Certified Nursing Assistants Research Articles

An Evaluation of Virginia Gold: A Medicaid Program to Improve Nursing Facility Quality of Care

A qualitative case study design employing focus groups was used to evaluate certified nursing assistant (CNA) (n = 26) and resident (n = 30) perceptions of the Virginia Gold Quality Improvement Program, a Medicaid funded 2-year quality improvement intervention piloted in five nursing facilities. As part of the program, the nursing facilities implemented quality improvement projects to develop supportive work environments in an effort to reduce CNA turnover and improve quality of care. Overall, the focus group participants viewed Virginia Gold positively and reported that CNA turnover decreased, while care quality improved during the program. These findings are supported by a previous Virginia Gold evaluation as well as by the results from a quantitative analysis of nursing facility CNA turnover and quality of care data and interviews with selected nursing facility management staff (n = 7) 1-year following the program’s culmination. A key finding from the management interviews is that the quality improvement projects became self-sustaining over time allowing all five nursing facilities to continue the projects without state funding.

Hospice in the Nursing Home: Perspectives of Front Line Nursing Home Staff

ObjectiveUse of hospice has been associated with improved outcomes for nursing home residents and attitudes of nursing home staff toward hospice influences hospice referral. The objective of this study is to describe attitudes of certified nursing assistants (CNAs), nurses, and social workers toward hospice care in nursing homes. Design, setting, and participantsWe conducted a survey of 1859 staff from 52 Indiana nursing homes. MeasurementsStudy data include responses to 6 scaled questions and 3 open-ended qualitative prompts. In addition, respondents who cared for a resident on hospice in the nursing home were asked how often hospice: (1) makes their job easier; (2) is responsive when a patient has symptoms or is actively dying; (3) makes care coordination smooth; (4) is needed; (5) taught them something; and (6) is appreciated by patients/families. Responses were dichotomized as always/often or sometimes/never. ResultsA total of 1229 surveys met criteria for inclusion. Of the respondents, 48% were CNAs, 49% were nurses, and 3% were social workers; 83% reported caring for a nursing home patient on hospice. The statement with the highest proportion of always/often rating was ‘patient/family appreciate added care’ (84%); the lowest was ‘hospice makes my job easier’ (54%). More social workers responded favorably regarding hospice responsiveness and coordination of care compared with CNAs (P = .03 and P = .05, respectively). ConclusionsA majority of staff responded favorably regarding hospice care in nursing homes. About one-third of nursing home staff rated coordination of care lower than other aspects, and many qualitative comments highlighted examples of when hospice was not responsive to patient needs, representing important opportunities for improvement.

Is Elderspeak Appropriate?: A Survey of Certified Nursing Assistants

Elderspeak is a form of patronizing speech that is sometimes used with older adults and can result in unintended negative consequences. Certified nursing assistants (CNAs) working in long-term care facilities may be particularly prone to using elderspeak because they frequently interact with vulnerable and frail older adults who require assistance with activities of daily living. The purpose of the current study was to assess contextual variables that may prompt the use of elderspeak by CNAs. One hundred thirty-four CNAs completed a 36-item questionnaire intended to determine their evaluations of the appropriateness of elderspeak in a variety of contexts. Results indicated that specific resident-related variables (e.g., age, cognitive impairment) and situational variables (e.g., the absence of others during a CNA-resident interaction) were associated with higher ratings of appropriateness of elderspeak. These findings may have implications for improving communication training for CNAs.

Educating certified nursing assistants educational offerings on the run and more.

Certified nursing assistants (CNAs) are important partners in the delivery of quality care to patients. Nurse educators are challenged with providing "just-in-time" education to CNAs within the constraints of a fast-paced clinical environment. This article will discuss a successful CNA training program and lessons learned for improving just-in-time education to assistive personnel.

A Randomized Controlled Trial for an Individualized Positive Psychosocial Intervention for the Affective and Behavioral Symptoms of Dementia in Nursing Home Residents

This randomized controlled study tested the effectiveness of individualized activities, led by certified nursing assistants (CNAs), to increase positive and reduce negative affect and behavior among nursing home residents with dementia. Nursing home residents with mild to advanced dementia (N = 180) were randomly assigned to usual care (UC, n = 93) or 1 of 2 experimental conditions. Residents in the attention control group (AC, N = 43) participated in standardized one-to-one activities with their CNAs. Individualized Positive Psychosocial Intervention (IPPI) participants (n = 44) received a CNA-led activity matched to their interests and ability. Outcomes were residents' positive and negative affect and verbal and nonverbal behavior. The IPPI and AC groups experienced similar benefits-more pleasure, alertness, engagement, positive touch, and positive verbal behavior-compared with UC. The AC group displayed more anger, uncooperativeness, and very negative verbal behavior than UC or IPPI. This study demonstrates the value of individualized activities for nursing home residents with dementia. In a stringent test, residents were happier and less angry during a customized intervention compared with a standardized intervention. Even brief individualized CNA-led activities bring pleasure to nursing home residents and constitute an effective strategy to enhance positive affect and engagement in persons with dementia.

Nursing Staffing and Quality of Life in Western New York Nursing Homes

This study investigated the relationship between nurse staffing and quality of life (QOL) in Western New York State nursing homes. This was a cross-sectional, correlational study. The independent variables were hours per resident day (HPRD), skill mix, and turnover rate of nursing staff. The outcomes were measured using the self-reported QOL instrument. No coefficients were statistically significant with registered nurses' (RNs) HPRD. Certified nursing assistant (CNA) HPRD had a statistically significant positive impact on the spiritual well-being domain. There was a statistically negative relationship between the amount of licensed practical nurse (LPN) HPRD and food enjoyment; and the ratio of more RNs to fewer LPNs and CNAs had a statistically significant negative influence on the meaningful-activity, food-enjoyment, and security domains. The turnover of RNs had a statistically negative relationship with the sum of each domain. None of the coefficients was statistically significant with LPN turnover.

We Work Together, But Are We a Team?

We Work Together, But Are We a Team?

Absenteeism in Health Care: Using Interlocking Behavioral Contingency Feedback to Increase Attendance With Certified Nursing Assistants

This research used an ABA multiple baseline design across hospitals to evaluate a behavioral intervention designed to reduce absenteeism among 64 certified nursing assistants (CNA) in a rural health care organization. Pre-baseline assessments suggested that when CNAs were absent from work, other employees had to work unscheduled shifts. Because of this metacontingency, employees reported that they skipped work themselves to make up for the extra shifts they had to cover. This cycle created more unscheduled shifts and potentially caused the high absenteeism prevalent at the organization. An intervention with normative and metacontingency feedback significantly decreased the total number of days CNAs were absent per week across the three hospitals from a baseline mean of 0.24 (SD = 0.19) days per week (7.74% of their scheduled hours) to a mean of 0.13 (SD = 0.17) days per week (3.81% of their scheduled hours) during the intervention. In a return to baseline the total number of days CNAs were absent per week across the three hospitals increased to a mean of 0.24 (SD = 0.20) days per week (7.47% of their scheduled hours).

Effects of an Advanced Nursing Job Satisfaction, Turnover Rate, Assistant Education Program on and Clinical Outcomes

Certified nursing assistants (CNAs) have become an integral part of the health care system, spend the most amount of time with residents, and yet have the least amount of training. Recent reports demonstrate that CNAs believe their salary is not commensurate with their workload, and turnover rates in this field have indicated low job satisfaction. In light of these issues, we developed an advanced training program for CNAs in our institution to determine whether investing in our employees would increase job satisfaction and therefore impact turnover rates and clinical outcomes. Although overall job satisfaction improved slightly during the study period, satisfaction with training offered was the only area significantly affected by the intervention; however, significant decreases in turnover rates were observed between the pre- and postintervention periods. Clinical indicators were slightly improved, and the number of resident urinary tract infections decreased significantly. Offering an advanced training program for CNAs may be an effective way to improve morale, turnover rates, and clinical outcomes.

Effect of a Person‐Centered Mouth Care Intervention on Care Processes and Outcomes in Three Nursing Homes

To develop and test a person-centered, evidence-based mouth care program in nursing homes. Pre-post assessment, with an 8-week intervention period and a pilot 6-month extension at one site. Three North Carolina nursing homes. Ninety-seven residents and six certified nursing assistants (CNAs). CNAs already working in the facilities were trained as dedicated mouth care aides. A psychologist and dental hygienist provided didactic and hands-on training in evidence-based mouth care products and techniques and in person-centered behavioral care. Primary outcome measures for natural teeth were the Plaque Index for Long-Term Care (PI-LTC) and Gingival Index for Long-Term Care(GI-LTC) and for dentures the Denture Plaque Index (DPI); a dentist unmasked to study design obtained measures. Secondary outcomes included quantity and quality of care provided. Outcome scores significantly improved (P < .001 for PI-LTC and GI-LTC; P = .04 for DPI). Coding of videotaped care episodes indicated that care was more thorough (P < .001-P = .03) but took more time (P < .001) after training. Consistency of care appeared to be more important for natural teeth than dentures. As little as 8 weeks of mouth care can significantly improve oral hygiene outcomes. Given the consequences of poor oral hygiene, greater attention to mouth care education and provision are merited. The dedicated worker model is controversial, and future work should assess whether other models of care are equally beneficial.

Obesity and Pressure Ulcers Among Nursing Home Residents

To examine the prevalence of obesity and its relationship with pressure ulcers among nursing home (NH) populations, and whether such relationship varies with certified nursing assistant (CNA) level in NHs. DATA AND STUDY POPULATION: The 1999-2009 nationwide Minimum Data Sets were linked with Online Survey of Certification and Reporting records. We identified newly admitted NH residents who became long-stayers and followed them up to 1 year. The outcome variable was presence of pressure ulcers during the 1-year follow-up period. Residents were categorized as normal [18.5 ≤ body mass index (BMI)<30 kg/m2], mild obesity (30 ≤ BMI <35 kg/m2), and moderate or severe obesity (BMI ≥ 35 kg/m2). Pooled and stratified analyses were performed to examine the relationship between obesity and pressure ulcers, and how it varied by facility CNA level. The prevalence of obesity increased from 16.9% to 25.8% among newly admitted NH residents over the last decade. Obesity was associated with higher risks of pressure ulcers among long-stay residents. The relationship between obesity and pressure ulcers persisted after accounting for individual health conditions at the baseline and facility-level variations. Further, the within-facility relationship between obesity and pressure ulcers varied by facility CNA levels. The odds of pressure ulcers were 18.9% higher for residents with moderate or severe obesity than for nonobese residents within NHs with low CNA levels. The percents for medium and high CNA level facilities were 14.0% and 12.8%, respectively. To prepare for the growing obesity epidemic in NHs, policies should focus on strategies to improve care provided for obese residents.

Relationship between nursing staffing and quality of life in nursing homes

Purpose: To investigate the relationship between nurse staffing and quality of life in nursing homes. Methods: This is a descriptive, correlational study. The independent variables were nursing staffing hours per resident day (HPRD), skill mix HPRD, and turnover rate of nursing staff. The data for the dependent variables were collected using the quality of life (QOL) section of minimum data set (MDS) version 3.0. Hierarchical linear models were used for data analysis. Results: Few staffing variables were statistically associated with residents’ QOL. More RN HPRD were associated with better comfort and enjoyment domains, more licensed practical nurses (LPN) HPRD were associated with better dignity, and more certified nurse assistant (CNA) HPRD were associated with better functional competence domains. In terms of skill mix, the unique contribution of more RNs (to less LPN or CNAs) was supported in the functional competence of residents. However, surprising results were that: (a) as the HPRD of RNs increased, the scores of meaningful activity and relationship decreased; and (b) the contribution of LPNs (more LPNs to less RNs) were supported in the autonomy and spiritual well-being domains. Interestingly, nursing staff turnover is positively correlated with some domains of QOL: (a) a higher score in the enjoyment domain with increased RN turnover; and (b) a higher score in privacy, relationship, and individuality domains with increased turnover of LPNs. Conclusion: This is a preliminary study to investigate the relationship between nursing staffing and QOL for nursing home residents. Further examination is needed to confirm the relationship and provide policy guidelines, including nurse staffing recommendations.

Case studies of IT sophistication in nursing homes: A mixed method approach to examine communication strategies about pressure ulcer prevention practices

Most nursing homes lack information technology (IT) for supporting clinical work in spite of its potential to improve the safety, quality, and efficiency of nursing home care in the United States. Increased attention to medical error and concern for patient safety have prompted general recommendations to develop sophisticated technologies to support clinical decision making at the point of care, to promote data standards in electronic records, and to develop systems that communicate with each other. However, little is known about what IT applications best support communication and risk assessment practices to improve resident outcomes in nursing homes. Thus, the overall aim of this study was to evaluate how differences in IT sophistication in nursing homes impact communication and use of technology related to skin care and pressure ulcers. We used a mixed method approach to conduct case studies on two nursing homes – one with high IT sophistication and one with low IT sophistication. Observational analysis and social network analysis were used to identify patterns in communication types and locations; also, focus groups were conducted to explore communication strategies used by Certified Nursing Assistants (CNAs) to support pressure ulcer prevention practices. Overall, results from social network analysis of observational data indicate that direct interactions between CNAs and registered nurses (RNs) or licensed practical nurses (LPNs) were more frequent in the low IT sophistication home and occurred in more centralized locations (e.g. the nursing station) compared to the high IT sophistication home. Moreover, these findings are supported by focus group results, which indicate that the high IT sophistication home had more robust and integrated communication strategies (both IT and non IT) that may allow for interactions throughout the facility and require less frequent face to face interactions between CNAs and RNs or LPNs to verify orders or report patient status. Results from this study provide insight into the design and assessment of different forms of communication to support clinical work in NHs. Relevance to industryNurses bear great burdens for nursing home care; yet, issues persist with poor quality, variable performance of caregiving, and lack of implementation of proven care interventions. One new hope for improvement in nursing home care is the introduction of IT to improve communication, clinical decision-making, and quality of care.

State Regulatory Oversight of Certified Nursing Assistants and Resident Outcomes

This study aimed to describe state regulatory certified nursing assistant (CNA) oversight in two domains—use of registry or licensing for credentialing and initial CNA training and continuing education (CE) requirements—and to evaluate whether CNA oversight is associated with resident outcomes in nursing homes.This cross-sectional secondary analysis combined 2004 data on state-level regulatory requirements for CNA oversight, training, and CE with nursing home resident outcomes data collected in 2004 from 16,125 U.S. facilities in 49 states. Though 26 states required CNAs to have more initial training hours than the federal requirement of 75 hours, only four states required additional yearly CE hours to maintain CNA certification. The combination of increased initial training and annual CE hours was significantly associated with nursing homes reporting lower antidepressant and antipsychotic use and lower average medication use. Use of a registry or licensing board for credentialing was significantly related to lower catheter use, and CNA licensure was significantly associated with lower odds of falls. Findings suggest that regulatory modifications could be beneficial to improve resident care outcomes in nursing homes.

Nursing Assistants’ Dilemma: Caregiver Versus Caretaker

Focus groups were conducted with over 150 certified nursing assistants (CNAs) in seven nursing homes to obtain their opinions on how the work environment supported or impeded their caregiving to residents. Strong opinions emerged about work environment interference with CNAs’ ability to provide quality and comprehensive care. Participants also believed that their supervisors did not respect the value of the care and nurturing that CNAs provided. This contrasted with the respect that CNAs voiced for residents. The findings highlight the need for improved relationships between CNAs and management and suggest some desirable features of work organization in nursing homes.

Training of Home Health Aides and Nurse Aides: Findings From National Data

Training and satisfaction with training were examined using data from nationally representative samples of 2,897 certified nursing assistants (CNAs) from the National Nursing Assistant Survey and 3,377 home health aides (HHAs) from the National Home Health Aide Survey conducted in 2004 and 2007, respectively. This article focuses on the commonalities and differences in the perceptions of CNAs and HHAs regarding the initial and continuing education they received to prepare them for their job. More than 80% of HHAs and all CNAs received some initial training. Of these, significantly more HHAs compared to CNAs felt that training had prepared them “very well” for their jobs. The two groups also differed in their assessments of the content of the initial training; for example, more CNAs believed that their training was “excellent” in helping them address patients' limitations in activities of daily living compared to HHAs. The vast majority of HHAs and CNAs received continuing education, and about three fourths in each group assessed this training as being “very useful.” In light of the increasing demands for HHAs and CNAs with the aging of America, findings from these national studies could be used to inform educational and training initiatives for this critical workforce.

Certified Nursing Assistants' Perspectives of Nursing Home Residents' Pain Experience: Communication Patterns, Cultural Context, and the Role of Empathy

This study explored the following issues related to pain management among nursing home (NH) residents: 1) communication patterns between NH residents and certified nursing assistants (CNAs) about pain; 2) how race and ethnicity influence NH residents' pain experiences; and 3) CNAs' personal experiences with pain that may affect their empathy toward the resident's pain experience. The study consisted of a convenience sample of four focus groups (n = 28) from a NH in central Florida. A content analysis approach was used. Data were analyzed with the use of Atlas.ti version 6.2. The content analysis identified four main themes: 1) attitudes as barriers to communication about resident pain care; 2) cultural, religious, and gender influences of resident pain care by CNAs; 3) the role of empathy in CNAs care of residents with pain; and 4) worker strategies to detect pain. Attitudes among CNAs about resident cognitive status and perceived resident burden need to be recognized as barriers to the detection and reporting of pain by CNAs and should be addressed. In addition, NHs should consider a person-centered approach to pain that is culturally competent given the cultural influences of both residents and staff. Finally, educational programs for CNAs that include empathy-inducing scenarios could potentially improve the care provided by CNAs when dealing with residents' pain.

The first year: employment patterns and job perceptions of nursing assistants in a rural setting

The aim of this study was to follow rural certified nursing assistants (CNAs) (n=123) in the United States for 1 year post-training to identify retention and turnover issues in the long-term care (LTC) setting by exploring the CNAs' perceptions of the LTC work experience. Turnover among CNAs impacts the quality of care, imposes a financial burden on facilities and taxpayers, and creates increased stress and workloads on those who remain. A longitudinal survey design was used to track individuals completing CNA training for 1 year. At 1 year post-training, 53.7% of respondents currently worked in LTC, 30.9% worked in LTC and left, and the remaining 15.4% never worked in LTC. While the training site does not appear to impact retention, the first 6 months of employment appear critical. The CNAs cited pay as a reason for leaving LTC, but better pay did not characterize the jobs taken by the CNAs who left. Implications for nursing management. This study highlights the importance of the first 6 months of employment to retention and provides practical information for nurse managers evaluating the resource-effectiveness of hosting training programmes. Additionally, the key issues influencing retention were identified and practical suggestions for nurse managers to improve retention are provided.

Falls in Newly Admitted Nursing Home Residents: A National Study

To examine the relationship between nursing home (NH) organizational characteristics and falls in newly admitted NH residents. Observational cross-sectional study from January 1, 2006, to December 31, 2006. NHs in the United States in 2006. Individuals (n = 230,730) admitted to a NH in 2006 without a prior NH stay and with a follow-up Minimum Data Set (MDS) assessment completed 30 days or more after admission. The relationship between experiencing a fall noted on the MDS assessment and NH characteristics (e.g., staffing, profit and chain status, religious affiliation, hospital-based facility status, number of beds, presence of a special care unit, funding) was examined, adjusting for NH resident characteristics. Twenty-one percent of this cohort (n = 47,750) had experienced at least one fall in the NH at the time of the MDS assessment, which was completed for newly admitted NH residents who had at least a 30-day stay. NHs with higher certified nursing assistant (CNA) staffing had lower rates of falls (adjusted odds ratio = 0.97, 95% confidence interval = 0.95-0.99). For newly admitted NH residents, NHs with higher CNA staffing had a lower fall rate. In an effort to maximize fall prevention efforts, further research is needed to understand the relationship between CNA staffing and falls in this NH population.

The Correlates of Nursing Staff Turnover in Home and Hospice Agencies

Using data from the 2007 National Home and Hospice Care Survey, this study provides an update of nursing staff turnover at U.S. home health and hospice agencies and explores correlates of nursing staff turnover. Results show that the three-month turnover rates of registered nurses (RNs), licensed practice nurses (LPNs), home health aides (HHAs), and certified nursing assistants (CNAs) in 2007 were 10.2%, 14.3%, 12.5%, and 12.9%, respectively. A higher nurse staffing level reduced the odds of RN and HHA turnover; the availability of communication aids reduced the odds of LPN turnover. Moreover, among benefit programs, the provision of partial insurance for family reduced the odds of HHA turnover; dental or vision health insurance reduced the odds of RN turnover; mileage reimbursement or agency car reduced the odds of LPN turnover. The provision of a 401k plan and a paid-time-off program increased the odds of RN turnover. The study results suggest that high staffing levels and benefit programs (e.g., health insurance) may reduce the odds of experiencing nursing staff turnover. Initiatives to minimize nursing staff turnover should consider these factors.