Ideally,  training to be a certified nurse assistant (CNA) is the start of a powerful journey in the world of caring. It is more than just classes and testing. It is about nurturing and growing skilled team players. It is about attracting great employees and retaining them over time.

“We have to make an investment in caregivers. There are multiple benefits that will positively impact our residents and our facilities,” said Robert Vande Merwe, executive director of the Idaho Health Care Association.
There are many options for CNA training. Some long term care organizations have their own programs, and there are programs provided by vocational schools and community colleges. There are online courses and in-person classes. Costs range from several hundred dollars to a few thousand. However, Vande Merwe pointed out, “This doesn’t come near the cost to replace and train new CNAs or the high cost of hiring agency staff.” 

In-House Programs: Targeted Training

It can be challenging and expensive for communities to create and maintain their own CNA training program. But some do it and do it well. For instance, Deborah Rowe, MS, RN, PHR, CHCR, vice president of nursing workforce development at Genesis HealthCare, shared her organization’s experiences.

She recalled, “In 1999, Genesis created and received state approval for its nurse aide training program. This program consists of mandatory hours on the principles of nursing with supervised lab and clinical experience. At the successful completion of the training program, graduates are eligible to take their state competency examination for certification/licensure as a nursing assistant.” Genesis trialed one center in Maryland and expanded the model over time.

Rowe noted, “We offer the nurse aide training program primarily to students where there is an approved Genesis-affiliated training center and make it available to other affiliated centers. In the program, there is a dedicated nursing instructor to provide ongoing nurse aide training. We attract and hire candidates from the communities we serve while also offering incumbent team members the opportunity to advance and train employees for certification/licensure.” Currently, Genesis has more than 65 in-facility nurse aide training programs in more than 13 states.

“When training comes from the facility, it’s more focused on the facility’s needs,” said Vande Merwe—and this has benefits. 

Array of Options

There are several options for CNA training. According to federal regulations, for a nurse aide training and competency evaluation program to be approved by the state, it needs to meet specific standards, including no less than 75 clock hours of training, 16 hours of supervised practical training, and instructors that have completed a course in teaching adults or with experience in teaching adults or supervising nurse aides. Other personnel from health professions may supplement the instructor, including, but not limited to, registered nurses, licensed practical nurses, nursing home administrators, physical and occupational therapists, and gerontologists.

The American Health Care Association offers a robust, federally compliant nurse assistant training program designed to support workforce development in long term care. Now in its 8th edition, the How to Be a Nurse Assistant curriculum is a comprehensive solution for facility-based CNA training that includes a textbook, workbook, skills DVD, and an instructor website that provides chapter specific objectives, teaching tools, and sample calendars. AHCA senior director of marketing Chip Henderson notes that “we publish a new edition every five years to adopt updated federal guidelines as well as incorporate feedback from our customers—nurse instructors who depend on our vetted curriculum to prepare their students for a rewarding career in long term care.”

To build upon its curriculum offerings, AHCA partnered with Academic Platforms in 2016 to develop CNAonline, a hybrid training model. The program combines online coursework with in-person, facility-based skills training grounded in the How to Be a Nurse Assistant curriculum. “The hybrid model leverages proven technology to enhance the learning experience for students and to overcome the limited availability of qualified nurse educators,” says Julie Gdowski, RN, nurse instructor and vice president of clinical operations at Academic Platforms. “The flexibility of having the curriculum online allows students to engage with training 24/7 as their schedules allow.” Learn more at CNAonline.com.

In Florida, a personal care attendant (PCA) program was started during the COVID-19 pandemic. Kristen Knapp, APR, CAE, senior director of strategy and communications at the Florida Health Care Association, said, “I like to call it an ‘earn while you learn’ program.” Essentially, an aspiring CNA can come into the nursing home, go through competency training, and learn alongside an experienced CNA.

“They’re basically doing not quite everything that the CNA does but many tasks that the CNA performs using many of the skills they need,” said Knapp. The program is designed to prepare participants to take the CNA exam. After 120 days, they are no longer PCAs, so they have to take the certification test or move into another position—such as dietary aide—if they decide they don’t want to be a CNA.

Content Counts

Of course, it’s not just the type of training course that comes into play; content counts. While most programs cover the basics, there likely are some variations. “Some caregivers have limited training in mental health or dementia,” Vande Merwe explained, “and the bulk of our residents have some kind of dementia, depression, or other mental illnesses and behavioral health issues. So we have to do on-the-job training and/or education in our own classrooms on those topics.

“The key to keeping good CNAs is to make sure they are competent and confident,” he said.

It is important to know what competencies new hires have specific to the facility’s needs and identify any gaps that need to be filled. Vande Merwe observed, “Every facility has a slightly different population. Some have memory care units, some have more residents with behavioral health issues, some do mostly rehab, some have wound care programs, and so on. CNAs come out of training as generalists, so it’s up to each facility to make sure they have the special skills to deal with its population.”

He added, “This additional training is important because if you’re asking people to do tasks they’re not confident doing, it’s just a recipe for turnover.”

As with training for many other professions, CNA training doesn’t necessarily include nonclinical skills such as conflict resolution, having difficult conversations, leadership, and stress management. Vande Merwe noted, “Most CNAs come to us straight out of high school with little or no work experience, so they need some training on how to be an effective worker. This not only means information about conflict resolution and other skills; they also need to know the importance of punctuality, respecting your colleagues, and budgeting and financial management.”

CNAs should be encouraged to seek additional training and education over time. “We need to figure out how to use the skills they have and maintain a culture where CNAs are comfortable going to a supervisor and asking for additional or repeated training on issues that impact their work,” Vande Merwe said.

Team leaders and members also need to value CNA training, and this can be challenging when there are wide age gaps between staff members. Vande Merwe observed, “Most new CNAs are in their late teens or early twenties, and they may be working with nurses and others who have been on the job for twenty or more years.
When everyone sees CNAs as valuable members of the clinical care team and treats them as such, caregivers are more likely to take pride in their work. This is a strong contributor to retention.

Just this year, the National Association of Health Care Assistants launched the CareForce Academy, an education center for frontline direct care professionals. The organization recruits students and connects them with direct care education and training via curricula designed and taught by health care leaders. 

Beyond Training: Career Prep

Vicky Castillo, MSNed, RN, CNE, president and founder of Facets Healthcare Training, said, “There’s been a lot of concentration in nurse assistant training and education, and I’ve started and worked with many different types of programs.”

For instance, she was a program coordinator/manager for a large nurse assistant instruction program in Arizona, where 650 to 800 students per year were trained. She discovered there was a dearth of certification test-preparation programs for nurse assistants, so she created one. Because testing and certification varies from state to state, this training has to be state-specific.

Similarly, CNA Simulations works to ensure students succeed in their future roles in long term care while also helping them get ready for the CNA skills exam. Through partnerships with schools and employers, the company offers virtual clinical skills simulations for CNAs, home health aides, and family caregivers. Founder and CEO Charlene Brown, MD, MPH, explained, "We focus on essential clinical and critical thinking skills, allowing students to simulate real-life care scenarios. This helps them respond to unexpected challenges and refine the skills they've learned. CNA training programs use our simulations to enhance their teaching."

Brown emphasized that giving CNAs a chance to practice risk-free, realistic care before they start is crucial for retention. "I found that CNAs often wish they had more clinical experience, especially in areas like infection control and dementia care," she said. "Simulations help to bridge this gap. When CNAs start feeling prepared and know what to expect, they're more likely to thrive and feel confident in their roles."

What CNAs Want

Like most adult learners, CNAs prefer programs that are interactive and hands-on. Deborah Rowe said, “The nurse aide students I’ve worked with like working directly with the residents and patients. They enjoy the relationships they establish as they are practicing their skills in the clinical setting.”

Sherry Perry reflected, “I think a lot of CNAs would prefer a training program that enables them to be a well-rounded professional who can work anywhere.” She noted that when she was training, she and her fellow students especially appreciated learning about issues such as medical side effects, signs and symptoms of various illnesses and conditions, and various medical terminology.

Behavioral management is a huge issue in long term care today, and Perry said, “There are many residents with dementia and mental illness, as well as young residents who are there because of strokes, aneurysms, and head injuries. CNAs need to be prepared to help manage behavioral issues to protect residents, their colleagues, and themselves.”

Isaac Zralii, a longtime CNA who has worked in hospitals and nursing homes, has participated in multiple training programs, but the best, he said, was one offered through a high school vocational program. He explained, “I definitely felt like I had more hands-on learning. We also did clinicals in the hospital and nursing home. Our instructor was very good about conducting clinical debriefings that helped us learn.”

Meeting an Ongoing Need

Nurse aide training needs to be a priority, said Castillo. While there are many good programs, there are still some gaps. She said, “I’ve been to parts of Texas where they have one training program in a one-hundred-mile radius. This can be a significant deterrent for people who would like to be a CNA but can’t get to the training.”
While most training programs are relatively affordable (less than $2,500), paying for training can be difficult for many people. Working with students to make the finances doable is useful. One option growing in popularity is apprenticeships.

Vande Merwe said, “Apprenticeships present a great opportunity for people to preview the job they’re going to be doing. There actually are Department of Labor funds that can help pay for things like day care and transportation. These programs can help attract people to our industry.”

Castillo said, “At least some students will still have to work another job while they are going through training, or they may be juggling school and family. Programs need to be flexible and not just nine-to-five Monday through Friday.”

It behooves facilities to help potential CNAs picture working in the field. Knapp said, “Before they spend the time and money to study, people want a better idea about what their job is and how it may be an important career step for them. I talked to one woman who worked as an amusement park train operator and wanted to do something else. She became a PCA and then a CNA, and she has goals to become a nurse. Our program gave her an opportunity to launch her health care career.”

Another woman was a stay-at-home mom looking to get back into the workforce. She went from a PCA to CNA. She landed in her facility’s business office in an administrative role and hopes to become a nurse. Not everyone who goes through a CNA training program will want that job for life, but it can be a stepping stone for someone who is a valuable employee in another role.

Vande Merwe said, “We have to figure out how to incentivize young people to choose a career or an entry level job as a CNA. There's just not enough bodies in America to care for all the boomers coming our way. If you don't think about how you're going to attract young people already, you better start investing in robots that can take care of seniors. And I don't think that's happening anytime soon.”

AHCA/NCAL’s How to Be a Nurse Assistant training curriculum reflects current best practices, including updates on infection control, nutrition, resident rights, and care for individuals with intellectual and developmental disabilities, mental health conditions, and substance use disorders. Learn more.

Joanne Kaldy is a freelance writer and communications consultant based in New Orleans.​