Covering the Hidden Costs of ‘Free’ Nurse Training

As the U.S. grapples with nurse shortages—in some cases severe—Massachusetts is using American Rescue Plan Act funds in an unusual way to address the problem. 

A few weeks ago, Work Shift published a series of stories spotlighting the challenges that entry-level healthcare workers face in advancing their careers to become nurses. Some states are using apprenticeships to bridge the gap, while others are investing heavily in healthcare programs in high schools to get students on the nursing track earlier. We’ve heard from others since, including Massachusetts.

There, the nonprofit Social Finance worked with the Massachusetts Senior Care Association and MIT economics professor Jonathan Gruber to create the Career Ladder Program. Now in its second year, the program is overseen by the Massachusetts Executive Office of Health and Human Services and funded with $6M from the state legislature and U.S. Department of the Treasury through ARPA.

How It Works: The program pays half of the paycheck for certified nursing assistants who want to pursue their licensed practical nurse certification, allowing them to work half-time and retain their benefits while going to school. The program has also partnered with Jewish Vocational Service to provide academic and personal coaching to help students finish the program and pass the nursing exam. With free tuition at community colleges in the state, time is the biggest barrier many prospective students face.

“It’s a one-year program, and you can have a meaningful jump in income for a learner if you can figure out how to support them and get them through the program,” says Justin Bakule, vice president of impact investments at Social Finance. In Massachusetts, CNAs make about $22 an hour on average, whereas LPNs make about $37 an hour, according to the Bureau of Labor Statistics.  

The program is off to a slow start. In its first year, eight students enrolled and four graduated. This year, 18 enrolled, and at the close of the first semester, only one had dropped out. The original goal was to serve 325 CNAs over five years. While the program may need more time to reach that target, employers are eager to participate. So far, 27 across the state—from large health systems to small rural “mom-and-pop” facilities—have signed up.

Some health systems across the country, including Advocate Health in Charlotte, N.C., and University Hospitals in Cleveland, have implemented similar earn-and-learn programs, but the Massachusetts program scales it statewide. It also eases the burden on skeptical employers—key players in the success of such models. 

The CLP fund pays for the students’ time where they would otherwise be at work. If students who get licensed as LPNs don’t want to pay back those training costs, they have to stay with their employer for at least two years. Employers, in turn, pay back the fund over four years, dependent on the worker’s continued employment. That money is then recycled for another student. 

If a student doesn’t finish the program or pass their licensing exams, they are not committed to the employer and don’t need to pay back the funds. CLP absorbs that cost.

‘A Heavy Need’

On the Ground: Last year, Quaboag Rehabilitation and Skilled Care Center, a rural facility in West Brookfield, Mass., with fewer than 300 employees, joined the program. They enrolled one employee, a single mother of three children who aspires to be a registered nurse. She’s now working as an LPN.

Jessica Macdonald, executive director of the center, says it has long supported employees’ upward mobility, including with tuition reimbursement. But the center wouldn’t have been able to offer paid time off and full benefits without the CLP fund. Macdonald hopes the program will help lessen the nursing shortage. 

“There’s definitely a heavy need,” Macdonald says. “We have a few positions that require an RN, but many others that can be RN or LPN. Hopefully this opportunity will help close that gap.”

Working Out Kinks: This year, two employees at Quaboag are taking part in the program, with another two taking the prep course to start next year. Macdonald says they are running into more scheduling issues this time around. Students can enroll in any LPN program, but not all programs have flexible schedules that allow students to work part-time. The facility has to make sure it has enough employees to cover shifts, and inflexible school schedules that are released at the last minute make that challenging. 

In smaller facilities, there are also only a limited number of LPN roles available at a given time. Macdonald must ensure there’s an open job for any student who enrolls in the program, so she works with other senior care facilities in the same healthcare system to fill open LPN roles they may have.

The retention requirement has also been a challenge, Bakule says. Completers initially had been required to stay at their employer for four years, which employers liked. But that wasn’t a realistic commitment for a lot of employees, so CLP recently lowered the requirement to two years based on feedback that suggested it was discouraging enrollment. 

Bakule is hopeful the model will work in the long run, and possibly even extend to other in-demand healthcare positions. 

The Kicker: Employers are willing to get creative, he says, when the labor problem is both chronic and painful.

“There really needed to be this supply and demand imbalance that was verified from the employer perspective to make the recycling mechanism a reality,” Bakule says. “There are a lot of jobs where an employer would like to hire more people, but they’re not willing to pay for it.”