Nursing Assistant Training and Education: recommendations for change; contributors to a recent government-sponsored report on minimum staffing ratios suggest improvements for staff training. (Feature Article).

This is part two of a two-part series on a chapter on nursing assistant training and education that we wrote as part of Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. The Phase II report was released to Congress by the Centers for Medicare and Medicaid Services (CMS) this past spring.

Part one of this feature, "Nursing Assistant Training and Education: What's Missing?" in Nursing Homes/Long Term Care Management, June 2002, p. 48-51, summarized our chapter's key findings on what's generally missing from CNA training. The following are recommendations for improvement from the Paraprofessional Healthcare Institute (PHI), published as an appendix to the report.

The recommendations describe an educational approach, structural framework and a set of relationships that need to be in place to prepare nursing assistants to give good care to residents. They address the educational and related financial needs of caregivers along a learning continuum, from prospective trainee through experienced CNA.

In general, PHI recommends expanding the training requirements for CNAs. "Raising the bar" for entrance into the field might seem counterintuitive at a time of such widespread vacancies. However, these recommendations are based on an assessment that retention of nursing assistants once in the field is the primary solution to addressing vacancies, and that providing CNAs with adequate preparation and support through improved training is key to improving retention.

PHI's recommendations are divided into four sections: those for CMS, those for states (most of which echo the recommendations for CMS), those for nursing facilities and those applying specifically to course content, teaching and testing methods.

For CMS and States

Mandate more hours of training for CNAs. Many of our key informants suggested that CNAs need well over the federally mandated 75 hours of training, perhaps no less than 160 hours. Nearly all stressed that clinical training should be part of that training (as some states already require).

Standardize state training regulations and requirements. This would remove barriers for CNAs who are certified in one state and are seeking employment in another and thus help ease providers' recruitment difficulties. In doing so, CMS should consult an evaluation of state CNA training programs by the Office of Inspector General of the Department of Health and Human Services (HHS), due this year.

Develop a curriculum for workers across long-term care settings. Many direct care workers work in more than one part of the long-term care and personal assistance spectrum, sometimes holding multiple jobs at once in home care, nursing homes, assisted living, hospice and/or other settings. A standardized core curriculum, augmented by modules that target particular settings, would develop a versatile direct care workforce and ensure that all workers had learned basic skills regardless of setting.

Abolish cost-containment limits on Medicaid reimbursement for training costs. CMS and state Medicaid departments should pay the full costs of all allowable and required training expenses. Some states impose "reasonable cost guidelines," based on the median cost of training reported by all facilities in the state or by a predetermined group of facilities. These states reimburse eligible expenses only up to a certain point, which is usually more than the median but less than is spent by a considerable number of facilities. States may impose other limits, as well. In Oregon, for instance, facilities are reimbursed based on the percent of Medicaid clients served at the facility, so if 75% of its residents are Medicaid recipients, the facility recovers only 75% of its allowable training costs. CMS and the states should also reimburse nursing homes for training nursing assistants who go on to work in other facilities or in related fields such as home health or acute care.

Build in financial incentives for specialized competencies. Nursing home rates would include extra pay for CNAs who gain competency in specialized areas of long-term care, such as Alzheimer's, pediatrics or AIDS.

Develop and sustain a high-level, standing federal task force to focus on direct care workers. On this task force, CMS would work in tandem with the Department of Labor, the welfare side of HHS and the Department of Education to develop programs and funding mechanisms to support CNAs in training and those who are new on the job. Supports should include funding to schools for accessible graduate equivalency degree (GED) and English as a second language (ESL) programs, as well as scholarships to would-be nursing assistants who need GED or ESL classes. The federal task force should be replicated at the state level in all 50 states.

Monitor nursing assistant trainers. Develop standards for trainer qualifications and their methods of training. Require that trainers be knowledgeable about adult training methods and must incorporate variety in their teaching methods.

Provide sufficient funding to state departments that oversee CAN training to allow them to properly assess and oversee current and proposed curricula and training programs.

For Nursing Facilities

Create strong connections with community-based training providers, such as community colleges and the Red Gross. Facility representatives who supervise CNAs should help design and monitor training programs to ensure that what is taught is consistent with "real life" situations in the facility.

Foster a caring relationship between nursing assistants and residents. The emphasis should be less on performing tasks and more on getting to know residents as individuals, learning their habits and preferences, and incorporating that information whenever possible into their care. In part, that means allowing each nursing assistant to care for the same group of residents over time.

Invest in workers for the long term. A key ingredient to a decent job is having a clearly defined framework for advancement. This includes:

* A clearly defined job ladder. It gives nursing assistants who want to stay in the profession a way of earning more money and enhancing their skills without having to abandon the field.

* Leadership roles for experienced CNAs. This might involve using nursing assistants as associate trainers or as peer mentors, or giving them special roles on the caregiving team.

* Access to a variety of educational opportunities. These might include GED programs, ESL courses, community college programs, or regional or national conferences for nursing assistants.

Ensure that the nurse managers are trained in supervisory skills. Nurses who supervise CNAs need training in how to set consistent standards and hold workers accountable while respecting employees as individuals. Training should cover cultural sensitivity, since nursing home managers often come from a different ethnic group, class or country of origin than the people they supervise, and those differences can lead to misunderstandings.

Develop effective and substantive orientation programs. Such programs should last for the first three months a new worker is on the job and may include mentoring by an experienced peer. Mentors should be trained, supervised and compensated for these responsibilities.

For Course Content, Teaching Methods and Testing

One of the key changes PHI recommends is to use adult education methods. Many CNAs have not had good experiences in the traditional school system and find it difficult to learn from lectures, videos and books. Adult education is, or should be, dynamic and interactive. It might include role playing, small group discussions, case-study reviews and hands-on practice of clinical skills.

Other recommendations for course content and teaching methods include:

* Foster staff skills in problem solving, critical thinking and conflict resolution.

* Incorporate extensive field experience from the nursing home into precertification training.

* Design in-service training to respond to CNAs' specific learning needs.

* Teach communication and other "soft" skills, as well as technical skills and tasks.

Elise Nakhnikian is a long-term care specialist at the Paraprofessional Healthcare Institute (PHI), [e-mail]. Mary Ann Wilner, PhD, is director of health policy for PHI, [e-mail]. Donna Hurd, RN, MSN, is a senior analyst at Abt Associates, Inc., don [e-mail]. To read Phase I of the federal nursing home staffing report, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, go to www.hcfa.gov/medicaid/reports.