Since she was 10 years old, Latoia Arnett knew she wanted to dedicate her life to caring for people, starting with her grandmother. At 18, she turned her passion into a career, studying to be a certified nursing assistant with hopes of continuing on to become a nurse. Arnett graduated from the CNA program but never took the certification exam.
Nonetheless, for the next decade, she was able to work at an assisted living facility in Pittsburgh administering medications to patients under a licensed nurse’s supervision. She also provided general caregiving to patients, such as help with bathing and eating—work typical of a CNA. She later worked as a nursing assistant at a hospital, where she received training but still no certification.
Early in her career, Arnett had started taking prerequisite classes to attend a registered nursing program. But she had three young kids at home and was working double shifts every weekend, making about $7 an hour. Despite support from her husband and mother, she didn’t have enough time to study and failed the exam that is required to enter nursing school.
“With childcare, finding reliable babysitters, and also the funds I needed to pay for school—I ran into a lot of difficulty,” Arnett says. “After failing the entrance exam, I was defeated and it took a backseat.”
Now 44, Arnett recently passed the CNA exam and is planning to start a program soon to become a licensed practical nurse, and then eventually a registered nurse.
Arnett’s experience spending decades in a job she intended as a first step is common among CNAs, medical assistants, and other entry-level healthcare workers, many of them women of color from low-income backgrounds. Amid a nationwide nursing shortage, elevating those workers seems like an obvious solution, but the path from CNA to nurse isn’t so much a ladder as it is a huge leap.
And obstacle after obstacle is strewn in the way. The high cost of nursing school, lengthy prerequisite requirements, rigid schedules, and unpaid clinical hours make it difficult for many CNAs to advance in their careers, despite their willingness and ability and the dire need of healthcare facilities.
While there are no national statistics about the number of entry-level healthcare workers who move on to higher-paid positions, a study of federal grants for CNA training showed that only 3% of those who completed the training went on to pursue further education to become an LPN or RN. Only 1% obtained an associate degree or above. A similar study in California showed that 22% of people who completed CNA certificate programs at community colleges went on to get a higher-level educational credential in health, but only 13% became registered nurses within six years.
That reality perpetuates chronic shortages in nursing, and it also keeps hundreds of thousands of healthcare workers locked below a living wage, often for decades.
Some community colleges, including Monroe Community College in Rochester, N.Y., and Pierce College in Washington, are starting to rethink their admissions processes and programs to make the jump from CNA to nursing more doable. And a few hospitals are getting serious about helping their entry-level employees move up. The Aspiring Nurses program at Advocate Health, for example, has seen promising results in moving CNAs into more advanced roles. But such programs are still few and far between.
Susan Mayer, chief learning officer at the nonprofit Achieving the Dream, which is overseeing a project to diversify nursing pathways at community colleges, likened the problem to early childhood education—another low-wage but essential career.
“Our communities need CNAs,” Mayer says. “But we need to partner in ways that enable them to have career pathways, if they choose, to give them information so they know there are options beyond this.”
‘Fighting a Battle Every Day’
More than 1.3M people in the United States work as nursing assistants, and a third of them are people of color. In comparison, fewer than 20% of registered nurses—and even fewer nurse practitioners—are people of color. And the pay for nursing assistants is significantly lower, with a median wage of just under $19 an hour.
People like Arnett are often filtered out of nursing school before they have a chance to enroll. Nursing programs have very few slots relative to the need. Like the field itself, the programs face chronic shortages of qualified staff. Nursing instructors are required to have master’s degrees, a rarity among nurses, and colleges often can’t compete with the private sector for those who meet the qualifications. Hospitals too are short-staffed and often don’t have nurses available to oversee students’ clinical hours.
With limited capacity for students, higher education institutions want to enroll only those who are most likely to complete and pass the licensing exam. Due to the rigor of schooling and unpaid clinical hours, those tend to be younger students without children and with family support.
Iris Palmer, director for community colleges with the education policy program at New America, says there are myriad reasons that entry-level workers like CNAs don’t end up becoming RNs, but a lack of flexibility in programs is a root cause.
“The people who tend to become CNAs are people with very busy lives,” Palmer says. “They tend to be single women of color who have children. … We’ve heard this over and over again in all our work around adult students and parenting students: nursing programs are the least flexible and the least understanding of people with children.”
Becoming a licensed practical nurse is often a bridge to advancement, as it requires a certificate instead of an associate or bachelor’s degree. But even those programs typically require a year of full-time classes and clinicals. Many prospective students are unable to give up their jobs and benefits to go back to college.
Socrates Darius, 34, took the CNA to LPN path on his way to becoming a registered nurse earlier this year, but it took him more than 14 years. After getting laid off from his job as an Amazon warehouse worker in 2012, he trained to be a CNA with a goal of eventually becoming a nurse anesthetist. He started working in healthcare and quickly set his sights on an LPN program.
From the beginning, he encountered challenges. The coursework was manageable given his experience as a CNA, but the class schedules and cost were almost too much. Darius was making $13.50 an hour in Reading, Pa., a wage that was better than most other CNAs he knew, but still only enabled him to save about $30 a week—far below what he needed to set aside for a nursing program that would cost several thousand dollars.
Darius ended up getting tuition assistance from the local chapter of Service Employees International Union, and a nurse colleague talked the administrator into letting him continue working full-time despite the challenge of scheduling around his classes.
Then though, Darius had to make it to both a job and classes with limited transportation options. At the time, he lived with his two brothers and a friend, and all four shared one car. He had to leave home early so there was time to drop everyone off at their respective jobs. He was only sleeping about four hours a night.
“Nursing school is not known for flexibility,” Darius says. “It tends to be very old-school in its way of thinking. Even wearing a uniform that wasn’t all white was an issue. They said it was to maintain a professional look. So on top of an already hectic schedule, you have to fit in time for laundry because if you show up with dirty clothes, they take off points for that. It was like fighting a battle every day.”
On-Ramp to Where?
Training programs for CNAs tend to be much more flexible than nursing programs and are lower cost or even free. Many also include wraparound support. JVS SoCal HealthWorks offers one such program for eight weeks at no cost to participants. In addition to teaching the necessary skills for the job, the program also includes resume building and coaching for interviewing. A supportive service coordinator helps students get grants to cover rent, childcare, equipment, transportation, and even clothing.
“Every person deserves an opportunity to get into a career without that financial barrier being in the way,” says Paola Rodriguez, the CNA program coordinator. “Primarily we focus on giving this opportunity to low-income students who never believed they were worthy of taking a course like this, especially for free.”
But programs like JVS SoCal’s are only able to train people for entry-level roles. From there, students like Otilia Cruz must go to nursing school, which often comes without that type of support and flexibility.
Cruz has wanted to be a nurse since she was a kid living in Mexico. But when she moved to the United States, she studied English, worked as a house cleaner, and raised five kids, three of her own and two of her sister’s after her sister passed away. Now 43 with grown kids, Cruz enrolled in JVS SoCal’s program and is working as a CNA in Los Angeles. She still wants to become a nurse, but she’s not sure how to navigate the educational system and if the credits she earned at her vocational school in Mexico will transfer. The cost is also a deterrent.
“If I don’t work as much, obviously I’m not going to have as much money,” Cruz says. “I’ll have the time, but not the money.”
‘We Have a Place for You’
Some higher education institutions, especially community colleges, have been reforming nursing programs in recent years to better accommodate students like Cruz. There are many bridge programs for LPNs who want to become RNs, streamlining the curriculum and offering credit for prior learning. But few programs like that exist for CNAs who want to move to LPN.
Monroe Community College in Rochester, N.Y., began offering a CNA program in 2019, followed by an LPN program in 2021. For both programs, students meet with a success coach right at the beginning to help them with barriers that may prevent them from completing the program. Through grant funding, the college offers bus or gas cards to help with transportation, free food in the cafeteria, and Walmart gift cards to cover some personal expenses. The college also hosts $84 workshops for students who need to improve in English, math, or science to pass the entrance exam for nursing. If they complete the workshop, the college will cover the cost of the test itself, which is more than $100.
“We like to express to people who are interested in a career in healthcare that we pretty much have a place for you to jump on and off on that pathway,” says Julianna Frisch, director of healthcare programs in the Economic & Workforce Development Center at the college. “No matter where you are, what your experience is, what your interest is, what your background is—we have a place for you.”
Three years ago, through the initiative at Achieving the Dream, 10 community colleges received $300K each to help diversify nursing pathways. Many of the colleges either directly or indirectly tackled the problem of low mobility among CNAs or other entry-level jobs. Northern Virginia Community College developed a competency-based program in which people who had been CNAs could get prior learning credit and enter an accelerated LPN to RN program. Kingsborough Community College in Brooklyn and Pierce College in Washington changed their admissions policy to include lived experiences and work history instead of only test scores.
Mayer, chief learning officer at Achieving the Dream, says one commonality among the colleges’ efforts was their focus on culture and wraparound support, rather than just academics.
“They addressed basic needs, offered financial assistance, and created a sense of belonging,” Mayer says. “Our colleges still focus student support on traditional-aged students coming directly from high school, but that doesn’t apply to a lot of students, particularly coming from CNA, if they’re adult learners. So how do we create the policies, spaces, and engagement opportunities for adults to feel that they belong in the community?”
Hospitals Get Creative
Some hospitals are taking a more active role in helping their entry-level staff advance. Healthcare systems have long offered employee benefits that help defray the cost of nursing school, but workers have to front the cost and only get reimbursed after completing a semester or passing exams. That’s not feasible for many lower-paid workers. So last year, Advocate Health Care in Chicago, which is part of the larger Advocate Health system, started offering to pay tuition upfront for employees making less than $55K a year.
“It enables us to promote internal mobility and get our teammates to move into positions in which we have a very high demand and there’s a talent shortage,” says Michele Smith, vice president of workforce development and career innovation, who is based in Chicago.
Three years ago, Advocate Health also started an Aspiring Nurses program in Charlotte, N.C., where the system is based, that not only pays tuition up front, but also pays employees their full-time salaries and benefits while allowing them to work only 20 hours a week and spend the rest of the time on their classes and clinicals. Nearly everyone who takes advantage of the program has stayed with the hospital, improving its staff retention rate. Smith says many of those who have participated were CNAs, but they’ve also had employees working in food and guest services. The only requirement is they must be accepted into a nursing program.
University Hospitals in Cleveland has a similar earn and learn program for CNAs who want to become LPNs. The hospital system was influenced, in part, by the success of nursing apprenticeships, which have begun to grow in certain parts of the country. [More on that in the next part of this series.]
The program has proved beneficial to the employees, most of whom graduate and then stay with the hospital. But, according to Holly Ma, vice president of nursing professional development, practice, and research at University Hospitals, creating new initiatives in the healthcare industry can be challenging, especially when staff are already stretched thin.
“We had to have a lot of conversations with those leaders who are responsible for staffing,” Ma says. “It was important to clearly state our goals, and explain how leaders could play a pivotal role in the program to make it successful.”
Like most hospitals across the country, University Hospitals and Advocate Health Care in Chicago still have nursing shortages. Systemic issues outside the workplace are one factor, Smith says. For example, there aren’t as many nursing programs on the South and West Sides of Chicago, where many lower-income employees live. Long commute times can deter students enrolling, even if they are accepted.
Changes can’t come fast enough for people like Arnett, who is now studying for the nursing school entrance exam and planning to enroll in an LPN program next year. She plans to work as a CNA on a per diem basis as she goes through the program, so she can better balance the demands of work and study. Now that her kids are grown and living on their own, she finally has the capacity to get the education—and the credential—she needs to achieve her original goal.
“I have all this knowledge working in healthcare,” Arnett says. “I just feel like I need to be compensated for it. I’m in my 40s and now is the time where I can really focus and check off those boxes I haven’t been able to complete. Now is the time.”
Editor’s Note: This is the first in a three-part series looking at pathways for certified nursing assistants to move up into nursing.
This story has been updated to clarify that the Aspiring Nurses program is in Advocate Health system’s Charlotte, N.C., location.