By Orah R. Burack, Joann P. Reinhardt, Wingyun Mak, and Emily Franzosa
We now have a cohort of experienced certified nursing assistants who have worked through a health crisis. Let’s use their knowledge to improve nursing home care.
For years, certified nursing assistants (CNA) have been recognized as the unsung heroes of skilled nursing facilities (SNF) because they provided the majority of hands-on care, spent the most time with residents, and grew to know residents better than anyone else.
Despite this recognition, CNAs continue to be undervalued by nursing home leadership, often feel disrespected, and have little opportunity for job growth.
A number of initiatives have been introduced to elevate the standing of CNAs within the care team, such as including CNAs in care plan meetings, teaching CNAs to identify early signs of illness onset, and offering CNAs instruction in methods that help to prevent resident decline. These initiatives, though effective, have not been adopted widely and, when they are adopted, typically are not sustained through daily practice.
The importance of CNAs and the critical role they play in society became apparent during the past year as COVID-19 swept through U.S. nursing homes. As the majority of Americans stayed home to avoid contracting COVID-19 and “flatten the curve,” CNAs, along with other essential staff, were expected to continue their critical work.
Between March and June 2020—shortly after the first wave of COVID-19 engulfed New York City SNFs—we conducted focus groups with 56 experienced CNAs from five large SNFs across downstate New York. Our primary goal was to understand the strategies CNAs used to overcome the overwhelming challenges encountered during the pandemic. A secondary goal was to identify ways to support CNAs in the workforce and reduce turnover.
During our discussions, CNAs identified the extreme hardships and challenges encountered at work and at home during the pandemic. Most had families and were cognizant of the real danger of bringing COVID-19 into their own homes. They discussed in detail the emotional and physical toll of caring for nursing home residents who contracted a novel, highly contagious disease that so often resulted in death. The added responsibility of caring for residents in the physical absence of family and friends weighed heavily on some CNAs.
When asked about how they were able to continue with their work, recurrent themes emerged. In addition to their dedication to residents, CNAs demonstrated an impressive resilience, and an ability to learn quickly from their experiences, incorporate new protocols, and adapt to challenging situations.
The expertise that CNAs accumulate during years of caregiving has always been a valuable, albeit underutilized, resource. Now we have a cohort of CNAs who are experienced in standard care of frail older adults, and who have worked through a sustained crisis, often short staffed, without adequate equipment, and under rapidly changing care protocols. Many CNAs suffered psychological, physical, and personal hardship, but they made it through, gained practical knowledge, and were able to adapt.
We should learn from the expertise of CNAs and think of ways their experience can be used to improve care for older adults and to support CNAs in the workforce. The following are several recommendations, based on the focus group discussions, that could help us take necessary steps to value the knowledge of CNAs, provide opportunities for them to grow and develop in their careers, show our respect for them and their work, strengthen the LTSS workforce, and improve quality of care.
INVITE CNAs TO BE EDUCATORS AND MENTORS
During the pandemic, CNAs learned quickly and executed new protocols of infection control. Incorporating CNAs into a nursing home’s education process would have many practical benefits. CNA educators could become an ongoing source of knowledge and support to their colleagues.
Focus group participants noted that float or per-diem staff can be a source of difficulty as they often are not aware of unit protocols or, more importantly, do not know residents well. A CNA mentor could have the responsibility of teaching CNAs who are new to the field, care setting, and/or floor about protocols and the individualized needs and preferences of each resident.
APPOINT CNAs AS DEPARTMENTAL LIAISONS
Communication was a recurrent challenge reported in the focus groups. Communication problems occurred across a wide variety of circumstances, and resulted in:
- Lack of information about the presence of COVID-19 patients in the care setting.
- Confusion regarding changing protocols for personal protective equipment.
- Uneven distribution of knowledge about benefits that were available to CNAs during the pandemic.
CNA liaisons, along with nurse leaders, could help improve communication between CNAs and other departments. Involving CNAs in a nursing home’s communication network would strengthen communication on a day-to-day basis and facilitate the care setting’s functioning during any future crisis.
FACILITATE PEER SUPPORT AMONG CNAs
CNAs often relied on each other for emotional support during the pandemic, to help them cope with the loss of so many residents and, in some cases, with the trauma of contracting COVID-19 themselves.
While professional therapists should be available to all health care workers as needed, peer support can be an effective coping strategy and source of comfort. Regularly scheduled peer support groups, incorporated into the work schedule, would provide the opportunity for CNAs to meet periodically with compassionate colleagues who have shared experiences. CNAs can fulfill this important support role for each other especially as many struggle with the difficult reality of losing residents who, in many cases, they have cared for over years.
Orah R. Burack, MA, is a senior research associate at The Research Institute on Aging at The New Jewish Home (TNJH) in New York.
Joann P. Reinhardt, PhD, is director of The Research Institute on Aging at TNJH.
Wingyun Mak, PhD, is a senior research scientist at The Research Institute on Aging at TNJH.
Emily Franzosa, DrPH, is an assistant professor in the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, and a research health science specialist at the Geriatric Research, Education and Clinical Center, James J. Peters VA Medical Center in New York.
This study was funded by 1199SEIU Training and Employment Funds, Ladders to Value Workforce Investment Organization.