Hundreds of aspiring nurse aides can start taking their certification exams in Spanish and Chinese next year, the start of a multilingual policy that advocates and lawmakers say will tackle a major workforce shortage in nursing homes and other long-term care facilities.
The English-only exam for certified nurse aides (CNAs) has prevented non-native speakers — including those with years of nursing experience in other countries — from accessing the entry level health care role here. The new language options were included in a policy section within the fiscal 2024 budget that Gov. Maura Healey signed into law last week, but lawmakers say it is only the first step in breaking down barriers for immigrant CNAs and improving care for nursing home residents who don't speak English.
"Just before the pandemic, we turned away probably three dozen applicants that wanted to become nurse aides because we knew they couldn't pass the test in English, so this is going to be a huge help for us, and I think it's going to benefit other populations, as well," said Bill Graves, president and CEO of the South Cove Manor, a nursing and rehabilitation facility in Quincy where the vast majority of residents are native Chinese speakers. "We could hire another dozen tomorrow and put them to work right away if they could pass the test."
An influx of new CNAs — who provide care for daily tasks like bathing, eating and dressing — would improve staffing ratios and help staunch burnout among current staffers who must work overtime, Graves said.
Asani Furaha, a refugee from the Democratic Republic of the Congo and a former longtime nurse for Doctors Without Borders, said at a July committee hearing that she failed the written part of the CNA exam three times due to language barriers. Yet she passed the clinical component on the first try, calling it "simple."
The policy to expand language offerings for the CNA written exam made it to former Gov. Charlie Baker's desk last year as part of a broader economic development bill, and he returned it to lawmakers with an amendment asking for an implementation date and tacked on other initiatives for mental health exams for incarcerated people. The Legislature didn't take up Baker's proposed changes, though Sens. Jo Comerford and John Keenan and Rep. Tackey Chan revived the issue with similar legislation this session.
Under the budget signed by Healey, the Department of Public Health must offer the CNA exam in a language other than English by Oct. 1, 2024, though Keenan said he intends to urge officials to target a faster timeline. The CNA exam used to be available in Chinese before the COVID-19 pandemic, when the state used a different exam provider, Keenan and Chan said.
"The demand is immediate — it's now, and I think we have to respond as quickly as possible," Keenan, a Quincy Democrat, told the State House News Service. "It's long overdue. I can't imagine how isolating it must be when somebody is in a room and unable to communicate with a nurse, CNA or anyone that comes in."
At the committee hearing last month, Keenan lamented the disconnect between the CNA exams being offered in just English, compared to the learner's permit exam in more than 30 languages.
Tara Gregorio, president of the Massachusetts Senior Care Association, also called on DPH to implement the policy "as soon as practical" to grow the volume of CNAs, who she said deliver the majority of direct care and provide "vital companionship" to residents at nursing facilities.
There are 3,240 vacant CNA positions, Gregorio said, citing a July 2023 workforce survey from the association. That translates into a 20% vacancy rate, she said.
"Quality of care and quality of life for individuals living in nursing facilities is directly dependent upon an adequate number of caregivers at a time when demand critically outpaces supply," Gregorio said in a statement to the News Service. "As demand for nursing home services continues to grow, it is critical that we continue to work together to adopt policies, like this new provision, that embraces our direct care workforce and aging population and allows nursing facilities to continue to recruit and retain a more stable and skilled workforce."
At South Cove Manor, Graves said CNAs who can only speak English sometimes need to ask a bilingual colleague for help translating on behalf of residents, who could be expressing that they're in pain or need another meal. Hiring CNAs who are fluent in Chinese would be a "huge benefit" for his facility, said Graves, the former chair of the Massachusetts Board of Registration of Nursing Home Administrators.
"For us to hire all English-speaking nursing aides doesn't make sense," Graves said.
The related Senate bill that's pending on Beacon Hill calls for the CNA exam to be in a "language other than English, including but not limited to Portuguese, Haitian Creole, Spanish and Chinese." Meanwhile, the policy approved through the budget only invokes Spanish and Chinese, while likewise allowing DPH to determine which other languages are needed.
A DPH official told the State House News Service the department will make future decisions about providing additional choices without specifying what other languages could be under consideration.
DPH is working with the state's CNA testing provider to ensure exam guides are developed, translated and made available to applicants, the official said. There will be a public comment period, as well as a public hearing, as DPH modifies nurse aide regulations, the official said.
The language policy in the budget falls short of the legislation that Comerford said she will still pursue "without question" this session — including "commonsense measures" aimed at making the CNA exam more comprehensible to non-native speakers, who struggle with the phrasing of certain multiple choice questions.
Comerford said the budget leaves DPH with a "good deal of latitude" for crafting rules and regulations to implement the exam policy.
"It's a wonderful first step honestly, and it's an acknowledgement of what it's going to really take to break down barriers to access for those who would like to become certified nurse aides," the Northampton Democrat said of the budget. "I have faith in DPH that they're going to want to make this test as accessible as possible within the limits of the law."
The current CNA exam is not "straightforward," said Laurie Millman, executive director of the Northampton-based Center for New Americans, which offers training for students preparing for the CNA exam. Millman said immigrants view the CNA role as an opportunity to strengthen their English vocabulary before they continue their education and pursue other health care positions, such as medical assistants or phlebotomists, that allow them to save up for a house and car, among other expenses.
Yet due to the language barrier, only 60% of students who are learning English at the center pass the written exam, compared to 80% who pass the clinical exam, according to Millman. She said she regularly fields "frantic" calls from long-term care facilities who are searching to hire CNAs.
"We end up taking so much time decoding the exam rather than measuring what students know," she said. "We are receiving a lot of immigrants; the smart money figures out who's highly qualified and removes the barriers. If you have the lens that says Americans are not the only people who are qualified — there are highly qualified people all over the world — figure out how to make these pathways more accessible."