A community focus on CNA performance.

What do CNAs need and want? These researchers convened a community forum to find out

In recent years, increasing attention has been paid to the key role of the Certified Nurse Aide (CNA) within nursing homes. CNAs provide the vast majority of the intimate, personal care for residents,[1] and comprise 71% of the full-time nursing staff in our nation's nursing homes.[2] Thus, the quality of CNA care directly affects the daily well-being of most nursing home residents. Despite this key role, CNAs are often excluded from patient care planning as well as the development of working procedures and policies.

A major difficulty with the CNA role is the extraordinarily high rate of staff turnover.[3] This attrition could be related to CNAs' lack of training, the absence of a career ladder, relatively low pay, high stress and poor morale. Moreover, CNAs are often uneducated, entry level workers[4] who are nevertheless faced with the challenge of setting a high standard of interpersonal interaction and professional conduct. These concerns are frequently recognized and voiced by researchers, management, physicians and nurses involved in long-term care. Seldom are CNAs themselves asked to engage in a serious problem-solving discussion around these issues.

The nursing home industry recognizes that the challenges attendant to the CNA role are larger than any one facility can solve. Community level interventions that draw a broad set of constituents into a problem-solving effort might be a promising approach to address this pressing issue. Indeed, communities are recognized to have "standards of care" by which quality of care in one facility can be judged, but rarely do communities come together to cooperate in trying to raise standards. We implemented a project to engage our community in a public discussion of strategies for improving CNA roles with the goal of raising the standard of care in nursing care facilities. Specifically, the long-term care community of Colorado Springs was invited to address quality of care provided by CNAs in a collaborative half-day, community-wide CNA Forum.

The background impetus for the Forum was a local research project examining mental health needs in nursing homes. The report from that project recommended focusing community efforts on improving the quality of CNA skill and performance.[5] The project involved a substantial number of key informants from the local nursing home industry, thus laying a foundation for community involvement in the problem of quality of care. Based on recommendations resulting from the research effort, a planning team consisting of various community leaders involved in geriatric services was brought together to create a format in which CNAs could brainstorm, prioritize interventions, and share their concerns and ideas with long-term care community leaders. The goal was to generate solid, workable action plans from CNAs that could receive the consensual commitment of all local nursing home facilities. Each facility would then be asked to implement the action plans, and to report back progress to the Forum in one month.

One CNA per shift from each of the 20 local nursing care facilities in Colorado Springs was invited to participate. In addition, healthcare leaders in the community (e.g., all medical directors of nursing homes) and all administrators and directors of nursing (DONs) from local facilities were invited to join in the second half of the meeting to hear the ideas generated by the CNAs and participate in the goal setting. A total of 69 persons attended. Twenty-six CNAs participated, representing 14 (70%) of the local facilities and one from another county. In addition, 40 administrators, DONs, and other professionals participated. Representatives from the county and state departments of health also participated as observers (and supporters) of the process.

The half-day Forum began with four one-hour brainstorming sessions, which included 6 to 8 CNAs and 1 local professional who served as the facilitator. Facilitators were chosen for their knowledge of nursing homes, their facilitation skills, and lack of personnel power over the CNAs (e.g., the manager of the geriatric program at the local mental health center, nursing home ombudsman, a senior social services agency director). CNAs were assigned to the brainstorming sessions to ensure that they did not cluster with colleagues from their own facility.

Following a brief break during which the nursing home administrators, DONs and other professionals joined the Forum, a CNA representative from each group presented the ideas generated by their group to the larger audience. Each idea was listed on an overhead projector screen. When all ideas had been presented, the entire audience reviewed the list.

The full set of participants were then divided into consensus-building groups with a mixture of CNAs and other levels of staff. Participants were encouraged to join groups that did not contain their own co-workers, but no external facilitator was assigned. The groups were given the task of identifying high-priority action plans that, if implemented by facilities, could improve the quality of care given by CNAs in the local community. After 40 minutes of deliberation, the groups reconvened to share their discussions.

There was considerable overlap in the priorities set by the groups, so the Forum participants were able to identify four primary goals within a few minutes. Further, specific action plans were agreed upon for each goal. Before leaving the CNA Forum, CNAs were asked to complete a brief, three-item rating scale indicating their reaction to the activities of the Forum.

Table 1. CNA ratings of their perceptions of forum (n = 26).

Item                                                        Response

1. How well did the focus-group setting                        62
give you a chance to express your real
opinions here today?

(1 = felt very unsafe, 6 = felt very safe)

2. How well did you feel that the                              35
Implementation Group participants
understood you and other CNAs today?

(1 = not at all, 6 = very much)

3. How confident are you that something                        58
useful might come from the meeting this
morning?

(1 = not at all confident, 6 = very confident)

[TABULAR DATA FOR TABLE 2 OMITTED]

A few days later, the organizers sent a letter to each local facility, whether it participated in the Forum or not, describing its process and outcome. Each administrator was encouraged to join in the community effort to improve CNA performance and quality of care by implementing the action plans related to the four goals. Also, a list of the ideas brainstormed by the CNAs was distributed to the administrators to use in any way they preferred.

One month after the Forum, a follow-up meeting was held. All Forum participants, as well as representatives from nonparticipating facilities, were invited. The results of the Forum were discussed and participants shared their successes and the challenges they faced implementing the action plans. Following that meeting, a letter was sent to each administrator asking him or her to complete a form indicating whether each action plan had been implemented prior to, or as a result of, the CNA Forum. Facilities that did not respond to the letter were contacted by telephone and encouraged to reply.

The CNA ratings that described their perceptions of the CNA Forum are listed in table 1, along with response formats. The questions asked of administrators at all facilities at one-month follow-up are included in table 2.

CNA ratings of their perceptions of the Forum showed high levels of perceived safety and understanding, and moderate confidence that actions would be implemented. A wide range of suggestions was generated during the brainstorming sessions. Suggestions endorsed by more than one group covered such topics as nursing home organizational structures, personnel management strategies (e.g., handling poor employee performance immediately), needed levels of training, career ladders for CNAs, incentives for providing exceptionally high levels of care, support for personal concerns of CNAs (e.g., day care, counseling) and implementing standards of care. Much of the discussion focused on strategies for stabilizing the work-force of CNAs.

Relatively little discussion focused on specific bed-and-body care principles, focusing instead on policy and organizational approaches to improving quality of care. Despite the administrators' initial concerns that the CNAs would focus only on improving the wage structure, the CNAs devoted little time to that issue, although all participants agreed it was critical. The CNAs readily identified other workable strategies for improving quality of care.

The Forum produced four goals with action plans for each (table 3). Two of the goals focused on improving the career structure for CNAs: establishing advancement criteria and developing recognition plans for excellent performance. Each was an effort to focus attention on persons doing well, in order to encourage retention of dedicated, competent employees and to set standards. The third goal encouraged increased communication regarding policies that affected their work, specifically, how staffing patterns were determined. This goal was deemed important because staff morale was reportedly affected by the perception that they were being exploited by understaffing. The fourth goal addressed support for the often stressful personal lives of the CNAs by exploring the feasibility of developing on-site day care centers.

At one-month follow-up, 16 facilities responded to the follow-up questionnaire, including all but one of the facilities that participated in the Forum and two nonparticipants. Respondents included administrators, DONs, and staff development coordinators. As per table 2, one-month follow-up data showed that, as a direct consequence of the Forum, the median implementation rate of eight action plans by facilities was 22%, with a range of 6 to 38%. Obviously, many of these were not new ideas; indeed, between 13 and 75% of facilities had worked on these action plans prior to the Forum, especially the development of a reward plan for CNA performance and explanation of staff-to-patient ratios (table 2). The most frequently implemented action item was meeting with the staff to discuss staff scheduling, for which 38% of the facilities established meetings as a result of the Forum (50% had meetings prior to the Forum). Frequency data from 11 of those facilities showed that an average of 4 staff meetings had been held in the previous month (range 1-16). The action items that were least frequently implemented as a consequence of the Forum were creating a draft of criteria for CNA advancement (19%) and distributing the draft for CNA feedback (6%).

Discussion

Our findings show that an interactive, community-wide CNA Forum devoted to engaging CNAs in improving performance in nursing homes resulted in a meaningful experience with positive outcomes. We found that CNAs were able to participate productively in the Forum, generating many useful ideas for improving work conditions and quality of care for their patients, and that many local facilities were able to make some positive changes based on the ideas generated by Forum participants. The CNAs reported feeling very safe to express their true feelings and opinions during the focus groups, and they strongly believed that administration understood their points clearly. CNAs also reported feeling moderately confident that actions would be implemented as a consequence of their participation.

These positive perceptions were likely a result of several factors: the nonjudgmental attitude displayed by group facilitators, the active participation of most local facilities and the presence and support of community leaders. Perhaps most important was the obvious shared goal between CNAs and administrators to improve work conditions and the quality of patient care. It became apparent that participating CNAs were concerned caregivers, dedicated to improving patient care and taking steps to address the turnover problem.

CNAs and administrative staff reached consensus on four priority goals. It is apparent from the first goal (development of advancement criteria) that many CNAs strive to perform their duties well and want to be rewarded for outstanding performance. CNAs noted that a career ladder that gives credit for experience, education and competence would keep committed CNAs in the industry. In fact, several CNAs expressed frustration that facilities retain incompetent employees who often earn a similar wage to that of employees with a long history of excellent performance. Some called for stricter hiring standards, a longer training period during which a new CNA would be paired with an experienced CNA, and classification of "beginner" and "advanced" CNA status based on experience and education. Many CNAs desired opportunities for enhanced training to strengthen existing skills and learn new ones to provide better patient care. CNAs strongly endorsed the idea of company-supported education so interested employees could advance to LPN or RN status.

The second goal (development of a recognition plan) arose out of a strong desire of CNAs to be recognized and praised by administration for their work. It should be noted that CNAs typically do most of the unpalatable work in facilities, and they expressed a desire to be praised for their successful performances. CNAs identified many nonmonetary rewards, which would make them feel more appreciated and promote continued high-quality care. Even simple behaviors such as being told "thank you" or "keep up the good job" by an administrator were highly valued by CNAs.

Goal three (inform staff about staffing patterns) reflected CNAs' stated desire to have more open lines of communication with administration. Many CNAs wanted to periodically meet with administrators to discuss staffing patterns so improvements could be made, and called for formalized staffing patterns to be publicized. Interestingly, many CNAs acknowledged their ignorance of constraints on administrators during "understaffed" periods, and believed that if the CNAs were informed about those constraints, they would not build up resentment.

The fourth goal (explore day-care options) reflected the participants' view that a leading cause of absenteeism was unaffordable and inadequate childcare that necessitated the employee to stay home with a sick child. Administration also recognized this challenging situation, and efforts to explore options were reported by several facilities.

Overall, data from one-month follow-up indicated that, as a direct consequence of the Forum, most recommendations had been implemented by at least several facilities, with a median implementation rate of 22% (range 6 to 38%). These results suggest that facilities want to improve patient care and can successfully implement meaningful suggestions from CNAs. The most frequently implemented plans, as a consequence of the Forum, were meetings to discuss staff scheduling patterns and development of a formal plan to reward CNA performance. Not surprisingly, a relatively low level of implementation was noted for the exploration of daycare, although sensitivity to this problem could produce more positive effects in the future.

Clearly, there is a need for more in-depth research on mechanisms for strengthening the industry's support for the CNA role. Future studies might evaluate the immediate and long-term effects of interventions on concrete outcomes such as CNA morale, job satisfaction and improved patient care. The community CNA Forum was an effective strategy to promote open interaction and problem solving between CNAs and administration. We think this process can be replicated and enhanced in other communities, and can help them discover common concerns and solutions.

Table 3. Goals and Action Plans from the Community Forum

Goal #1: Create advancement criteria for CNAs that takes into account years of experience and some system for rewarding merit/performance excellence.

Action Steps:

* Draft a version of the advancement criteria using CNA input.

* Distribute to staff for feedback.

* Make first contact with administrative structure above you informing them of this effort.

Goal #2: Create a way to recognize the important roles played by CNAs in your facility.

Action Steps:

* Help the CNAs in your facility develop a recognition plan that can be implemented with little or no money.

Goal #3: Inform staff of the facility's policy regarding staff:resident ratios and engage staff in discussions of which staffing patterns work well and which may need attention.

Action Steps:

* Distribute to CNAs the official staff:resident ratios.

* Administrators meet with CNAs twice this month to discuss in-house scheduling patterns.

Goal #4: Examine the feasibility of a community-wide day care center for nursing home staff that could operate on a 24 hour basis.

Action Step:

* Collect data from each facility about the need for such a facility (e.g., staff interest, sick days for child care related concerns).

References

1. Smyer MA, Cohn MD, Brannon D. Mental health consultation in nursing homes. New York: New York University Press, 1988.

2. Sheridan JE, White J, Fairchild TJ. Ineffective staff, ineffective supervision, or ineffective administration? Why some nursing homes fail to provide adequate care. The Gerontologist, 1992;32:334-41.

3. Waxman HM, Carner EA, Berkenstock G. Job turnover and job satisfaction among nursing home aides. The Gerontologist, 1984;24:503-9.

4. Novak M, Chappell NL. Nursing assistant burnout and the cognitively impaired. International Journal of Aging and Human Development, 1994;39:105-20.

5. Qualls SH. Mental health in nursing homes: Needs, challenges, and directions (Executive Summary of Technical Report). Colorado Springs, CO: University of Colorado at Colorado Springs, 1994.

Daniel L. Segal, PhD, and Sara Honn Quaffs, PhD, are with the Department of Psychology, the University of Colorado at Silver Springs. Fred M. Feinsod, MD, MPH, CMD, is with Pinon Management and the University of Colorado Health Sciences Center, Division of Geriatric Medicine.