How to become a CNA: training, exam, and career path

The nursing career ladder starts at the CNA level. Becoming a certified nursing assistant takes weeks, not years – most programs run four to twelve weeks, cost under $2,000, and place graduates directly into hands-on patient care. For anyone who wants to enter healthcare quickly, the CNA credential is the clearest path in.

It’s also how many nurses begin. A significant share of working RNs spent time as CNAs first. The direct patient care experience, the clinical vocabulary, the comfort with physical care and bedside communication – all of it transfers. Programs that require clinical experience for admission often weight CNA experience heavily. Some LPN and ADN programs even grant credit for CNA hours toward clinical requirements.

This guide covers the full pathway: what a CNA does, how training works, the federal and state requirements behind the credential, the certification exam, salary and job outlook, and how to advance from CNA to LPN to RN.

At a glance: CNA overview

What does a CNA do?

CNAs provide direct patient care under the supervision of a registered nurse or licensed practical nurse. The core function is assisting patients with the activities of daily living (ADLs) – the basic physical tasks that illness, injury, or age can make difficult or impossible to perform independently.

Core duties

• ADL assistance – bathing, grooming, oral hygiene, dressing, toileting, ambulation, and positioning. These are the highest-volume tasks in CNA practice.
• Vital signs monitoring – temperature, pulse, respirations, blood pressure, oxygen saturation, pain level. CNAs take and record vitals, then report findings to the supervising RN or LPN.
• Nutrition support – feeding assistance, intake and output tracking, meal documentation
• Specimen collection – urine samples, stool samples; some facilities train CNAs for blood glucose monitoring
• Patient communication and observation – CNAs spend more direct time with patients than any other clinical role. They are often the first to notice a change in condition and are responsible for reporting it up the chain.
• Repositioning and skin integrity – turning immobile patients to prevent pressure injuries, with scheduled repositioning documented in the chart

Work settings

Long-term care – skilled nursing facilities (SNFs) and nursing homes – is the largest employer of CNAs. Home health agencies are the second-largest and the fastest-growing setting. Hospital employment varies: some hospitals use CNAs extensively as patient care technicians (PCTs); others have transitioned to using unlicensed assistive personnel under different titles. Assisted living communities, rehabilitation centers, adult day programs, and hospice agencies also employ CNAs.

Scope of practice vs. LPN and RN

The scope of practice line is clear: CNAs assist with care; they do not provide clinical interventions. For students heading toward NCLEX-PN or NCLEX-RN, understanding this distinction matters both for exam purposes and for future delegation decisions.

For a broader overview of the CNA credential and how it fits within the nursing education hierarchy, see our CNA level guide.

CNA training requirements

The federal floor: OBRA 1987

The minimum training standard for CNAs is set by federal law. The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) established the Nurse Aide Training and Competency Evaluation Program (NATCEP), which requires:

• Minimum 75 hours of training for CNAs working in Medicare- or Medicaid-certified facilities
• At least 16 of those hours must be supervised clinical training under the direction of an RN with at least two years of nursing experience
• Completion of a state-approved training program before working in a certified facility

This 75-hour minimum was set in 1987. It is a floor, not a benchmark. Most states have significantly exceeded it.

State requirements: how much more than the federal minimum?

The typical state requirement sits between 120 and 175 hours. Some exceed that range. Oregon requires 175 hours; California requires 160 hours. The additional hours usually come in the form of expanded clinical rotations, additional skills validation, or specific competency areas (dementia care, infection control, patient rights).

A handful of states (Alabama, Montana, South Carolina) use the 75-hour federal minimum. Most students in those states end up with more training anyway because employer-sponsored programs tend to exceed the state requirement.

Program structure

Every approved CNA training program has two components:

Theory/classroom instruction covers: anatomy and physiology basics, infection control and standard precautions, patient rights and dignity, communication skills, nutrition, safety and emergency procedures, restorative care, and state-specific regulations.

Clinical instruction places students in actual care settings – usually a nursing home or skilled nursing facility – under the direct supervision of a licensed nurse. Students practice the skills they’ve learned in the classroom on real patients.

Where to find approved programs

State nursing aide registries maintain lists of state-approved training programs. The Centers for Medicare & Medicaid Services (CMS) also maintains a public database of approved programs through their Nurse Aide Training and Competency Evaluation Program (NATCEP) tracking system. Programs offered through community colleges, vocational schools, and Red Cross chapters typically appear on both lists.

Employer-paid training: a path many students miss

A significant share of CNA training is paid for by the employer – not the student. Skilled nursing facilities and some hospital systems sponsor CNA training programs in which the facility covers tuition, supplies, and sometimes wages during training, in exchange for a 6–12 month work commitment after certification.

This arrangement works because SNFs have consistent, high turnover and a structural need for CNA staffing. Paying for training and locking in a period of employment is less expensive than recruiting externally. For students without the funds for a private vocational program, contacting local SNFs directly to ask about sponsored training is often a faster path than searching for scholarships.

State CNA training requirements: selected states

Sources: State nurse aide registry pages and CMS NATCEP database, verified 2025. Requirements can change – confirm with your state’s registry before enrolling.

The CNA exam

The NNAAP: national standard with state variations

The National Nurse Aide Assessment Program (NNAAP) is the certification exam used by most states to assess CNA competency. It is developed by the National Council of State Boards of Nursing (NCSBN) and administered by Pearson VUE in most jurisdictions. Some states use different exam vendors or their own state-developed exams.

Two parts to the exam:

Part 1 – Written knowledge test (or oral version): A multiple-choice exam covering the content areas taught in CNA training programs: patient rights, safety and emergency procedures, infection control, communication, basic nursing skills, and restorative care. Most states offer an oral version of the test (with recorded audio) for candidates with limited reading proficiency. The written exam is typically 70 questions with a 90-minute time limit.

Part 2 – Clinical skills evaluation: The candidate performs five randomly selected nursing skills in front of a trained evaluator. Skills are drawn from a standard pool that includes hand washing, vital signs, range of motion exercises, catheter care, positioning, and similar tasks. The evaluator scores each skill against a detailed competency checklist. Every step counts – for instance, hand hygiene steps performed in the wrong sequence may result in a failed skill even if the core task was completed correctly.

Both parts must be passed. A candidate who passes the written exam but fails the skills evaluation must retake only the skills portion, and vice versa. Most states allow three attempts before requiring additional training.

State variations in exam administration

The “NNAAP” label can be misleading because the exam administrator varies by state:

• Pearson VUE administers the NNAAP in most states (including Florida, New York, Illinois, Oregon, Washington, and others)
• Prometric administers in California and a small number of other states
• Headmaster is the exam vendor for Texas – the state uses its own CNA exam, not the NNAAP
• A few states develop and administer their own exams through the state board of nursing or a contractor

This matters if you move states or take the exam near a state border. Verify your state’s exam vendor at the state nurse aide registry, not from general CNA prep resources.

Exam preparation

CNA exam pass rates vary by state and testing vendor but typically range from 75–90% for first-time candidates from approved programs. The skills evaluation tends to have a higher failure rate than the written exam, usually because of incomplete steps or incorrect hand hygiene sequencing.

Effective preparation:

• Review the skill competency checklists published by your state’s registry or testing vendor; they list every scored step
• Practice the skills with a partner who reads the checklist aloud while you perform
• Complete practice written questions using the NNAAP study guide (available from Pearson VUE) or state-specific prep materials

CNA salary and job outlook

Salary data (BLS, 2024)

The median annual salary for nursing assistants in the United States is $35,740 ($17.18/hour), based on BLS Occupational Employment and Wage Statistics, May 2024 (SOC 31-1131).

The range is wide: the 10th percentile earns approximately $26,400 ($12.70/hour); the 90th percentile earns approximately $48,760 ($23.44/hour). Setting and geography drive most of this variation.

Hospital vs. SNF pay gap

The most significant pay divide in CNA employment is between hospital settings and skilled nursing facilities. Hospital CNAs – often working under the title “patient care technician” or PCT – typically earn $4,000–$8,000 more annually than CNAs in SNFs, even in the same market. Hospitals offer better staffing ratios, stronger benefit packages, and often pay for additional certifications (EKG technician, phlebotomy) that increase both scope and compensation.

SNFs are the largest single employer of CNAs, which means they set wages for the majority of the workforce. Hospital CNA roles are more competitive but meaningfully better compensated.

Top-paying states

States with high nursing labor costs, strong union presence, or favorable nurse-patient ratio laws tend to pay CNAs more:

• California: ~$42,000–$48,000/year median (highest in the country)
• Massachusetts, Washington, Alaska, Hawaii, Oregon: generally $38,000–$44,000/year median
• Southeast and Midwest states: generally $28,000–$34,000/year median

Job outlook

Employment of nursing assistants is projected to grow 4% from 2022 to 2032, slightly faster than the average for all occupations. The BLS projects approximately 216,000 annual job openings – one of the highest job opening figures for any healthcare occupation – driven largely by replacement needs as the existing CNA workforce ages and turns over.

The aging US population (Baby Boomers moving into the 75+ age group through the 2030s) is the primary structural driver. Demand in long-term care and home health settings is expected to remain strong throughout the decade.

The nurse aide registry and license reciprocity

What is the nurse aide registry?

Every state maintains a Nurse Aide Registry (NAR) – a publicly searchable database of individuals who have completed approved CNA training and passed the certification exam. Medicare- and Medicaid-certified facilities are legally required to verify a candidate’s registry status before employment. Being listed on the registry is what makes a CNA legally employable in those facilities.

The registry also records findings of abuse, neglect, or misappropriation. A substantiated finding will appear on the registry and may disqualify the individual from CNA employment even if no criminal charges were filed.

Reciprocity between states

CNAs who move to a new state do not always need to repeat training or retake the exam. Most states offer a reciprocity process – sometimes called “endorsement” – through which a CNA currently listed on another state’s registry in good standing can be added to the new state’s registry without re-examination.

The process typically requires:

• Proof of active registry status in the previous state
• Documentation of hours worked (some states require at least 8 hours of paid employment within the past 24 months)
• A background check in the new state
• The application fee for the new state’s registry

If the CNA’s registry is inactive (because they haven’t worked as a CNA recently), reciprocity may not apply and retesting or retraining may be required. For detailed guidance on transferring your CNA credential across state lines, see our CNA license transfer guide.

Career advancement: CNA → LPN → RN

The CNA credential is often a starting point, not a destination. The nursing career ladder has well-defined steps, and CNA experience directly benefits candidates at every level above it.

CNA to LPN

The transition from CNA to LPN adds a full licensed nursing scope: medication administration, IV therapy (in most states), patient education, and supervisory responsibilities over CNAs. LPN programs run 12–18 months at vocational schools or community colleges and culminate in the NCLEX-PN.

CNA experience can shorten the LPN path in two ways: some programs grant partial credit for CNA clinical hours, and the clinical competence a CNA brings to program entry typically results in stronger clinical rotation performance and NCLEX-PN prep.

For CNA-to-LVN bridge programs specifically designed for this transition, see our CNA-to-LVN bridge programs guide.

LPN to RN

LPN and RN scopes of practice are related but distinct. The LPN-to-ADN bridge is a well-established path that shortens the ADN from two years to approximately 12–18 months for practicing LPNs. The step up in compensation and scope is significant.

For the full RN pathway and what program types are available, see our how to become a registered nurse guide.

RN to advanced practice

Once licensed as an RN, the advanced practice tracks open: nurse practitioner, CRNA, CNM. The LPN guide covers the NP pathway context; see our how to become an LPN guide for detailed information on the LPN-to-RN transition and the credential comparisons most students need before deciding between these paths.

Timeline and cost comparison

BLS salary data: SOC 31-1131 (CNA), SOC 29-2061 (LPN), SOC 29-1141 (RN), May 2024.

The cost gap between CNA and RN training is substantial, but so is the salary gap. Many nurses who started as CNAs view the credential as a low-cost entry point that provided working income and clinical experience while they decided whether to pursue LPN or RN-level education.

Is becoming a CNA right for you?

Strong fit

• You want to enter patient care within 2–3 months, not 2–3 years
• You’re exploring nursing as a career and want real clinical exposure before committing to a full program
• You’re starting from a position where LPN or RN program costs are prohibitive right now
• Your interests align with long-term care, home health, or direct physical care of patients
• You want to strengthen an LPN or ADN program application with clinical experience

Worth considering before you commit

• The physical demands are real – repositioning patients, extended standing, high patient contact in physically intensive care settings
• CNA wages are among the lower compensation levels in healthcare, and the gap between CNA-level and LPN-level work is meaningful ($24,000/year or more at the median)
• Scope of practice is tightly constrained – if you are motivated by clinical decision-making, medication management, or independent assessment, the LPN or RN level is where those responsibilities live
• SNF environments can have high workload and staffing stress; hospital CNA roles have better ratios but are more competitive to land

The CNA credential is a legitimate career on its own terms and a well-documented entry point into higher nursing credentials. Knowing which of those two things you’re looking for will help you evaluate whether CNA is the right move now.

Next steps

1. Find your state’s nurse aide registry and verify training hour requirements and approved programs
2. Contact local SNFs to ask about employer-sponsored training programs before paying tuition
3. Enroll in a state-approved program and schedule your NNAAP exam upon completion
4. Once certified, start building clinical experience – the hours matter for every program above CNA level

When you’re ready to advance, the CNA-to-LVN bridge programs guide and how to become an LPN guide cover the next steps in detail.