Trends in Contract Nursing Assistant Staffing and Quality of Care

Project start: 9/01/2022

Certified nursing assistants (CNAs) play a critical role in ensuring quality care for nursing home residents. They provide twice as many hours of hands-on care per resident per day than licensed practical nurses and registered nurses combined, and the amount of care provided by CNAs is positively associated with improved quality outcomes for residents. During the COVID-19 pandemic, higher CNA staffing levels have been associated with a reduced likelihood of COVID-19 outbreaks and deaths among residents.

To bolster CNA staffing in nursing homes, a number of states have recently implemented or amended minimum staffing requirements. The Biden administration has also committed to establishing minimum staffing requirements across all Medicare- and Medicaid-certified nursing homes. However, low wages and other job quality concerns drive high turnover within the CNA workforce and impede efforts to maintain minimum staffing levels.

One strategy that nursing homes use to address staffing deficits is to hire contract CNAs through staffing agencies. Contract CNA staffing is negatively associated with care quality, however, likely due to unfamiliarity by contract CNAs with residents’ needs and preferences. Reports from the field indicate that nursing homes have relied even more heavily on contract staffing during the pandemic. More research is needed on how nursing homes have managed CNA employment challenges in recent years and with what implications for resident care. This longitudinal analysis of CNA staffing patterns and quality outcomes in nursing homes will address this gap and inform policy and practice recommendations for strengthening and stabilizing nursing home staffing.

This study will examine staffing levels and patterns for fully employed versus contract certified nursing assistants (CNAs) in skilled nursing facilities (SNFs) over the past five years and assess how these staffing trends are associated with quality outcomes for nursing home residents. We will leverage several data sources to conduct this analysis, including skilled nursing home data from CMS, LTCFocus data from Brown University and the National Institute on Aging (NIA), COVID-19 tracking data from the Centers for Disease Control and Prevention (CDC), and labor market data from the US Bureau of Labor Statistics (BLS).


Key Questions

This project aims to answer four research questions:

  • How did nursing home occupancy and overall CNA staffing levels covary in the past five years, from 2017 through 2022?
  • How did staffing patterns among employed versus contract CNAs vary during the same period?
  • How did CNA staffing trends vary according to facility-level characteristics, local labor market conditions, and pandemic-related factors?
  • What is the relationship between CNA staffing levels and patterns and care quality for nursing home residents?


This study is a collaboration with PHI.

For more information, contact Laura Wagner.



Stepick, L, Laurie H, Scales, K, Wagner, LM. The Increase in Contract CNA Staffing in U.S. Nursing Homes and Associated Care Quality Outcomes.