospital a potential pipeline of quality nurses who are already acquainted with the facility. This model is not the first of its kind and could be adopted by nursing schools and healthcare facilities across the country.
Finally, there doesn’t only need to be changes in the education of CNAs; there needs to be system-wide improvements from employers to retain CNAs once they are in the workforce. Competitive pay, safe staffing ratios, options for loan repayment, recognition for quality work, and opportunities for career advancement are great places to start when creating an environment that encourages employees to stay and do their best work. Investing in quality electronic medical records as well as equipment and technology to make nursing more streamlined can help reduce burnout and work-related injuries and improve job satisfaction and employee retention. Additionally, taking a look at hours worked—particularly for older nurses—and altering them (perhaps from 12-hour shifts to eight-hour ones) could help keep people from retiring early.
By restructuring much of what is currently done to train and retain CNAs, there may be a positive shift in the overall image of the career, which could help increase the number of people considering this career path. Regardless of how schools and employers choose to address the nursing shortage, there is no denying the issue is growing, and action must be taken to improve the future of healthcare.