As an Instructor and Coordinator, I would like to offer my support for this petition. Nurse Aide (NA) programs have difficulty securing clinical sites and this request would remove some of the clinical site barriers for nurse aide students and programs. As many hospitals prefer CNAs as entry to practice in bedside care, this would also provide experience in these facilities. Hospitals have many opportunities for students to perform skills required by NA students. Some hospital units, such as Medical-Surgical, often have more opportunities for students to perform care than nursing homes such as catheter care, bedpan, bed bath, and Vital sign measurement- skills that are the most failed on the exam demonstrating the need for more practice opportunities. I don't agree that ALL units of a hospital would be appropriate for NA students, but this could be remedied by requiring the units have skilled care, adult patients.

Additionally, because Nurses (LPNs and RNs) approved to teach are required to have 12 hours of training before they are allowed to teach in a NA program, it is unnecessary for nurses, who are trained in all levels and stages of patient care, to have a nursing home experience requirement to teach. It is necessary for instructors to be experienced nurses, but the nursing home experience requirement is so restrictive that many well-qualified instructors are turned away from teaching. This leads to a shortage of well-qualified instructors.

Finally, it makes sense to allow clinical instructors to oversee a lower ratio of students while they are in the facility working. With concerns about the prevalence of infection and introducing non-essential personnel to at-risk clients such as the elderly, this would be a great compromise. In my opinion, Directors of Nursing should not oversee students as they have too many responsibilities to effectively monitor students, but Staff Development Coordinators/Educators and floor nurses are great options to oversee students working on their units.

Thank you for considering this petitioner's request. With the addition of requiring the hospital units have skilled care, adult patients, I fully support these changes.

I am in FULL agreement with this Petition for Rulemaking regarding the changes to the VBON/state regulations for CNA programs!

We, as instructors, have struggled to keep our programs afloat during the Covid restrictions.  The term "difficult" would be an understatement of how hard it's been to meet the mandate clinical hours especially with the vaccine mandates and the waivers no longer allowing sites other than Long-term Care facilities. *** The only thing I'd like to add would be the allowance of using Assisted Living Facilities so that those students that are choosing not to be vaccinated (or their parents object) could still meet requirements to take their CNA certification exams!  There are plenty of non-governmentally funded facilities as well as private in-Home care opportunities that need to be accommodated with CNA's.

The rule of mandating an instructor for a CNA program to have had long term care experience is truly removing some amazing applicants from the lists of employment!

Lastly but most important, To the powers that be: anything we can do to encourage and increase entry into the health care career clusters should be made as easy and accessible as we can can make it!!  We need them!

I can not support this petition in its' entirety.  

I support using licensed hospitals "in addition to" the LTC arena but not "rather than".  Students have valuable experiences in the LTC setting, including but certainly not limited to communication challenges, holistic care, basic personal care, positioning, and establishing a relationship with residents.  The turnover in acute care often does not allow this to occur. 

I have to question if on-site working RN's and LPN's can give the NA the attention that is often necessary when clinical rotation begins. The introduction to providing care to a patient in an acute care facility may differ from care in LTC.  LTC allows for direct care to be completed versus acute care may be more of observational role.

I do not believe, RN/LPN's need LTC experience prior to teaching the NA class.

I am in full support of this petition.  As a program coordinator for a hospital based program with a goal of hospital nurse aide recruitment, I can say that clinical experiences in the acute care setting would be much more beneficial for our students.  Both didactic and clinical training are focused nearly exclusively on care in the long term care setting.  While this may assist in forming a foundation for learning fundamental nursing skills, it does not provide for the expansion of learning in the acute care setting nor foster critical thinking skills among students.  I can certainly appreciate the benefit of the long term care setting for clinical training for nursing home based programs, however, it may somewhat hinder those destined for the acute care setting in acquiring necessary skills and knowledge that will be needed.  

In addition, many of the skills needed for state certification are nearly non-existent in current healthcare practice in the long term care setting.  Urinary catheters and ambulation are examples of skills rarely utilized and thus neglected in teaching when focus remains on the long term care population.  

In conclusion, adding the ability to complete clinical training for nurse aides in settings other than long term care would benefit both students and the patients who will be cared for by those students.

I am in full support of having more flexibility related to clinical training environments and instructional personnel requirements.  Regarding the requirement of LTC experience needed for instructors, the viable candidate pool, including nurses with exceptional acute care performance, which may be valuable for students bound for acute care or long term care practice, is limited.  Severe COVID-19 outbreaks in facilities have been problematic and created barriers to training with adequate resident cohorts.  With the frequency and quantity of LTC residents who are hospitalized, the geriatric portion of learning is often experienced adequately outside of the long term care setting.  In addition, many of the skills required for certification testing are very rare in LTC, to include catheter care, bed baths, ambulatory weights with beam scale, bedpans, and recording urinary output.  Emergency care skills and observational procedural experience is even more limited for those who are not able to attend clinical training in a hospital environment.  I am asking that the current regulations be amended and updated to include training options in acute care settings.

I am a CNA and recently finished the NATP program at Valley Health. I have experience in both long term care and the hospital setting. During my NATP clinicals, we spent time in both the long term care setting and hospital setting. As I understand, the current rule has a mandatory long term care setting clinical rotation. This is not entirely feasible. COVID has created an issue with interacting with patient in a long term setting and to be honest it does not give you a lot of diversity of the type of patients that you will encounter. By engaging in the same routine care of patients, CNAs can become stagnant in their skills and quite frankly that is dangerous for our long term care population. I have seen this first hand. Also, I do have hospital experience as a CNA, which is most of my professional career. The hospital setting gives you the ability to see different patients on a routine basis and allows the chance to use different skills daily making the CNA well rounded. Additionally, the CNA has the ability to learn new skills that she would necessarily not be able to learn in the long term care setting. Personally, I was able to learn to do bladder scanners on patients. This is something that I do not think I would have had the opportunity to do in the long term care setting. Sadly, by making the long term care rotation mandatory, you are creating a pigeon hole and limiting us for doing more for our patients. I hope you take this into consideration from someone who is working in the trenches as a CNA and nursing student. 

First, as a nurse aide program director, I agree that NA students should be allowed to have clinical hours committed to a hospital setting. Most hospitals only require an entry level NA experience to practice in the acute care setting. 

I do believe that nurses who are teaching in the NA program should have long-term care and acute care experience. These experiences will help ensure a good learning environment for the students and ensure that they are receiving good feedback. 

I do NOT believe that we should decrease the number of students to instructor as 10:1 is the standard for all nursing programs. This number is doable and should be decreased if the facilities and faculty are available to provide a lower student-teacher ratio. Again, we have to think about our resources within our communities. 

Thank you for your consideration of these comments. 

Dear Ms. Douglas:

On behalf of the Virginia Hospital & Healthcare Association’s (“VHHA”) 26 member health systems, with more than 125,000 employees, we are writing in support of the petition received by the Board of Nursing on January 10, 2022, requesting amendments to the Regulations for Nurse Aide Education Programs (hereafter referred to as the “Proposed Amendments”). The petitioner has requested that regulations pertaining to nurse aide education programs (the “Regulations”) be amended to (i) allow the use of licensed hospitals for clinical education in addition to nursing homes; (ii) eliminate the requirement that registered nurses (“RNs”) and licensed practical nurses (“LPNs”) serving as clinical instructors have experience working in nursing homes; and (iii) allow clinical instructors to be on site and to perform their regular work at the same time, but reduce the ratio from 10:1 to 4:1 for students to instructors. The Commonwealth has been experiencing a health care workforce shortage for several years that has been further exacerbated by the COVID-19 pandemic. Accordingly, we strongly support the proposed amendments as one method of helping to bolster the available number of health care professionals in the Commonwealth.

1. The Proposed Amendments Are Consistent With State And Federal Law And Regulations

The Board of Nursing has been provided with the legal authority to establish the minimum standards of and regulations pertaining to nurse aides provided that those regulations are consistent with federal law and regulation. Virginia Code § 54.1-3005 provides that the Board of Nursing may “prescribe minimum standards and approve curricula for education programs preparing persons for licensure or certification…” and has the authority to “certify and maintain a registry of all certified nurse aides and to promulgate regulations consistent with federal law and regulation.”

The Centers for Medicare and Medicaid Services (“CMS”) has promulgated regulations at 42 CFR § 483.150 et seq. establishing minimum standards for state nurse aide training and competency evaluation programs (the “CMS Regulations”) at long term care facilities. Part 483 of the Federal Code of Regulations is specifically intended to apply to long term care facilities and is titled, “Requirements for States and Long Term Care Facilities.” The CMS Regulations note that training can take place at a “facility” but do not expressly identify a hospital as a “facility.” The content of the CMS Regulations suggest that “facility” is intended to specifically refer to nursing, skilled nursing, or other long-term care facilities. For example, the CMS Regulations at subsection (b)(iii)(2) discuss the exclusory criteria for nurse aide training and competency evaluation programs or competency evaluation programs offered by or in a “facility.” The exclusory criteria within subsection (b)(iii)(2) specifically refer to “skilled nursing” and “nursing” facilities but make no mention of hospitals. Similarly, the requirements for instructors contained in 42 CFR § 483.152(a)(5)(i) note that “[t]he training of nurse aides must be performed by or under the general supervision of a registered nurse who possesses a minimum of 2 years of nursing experience, at least 1 year of which must be in the provision of long term care facility services” (emphasis added). Therefore, the Proposed Amendments are consistent with the CMS Regulations which do not require nurse aide instruction to take place in hospitals or prohibit instructors who have experience in other settings from providing instruction in hospitals.

2. The Proposed Amendments Would Increase The Pool Of Available Nurse Aides And Instructors

Virginia’s existing nurse aide training regulations at 18VAC90-260-10 et seq. were drafted with the expectation that nurse aide instruction would take place solely within nursing facilities with the intent of ensuring that students caring for geriatric patients would receive training in the environment they would be working upon certification. Despite the original intent of these regulations, the existing regulations at 18VAC90-26-50(C)(3) recognize the benefit of clinical hours outside of a nursing facility setting by allowing for five out of the 40 required clinical hours to be in a setting other than a long term geriatric care facility.

Hospitals are increasingly implementing nurse aides within their staff to augment the ongoing staff shortages, and these health professionals are engaged to care for a variety of patients other than geriatric patients and in a variety of settings. The Proposed Amendments would help to increase opportunities to expand the role of nurse aides to these other settings.

Throughout the COVID-19 pandemic, we have all seen the impact workforce shortages have had on Virginia’s hospitals and health systems. Governor Youngkin recognized the “severe staffing shortages…placing an unsustainable strain on our health care system and health care workforce” in Executive Order 11 and requested flexibilities be provided to healthcare providers throughout the Commonwealth. Indeed, these severe staffing shortages are expected to continue for the foreseeable future. Therefore, we strongly support any measure that will remove entry barriers to the health care profession, such as those suggestions included in the Proposed Amendments.

In closing, we strongly support the Proposed Amendments. The Board of Nursing has been granted broad authority under state law to promulgate regulations pertaining to nurse aide education programs provided that those regulations are consistent with federal law and regulations. As noted above, federal regulations apply to nurse aide education in nursing facilities, but do not prohibit expansion to hospital settings. By implementing the Proposed Amendments, the Board of Nursing would remove barriers to entry for potential nurse aides by allowing instruction to take place in a hospital and thus increasing the availability of training sites throughout Virginia. Additionally, by removing the requirement that RNs and LPNs serving as clinical instructors have experience working in nursing homes and allowing for clinical instructors to be on site and to perform their regular work at the same time, the available pool of instructors would increase and provide the opportunity for those who are currently employed by hospitals or considering leaving a clinical setting with the option to become nurse aide instructors.

Thank you again for the opportunity to comment on the permanent regulation. Please do not hesitate to contact Brent Rawlings (brawlings@vhha.com, 804-965-1228) or me at your convenience if we can provide any additional information.

Sincerely,

Sean T. Connaughton

President & CEO

I would like to offer my support to amend regulations to allow for greater flexibility around the current nurse aide education programs to include:

-The use of licensed hospitals for clinical education rather than only nursing homes: I firmly believe that students enrolled in approved nurse aide education programs will benefit greatly from a broader clinical experience. 

-The elimination of the requirement that RNs and LPNs serving as clinical instructors have experience working in nursing homes: We are eliminating great talent by requiring RNs and LPNs to have experience working in nursing homes.

To echo Vicki Owen, RN, Instructor/Coordinator, Amherst High School- anything we can do as educators to remove obstacles and make access to the health care career clusters education and skills more attainable should be our goal. The system is desperate for enthusiastic and fresh caregivers. 

I do not support changes to decreasing the student to instructor ratio. Facilities and faculty should work together and decrease student to instructor ratios where necessary based on the capacity of the facility.