The nursing assistant is the only tier of American nursing that holds no nursing licence, and after registered nurses it is the largest. About 1,558,700 people worked as nursing assistants or orderlies in 2025 — more than twice the practical nurse workforce.
The work is direct and physical: bathing, feeding, toileting, transferring, turning, dressing, taking vital signs, and being the person in the building who sees the patient most often. That last point is the one hospitals and nursing homes keep rediscovering. The assistant is usually the first to notice that a resident is eating less, that a heel is reddening, or that someone who walked yesterday cannot stand today.
No independent scope
The defining legal fact about the tier is that its members have no scope of practice of their own. Everything a nursing assistant does clinically is a task delegated by a licensed nurse, and the nurse who delegated it keeps accountability for the outcome. The assistant is accountable to their employer and, where a state registry exists, to that registry — but not to a board of nursing under a practice act, because there is no practice act that covers them.
This has a practical consequence that new nurses learn late. A registered nurse cannot delegate assessment, nursing judgment, or the evaluation of a patient's response to care, because those are the acts the licence exists to authorize. A nurse may delegate taking a blood pressure; a nurse may not delegate deciding what the blood pressure means. See scope of practice and the nursing process.
The federal training floor
Nursing assistant training is one of the few parts of American nursing regulated first at the federal level rather than by the states. The nursing home reform provisions of the Omnibus Budget Reconciliation Act of 1987 required facilities that take Medicare or Medicaid money to use only aides who have completed an approved training and competency evaluation programme, and the implementing regulation sets the floor.
That floor is 75 clock hours. At least 16 of them must be supervised practical training, in which the trainee performs tasks on a person under the direct supervision of a registered or practical nurse. A further 16 hours of instruction must come before the trainee touches a resident at all, covering communication, infection control, safety and emergency procedures, promoting independence, and residents' rights. States must also maintain a registry of aides who have passed the competency evaluation, and must record findings of abuse, neglect, or misappropriation of property against a name on it — a listing that effectively ends employment in long-term care nationwide.
Most states require more than 75 hours. Several require well over 100, and the range across the country is wide enough that an aide who is fully qualified in one state may need additional training in another. The federal floor applies to nursing homes; a hospital hiring an assistant for a medical-surgical floor is not bound by it, which is why some hospital assistants have completed a certification programme and others were trained on the job.
Why the title varies
The credential goes by different names in different places. Certified nursing assistant is the most common; Ohio uses state-tested nursing assistant, and other states use certified nurse aide, nurse aide, or registered nurse aide. Hospitals add their own job titles on top — patient care technician, patient care assistant, nursing technician, monitor technician — which may or may not require the state credential and often bundle in extra skills such as phlebotomy, electrocardiogram leads, or point-of-care glucose testing.
There is no national certification and no reciprocity in the sense the nurse licensure compact provides for nurses. Moving states means dealing with that state's registry, and whether a transfer is straightforward depends on where you trained.
Pay and where the jobs are
The median wage for nursing assistants was about $42,260 a year in 2025; orderlies, a smaller and separately counted group who do mostly transport and heavy lifting, had a median near $38,290. Roughly 36 percent of nursing assistants work in nursing care facilities, 32 percent in hospitals, and 11 percent in continuing care retirement communities.
Projected growth through 2035 is about 3 percent, which is unremarkable. The number that matters more is openings: around 203,300 a year, the overwhelming majority of them replacements for people who leave. That figure is the shape of the tier's central problem. Long-term care has among the highest turnover of any healthcare setting, and low pay, heavy assignments, injury rates, and limited advancement all contribute. See nurse turnover and retention.
Federal minimum staffing rules for nursing homes have treated the assistant tier as a distinct staffing category rather than folding it into total nursing hours, which is a recognition that the work is not interchangeable with licensed nursing time. See nursing home staffing requirements.
As a route into nursing
A large share of practical and registered nurses started here, and the pathway is deliberate for many of them. Assistant work is the cheapest and fastest way to find out whether bedside care suits you, it satisfies the healthcare experience some nursing programmes prefer, and it pays while you study. Some employers fund tuition for assistants entering a practical or registered nursing programme, which is one of the few retention tools in long-term care that demonstrably works.
The reverse move also exists. Nursing students frequently work as assistants during school, in roles sometimes titled nurse extern or student nurse technician, where the employer may permit a slightly wider task list based on completed coursework.
Related
- Levels of nursing
- Licensed practical and vocational nurses
- Scope of practice
- Nursing home staffing requirements
- Nurse turnover and retention
Sources
- Occupational Outlook Handbook: Nursing Assistants and Orderlies — U.S. Bureau of Labor Statistics, 2025 data. Accessed September 9, 2026.
- 42 CFR 483.152: Requirements for approval of a nurse aide training and competency evaluation program — Electronic Code of Federal Regulations. Accessed September 9, 2026.
- 42 CFR 483.151: State review and approval of nurse aide training and competency evaluation programs — Electronic Code of Federal Regulations, including the nurse aide registry requirement. Accessed September 9, 2026.
- National Guidelines for Nursing Delegation — National Council of State Boards of Nursing and American Nurses Association, 2019. Accessed September 9, 2026.