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CEDAR RAPIDS, Iowa (AP) — The first thing Darwin Boots does when he arrives for his shift at Virginia Gay Nursing & Rehab in Vinton every afternoon is say hello to “my people.”

Pretty soon, the 55-year-old certified nursing assistant, or CNA, will start his preparations — making sure he has the supplies needed to take care of the long-term care residents he’s been assigned.

But greeting them—ensuring they’re comfortable—comes first.

That’s what it’s about for Boots, who only discovered his CNA career two years ago after his wife encouraged him and he completed Kirkwood Community College’s nurse aide program.

“The gratitude from the residents for the people on the staff is awesome,” he said. “To hear somebody say thank you for helping me with day-to-day activities, whether it be feeding dinner or giving them a bath or sometimes just stopping in and talking.”

Boots is somewhat of an exception, as droves of people left health care professions during the pandemic, according to the Cedar Rapids Gazette.

Hospitals, clinics, senior-living communities, long-term care centers and in-home services — all struggle to retain staff, recruit new workers or even get them to show up for interviews.

Boots started working as a CNA in March 2020, just as the pandemic hit Iowa.

Never fearing for his own health, Boots said the work was uplifting and felt imperative.

“During COVID time, so many of them were confined to their rooms, so you had to come in and be everything,” he said. “A counselor, magician, comedian, weatherman. You know, whatever you had going on in your personal life, you pretty much had to leave it outside the door.”

“There just seems to be way less people looking to come into our field,” said Kayle Neegaard, director of culture and team development at Jaybird Senior Living, which is based in Cedar Rapids and has 70-plus properties across the Midwest.

“What I hear at the community level is, sure, we might get a bunch of applicants, but we’ll reach out to them and they won’t respond, or we’ll schedule an interview and they won’t show up, ” she said. “It just seems like we can’t compete a lot of times wage-wise with some of the bigger operators.”

Those operators — like hospitals and clinics — hire nurses and providers with a range of education and certification, from the basic CNA that’s common in senior-living communities to next-level licensed practical nurses, registered nurses with associate or bachelor degrees, and advanced practice registered nurses with master’s degrees.

And workers with all those credentials are lacking not just regionally but nationally, with the US Bureau of Labor Statistics at the end of last year reporting the hospital subsector’s workforce dropping nearly 90,000 since March 2020.

Among nurses, the American Nurses Association had projected 100,000-plus RN jobs to become available annually. Just before the pandemic, the federal Labor Statistics Bureau projected 9 percent growth in registered nursing jobs between 2020 and 2030.

The rising demand, juxtaposed with the mounting exodus, is creating ripple effects at both the education and training level and in hospitals, clinics and care facilities — with employers paying top-dollar for agency nurses who’ll travel wherever they’re needed to fill gaps.

“It was unheard of for our organization to use agency in the past,” Neegaard said, “because we know the value of having team members who know our residents, who love on them and are not just coming in to check items off the list .”

Pre-COVID, Neegaard said, resorting to agency nurses even sporadically would have been “earth-shattering.”

“Now I would say 60 to 75 percent of our properties have used agency nurses in the last month.”

And Jaybird — like most long-term and senior-care entities — is taking action, beyond just offering better pay when and where possible.

“We’re really having to get creative on what is appealing to this demographic of worker,” Neegaard said.

New employee perks that Jaybird is offering include pet insurance, flexible work schedules and more education and training pathways.

“We’re really trying to go the approach of grow your own nurses,” Neegaard said. “Get your experience with us, and then we’ll help you get through school.”

Jaybird will hire CNA prospects—meaning those who are not yet CNAs—to start working immediately while pursuing a certificate, offering tuition reimbursement of up to 25 percent a year.

“As soon as you’ve worked with us for four years, we’ll pay 100 percent of that cost,” she said. “So we can continue to grow our field.”

Those efforts are happening at the college-level, too, where student interest has been waning, according to Katie Lyman, the dean of Kirkwood’s Health Occupations & Simulation Center who oversees its Certified Nursing Assistant Program.

“We are definitely seeing a decrease in enrollment in the CNA program, which is interesting because, quite honestly, we have a variety of funding mechanisms,” Lyman said. “Very few of our students are actually paying for CNA.”

Without aid, the cost to become a CNA through Kirkwood amounts to $770 — $595 for tuition, $115 for skills testing and $60 for the computer test.

But students rarely have to cover the full cost, if any of it, given the dire demand for CNAs and the grants and tuition assistance available.

“Anybody who wants to pursue a CNA at this point, we can find funding for them,” she said. “And that includes wraparound services — so things such as the scrubs that they need, or a stethoscope, or a watch with a timer. … There’s always hidden costs. And so the hidden costs of state testing and those types of things, all of that is free.”

Just as Iowa isn’t unique in the nursing shortage, it also isn’t alone in trying to drum up interest with aid and other incentives.

“Minnesota is offering anyone and everyone who’s willing to take CNA, it is fully free of charge,” Lyman said. “So it’s not just Iowa. It’s a national crisis.”

Mirroring the “grow your own nurses” opportunities offered through some care facilities, Kirkwood also supports “earn and learn” models and apprenticeship programs. Those not only help students but benefit participating hospitals or clinics by committing the trainees to work at the paying facility for at least a year.

Even at the high school level, Kirkwood has ramped up offerings and opportunities for teenagers to explore the prospect of a nursing career. A CNA options is among the college’s “high school academies” providing students with a yearlong career-path experience.

“That CNA option is really attractive to high school students,” Lyman said, noting nearly all those who participate take and pass the CNA test.

“But then it’s what do they do with it?” Lyman said. “Some use it and go on into nursing, and others say, ‘That’s not for me.’ And you know what, that’s OK at the high school level.”

Interest at the high school level, though, has been waning, too.

In 2017, 228 were involved in Kirkwood’s CNA high school academy program. Numbers dropped to 206 in 2019 and 157 in 2020 — a loss largely unaffected by the pandemic, because the course lecture and lab already had finished.

In 2021, the academy — done largely via Zoom — attracted 159. And the program this year has seen a slight increase to 167.

Similar trends have occurred in Kirkwood’s nurse aide program — with enrollment reaching 599 in 2017 and then 629 the following year before declining to 475 in 2019 and 254 in 2020.

“You can see that 2020 was tough for enrollment, which likely equates to some of the shortage we see now in the industry,” Lyman said.

But 2021 numbers showed promise, including CNA testing numbers at Kirkwood, a state-sanctioned testing site.

Kirkwood’s nurse aide training enrollment grew to 517 last year, and its testing numbers bumped up to 1,667 from 1,096 in 2020. Still, that’s below the 2017 testing level of 2,072.

As for the “why” so many facilities are struggling to retain and attract CNAs, Lyman offered a range of possible causes — starting with floundering pay.

“When you look at a wage for a CNA, you would stop to think whether or not you want to put yourself or your family at risk of contracting COVID at a pretty low wage,” Lyman said. “It already has caused industry partners to really stop and think about what we’re paying health care providers.”

Starting pay for a CNA has hovered between $14 and $16 an hour, according to Indeed, which reports average annual earnings of $34,670 — with Iowa paying under that at $33,259 and Vermont paying the highest average of $39,349.

The lowest paying state, on average, is Louisiana at $22,938.

“That’s a pretty tough sell, when you can go to Target and make more stocking shelves,” Lyman said.

COVID also played a massive role in the drop in interest across health care.

“We’re seeing an economy where people are evaluating what they want to be paid for the service that they’re providing,” she said. “So when you’re a CNA, you’ve gone through this training, you’re caring for other human beings, and you’re making $15 an hour and at risk for COVID. … You really start to re-evaluate whether this is a profession that you want to pursue.”

Demand for health care in Iowa is going to spike in the coming years, according to industry experts and analysts.

The state’s aging population is living longer with advancing medical interventions — not to mention the prospect that COVID survivors could increase the number of patients with more advanced needs.

University of Iowa Health Care recently reported that the existing unmet demand for physicians in Iowa is about 145 primary care doctors and 213 specialty providers. In a decade, those numbers will surge to 418 primary care doctors and 408 specialists.

“It really can’t continue,” Lyman said. “I think what we’re seeing is industry partners — Mercy, St. Luke’s, the University of Iowa Health Care System — they are equally concerned because they are starting to think about apprenticeship models.

“Ten years ago, that wasn’t a model that really existed. But there’s clearly evidence that we have to inspire and incentivize individuals to want to come into health care.”

James Katta, 40, has been a CNA since 2014 and has worked at Garnett Place Retirement Community in southeast Cedar Rapids for seven years.

He said he loves his job — even as his colleagues come and go.

“I want them to stick around a lot longer because there are a lot of problems with that — the residents are not happy about it,” he said.

He suggests low pay is the driving force behind the lagging interest. And when asked whether he feels well compensated, Katta said, “I just have a passion for the job.”

“I put a smile on people’s faces,” he said. “Most of them appreciate me.”

Boots, at Virginia Gay, said he, too, feels part of his residents’ families, and they notice when he’s gone.

One day recently, he said, he came into work on his day off, and one of the residents asked why he was there.

“She’s like 88, and I was like, ‘How do you know that?’ ” he asked, noting that residents often forget things. “But she knew I wasn’t supposed to be there.”

Though others might be leaving health care, Boots said he’s happy he made the leap into the field.

“Looking back, it’s something that I wish I would have done a long time ago.”


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