After publishing my article on A Care-Centric Approach to Nurse Scheduling, I received several messages asking whether the care-centric methodology can also be applied to CNAs and LPNs.

Nurse managers can apply the care-centric scheduling calculations to CNAs, LPNs, and other staff in their budget.

CNAs and LPNs are typically 40-hour employees if they are full-time. Their generally smaller total FTE numbers, in conjunction with the need to schedule 40 hours during a single week for full-time employees, create some specific staffing and scheduling challenges.

This article examines the impact of mathematical and operational factors in maintaining a stable supply of CNAs as well as some suggestions on mitigating staffing and scheduling challenges.

The Role of Certified Nursing Assistants (CNAs) in Healthcare

Certified Nursing Assistants (CNAs) are unlicensed, entry-level healthcare workers. They perform “important patient-centered tasks under the supervision of licensed nursing staff.”^[1]What is a CNA. (2019, June 27). Premier Nursing Academy. https://www.premiernursingacademy.org/certified-nursing-assistant/what-is-a-cna/

The activities that CNAs are allowed to perform can vary based on location and the type of facility in which they are employed.

Typical responsibilities include:

• “Answering call buttons and alerting nurses to emergencies
• Monitoring patient needs and reporting any issues to other healthcare personnel
• Helping patients with their daily needs, such as eating, bathing, dressing, and toileting
• Ensuring patient comfort by changing bedding, filling water jugs, and positioning items so they are in reach
• Repositioning patients in beds
• Helping patients move from a bed to a chair or wheelchair and back
• Assisting with lifting patients from their bed to examination tables, surgical tables, or stretchers”^[2]What is a CNA. (2019, June 27). Premier Nursing Academy. https://www.premiernursingacademy.org/certified-nursing-assistant/what-is-a-cna/

“Depending on state regulations and facility requirements, some CNAs may perform additional advanced duties that include:

• Measuring and recording food and liquid consumption
• Accompanying patients to off-site doctor appointments
• Stocking or issuing medical supplies, such as dressing packs or treatment trays
• Measuring vital signs, including blood pressure, oxygen level, and temperature
• Explaining medical procedures and tests to patients and their families
• Dispensing medication as prescribed
• Changing dressings and bandages
• Setting up equipment such as oxygen tents, portable radiograph (X-ray) equipment, or IVs.
• Assisting in minor medical procedures”^[3]What is a CNA. (2019, June 27). Premier Nursing Academy. https://www.premiernursingacademy.org/certified-nursing-assistant/what-is-a-cna/

“Certified Nursing Assistants (CNAs) represent an essential part of the patient-care team. In assisting the medical staff, CNAs not only provide physical care for patients but also emotional and spiritual support, truly making a difference in the lives of patients and families. CNAs are also the eyes and ears of the clinical staff, observing their patients carefully and making sure the health care team knows of any changes.” ^[4]Celebrating the importance of CNAs. (2018, July 30). Pennmedicine.Org. https://www.pennmedicine.org/news/internal-newsletters/hupdate/2018/august/celebrating-the-importance-of-cnas

Determining Certified Nursing Assistant (CNA) FTEs

To understand why it is so challenging to maintain a stable supply of CNA FTEs, let’s first look at the math behind the FTE calculations.

We’re using the same unit from the A Care Centric Approach to Nurse Scheduling but will calculate the FTEs needed to schedule CNAs at a generous 1:8 ratio. With an average census of 24 patients each day, we will need 3 CNAs on each shift. The methodology and calculations for determining FTEs are the same as for the RNs in the linked post above.

We will need to schedule 63 8-hour shifts totaling 504 hours each week to provide the desired 1:8 ratio for an expected 24 patients. Dividing 504 hours by 40 hours/FTE gives us 12.6 FTEs required for the patient care portion of the weekly schedule.

To determine the Total FTEs where 15% of our total FTE hours are available for replacement (non-productive or non-patient care) shifts, we divide 12.6 by 0.85 to get 14.8 Total FTEs.

Subtracting 12.6 Productive FTEs from the 14.8 Total FTEs yields 2.2 Replacement FTEs.

The hours above represent the total budgeted hours you can schedule your employees without utilizing overtime, per diem, or float resources. The FTE numbers are rounded to the nearest tenths.

Also, the 15% for replacement is a suggested starting point. It is recommended to analyze the historical replacement utilization and expectations for the upcoming budget year in determining the most appropriate replacement percentage for the budget.

While the example above is for an inpatient unit, the formulas and concepts can also be applied to long-term care facilities.

These budget numbers are the best-case scenario. You have all of your CNA positions filled, and none of your CNAs are on leave, orientation, or temporarily assigned to another unit. This best-case scenario gives you only 11 replacement shifts per week that you can schedule for non-patient care activities such as time off, education, and leave. Unscheduled time off will also deduct from these shifts. Scheduling more than 88 hours per week for non-patient care shifts would require pulling hours away from the patient care shifts.

Mathematical Factors Impacting The Stable Supply of CNAs

Of course, units rarely find themselves fully hired like this. So let’s see what happens to our scheduling capacity if we have one vacant position, one CNA on leave, and one CNA temporarily reassigned to a COVID unit.

Orientation is less of an issue for CNAs for scheduling as their orientation is much shorter than for nurses. You would only need to consider including the orientation time for CNAs in the care-centric calculation if they were not on the floor providing patient care and were, for example, in classes for an entire week.

• Filled FTEs: 14.8 – 1.0 = 13.8
• Budgeted Direct Care (Productive) FTEs: 12.6
• Orientation FTEs: 0.0
• Leave FTEs: 1.0
• Reallocated FTEs: 1.0

Filled FTEs – Budgeted Direct Care (Productive) FTEs – Orientation FTEs – Leave FTEs – Reallocated FTEs = Available Replacement (Non-Productive) FTEs

13.8 – 12.6 – 0.0 – 1.0 – 1.0 = -0.8 Available Replacement (Non-Productive) FTEs

Available Replacement (Non-Productive) FTEs x 40 hours/FTE = Available Replacement (Non-Productive) Hours

-0.8 FTEs x 40 hours/FTE = -32 hours

With a best-case scenario of only 2.2 replacement FTEs, a loss of 3.0 FTEs to vacancies, leave, and reallocation puts the unit in a negative replacement scenario. Another way of looking at it is to deduct the 3 unavailable FTEs from the 14.8 budgeted FTEs. This leaves us with only 11.8 total available FTEs which is 0.8 FTEs less than the 12.6 FTEs required to provided the desired budgeted level of care for the budgeted volume of patients.

-32 hours of replacement time per week means that you are short-staffed for four 8-hour shifts per week even before you grant any time off for your CNAs. At this point, each time-off or other non-patient care shift that is approved will remove another shift from patient care. Examining your average weekly sick call volume may also provide insights into how many additional shifts you can expect to be short-staffed.

When the census increases such that the staffing plan calls for additional CNAs, there are no additional resources to pull from. Staff may be less likely to pick up overtime shifts for increased census if they have already been working overtime shifts to deliver baseline staffing numbers.

The smaller the number of Total FTEs, the more vulnerable the unit to understaffing due to resource variances. A CNA:Patient ratio of 1:10 would generate 1.8 Replacement FTEs totaling 72 hours in the budget example above, while a ratio of 1:12 would result in only 1.5 Replacement FTEs or 60 hours. Again, these are best-case-scenario numbers before losing any FTEs to vacancies, leave, or reallocation.

Using the care-centric scheduling formula, one can quickly see how a few unfilled or unavailable FTEs can negatively affect your ability to provide a stable supply of CNAs at the bedside.

Using more than the available replacement hours for non-patient care shifts will translate into unfilled patient care shifts or shifts covered by unbudgeted resources such as overtime, float pool, agency, or travel staff. Utilizing these unbudgeted resources for staffing will likely harm the unit’s financial performance.

Other Factors Impacting The Stable Supply of CNAs

During the pandemic, CNA turnover has risen to 27.5%.^[5]NSI Nursing Solutions, Inc. (2021). 2021 NSI National Health Care Retention & RN Staffing Report. … Continue reading At this rate, a facility will have replaced all of its CNAs in less than four years.

A 2008 study^[6]Squillace, M. R., Remsburg, R. E., Harris-Kojetin, L. D., Bercovitz, A., Rosenoff, E., & Han, B. (2009). The National Nursing Assistant Survey: improving the evidence base for policy initiatives … Continue reading explored what CNAs liked and disliked about their jobs and the reasons that they left their jobs.

Reasons CNAs liked their jobs included because they like caring for others, they felt good about the work they do, the location of their job, flexible hours, because they enjoyed working with their coworkers, and opportunities for career advancement.^[7]Squillace, M. R., Remsburg, R. E., Harris-Kojetin, L. D., Bercovitz, A., Rosenoff, E., & Han, B. (2009). The National Nursing Assistant Survey: improving the evidence base for policy initiatives … Continue reading

Reasons influencing CNAs to leave their jobs included a poor work environment, lack of respect or appreciation, not feeling like part of the healthcare team, heavy workload, poor pay, and poor benefits. ^[8]Squillace, M. R., Remsburg, R. E., Harris-Kojetin, L. D., Bercovitz, A., Rosenoff, E., & Han, B. (2009). The National Nursing Assistant Survey: improving the evidence base for policy initiatives … Continue reading

A review of stories by and about CNAs in the news, on Twitter, CNA groups on Facebook, and the nursing and CNA subreddits, suggest that the above likes and dislikes are still relevant today.

The work of CNAs can be both physically and emotionally demanding. Nursing assistants have one of the highest rates of injuries and illnesses of all occupations due to frequently moving and repositioning patients and other physically demanding tasks.^[9]Bureau of Labor Statistics, U.S. Department of Labor. (n.d.). Occupational Outlook Handbook, Nursing Assistants and Orderlies. Retrieved March 18, 2022, from … Continue reading With the increased stress and workload of the pandemic, many CNAs have experienced burnout, moral distress, and physical fatigue.^[10]Jenny Rollins, for KSL.com. (2021, September 26). Front-line fatigue: “I don’t want to lose my humanity” — CNAs weighed down by empathy exhaustion. Ksl.Com. … Continue reading

The US Bureau of Labor Statistics reports that the average wage for CNAs in 2020 was only $14.82 per hour.^[11]Bureau of Labor Statistics, U.S. Department of Labor. (n.d.). Occupational Outlook Handbook, Nursing Assistants and Orderlies. Retrieved March 18, 2022, from … Continue reading

With the recent push for a living wage of at least $15 an hour^[12]Glasmeier, A., & Omens, A. (2021, September 6). $15 an hour isn’t enough: U.S. workers need a living wage. Fortune. … Continue reading, some employers, such as Costco and T-Mobile, are offering wages greater than $15 an hour for their entry-level positions. The work of these positions is likely less emotionally and physically demanding than that of CNAs.

CNAs may be used as 1:1 sitters for patients that are confused and at high risk of falls. One report estimates that there are over 700,000 falls in hospitals each year.^[13]Agency for Healthcare Research and Quality. (2013). Preventing Falls in Hospitals, A Toolkit for Improving Quality of Care. … Continue reading Approximately a third of these falls will result in an injury that, on average, will increase the patient’s length of stay by 6.3 days and cost the hospital over $14,000 per incident.^[14]Joint Commission Center for Transforming Healthcare. (n.d.). Preventing falls. J. Pract. Nurs. Retrieved March 18, 2022, from … Continue reading While using CNAs as 1:1 sitters may make financial sense for the hospital’s bottom line, it increases the workload for the rest of the staff taking care of patients. CNAs working as sitters may be counted in the patient care hours for productivity. Still, from a workload perspective, the unit would be “understaffed” as the sitter would not be performing their normal duties for other patients.

Since the start of the pandemic, there have been significant increases in catheter-associated urinary tract infections, falls, and hospital-acquired pressure ulcers that have been tied to shortages of staff and supplies.^[15]Fleisher, L. A., Schreiber, M., Cardo, D., & Srinivasan, A. (2022). Health care safety during the pandemic and beyond – building a system that ensures resilience. The New England … Continue reading The work of CNAs directly impacts these safety metrics.

Given the typically smaller numbers of FTEs budgeted for CNAs and high turnover, it’s virtually impossible to maintain a stable supply of CNAs due to the low (and sometimes negative) available replacement hours. These issues can frequently lead to chronic and sometimes severe understaffing.

While the focus of this article has been on CNAs, the issues, concepts, and formulas outlined above can apply to any skill where there is a small number of FTEs. Small nursing units employing RNs and LPNs will encounter the same staffing challenges.

Strategies For A Stable CNA Workforce

To counter the effects of low available replacement hours for CNAs, some strategies can help mitigate the staffing and scheduling challenges:

Flexible Staffing Resources

Flexible staffing resources such as float pool, part-time, and per diem staff can help to ensure that there are an adequate number of CNAs available for patient care. An analysis of unfilled shifts and turnover rate can provide insights into the number of flexible staffing FTEs needed.

Dedicated Sitter Resources

If a facility has sufficient regular requirements for 1:1 sitter assignments, they may want to investigate hiring dedicated sitter resources such as Patient Safety Assistants. Dedicated sitters can help minimize pulling CNAs from their normal patient care assignments. A properly designed sitter program can help decrease the number of falls and the costs associated with those falls. “The cost savings achieved in decreasing rates of falls with harm, both in terms of money saved and decreased severity of injury, may justify the costs associated with implementing and maintaining a sitter program.”^[16]The Use of Patient Sitters to Reduce Falls: Best Practices. (2014). Pennsylvania Patient Safety Advisory, 11(1), 03/2014. http://patientsafety.pa.gov/ADVISORIES/documents/201403_08.pdf

Improved Work Environment

CNAs cited a poor work environment, lack of respect or appreciation, not feeling like part of the healthcare team, heavy workload, poor pay, and poor benefits as dissatisfiers for their job.^[17]Squillace, M. R., Remsburg, R. E., Harris-Kojetin, L. D., Bercovitz, A., Rosenoff, E., & Han, B. (2009). The National Nursing Assistant Survey: improving the evidence base for policy initiatives … Continue reading Efforts to address these issues may lead to reduced turnover, improved retention, and increased employee satisfaction.

Opportunities for Nursing Informatics

Given the right tools and data, informatics nurses well versed in staffing and scheduling operations and finance can proactively identify units at risk for staffing problems due to inadequate schedules and guide nursing and finance leadership on the root causes of the identified issues. Given the many quality, safety, and financial metrics negatively affected by understaffing^[18]Shin, S., Park, J.-H., & Bae, S.-H. (2018). Nurse staffing and nurse outcomes: A systematic review and meta-analysis. Nursing Outlook, 66(3), 273–282. … Continue reading, even minor improvements in staffing and scheduling could reap significant rewards for patients, patient care staff, and facilities.

In Conclusion

Certified Nursing Assistants (CNAs) are often underpaid and underappreciated for the mentally and physically demanding patient care that they provide. Due to the nature of their work, they are often the healthcare providers that spend the most time with the patients. When units are short-staffed on nurses and CNAs, patients are deprived of caring and compassionate care during their most vulnerable moments. The understaffing or absence of CNAs also significantly reduces the number of caregiver eyes and hands on patients that can help identify issues and reduce adverse outcomes such as falls, hospital-acquired pressure ulcers, and urinary catheter infections.

CNAs are valuable and cost-effective resources for improving patient care and decreasing nurses’ workload. By leveraging the care-centric scheduling calculation, managers can better understand how to schedule their CNAs more effectively.

CNAs can also use the calculations, questions and concepts outlined in my original Care-Centric Approach to Nurse Scheduling to facilitate discussions with their managers regarding resource needs and staffing concerns.

I welcome thoughts, feedback, and ideas regarding my posts. I would love to connect with anyone interested in or working on exploring solutions to the staffing challenges healthcare is experiencing.

If your facility is struggling with understaffing, I may be able to help.

You can reach me on Twitter at @In4maticsNurse and on LinkedIn.