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CNAs: opening the career door.

The nursing home industry has experienced rapid change in the last few years, particularly with the implementation of OBRA. One thing that remains the same is most of the care provided in a long-term care facility is delivered by a certified nursing assistant (CNA). And, although CNAs were plentiful in years past, many facilities report that they are now experiencing difficulty in recruiting and retaining them.

Although the nursing assistant population differs around the country, CNAs have many characteristics in common. They are entry level with minimal education, often living below the poverty line and dependent on public assistance. Many have not been taught nor do they feel they have the ability to learn how to do anything other than personal care. This "poor self-esteem trap" may have ensured recruitment and retention in the past, but will no longer guarantee a staff in the future or do anything to promote job satisfaction.

Many factors have changed the playing field. With the shrinkage of the skilled workforce, many service industries are targeting minorities. Funding for job training is available. And, as if the physical demands of long-term care were not enough (the average nursing assistant lifts 2,000 lbs. a day), the job is equally taxing on the nerves and receives little praise.

Facilities experiencing recruitment and retention problems with both nurses and nursing assistants often feel helpless to change the situation. With tight limitations on salary and benefits, they feel they are unable to compete with other health care settings. Unfortunately, they are unaware of other factors, aside from salary and benefits, which make employees unhappy.

Not that some individuals are not tempted to leave for the $.50/hr. more that the facility down the street is offering, and fail to see that the loss of sick time and vacation time alone during a new probationary period will quickly eat up any small salary increase. This may be irrelevant, in any event: Most CNAs leave their place of employment because they are unhappy with work conditions but find that their concerns fall on deaf ears. They recognize that they are powerless and have no voice, and feel the only way they can get attention is to remove themselves from the ranks. Unfortunately, their action is seldom seen as simply a request for better communication and their resignations are accepted as a matter of course.

In an attempt to identify staff concerns, facilities required exit interviews asking "why are you leaving?" This is not very effective. Most people are smart enough to realize they need a good reference from their soon-to-be ex-employer and will not give an honest response. Others are so angry they blame specific individuals for the facility's shortcomings. Instead of asking why people leave, the facility should focus on employees who stay and ask, "why do you work here?"

Many facilities know they have a morale problem but honestly believe they have made an effort to improve the working conditions of CNAs. The problem may not, however, be only working conditions. Most CNAs complain about work relationships, particularly with the nurses.

If you are unsure if you have an atmosphere that recognizes the CNAs as contributing members of the health care team, you might ask the following questions:

* Do CNAs "cover the floor" during staff meetings and facility inservices?

* Are CNAs involved in decision-making at any level? Do they have input into team make-up or assignments, facility policies and procedures, topics for inservices, etc.?

* Is there a career ladder?

* Are there merit increases or does everyone get the same raise on annual review?

* Are there are awards programs other than "employee of the month"?

* How individualized is orientation?

Ways to Empower CNAs

Review your system of evaluation. Is it objective? Give a copy to each employee on hire so they know what to expect. Tell them how they can achieve the best evaluation, what is expected and what they can receive for good performance.

Example: How do you evaluate initiative? Tell the employee that you have a monthly mandatory staff meeting and that if she attends every month during the probationary period, she will receive an excellent score for initiative. If she attends only two meetings, her score will be "good" and for attendance at only one meeting, she will be scored "poor." This enables the individual to understand and control his/her destiny.

Identify the strengths of each CNA. Everyone is good at something! Utilize this "strength" during orientation and inservice training. Example: If Mary Smith is good at body mechanics during resident lifting and transfers, have her assist the physical therapist during the facility inservice program on resident transfers and utilize her as a preceptor for new employees (including LPNs and RNs).

Identify one CNA on each shift to serve as a preceptor of orientation. Most facilities utilize some sort of skills checklist, but no one really takes responsibility to ensure that the new employees are actually proficient at each skill. Make this the responsibility of the CNA preceptor.

Consider primary assignments. Select a task force of CNAs and have them select the resident-oriented teams. Assign permanent teams to your tenured CNAs. They will have the same group of residents every day they work. On their days off, other CNAs will be assigned to their teams. The primary concept allows the CNA to have a vested interest in her job. Her residents are a reflection of her work. She will not only be responsible for the daily care of the residents assigned to her team, but will be accountable for their closets, bedside tables, nail care, weight-taking, and achievement of their care plan goals.

Evaluate the relationship between the nurses and the CNAs. Do your nurses pass medications and then take a cigarette break until the next medication pass? Since we use "functional nursing" as the delivery model in LTC, many nurses see their role as task-oriented. "My job is to pass medication and give treatments, not transfer residents or pass out lunch trays." Although functional nursing delegates tasks and ensures that everything gets done, it does not promote teamwork.

The facility may have to take a strong stand regarding everyone's role to assist with a variety of functions, and may wish to start by having a meeting of CNAs and asking nurses to answer call lights and "watch the floor." Don't allow "functional nursing" to set up a class system in your facility.

Change the name. "Nursing assistant" somehow conjures up the thought that they are there to assist nurses. Yet our CNAs work independently of nurses. Perhaps Nurse Technician is a title they would prefer. Better yet, put out a suggestion box and ask the CNAs to suggest a new title.

Understanding what nursing assistants want really isn't that difficult. It's the same thing we all want: someone to value their opinion, recognize their contribution and to say thank you. They want to be perceived as an important member of the health care team, and not simply stuck at the bottom of the totem pole.

Janis Breedlove, R.N., M.A., is a Nurse Specialist for RehabWorks, Clearwater, Florida.
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Title Annotation:certified nursing assistants
Author:Breedlove, Janis
Publication:Nursing Homes
Date:Jun 1, 1993
Words:1185
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