CNA Training Requirements and Resident Care Outcomes in Nursing Homes

Purpose of the Study: To examine the relationship between certified nursing assistant (CNA) training requirements and resident outcomes in U.S. nursing homes (NHs). The number and type of training hours vary by state since many U.S. states have chosen to require additional hours over the federal minimums, presumably to keep pace with the increasing complexity of care. Yet little is known about the impact of the type and amount of training CNAs are required to have on resident outcomes. Design and Methods: Compiled data on 2010 state regulatory requirements for CNA training (clinical, total initial training, in-service, ratio of clinical to didactic hours) were linked to 2010 resident outcomes data from 15,508 NHs. Outcomes included the following NH Compare Quality Indicators (QIs) (Minimum Data Set 3.0): pain, antipsychotic use, falls with injury, depression, weight loss and pressure ulcers. Facility-level QIs were regressed on training indicators using generalized linear models with the Huber-White correction, to account for clustering of NHs within states. Models were stratified by facility size and adjusted for case-mix, ownership status, percentage of Medicaid-certified beds and urban-rural status. Results: A higher ratio of clinical to didactic hours was related to better resident outcomes. NHs in states requiring clinical training hours above federal minimums (i.e., > 16 hr) had significantly lower odds of adverse outcomes, particularly pain falls with injury, and depression. Total and in-service training hours also were related to outcomes. Implications: Additional training providing clinical experiences may aid in identifying residents at risk. This study provides empirical evidence supporting the importance of increased requirements for CNA training to improve quality of care.