Inadequate Training in Nursing Homes

Nursing homes have a responsibility to provide specialized care to elderly patients, but direct care of these patients is almost always performed by the most poorly trained workers in the industry.

Senior People in Nursing Home

The increased life expectancy and rising number of baby boomers aging into nursing homes have increased the demand for nursing home facilities. According to Macrotrends, life expectancy has increased by more than 10 years, from 68.14 in 1950 to 79.05 today.

While advances in modern medicine have played a significant role in longer life expectancy, it has also raised quality of life challenges. Older patients will almost certainly require higher maintenance and the most advanced medical technology. Gerontology has become a specialized field, but few health care workers have received specialized training in geriatric care.

According to the Eldercare Workforce Alliance, less than three percent of medical students choose to take geriatrics electives. Less than one percent of RNs, physical therapists and pharmacists are certified in gerontology. Studies by the National Institute of Health have found that higher levels of training are associated with better patient outcomes. 

However, certified nursing assistants (CNAs), who provide approximately 90 percent of direct patient care in nursing homes, are the least trained.

What is gerontology?

Gerontology is the medical study of old age, which addresses the unique needs of the elderly. Elderly patients often face simultaneous health challenges, and their responses to infection, disease and treatment vary from the general population.  

Their physical, mental, emotional, cognitive and behavioral needs are also unique. They experience specific social and economic challenges. Elderly patients generally take more medication than the younger population, and their health requires more continuous monitoring.

Health care workers trained in geriatrics are better equipped to meet the specialized needs of the aging population in nursing homes.

Types of Direct Care Staff Employed by Nursing Homes

While doctors and therapists play a vital role in nursing home care, direct care is primarily overseen and provided by nursing staff, as follows:

  • Registered Nurses (RNs) – Typically have a bachelor’s degree in nursing
  • Licensed Practical Nurses (LPNs), also known as Licensed Vocational Nurses (LVNs) – Typically have an associate’s degree in nursing
  • Certified Nursing Assistants (CNAs) – Low-wage workers without post-secondary education

RNs are generally the highest-paid direct care workers, although they typically provide the least amount of direct care. LPN duties often overlap with CNA duties. Many nursing homes hire a minimal quantity of RNs and a proportionately higher number of lesser-trained LPNs and CNAs to decrease labor costs and maximize profits.

What is a certified nursing assistant?

Despite their low rate of pay and lack of post-secondary education, CNAs bear the majority of the direct care responsibilities, which may consist of the following:

  • Turning patients
  • Assisting patients with activities of daily living (ADLs)
    • Grooming
    • Bathing
    • Dressing
    • Toileting
    • Eating
  • Checking vital signs
  • Answering patient calls
  • Cleaning patient rooms and bed linens
  • Providing assistance for some medical procedures
  • Transporting patients
  • Caring for wounds

Training Requirements for Certified Nursing Assistants

The federal government imposes minimal training requirements for CNAs under the Omnibus Reconciliation Act of 1987 for Medicare-approved nursing homes. Some states require additional training beyond the federal requirements, which are as follows:

  • 75 hours of initial training
  • 16 of those hours in supervised clinical training
  • Passage of a state certification exam and skills test
  • Completion of 12 hours of annual continuing education

According to the Gerontological Society of America, this is the equivalent of 1.5 university classes lasting one semester, which is less than half the course load of a college student in one semester. In addition, CNAs can be hired up to four months prior to their completion of the training program and passage of the exam. They are not required to be proficient in reading or writing in English.

A study by the Gerontological Society of America revealed that a higher ratio of training is associated with better resident outcomes, especially in relation to pain, falls with injury and depression. The conclusion of the study is that federal training requirements are inadequate.

According to findings by PHI National, over half of states have imposed requirements beyond the federal minimums, with 13 states requiring a minimum of 120 or more training hours, which meets the standard recommended by the National Academy of Medicine.

The Need for Specialized Training

The AARP Public Policy Institute conducted a study on training programs for CNAs in 2006. The study noted that the federal standards have not changed since 1987, despite the fact that the needs of nursing home patients have become more complex.

Those interviewed for the study asserted the following:

  • The federal requirements should be updated from 75 hours to 100 to 120 hours.
  • Hands-on clinical skills training should be increased to a minimum of 50 to 60 hours. 
  • Student/teacher ratios should be no more than five students per teacher. 
  • English as a Second Language (ESL) programs should be more accessible to students.

The study also noted that better training gives students a better idea of what they are getting themselves into. The more that is invested into students and the better prepared they are, the more likely they are to stay. This suggests that lack of training contributes to understaffing and high staff turnover at nursing homes.

Behavioral Training

According to a study published in the Journal of the American Geriatrics Society, behavioral disorders affect 65 to 90 percent of nursing home residents, but behavioral health training is not universally required. Consequently, behavioral needs are unmet in a third of all nursing homes.

The study also found that nursing homes with well-trained RNs had lower staff turnover and superior coordination of care to patients.

Dementia Training

According to Hall et al in the Annals of Long-Term Care, 27 percent of all workplace violence occurs in nursing homes, with as many as 90 percent of the assaults committed by Alzheimer’s patients. The forms of aggression most often reported include the following:

Surveillance studies show that 70 percent of nursing home staff are assaulted at least once monthly, with CNAs experiencing an average of nine assaults per month. As many as half of nursing home staff report being assaulted at least once during their careers, and 38 percent have required medical treatment. When CNAs receive specialized behavioral training, their patients experience less agitation, resulting in fewer assaults.


Many nursing home residents require assistance with eating, even to the point of needing to be spoon fed by staff. This responsibility often falls on CNAs, whether or not they have received proper training. Studies suggest that 40 to 60 percent of nursing home residents have difficulty swallowing, a condition referred to as dysphagia.

Improper management of this condition, including improper feeding, can lead to several life-threatening outcomes:

  • Aspiration pneumonia
  • Choking
  • Chronic malnutrition
  • Decreased quality of life

How does inadequate training contribute to staff shortages?

Minimal training allows nursing homes to justify low wages and poor work conditions. The result is that nursing homes find it increasingly difficult to retain and recruit staff. CNAs work long hours for low pay and receive little respect. The result is burnout, high turnover rates, chronic understaffing and an increased risk of patient neglect and abuse.

Patients Pay the Price for the Poor Training of Nursing Home Staff

Patients are the ones that ultimately suffer as a result of inadequate training, even while nursing homes increase their own profitability by hiring and keeping poorly trained staff, stretching them to their limits and paying them as little as possible.

  • According to the Centers for Medicare and Medicaid Services, staff turnover in long-term care means patients do not get the benefit of direct care staff who are familiar with their specific needs.  
  • Staff who are untrained in behavioral or cognitive issues are more likely to abuse patients.
  • Poorly trained staff are more likely to neglect important patient needs.
  • Poorly trained staff may be unprepared for the challenges involved with direct care, resulting in high staff turnover, understaffing and an increase in the odds of patients being abandoned.
  • Poorly trained staff can cause harm due to their lack of knowledge.

The overall environment in nursing homes should be caring and nurturing, but instead, elders are often forced to convalesce in an environment that is rushed and tense because of a poorly trained, overworked, underpaid and undervalued workforce.

What changes should be made to training requirements?

In its publication entitled Retooling for an Aging America: Building the Health Care Workforce, the Committee on the Future Health Care Workforce for Older Americans Board on Health Care Services recommends making the following adjustments to the federal CNA requirements:

  • Increase minimum training standards for all direct care workers
  • Increase CNA training requirements as follows:
    • Raise minimum training hours from 75 to 120 hours
    • Require CNAs to demonstrate competence in the care of older adults
  • Include geriatric care in all health care licensure and certification programs
  • Encourage training in nursing homes and other settings where elderly patients receive care
  • Increase pay and fringe benefits for direct care workers

Additionally, the Alzheimer’s Association recommends that states require dementia training for all direct care staff.

Nursing Homes Have No Excuse

Nursing homes are meant to provide a safe, comfortable environment for elderly individuals with medical needs their families are unable to accommodate. Family members trust nursing homes to provide their loved ones with a positive experience and quality care. Nursing homes owe these patients quality care delivered by qualified, well-trained staff.

If your family member has been harmed in a nursing home, they deserve better. Contact us today for a free consultation.

Medically Reviewed by:

Dr. Patricia Shelton, MD

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  • University of Washington, Doctor of Medicine – MD. June 2008
  • University of Washington, Bachelor of Science – BS, Jun 2003


Neuroscience and Medicine


  • Dr. Shelton primarily writes content for health-related websites, but has also written test prep materials, white papers, published research articles, court documents, and more.
  • Dr. Shelton teaches anatomy and physiology at the college level for the National Institutes of Health.

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Our fact-checking process begins with a thorough review of all sources to ensure they are high quality. Then we cross-check the facts with original medical or scientific reports published by those sources, or we validate the facts with reputable news organizations, medical and scientific experts and other health experts. Each page includes all sources for full transparency.