Certified Nursing Assistants Research Articles

Learning transfer and transition of certified nursing assistants' to baccalaureate nursing programs.

Certified nursing assistants (CNAs) provide vital care to patients in a variety of care settings, yet little is known about their transition and transfer of learning to baccalaureate nursing education. Faculty play a key role in helping them successfully progress through their educational journey. Using a qualitative descriptive design, semi-structured interviews of eight CNAs enrolled in U.S. schools in the south-central region of Pennsylvania were conducted. Data were analyzed using content and thematic analysis. The influence of prior health care experience afforded participants confidence in their transition to BSN education, as well as accelerated learning. Three themes emerged from participant data related to transfer of learning: jumping in and demonstrating confidence from the beginning, learning from a foundation to transform my thinking from tasks to process, and merging new learning into practice. Results support that even if CNAs face varying challenges entering nursing education, most possess some clinical reasoning and critical thinking skills, as well as experience working with patients and within teams. All of which can influence the learning experience. Findings can help faculty identify CNAs' strengths, which may facilitate learning transfer, foster leadership potential, and engage them in peer teaching and mentoring; ultimately positively influencing the transition to practice.

Management of patients with type 2 diabetes mellitus in the Grand-Aides Program

Objective: To evaluate the Grand-Aides Program for patients with type 2 diabetes mellitus (T2DM) according to the variables of body weight, blood pressure, medication adherence, and hospital consultation and readmissions.Methods: Patients ages 18 years or older with a past medical history of T2DM, hypertension (HTN), and/or obesity and who were recently seen in the emergency department (ED) or recently admitted to the hospital were eligible to enroll in the Grand-Aides Program. Eligible patients were identified after hospital or ED discharge and were asked to enroll in the in-home based program from March 2016 through June 2018. In-home visit protocol was defined prior to patient enrollment with intense in-home visits during the first weeks of enrollment followed by monthly visits for the duration of enrollment in the program. In-home visit frequency was adjusted on as needed basis so that patients at higher risk for ED visits or hospitalization were seen more frequently. In-home visits were performed by trained Grand-Aide who for the purpose of this study was a certified nursing assistant (CNA). The Grand-Aide underwent eighty hours of didactic training which included visit protocols, visit schedules, and data collection. The one-on-one in-home patient with every visit were supervised by a registered nurse (RN) or nurse practitioner (NP) via video or telephone contact near the conclusion of the visit. Active patients at the University of Virginia Family Medicine clinic were eligible for enrollment. Fifty-seven patients with T2DM worked with Grand-Aides for three months and an additional forty-eight T2DM patients worked with Grand-Aides for twelve months. Emergency department visits, all 30-day hospital readmissions, as well as blood pressure readings, medication adherence, weights, and glycated hemoglobin (HbA1c) were compared with the prior twelve months.Results: Systolic (p < .001) and diastolic (p < .01) blood pressures decreased (p < .01) at 1 year. At baseline 56 percent of the patients had a systolic blood pressure of >130 mmHg despite treatment; after 12 months, 48 percent of these were < 130. In those whose baseline diastolic blood pressure was > 90 mmHg, 100 percent had diastolic blood pressure < 90 mmHg at 1 year. Medication adherence by ARMS test at 1 year was 94 percent. Despite trending downward, weight and HbA1c did not change significantly. In the preceding, 58 percent had at least one ED visit, which was reduced by 50 percent (p < .01) with Grand-Aides; 30-day all-cause readmissions reduced by 50 percent to 6.3 percent. Conclusions: The Grand-Aides program was associated with a significant change in blood pressure control, high medication adherence and reductions in ED visits and readmissions that compare favorably with published comparative data. For systems “at risk” for preventable increased health care expense burden, the Grand-Aides program can result in significant savings.

CNA WORK IS BETTER LEARNED HANDS-ON: TRAINING CERTIFIED NURSING ASSISTANTS TO FEED RESIDENTS WITH DEMENTIA

In nursing homes across the United States, Certified Nursing Assistants (CNAs) provide essential mealtime assistance to residents with dementia who have difficulty feeding themselves. However, dementia-related training content in CNA programs can vary. In this qualitative study, we sought to understand the training provided to CNAs in Alabama, and to identify the ideal training modality for content related to feeding residents with dementia. Nine focus groups were conducted with 53 CNAs. Each participant had at least one year of working experience as a CNA caring for older adults. Focus groups were audio recorded and transcribed verbatim. Data were analyzed using the directed content analysis approach. Analyses revealed several key themes related to training CNAs to feed residents with dementia. Across focus groups, CNAs agreed that they needed additional training about feeding residents with dementia. They unanimously agreed that the best person to provide such training should be an experienced CNA, not a nurse or other healthcare provider. In terms of delivery, they preferred hands-on training and role playing. CNAs also emphasized that while some learning takes place in a didactic setting, the most valuable learning moments involve on-the-job experience in feeding residents, where they are mentored by seasoned CNAs. Findings from this study revealed the need for providing CNAs training on feeding residents with dementia. CNA training programs that includes hands-on activities mentored by seasoned CNAs could increase CNAs’ ability to provide optimal meal assistance to nursing home residents with dementia.

FOSTERING COMPASSIONATE CARE FOR PERSONS WITH ALZHEIMER’S DISEASE AND RELATED DEMENTIAS

The aim of this study was to examine the impact of the implementation of a new Compassionate Care (CC) curriculum, designed by social workers, on the quality of care provided by Certified Nursing Assistants (CNAs) to residents with Alzheimer’s disease (AD). Additionally, the purpose was to create a collaborative network of CNAs that supported each other. The sample included residents and CNAs from an experimental nursing facility and a control nursing facility. At baseline and 12-weeks, data were collected on AD knowledge, self-efficacy, caregiving satisfaction, and affiliate stigma. CNA changes in terms of their knowledge of AD, self-efficacy, caregiving satisfaction and affiliate stigma were analyzed using a two-way mixed method MANOVA. The stress levels of the residents, specifically agitation and salivary cortisol levels, was examined by testing a hybrid multilevel growth model. The final models were able to show how the changes in the CNAs specifically affected these positive outcomes. CNA knowledge and self-efficacy had the most impact on changing agitation levels, and CNA knowledge and agitation levels had the most impact on salivary cortisol levels. The results of this study showed that integrating a compassionate care curriculum into the work that CNAs perform can lead to positive outcomes on knowledge, self-efficacy, caregiving satisfaction, affiliate stigma and a reduction of agitation and cortisol levels in persons with AD.

ORGANIZATIONAL AND POLICY FACTORS INFLUENCING FEEDING IN RESIDENTS WITH DEMENTIA: NURSING ASSISTANTS’ EXPERIENCES

In the United States, Certified Nursing Assistants (CNAs) are critical in providing direct care to nursing home residents with dementia, which includes the challenging task of feeding residents. Guided by the Social Ecological Model (SEM), this qualitative study aimed to gain an in-depth understanding of organizational and policy constructs that CNAs encounter when feeding residents with dementia. Using purposive sampling, nine semi-structured focus groups were conducted with 53 CNAs. Each participant had at least one year of experience working as a CNA with older adults. Focus groups were audio recorded and transcribed verbatim. Data were analyzed using the directed content analysis. Factors that emerged were organized into organizational and policy categories within the SEM levels. CNAs identified organizational barriers such as exclusion from the interdisciplinary team, inability to meet resident needs and wants due to budgetary constraints, and inadequate staffing to function efficiently. Organizational facilitators included teamwork, interdisciplinary assistance, and varying dining styles and meal times to accommodate resident needs. Policy-related barriers included funding concerns, staffing ratios, and frustration with unrealistic regulations and state inspections. These results suggest that organizational and policy factors have a large influence on the ease of feeding nursing home residents with dementia. Involving CNAs in interdisciplinary collaboration, resident-centered accommodations, and subtler state inspection behaviors could improve the mealtime experience for both residents and CNAs. Careful attention to these factors may enhance facilitators and minimize barriers to improve the feeding experience of CNAs and residents with dementia.

NURSING ASSISTANTS’ OPINIONS ON CREATING THE PERFECT DINING EXPERIENCE FOR RESIDENTS WITH DEMENTIA

Feeding residents with dementia in long-term care settings can be challenging, partly related to environmental factors. Certified Nursing Assistants (CNAs) are primarily responsible for feeding residents with dementia who need assistance. Given that older adults with dementia have an increased risk of developing malnutrition, there is a need to develop standards in place for constructing an ideal dining environment to optimize residents’ dietary intake. This qualitative study was conducted to explore CNA’s perspectives of how dining areas could be enhanced to improve food intake of residents with dementia. Nine focus groups were conducted with a total of 53 CNAs who had at least one year of experience feeding residents. Focus groups were audio recorded and transcribed verbatim. Data were analyzed using directed content analysis guided by the Social Ecological Model. CNAs reported that distractions can significantly inhibit residents’ food intake; therefore, limiting distractions such as noise and crowding is important. CNAs also reported the benefit of playing music in the dining area depended on the individual resident. Additionally, CNAs emphasized the importance of offering a variety of appetizing menu choices tailored to residents’ preferences. CNAs have firsthand experience with residents with dementia and can provide valuable insights. Long-term care administration should consider interdisciplinary support to improve the mealtime experience of residents with dementia in an effort to enhance their dietary intake. In particular, providing a variety of menu choices in a well-lit, calm, spacious, and homelike dining environment can be beneficial.

ASSESSMENT OF PALLIATIVE CARE TRAINING NEEDS FOR CERTIFIED NURSING ASSISTANTS

It is unknown whether certified nursing assistants (CNAs) receive up-to-date palliative care training through continuing education. Also unclear is whether existing trainings cover the issues that CNAs encounter at work or are tailored to CNAs’ learning styles and preferences. This study aimed to assess the palliative care training needs of CNAs working at skilled nursing facilities (SNFs) in northern Illinois. CNAs (n=127) from 6 SNFs completed an online survey regarding palliative care training experience, perceived needs for palliative care training, and demographic and work-related information. The majority of the participants were female (88%) and White (58%) or African American (20%). On average, participants were 34 years old and worked for 8 years in the field. Four out of five preferred a training 90 minutes or shorter. Approximately one half preferred in-person training, and the rest preferred a hybrid (32%) or online delivery (19%). Discussions and videos were most preferred in training, while quizzes and mobile apps were least preferred. CNAs who worked longer in the field were less likely to have received training than their counterparts. The least-trained areas included utilizing advance directives and discussing death with patients. The most needed training areas were talking to a patient who wants to hasten death and addressing the complex needs of dying patients. The results indicate a relative deficiency of palliative care training among CNAs who have worked longer in the field. Training areas needing more attention include advance directives, discussing death with patients, and the complex needs of dying patients.

ONE-TWO PUNCH OF HIGH WAGES AND EMPOWERING PRACTICES FOR MAINTAINING CARE NETWORKS IN NURSING HOMES

Stabilizing certified nursing assistant (CNA) employment is necessary for maintaining care networks and providing high quality of care for nursing home (NH) residents. This study’s objective was to examine the relationship of high wages and empowerment practices on CNA retention. We used the 2015 Ohio Biennial Survey to construct a facility-level dataset of 547 NHs and estimated multivariable linear regressions. NHs that provided both high wages and high empowerment were associated with a 12.95 percentage-point improvement in the CNA retention rate (SE = 4.53, t-value = 2.86, p = 0.0045). High wages and a high empowerment score did not have significant effects individually (p > .05). Retention rates were similar between NHs that lacked high wages and scored low on the empowerment scale, and NHs that provided one at a high level but not the other. Implications for better retaining CNAs require multiple empowerment practices combined with high hourly wages.

ASSESSING APATHY IN LONG-TERM CARE RESIDENTS WITH DEMENTIA: COMPARING SELF-EVALUATION WITH PROXY RATINGS

Background: Apathy affects most individuals with dementia in long-term care. Apathy assessment is fundamental for appropriate treatment. Apathy involves subjective feelings thus individual’s self-evaluation may offer important perspectives for assessment. However, it is unclear whether self-evaluation is a valid assessment approach for this population. This study compared apathy ratings from resident self-evaluation to assessments from family, clinicians, and research staff. Methods: This pilot study enrolled 8 residents from two long-term care facilities in Pennsylvania. One family member, one certified nursing assistant (CNA), and one nurse or activity staff were also enrolled for each resident. Researchers interviewed each resident using the Apathy Evaluation Scale (AES) and rated their apathy levels. Family, CNAs, and nurses/activity staff independently rated the resident’s apathy level using the AES. Direct observations were conducted by researchers using the Person-Environment Apathy Rating (PEAR). Results: Correlation analysis revealed a discrepancy across raters in assessing apathy. While self-evaluation and family ratings where moderately positively correlated (r=0.48, p=.23), there was a moderate correlation in the opposite direction between self-evaluation and CNA ratings (r=-0.64, p=.09). Resident self-evaluation did not correlate with nurses/activity staff ratings (r=0.01, p=.99) or researcher observations (r=-0.08, p=.86). Discussion: These findings may reflect residents’ cognitive impairment and lack of insights, family and clinicians’ lack of understanding of apathy, or nurses’ and researchers’ lack of acquaintance with the resident. It remains undetermined whether self-evaluation provides valid information for apathy assessment for this population. Additional research is necessary to identify the most valid assessment approach for long-term care residents with dementia.

CHANGING NURSING HOME CULTURE: LONG-TERM CARE LEADERSHIP ACADEMY

Nursing homes that fostered open communication and teamwork were more likely to change their practices and adopt the “It’s Not OK to Fall” program. This pilot study evaluated the feasibility and acceptance of a team-building approach for developing leadership skills to three groups of coworkers: Administrators/Directors of Nursing, charge nurses, and certified nursing assistants (CNA) employed by nursing homes in Oklahoma. Each coworker group received one day of job specific leadership training, with another one half-day session where all levels engaged in team-building exercises. Participant satisfaction with course content ranged from agree-to-strongly agree. All stated that they could apply the leadership strategies at their facility. Administrators/Directors of Nursing found tools for tracking turnover/retention and strategies for improving staff communication helpful. Charge nurses and certified nursing assistants seldom viewed themselves as leaders, found coworker group communication very fragmented, and felt least knowledgeable about nursing home care best practices.

Positive Culture Change in Long-Term Care: A Procedure to Enhance Speech-Language Pathologist–Certified Nursing Assistant Collaboration

Background The majority of residents in long-term care (LTC) facilities have cognitive communication impairments impacting their ability to communicate basic wants and needs to caregivers, particularly certified nursing assistants (CNAs). Speech-language pathologists (SLPs) are the most qualified individuals to educate CNAs about residents' communication behaviors; however, there is limited literature that outlines specific, evidence-based procedures for CNAs and residents in the LTC environment. The purpose of this article is to describe such a procedure, including 2 case examples, within a framework of positive culture change. Method This clinical focus article aims to describe the details and benefits of providing professional support for CNAs during a communication plan intervention. Then, the article will discuss the association between professional support and positive culture change in LTC. Professional support involves valuing the experience and time CNAs spend with residents, consistently requesting feedback regarding trained communication strategies, educating, demonstrating, and problem-solving with CNAs, as well as acknowledging CNAs' use of communication strategies during daily care with residents. Conclusions SLPs can serve as trendsetters in establishing a positive, functional organizational culture in LTC by providing professional support to CNAs. This article outlined an evidence-based procedure designed for SLPs working in the LTC environment to contribute to such positive culture change.

Resident Preferences and CNA Empowerment: Testing Validity and Reliability of a Culture Change Survey Tool.

Culture change (CC) is an innovation to improve nursing home resident quality of life. Inconsistencies in how CC is measured make the interpretation of findings inconclusive. The purpose of this study is to determine the underlying factors of CC among Ohio nursing homes to extract the core essence of CC. Data from the 2015 Ohio Biennial Survey of Long-Term Care Facilities with n = 721 nursing homes answering a CC module comprising of 21 questions are included in an exploratory factor analysis (EFA). EFA results identified two underlying factors of CC that are extracted using principal factor method. These factors include items related to resident preferences for care (RPC) and certified nursing assistant (CNA) empowerment. This study presents two valid and reliable scales to advance the measurement of CC. These scales can be used to explore both RPC and CNA empowerment components as predictors or outcomes.

592. Assessment of Time Spent in the Room by Nurses and Nursing Assistants on a Pediatric Ward by Patient Isolation Status and Demographics

BackgroundPublished reports have raised concern that RNs spend less time in hospital rooms of patients requiring isolation precautions. Other patient-related factors including race/ethnicity, primary language, and socio-economic factors reportedly influence the mean time spent in the room by RNs and certified nursing assistants (CNAs). At a children’s hospital the automated hand hygiene monitoring system (AHHMS) has motion sensors that detect patient room entry and exit and sensors that detect hand hygiene events. Time spent in patient rooms by RNs and CNAs was examined using AHHMS data captured for patients on a 24-bed pediatric hospital ward for multiple patient characteristics to evaluate factors influencing the duration of visits.MethodsRNs and CNAs routinely wore badges with infrared signal technology to monitor hand hygiene compliance, generating time-stamped data for room entries and exits, identified by user job category. Over a 30 day period, April 2016, RN and CNA time in the room was compared by patient characteristics including: length of stay, white yes/no, Hispanic yes/no, interpreter needed yes/no, and isolation status of contact-droplet, contact, or none. Mean minutes spent in the room for RNs and CNAs were evaluated with a random-effects linear model and gamma distribution.ResultsAdmissions for 220 patients occurred in the 24 rooms during the evaluation period; 88 RNs and 28 CNAs completed 18,641 time-stamped room entries and exits. The natural log of patient length of stay (hours) was significantly associated with increased RN and CNA minutes spent in the room (P < 0.001). Interpreter required was not associated with time in the room (P = 0.72), nor was race (P = 0.60), nor was Hispanic ethnicity (P = 0.81). There were no significant differences in time spent in the room for contact, contact-droplet, and no isolation (P = 0.92).ConclusionData derived from infrared signal AHHMS badges can provide insight into RN and CNA care patterns. Isolation status and patient demographics were unrelated to mean RN and CNA time in the room. Patient length of stay was the only predictor of increased nursing time spent providing direct patient care. These results contrast with previous reports demonstrating fewer nursing interactions based on patient demographics or isolation.Disclosures All authors: No reported disclosures.

Certified nursing assistants as agents of creative caregiving in long-term care.

Certified nursing assistants (CNAs) provide most of the direct care for long-term care (LTC) residents, yet there are few CNA-led interventions aimed at improving quality of care. In our preliminary work developing a CNA art-based intervention, we describe CNA definitions and perceptions of creativity in relation to care of LTC residents. Data from six sequential focus groups with CNAs (n=14) in two LTC facilities were analysed to describe the concept of creativity in relation to LTC caregiving and its meaning to CNAs working in LTC. Certified nursing assistants defined creativity as formal art-making, yet they also described creative approaches to engaging residents in order to build relationships and reduce challenging behaviour. While most linked creativity with discerning and responding to resident needs, creativity was also foundational to time management, teamwork and navigating challenges. Developing CNA-centred interventions to promote creative caregiving may enhance both person-centred LTC and CNA empowerment, improving resident care. CNA creativity should be viewed as a skill with the potential to enhance care and increase CNA empowerment. Interventions should be developed, in partnership with CNAs, to promote creative caregiving.

PALTC Steps Up Strategies to Attract Nurses

PALTC Steps Up Strategies to Attract Nurses

Exploring social-based discrimination among nursing home certified nursing assistants.

Certified nursing assistants (CNAs) provide the majority of direct care to nursing home residents in the United States and, therefore, are keys to ensuring optimal health outcomes for this frail older adult population. These diverse direct care workers, however, are often not recognized for their important contributions to older adult care and are subjected to poor working conditions. It is probable that social-based discrimination lies at the core of poor treatment toward CNAs. This review uses perspectives from critical social theory to explore the phenomenon of social-based discrimination toward CNAs that may originate from social order, power, and culture. Understanding manifestations of social-based discrimination in nursing homes is critical to creating solutions for severe disparity problems among perceived lower-class workers and subsequently improving resident care delivery.

Barriers to ideal palliative care in multiple care settings: the nurses' point of view.

Nurses and certified nursing assistants (CNA) have a crucial role in 24/7 continuity of palliative care for many vulnerable patients and families, however, their perspective has been largely omitted in reported barriers to palliative care. To describe barriers to ideal palliative care that are specific to nurses and CNAs working in all care settings. A cross-sectional, online survey was distributed to members of the Dutch Nurses' Association. Almost 50% of the participating 2377 nurses and CNAs experienced more than five barriers to ideal palliative care in their work situation; nurses and CNAs employed in regional hospitals, mental healthcare and nursing home settings encountered more barriers than those working in other settings. The three most common barriers were: lack of proactive care planning, lack of internal consultation possibilities and lack of assessment of care recipients' preferences and needs for a seamless transition to another setting.

Intentional Rounding With Certified Nursing Assistants in Long-Term Care: A Pilot Project.

Intentional rounding (IR) is a strategy used by predominately acute care nursing staff to proactively address patients' needs at regular and consistent intervals. The current project piloted the use of IR with certified nursing assistants (CNAs) on a 60-bed unit of a 120-bed skilled nursing facility (SNF). Using a pre/post intervention design and the Plan-Do-Study-Act (PDSA) framework, the authors measured knowledge of IR's "4Ps" (potty, position, possessions, and pain) and the incidence of falls and lost possessions. Uptake of IR over 10 weeks of implementation and CNAs' perceptions of intervention were also assessed. The pilot showed positive outcomes for each of the five aims. Data suggest that IR was well received by CNAs and changed practice patterns regarding quality, safety, and satisfaction. Based on these findings, replication of this project in other SNFs is recommended, given the current small and underpowered study. [Journal of Gerontological Nursing, 45(6), 15-21.].

Certified Nursing Assistants Want to Use External Memory Aids for Residents With Dementia: Survey Results Within an Implementation Science Framework.

Purpose The purpose of this study was to assess the self-perceived knowledge and self-efficacy of certified nursing assistants (CNAs) when using external memory aids to enhance the communication and independence of residents with dementia living in skilled nursing facilities (SNFs). Method One hundred forty-four CNAs completed a measure pertaining to self-perceived knowledge and self-efficacy of external memory aids. Results CNAs had favorable beliefs about the usefulness of external memory aids to help both conversation and independence in activities of daily living for residents with dementia ( M = 4.0, SD = 0.84; M = 3.92, SD = 0.85) on a 5-point Likert scale, with 5 = strongly agree and 1 = strongly disagree. There were no statistically significant differences between CNAs who reported being trained to use external memory aids with residents with dementia and CNAs who reported they were not trained according to items related to self-efficacy ( U = 2203.5, z = -1.483, p = .138; U = 2179, z = -1.547, p = .122; U = 2115, z = -1.82, p = .069; U = 2320, z = -0.942, p = .346). Conclusions Results of this study indicated that the lack of uptake of external memory aids for residents with dementia in SNFs may not solely be due to lack of buy-in or lack of time on the part of the CNA. Speech-language pathologists should provide this training to support the uptake of external memory aids for residents with dementia; however, these data suggest that current training methods may not be considerate of the nuances of implementation. Speech-language pathologists and researchers should consider the finer aspects of theoretically grounded facilitation techniques as next steps to the broader implementation of this intervention for residents with dementia living in SNFs.

Improving Retention Among Certified Nursing Assistants Through Compassion Fatigue Awareness and Self-Care Skills Education.

Background: Retention of certified nursing assistants (CNAs) is an ongoing challenge for nursing homes. Purpose: To combat the effects of providing complex care needs to residents, this quality improvement project explored a 90-minute evidence-based education program on compassion fatigue awareness and multiple self-care skill strategies for CNA retention. Design: A single-group pre- and posttest design, mixed-methods approach. Method: A preintervention demographic survey, a postexperience survey, and the ProQOL (Professional Quality of Life; Version 5) tool measured the CNAs' level of compassion satisfaction, burnout, and secondary traumatic stress at three time points: preintervention, 1 month postintervention, and 3 months postintervention. Results: Forty-five CNAs participated. After 1 month, CNA retention increased by 43%, and at the end of the fourth month, the facility's retention rate was 100%. Forty-four percent of the full-time supplemental agency CNAs became full-time facility employees. The use of supplemental agency staff decreased to less than 5% of the total CNA hours worked. CNAs improved their compassion satisfaction, burnout, and secondary traumatic stress scores. Conclusion: This education program proved to be an effective, low-cost intervention. The quality improvement project highlighted the need for additional study on holistic interventions such as workplace education programs addressing compassion fatigue awareness and self-care skill strategies in this understudied group of formal caregivers.