Nursing assistant training and education: what's missing? (Feature Article).

The federal government-sponsored report on minimum staffing ratios offers several insights into the staff training issue

This is part one of a two-part feature summarizing key findings on nursing training from Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, a recent report to Congress prepared by Abt Associates, Inc. Phase I of the report, released in July 2000, is available online at www.hcfa.gov/medicaid/reports/rp700hmp.htm. Phase II was released this March by Department of Health and Human Services Secretary Tommy Thompson.

In a cover letter to members of Congress accompanying Phase II, Thompson said his agency considers the reports "insufficient for determining the appropriateness of staffing ratios" because of "serious reservations about the reliability of staffing data at the nursing home level."

The Phase II report doesn't claim to be definitive. However, its executive summary says the report "demonstrates that there are critical staffing thresholds, below which the quality of care delivered to nursing home residents could be compromised" and identifies "a number of staffing-relevant factors other than numbers/ratios that importantly impact quality."

We examined one of those significant factors: nursing assistant training and education. Our research included an extensive literature review, site visits and interviews with scores of nursing assistants, researchers, nursing facility administrators, trade association staff, nursing assistant educators, state nursing assistant education supervisors and consumer advocates. Our chapter of the report outlines the current state of nursing assistant education and identifies some programs and public policy initiatives that appear to be effective. It also points to gaps in what is typically offered.

Every area explored below is covered well by some facilities and training programs. But, in most facilities, they are either underdeveloped or missing altogether.

Sufficient time to cover the material, and hands-on clinical training, in pre-certification classes. Most of the nursing assistants and nursing assistant educators we interviewed agreed that the federally mandated 75 hours is not enough time to adequately cover all the material that students need to learn--and indeed, some states require as much as twice that many hours. In a 1998 study of nursing assistants, 86% rated education and training to do their job better as "very important," but more than a third (37%) said their certification training had not prepared them to do the job well. As one said, "I figure a lot out on my own because of my background, but I feel all of us would benefit from timely and complete training at the beginning of our employment." (1)

What's more, training must not be limited to the classroom. Most respondents to the Iowa Caregivers Association's focus groups agreed that the best way for nursing assistants to learn skills is "by being shown what to do, and then practicing 'hands on' until they can perform comfortably by themselves." (2)

Effective supervision that balances support and accountability. Good supervision, such as the coaching method practiced by Cooperative Home Care Associates, a home care agency in the South Bronx, provides direction, establishes acceptable behavior and holds workers accountable for meeting clear goals, yet it is essentially supportive rather than punitive. Effective supervision helps orient new employees, enhances retention, reinforces skills learned in training classes, and helps workers develop problem-solving skills and juggle competing demands. But most charge nurses receive no management training, and many are uncomfortable in their role as supervisors. A focus group with 36 licensed nurses who work in nursing facilities found that the respondents "consistently expressed a dislike for their role as supervisors of nursing assistants and frequently stated they were ill-prepared for these responsibilities." (3) No wonder one of the main concerns nursing assistants generally cite about their jobs is conflict with a supervisor. (2)

Organizational support. "The greatest determinant of the quality and effectiveness of training is the attitudes top management have about training," says researcher Robert Atchley. "Organizational values about the importance of frontline staff, inclusion of frontline staff in care planning, and ongoing training of frontline staff all have to be translated into management behavior rewarding those values, or the organization will not show much effectiveness of training, no matter how well designed the training program is."

On-the-job support. Many otherwise qualified nursing assistant (NA) candidates pass the certification exam, which may be given orally in either English or Spanish, without gaining the literacy skills they need on the job. Employers might need to encourage staff to attend English as a Second Language classes, perhaps even holding classes in their own facilities, as does Providence Mount St. Vincent nursing home in Seattle. Workers might also need help in accessing such things as food stamps, childcare, transportation or affordable housing.

Peer support. Having peer support groups and peer mentors and participating in regional or national conferences allow NAs to grow professionally, share ideas and brainstorm solutions to problems.

Problem solving, critical thinking and organizational skills. Workloads for nursing assistants tend to be heavy, yet training offers little insight into how to juggle competing demands. One study of three facilities with above-average turnover rates compared nursing assistants who stayed for more than a few weeks with those who left. (4) Those who stayed, the researchers found, generally developed relatively rigid routines and took shortcuts that "could be done extensively without being discovered." Those who left "tended to respond to each summons [from a resident] as it arose." Both methods left residents unattended to for long periods of time. The authors concluded that "orientation programs could be more effective if they incorporated open discussion of how to organize the work."

Communicating with residents and family members. Nursing assistants often find themselves in delicate, emotionally complex situations. "Frontline workers must deal with difficult or abusive residents or unhappy families at the same time they respectfully change a resident's clothes or give a bath," notes one report. "More emphasis on handling the interpersonal aspects of care could help employees maximize what they view as the best part of their job--relationships with residents and clients." (5) Communication can be particularly difficult with residents who have advanced dementia or who come from very different cultural, ethnic, religious or class backgrounds.

Communicating with supervisors. Differences in professional status--not to mention ethnicity, class and cultural values--often prevent nursing assistants and supervisors from communicating effectively. While nurse supervisors need to improve their management skills, nursing assistants could also benefit from learning how to communicate more effectively. In part, this means learning how to describe common conditions in the clinical terms used by other caregivers.

Teamwork. Nursing assistants can support or undermine each other in countless ways--either helping coworkers who need to do a two-person lift or remaining perennially unavailable; either sharing ideas with their coworkers or gossiping about them. Cooperation is also needed among workers on different shifts.

Specialized clinical skills. Nursing assistants commonly say they need more training in how to work with people with dementia, which affects most residents. Depending on the facility's resident population, a nursing assistant might need special training in other types of disabilities, such as mental illness, Parkinson's disease or Huntington's chorea.

Engaging and relevant continuing education. There's general consensus that in-service classes tend to be repetitive and boring. What's more, they're rarely geared to the needs of individual residents or nursing assistants, as mandated by OBRA. (6) More advanced topics are rarely offered for more experienced workers, and nursing assistants reportedly are often pulled out of class to deliver care.

All of the above illustrate the goals of effective staff training and some of the difficulties in attaining them. Our next installment will disclose recommendations for improvement from the Paraprofessional Healthcare Institute (PHI), an organization dedicated to improving the quality of direct-care jobs and the quality of care in long-term care and home- and community-based services. PHI's recommendations address government agencies, providers and training programs.

References

(1.) Hill Simonton Bell, LC. Certified nursing assistant (CNA) recruitment and retention pilot project. Phase I: Survey results. Iowa Caregivers Association. December 1998.

(2.) Hill Simonton Bell, LC. Certified nursing assistant (CNA) recruitment and retention pilot project. Phase II: Focus group study results. Iowa Caregivers Association. January 1999.

(3.) Schirm V, Albanese T, Garland TN, et al. Caregiving in nursing homes. Views of licensed nurses and nursing assistants. Clin Nurs Res 2000;9(3):280-97.

(4.) Bowers B, Becker M. Nurse's aides in nursing homes: The relationship between organizations and quality. Gerontologist 1992;32(3):360-6.

(5.) Straker JK, Atchley RC. Recruiting and retaining frontline workers in long-term care: Usual organizational practices in Ohio, Oxford, Ohio: Scripps Gerontology Center, Miami University; 1999.

(6.) Federal regulations, Title 42, Part 433, subpart B, section 483,75(e)(8)(i, ii and iii).

Elise Nakhnikian is a long-term care specialist at the Paraprofessional Healthcare Institute, [e-mail]. Mary Ann Wilner, PhD, is director of health policy for the Paraprofessional Healthcare Institute, [e-mail]. Susan Joslin, PhD, RN, is a nurse consultant at the Centers for Medicare and Medicaid Services (CMS), [e-mail]. Donna Hurd, RN, MSN, is on the staff of Abt Associates, Inc., [e-mail]. To order a copy of Phase II of Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, e-mail Steven Pelovitz at [e-mail].