This study is part of a larger interdisciplinary project that was awarded a Lamar University Visionary grant.
Lamar University, Beaumont, TX
Abstract: Alzheimer disease and other dementias are common diagnoses in long-term care (LTC). In this setting, certified nurse aides (CNAs) provide the majority of care for residents with dementia. The responsibility can be challenging, however, as evidenced by frequent CNA staff turnover. To gain an insider perspective of the needs, caregiving styles, and experiences of CNAs working with residents with dementia, we recruited 20 CNAs across 3 nursing homes in separate cities in the southern United States and established 4 focus groups. Qualitative analysis of exploratory interviews revealed 4 themes: (1) dementia as a dynamic; (2) a shift toward proficiency and confidence; (3) cultivating job satisfaction; and (4) disempowerment. To understand the unique barriers impacting CNA ability to care for patients with dementia, the interprofessional team should consider CNA perspectives and address expressed needs through various levels of support.
Key words: nurse aides, dementia, barriers, perspectives, interdisciplinary
Dementia is a growing public health concern. Some 7.7 million people are diagnosed with dementia every year, with significant increases predicted over the next 2 decades.1 Alzheimer disease and other dementias are common diagnoses in long-term care (LTC). In the last quarter of 2016, the Minimum Data Set (MDS) revealed a dementia diagnosis prevalence of 42.87% in Medicare- and Medicaid-certified facilities in the United States.2
In addition to cognitive decline, residents with dementia often demonstrate changes in behavior, agitation, and aggression. LTC facilities are increasingly challenged with caring for this population, whose behaviors can vary from wandering to physical aggression.3 In the first quarter of 2017, MDS data suggested 12.35% to 12.8% of behaviors of patients with dementia posed a risk for physical illness or injury to the patient or others. Some 21.86% of these patients’ behaviors significantly interfered with care. Between 18.68% and 21.94% of their behaviors interfered with participation in activities and social interactions.2 These behaviors are difficult to manage and can put both patients and caregivers at risk.
In 2014, the National Study of Long-Term Care Providers found the average length of time staff spent with residents was 3.88 hours per day. Of those hours, nurse aides spent 2.47 hours with each resident.4 Certified nurse aides (CNAs) are tasked with providing the majority of care to residents with dementia in LTC.
The Code of Federal Regulations (42 CFR 483.152) requires Medicare- and Medicaid-certified LTC facilities to employ CNAs with a minimum 75 hours of training, including 16 hours of clinical supervision. Specific requirements are mandated by individual states, with some states requiring more hours than the federal minimum. The average number of training hours across states is 98 hours.5,6 Federal requirements also stipulate annual CNA in-service training, with some hours (number unspecified) specifically in dementia training. This is detailed in F-tag 497 as a requirement of yearly training.5
The benefits of person-centered care are well studied and suggest improved resident outcomes.7-9 Person-centered care emphasizes that individuals maintain their identity despite cognitive impairment. Nurse aides are tasked with providing person-centered care for residents with dementia by implementing environmental approaches, such as redirection, during daily routines to meet patient needs and bring unique perspectives on caring.
Consistent staffing is key to providing person-centered care. Studies that examined CNA perspectives on staff turnover and job satisfaction indicate the importance of relationships, experiential learning, and positive work environments in providing quality care.9-13 However, the turnover rate of LTC nurse aides over the last decade was an estimated 52% to 79%.14-17 This threatens the ability of facilities to provide person-centered care. CNAs are a vital source of information for the interdisciplinary team, and the importance of including them is now being acknowledged. Recent changes to the Federal Code (§ 483.21) require inclusion of the CNA in person-centered interdisciplinary care planning at admission.5
The study presented below is part of a larger interdisciplinary project aimed at developing an online training program to improve everyday interactions between CNAs and residents with dementia. In this first phase of the project, focus groups were established with the primary objective of gaining an insider perspective of the needs, caregiving styles, and experiences of CNAs working with residents with dementia in LTC.
This study used a qualitative research methodology. The framework of phenomenology was used to guide procedures because it allowed for collection of naturalistic data to better understand CNA experiences, opinions, and beliefs.18
Participants and Setting
Maximum variation sampling was used as a purposeful sampling strategy to determine common patterns across a diverse set of participants and to increase generalizability.19 As such, no strict inclusion criteria were used for participation. Twenty CNAs were recruited across 3 nursing homes in separate cities in the southern United States. Cities were diverse in size, with populations ranging from 2000 to 120,000. Participant ages ranged from 20 to 56; the average age was 35. All but 2 participants were women.
Average time working as a CNA was 10 years overall, although individual CNA experience ranged from 3 months to 30 years. Time spent working in the current facility spanned 2 weeks to 22 years; 2.9 years was the average. All CNAs had a high school diploma or general education development certificate and were native English speakers. Ethical oversight was provided by Lamar University’s Institutional Review Board. CNAs provided verbal and written consent prior to participation.
Focus groups were chosen as the data collection source due to their usefulness in reflecting the social realities of a cultural group.20 Researchers chose to use heterogeneous focus groups because of the exploratory nature of the research and the likelihood of gaining rich information.21 Focus groups lasted from 45 minutes to 69 minutes. In all, 3 hours and 52 minutes of data was generated for analysis.
A researcher trained in conducting focus groups and semistructured interviews led 4 exploratory focus groups. Prior to beginning each focus group discussion, the moderator explained her role and the purpose of the study. Initial questions were general and included questions about routine interactions and communicative exchanges with residents with dementia.22 Questions were open-ended and flexible so the participants could direct the discussion and reveal candid perceptions and beliefs.
Focus groups were audio recorded and transcribed verbatim for data analysis. Analysis procedures followed phases for thematic analysis.23 The first phase included immersion into the data to become familiar with the breadth and depth of the content. Authors then independently began an inductive coding process in which data were coded line by line with a category of idea or action representing raw data. A process of peer debriefing was implemented in which authors came together to examine the list of codes and identify relationships among codes to uncover themes.24 Emergent themes were discussed and biases were clarified to ensure credibility and authenticity of findings. Discrepancies were resolved through discussion and linkage of final themes back to the raw data.
Data saturation was reached after analysis of the fourth focus group. At this point, no new insights emerged, and existing categories were well-established in the data.
Four discussion themes were identified: (1) dementia as dynamic; (2) shift toward proficiency and confidence; (3) cultivating job satisfaction; and (4) disempowerment. A list of themes and subthemes are outlined in Table 1. Quotations corresponding to themes and subthemes are listed in the Table and in the following sections to aid in interpretation and explication.
[Article continues below]
Dementia as Dynamic
Every focus group described dementia as a condition that is not static but variable and unpredictable. The label “dementia” carried a specific set of symptoms and behaviors recognizable to CNAs; however, this knowledge did not help them provide optimal care.
During care activities, dementia as a dynamic condition led to negative experiences such as confusion, fear, and physical pain. It also led to CNA uncertainty in how to provide care in specific situations (eg, periods of heighted agitation). CNAs were unsure of their role when residents with dementia refused to put on clothes or get out of bed. One participant expressed the desire for the resident to feel comfortable, “but she can’t always be in the bed,” the CNA added. These situations left CNAs feeling “mixed up” and “stressed.”
Contrary to CNAs’ observations of dementia as a dynamic condition, LTC facilities perpetuated the idea of dementia as a fixed condition. Staff members provided little resident-specific information to CNAs, such as individual preferences or level of physical ability. Narratives in all 4 focus groups detailed caregiving strains from day-to-day behavioral changes, medication adjustments, and disease progression. CNAs reported receiving little to no information about the state of residents prior to beginning their shifts and were often forced to enter into situations for which they were unprepared. One CNA voiced a need to know triggers or “what not to do” with particular patients to avoid negative behaviors.
Shift Toward Proficiency and Confidence
The aides discussed a continued movement toward self-assurance through experiential learning and familiarity with residents. The regularly changing behaviors of residents with dementia compelled CNAs to rely on experiential learning to become proficient in their work. Group members discussed how most learning occurred “on the job.” They acquired skills for anticipating behaviors and socializing while completing care.
Once on the job, CNAs quickly realized strategies learned during training were not multipurpose and developed new tools based on the individualities of each resident. For example, the strategy of redirection was specifically discussed in 2 of the 4 focus groups. Redirection caused confusion among the CNAs in both groups. It was a skill initially taught during training, but CNAs said it had little practical effect because “sometimes they [residents with dementia] are dead set” in getting their way.
Familiarity with residents was essential because it tended to ease tension and help in job performance. When residents recognized CNAs, tasks were performed more quickly and with more ease. Groups discussed the importance of learning family histories and idiosyncratic behaviors so they could communicate more effectively with residents during tasks and recognize when something was wrong. One participant credited resident familiarity with empowering her to be able to “tell [if] something’s going on.”
More practical issues of familiarity were also raised. Three of the 4 focus groups discussed how familiarity led to more confidence because it increased knowledge of a resident’s use of assistive devices, such as hearing aids, eyeglasses, and splints.
Cultivating Job Satisfaction
Several actions and attributes strengthened job satisfaction among CNAs. Retention seemed to be related to qualities such as resilience, empathy, and compassion. The groups discussed concepts to overcome challenging days, such as “keep going” and “look forward,” which underscored resilience and strength. Empathy and compassion also led to greater happiness in the workplace. One female CNA explained these feelings as “more than just a client-employee relationship.” Specific anecdotes that illustrated these qualities included making residents smile or laugh, sharing an intimate detail about family, and ensuring comfort.
Groups discussed the importance of developing work partnerships and nurturing these relationships through praise and dependability. Across all focus groups, CNAs consistently complimented each other on specific abilities. Group members explained that they rely on one another to help with difficult situations or patients. Their role was to “protect everybody” until tasks were completed. Inherent value systems (eg, faith) promoted job satisfaction and resulted in feelings of happiness and fulfillment. In 3 of the 4 focus groups, CNAs mentioned the profession was a “calling from God” and that they were “here for a reason.”
Unfortunately, many narratives in the data identified feelings of disempowerment. Situations and experiences were reported in which CNAs were marginalized by nurses, therapists, and administrative staff. Licensed nurses and therapists talked down to aides and made them “feel like peons.” CNA questions and comments about residents were often ignored or de-emphasized. One CNA explained how her competence as a professional was impacted when licensed nurses ignored her questions: “Y’all don’t listen, and we can’t get better.” Another participant said a scenario in which someone asked her perspective would be “shocking to me because no one ever asks.”
Day-to-day work activities combined with feelings of helplessness led to severe emotional and physical consequences, the CNAs said. Frustration and sadness were consistently voiced. One CNA described working with residents with dementia as a “kind of emotional toll” that was mentally taxing. CNAs in 3 focus groups discussed lifting or pushing heavy patients and regular “chasing” or “running” during their shifts. At least one CNA in all 4 focus groups mentioned a physical assault and back or neck injuries.
Dementia as Dynamic
Many of the themes and subthemes identified in the data illustrate that CNAs, at least initially, experience uncertainty and have low confidence in caring for people with dementia. CNAs recognize dementia as a dynamic condition that makes caregiving challenging. Challenges are exacerbated by limited training and a lack of resident-specific information. These findings reflect the minimal dementia education preparation required to work as a CNA.5-6 Additionally, these results confirm findings from other qualitative studies investigating person-centered care that reveal a conflict between institutional priorities and caregiver concerns about individual patient care needs.25,26
An inability to adapt interventions to the dynamic condition of dementia can have negative effects on patient and caregiver outcomes. Training that emphasizes the complexity of the disorder, on the other hand, could aid in preventing escalation of negative behaviors and overmedication of residents and help ease staff frustration. Studies suggest that focused, in-depth training can improve problem-solving and caregiving behaviors among CNAs.27-29 Patient safety and personalized care may be improved through strategies that provide pertinent information across the continuum of care, such as walking shift-change reports and briefing checklists.30
Shift Toward Proficiency and Confidence
Due to their lack of training and confidence in caring for residents with dementia, CNAs in this study were forced to rely on experiential learning and practical knowledge. This is consistent with previous work that has shown competence is not based on theoretical knowledge and skills but on experience-based knowledge and standard routines.13 CNAs spoke about the power of familiarity, which is an important component of person-centered care according to patients with dementia, family members, and staff.31
Consistent assignment is a commonly suggested intervention to improve outcomes in dementia care because it allows for relationship-building, trust, and person-centered care.32-34 Consistent assignment allows staff to recognize subtle changes in patients and report problems quickly. Studies in LTC facilities that use consistent assignment suggest reduced occurrence of pressure ulcers and contractures and slower declines in activities of daily living.17 Despite these findings, further research is warranted to link policies supporting consistent assignment with specific, measurable patient outcomes.35
Cultivating Job Satisfaction
In line with other experimental and qualitative studies examining CNA perspectives, thematic analysis of data from this study revealed the importance of empathy and positive work relationships to job satisfaction.7-12 Incorporating these aspects into training programs for CNAs is critical since it may help reduce CNA turnover.
Research suggests administrative support and feeling valued are also important predictors of job satisfaction among CNAs in LTC.36 Recognition programs and other incentives that acknowledge continuing education in dementia care may improve job satisfaction and retention. In addition, policies promoting CNA inclusion in interdisciplinary team care meetings may increase satisfaction as well as better support patient-centered care. Faith and other spiritual interventions, such as individual prayer or organizational religiosity, may also play a role in satisfaction and retention and thus merit further research.37
CNAs expressed feelings of disempowerment when caring for residents with dementia. Similar to findings from other studies, these feelings were periodically caused by the actions of other staff members with more authority (eg, licensed nurses and therapists).38,39 This illustrates a need for education of licensed staff and others about team care and valuing all members of the patient team. At other times, disempowerment was caused by the job’s constant emotional and physical toll. This theme is also consistent with previous studies.
Programs designed to empower direct care workers can positively impact patient outcomes. Exercise, music, reminiscence, and other types of sensory stimulation, also known as individualized positive psychosocial interventions, are feasible interventions that CNAs can personalize to patients. Research suggests that having CNAs lead customized activities is an effective approach to improve resident well-being.40,41 Specifically, reminiscence has been shown to increase well-being and decrease depression in older adults.42,43 Utilizing CNAs to provide these types of programs may also instill a sense of empowerment within the CNA.
Strengths and Limitations
Findings presented here represent an exploratory study of the perspectives of CNAs working with residents with dementia in LTC. The sample was small, and data was collected in a limited geographic area. However, purposeful sampling techniques increase the generalizability of the findings and provide a fair representation of the workforce in this region of the United States.
Future studies would benefit from including more participants across wider geographic regions. Registered nurses and licensed practical nurses may also be included in future studies to compare and contrast perspectives and to better clarify mechanisms that lead to confidence, or lack thereof, in caring for residents with dementia.
Caring for residents with dementia is challenging and unpredictable. As the primary team members providing care to patients with dementia in LTC, CNAs are vital members of the interdisciplinary team. High turnover rates can hamper the ability to provide person-centered care and negatively impact patient outcomes.
To understand the unique barriers impacting the ability of CNAs to care for residents with dementia, the interprofessional team should consider their perspectives. Only then can such barriers to person-centered care be understood and subsequently addressed through various levels of interprofessional support.
1. World Health Organization. Dementia: a public health priority. http://apps.who.int/iris/bitstream/10665/75263/1/9789241564458_eng.pdf?ua=1. Published 2012.
Accessed September 20, 2018.
2. US Centers for Medicare & Medicaid Services (CMS). MDS 3.0 frequency report. CMS website. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-
Data-and-Systems/Minimum-Data-Set-3-0-Public-Reports/Minimum-Data-Set-3-0-Frequency-Report.html. Accessed September 20, 2018.
3. Selbæk G, Engedal K, Bergh S. The prevalence and course of neuropsychiatric symptoms in nursing home patients with dementia: a systematic review. J Am Med Dir Assoc. 2013;14(3):161-169.
4. Department of Health and Human Services. Long-term care providers and services users in the United States: data from the National Study of Long-Term Care Providers, 2013-2014. https://www.cdc.gov/nchs/data/series/sr_03/sr03_038.pdf. Published February 2016. Accessed September 20, 2018.
5. Medicare and Medicaid programs; reform of requirements for long-term care facilities. Fed Regist. 2016;81(192):68688-68872.
6. Paraprofessional Health Institute. Nursing assistant training requirements by state. Paraprofessional Health Institute website. https://phinational.org/policy/nurse-aide-training-requirements-state. Accessed September 20, 2018.
7. Savundranayagam MY, Sibalija J, Scotchmer E. Resident reactions to person-centered communication by long-term care staff. Am J Alzheimers Dis Other Demen. 2016;31(6):530-537.
8. Stein-Parbury J, Chenoweth L, Jeon YH, Brodaty H, Haas M, Norman R. Implementing person-centered care in residential dementia care. Clinical Gerontologist. 2012;35(5):404-424.
9. Ross H, Tod AM, Clarke A. Understanding and achieving person-centred care: the nurse perspective. J Clin Nurs. 2015;24(9-10):1223-1233.
10. Savundranayagam MY, Lee C. Roles of communication problems and communication strategies on resident-related role demand and role satisfaction. Am J Alzheimers Dis Other Demen. 2017;32(2):116–122.
11. Han K, Trinkoff AM, Storr CL, Lerner N, Johantgen M, Gartrell K. Associations between state regulations, training length, perceived quality and job satisfaction among certified nursing assistants: cross-sectional secondary data analysis. Int J Nurs Stud. 2014;51(8):1135-1141.
12. Thompson MA, Horne KK, Huerta TR. Reassessing nurse aide job satisfaction in a Texas nursing home. J Gerontol Nurs. 2011;37(9):42-49.
13. Furåker C, Nilsson A. The competence of certified nurse assistants caring for persons with dementia diseases in residential facilities. J Psychiatr Ment Health Nurs. 2009;16(2):146–152.
14. Texas Center for Nursing Workforce Studies. Long term care nursing staffing study. https://www.dshs.texas.gov/chs/cnws/LTCNSS/2017/2017-LTCNSS-Facility-Characteristics.pdf. Published October 2016. Accessed September 20, 2018.
15. American Health Care Association. American Health Care Association 2012 Staffing Report. https://www.ahcancal.org/research_data/staffing/Documents/2012_Staffing_Report.pdf. Published 2014. Accessed September 20, 2018.
16. Frogner B, Spetz J. Entry and exit of workers in long-term care. http://healthworkforce.ucsf.edu/sites/healthworkforce.ucsf.edu/files/Report-Entry_and_Exit_of_Workers_in_Long-Term_Care.pdf. University of California San Francisco Health Research Center on Long Term Care website. Published January 20, 2015.
Accessed September 20, 2018.
17. Donoghue C. Nursing home staff turnover and retention: an analysis of national level data. J Appl Gerontol. 2010;29(1):89-106.
18. Wilkinson S. Focus groups in health research: exploring the meanings of health and illness. J Health Psychol. 1998;3(3):329-348.
19. Patton MQ. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. 4th ed. Saint Paul, MN: SAGE Publications; 2015.
20. Hughes D, DuMont K. Using focus groups to facilitate culturally anchored research. Am J Community Psychol. 1993;21(6):775-806.
21. Calder BJ. Focus groups and the nature of qualitative marketing research. J Marketing Res. 1977;14(3):353-364.
22. Kingry M, Tiedje LB, Friedman LL. Focus groups: a research technique for nursing. Nurs Res. 1990;39(2):124-125.
23. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77-101.
24. Lincoln YS, Guba E. Naturalistic Inquiry. London, England: SAGE Publications; 1985.
25. Nilsson A., Rasmussen BH, Edvardsson D. Falling behind: a substantive theory of care for older people with cognitive impairment in acute settings. J Clin Nurs. 2013;22(11-12):1682-1691.
26. Kirkley C, Bamford C, Poole M, Arksey H, Hughes J, Bond J. The impact of organisational culture on the delivery of person-centred care in services providing respite care and short breaks for people with dementia. Health Soc Care Community. 2011;19(4):438-448.
27. Gaugler JE, Hobday JV, Robbins JC, Barclay MP. Direct care worker training to respond to the behavior of individuals with dementia: The CARES® Dementia-Related BehaviorTM online program. Gerontol Geriatr Med. 2016;2.
28. Sengupta M, Ejaz FK, Harris-Kojetin LD. Training of home health aides and nurse aides: findings from national data. Gerontol Geriatr Educ. 2012;33(4):383-401.
29. Chaudhuri T, Yeatts DE, Cready CM. Nurse aide decision making in nursing homes: factors affecting empowerment. J Clin Nurs. 2013;22(17-18):2572-2585.
30. Spanke MT, Thomas T. Nursing assistant walking report at change of shift. J Nurs Care Qual. 2010;25(3):261-265.
31. Edvardsson D, Fetherstonhaugh D, Nay R. Promoting a continuation of self and normality: person-centred care as described by people with dementia, their family members and aged care staff. J Clin Nurs. 2010;19(17-18):2611-2618.
32. Advancing Excellence. Consistent assignment. https://www.nhqualitycampaign.org/files/factsheets/Consumer%20Fact%20Sheet%20-%20Consistent%20Assignment.pdf. Published 2012. Accessed September 20, 2018.
33. Koren MJ. Predictable scheduling: nursing homes can boost quality, bottom line with ‘consistent assignment.’ Modern Healthcare. 2010;40(33):21.
34. Pioneer Network. http://www.pioneernetwork.net/. Accessed September 20, 2018.
35. Roberts T, Nolet K, Bowers B. Consistent assignment of nursing staff to residents in nursing homes: a critical review of conceptual and methodological issues. Gerontologist. 2015;55(3):434-447.
36. Choi J, Johantgen M. The importance of supervision in retention of CNAs. Res Nurs Health. 2012;35(2):187-199.
37. Lucchetti G, Lucchetti AL, Oliveira GR, et al. Nursing home care: exploring the role of religiousness in the mental health, quality of life and stress of formal caregivers. J Psychiatr Ment Health Nurs. 2014;21(5):403-413.
38. Page CG, Rowles GD. “It doesn’t require much effort once you get to know them”: certified nursing assistants’ views of communication in long-term care. J Gerontol Nurs. 2016;42(4):42-51.
39. Howe EE. Empowering certified nurse’s aides to improve quality of work life through a team communication program. Geriatr Nurs. 2014;35(2):132-136.
40. Oyebode JR, Parveen S. Psychosocial interventions for people with dementia: an overview and commentary on recent developments. Dementia (London). Published online July 4, 2016.
41. Van Haitsma KS, Curyto K, Abbott K, Towsley GL, Spector A, Kleban M. A randomized controlled trial for an individualized positive psychosocial intervention for the affective and behavioral symptoms of dementia in nursing home residents.
J Gerontol B Psychol Sci Soc Sci. 2015;70(1):35-45.
42. Kris AE, Henkel LA, Krauss KM, Birney SC. Functions and value of reminiscence for nursing home staff. J Gerontol Nurs. 2017;43(6):35-43.
43. Stinson C, Long EM. Reminiscence: improving the quality of life for older adults. Geriatr Nurs. 2014;35(5):399-401.