March 16, 2021
By Neva L. Crogan, PhD, ARNP, GNP-BC, ACHPN, FAAN, fellow, Western Institute of Nursing, and professor, Department of Nursing, Gonzaga University
Nursing assistant staffing in nursing homes is a challenge. Speaking as a long-term care nurse and now provider, it has always been difficult. In their 2013 survey, the American Health Care Association (AHCA)1 reported a nursing assistant turnover rate of 51.5%, a median retention rate of 68.3% and a total of 47,300 vacant nursing assistant positions from facilities responding to the survey. These are dismal findings but typical of the nursing home industry. What is wrong with this situation? Why can’t our society recruit and retain nursing assistant’s? Is it the nature of the job? Is it the poor pay? It is probably due to a variety of reasons, all supported and accepted within our society and culture. Nursing home residents deserve better.
In response to this problem, the Geriatric Interest Group of Spokane (GIGS), a group of nursing home administrators, nurses, social workers, and others interested in improving the quality of life in nursing homes launched an initiative in 2017 to explore the possibility of offering a nursing assistant and medication assistant apprenticeship program for high school students in eastern Washington. Our vision was to offer an avenue for high school students to gain knowledge and experience in a health care field, thereby choosing a health care career after graduation. Further, that this two-year program also would provide a needed staffing boost for nursing homes.
In an attempt to address high turnover rates and low retention rates in nursing homes, one of our goals was to take the novice nursing assistant, match them with an expert nursing assistant and then mentor them to become competent nursing assistants. (Patricia Benner’s Novice to Expert Model2).
GIGS partnered with the local school district and in 2018 began meeting with a Washington State Apprenticeship Consultant. We held many meetings and believed we were making meaningful progress. In January 2019, the application was complete and forwarded to other State Apprenticeship officials for review. The application was returned with suggestions for improvement. We believed this was a temporary setback and continued meeting with our consultant and committee.
In Summer of 2019 the GIGS committee was informed by a different Washington State Apprenticeship official that our proposed apprenticeship program was not feasible. Alternatively, we were told that we could change to an on-the-job (OJT) training program by dropping the Medication Assistant portion of the program and shortening the nursing assistant portion to 800 hours. The application forms would remain the same.
This made no sense to us (the GIGS committee). Upon investigation, we found that the United States Department of Labor Employment and Training Administration3 does offer apprenticeship programs in a variety of occupations, including nursing assistant. So why is our apprenticeship program not feasible in Washington State? We were given two reasons.
First, that the nursing assistant occupation is not complex enough to meet the intent of WAC 296-05-003(c) “Involve the progressive attainment of manual, mechanical, or technical skills and knowledge which, in accordance with the industry standard for the occupation, would require the completion of at least two thousand hours of on-the-job learning to attain.”4
Second, that the nursing assistant occupation is not sustainable per WAC 296-05-003(e) “Involve sufficient skill to establish career sustaining employment.”5
We all know that a nursing assistant’s job can be fast-paced and demanding. Dealing with people who need help requires patience. The nursing assistant role is complex. Nursing assistants need skills in communication, customer service, multi-tasking, critical thinking, cooperation, attention to detail, stress tolerance, dependability and self-control.6 These skills are rarely present prior to or after a 3-week nursing assistant training program. An apprenticeship program may afford the novice nursing assistant a chance to grow and learn these time intensive skills in a supported environment.
The nursing assistant occupation is sustainable. GIGS members who are administrators have many employees who are career nursing assistants (10 years of experience or more) despite low pay. But with the increase in minimum wage, the starting wage in GIGS facilities is now well above $13.50 (WA State minimum wage) and most make at least $15.00/hour.
The GIGS committee met a couple more times in 2019 and then in early 2020. We then learned from the State Apprenticeship official that they were planning to update the OJT standards (application) spring 2020, thus our application was on hold until this work was done. At this time, GIGS has decided to not move forward with an apprenticeship or OJT program. This is unfortunate, in that we believe that this program could have impacted turnover and retention rates in participating facilities.
What went wrong?
Washington State offers 200 apprenticeship programs in Spokane County 7(our targeted area). Of these, most are typical trades such as carpenter, plumber, painter, electrician and roofer. Interesting, options also includes hair designer, manicurist, medical assistant, dental assistant and child care assistant. There are no listed occupations with the word nurse or nursing. The one youth focused apprenticeship program in the city of Spokane is the Youth Culinary Apprenticeship Program. This program trains youths interested in becoming preparation (prep) cooks. The journey wage for a preparation cook is $14.50/hour.7
As a health care provider, it is difficult to understand why nursing assistant and/or medication assistant is not on the list. How is it that hair designer, manicurist or prep cook made the cut? Are these occupations more complex than nursing assistant or medication assistant? Are the roles more sustainable? Based on my 40 years in nursing, 20 years as an educator and 15 years as a nurse practitioner, I believe that the role of a nursing assistant and medication assistant are complex roles with long-term sustainability. The negative feedback received from our application could be personal bias from uninformed individuals conforming to the social norm of not valuing older adults or the role of the caregiver.
However, as we look ahead, the older adult population is growing exponentially and we as a society will need many more trained caregivers as we all face retirement. Nursing homes need help in staffing their facilities. They need innovative programs that challenge societal norms and enhance the role of the nursing assistant. GIGS members were and are disappointed in the outcome of our efforts. We plan to regroup in the coming months because nursing home residents do deserve better.
Dr Crogan received her BSN from the University of the State of New York in 1983, a Master’s in Nursing from Eastern Washington University in 1992 and a PhD from Washington State University in 1998. Her post-doctorate education includes a Geriatric Nurse Practitioner Certificate in 2007 from the University of Virginia. She also is certified as an Advanced Hospice and Palliative Care Nurse.
Dr Crogan was the recipient of the 2011 Western Institute of Nursing–John Harford Geriatric Research Award for a senior researcher, is a Fellow of the American Academy of Nursing (the highest honor in nursing) and was the co-recipient of the 2013 Sigma Theta Tau International Research Utilization Award. In 2017, Dr Crogan was inducted into the Western Academy of Nursing (WAN) as a Fellow, and in 2019 received the Distinguished Educator in Gerontological Nursing award from the National Hartford Center of Gerontological Nursing Excellence.
- American Health Care Association & National Center for Assisted Living. LTC Stats, Data & Reports. Published 2014. Accessed April 6, 2020.
- Benner P. Novice to expert. http://www.jstor.org/stable/3462928. Amer J Nurs. 1982;82(3):402-407. Stable URL:
- US Department of Labor. Employment and training Administration. https://www.doleta.gov/OA/occupations.cfm. Accessed April 6, 2020.
- Washington Administrative Code, Washington State, WAC 296-05-003(c) https://app.leg.wa.gov/WAC/default.aspx?cite=296-05-003 Accessed April 6, 2020.
- Washington Administrative Code, Washington State, WAC 296-05-003(e) https://app.leg.wa.gov/WAC/default.aspx?cite=296-05-003 Accessed April 6, 2020.
- Nursing Assistants, My Next Move. https://www.mynextmove.org/profile/summary/31-1014.00. Accessed April 6, 2020.
- Find an Apprentice or Apprenticeship program, Department of Labor and Industries, Washington State. https://secure.lni.wa.gov/arts-public/#/program-search?fromProgramDetails=true. Accessed April 6, 2020.