What is the number one headache for nursing home Administrators and Directors of Nursing? Most will have a quick
answer for you: the dreaded State Survey. That time each year when every detail of their performance, and their staff's
performance, is placed under a microscope and all they can do is cross their fingers and hope that everything meets
regulations.
Well, they can do more than hope, right? Unfortunately not. Because ultimately they depend on their front-line
service providers, the Certified Nursing Assistants (CNAs), to perform their jobs according to regulations. And they just
can't be counted on to do that. Why not? Are they lazy? Unreliable? Apathetic? Absolutely not. They're just never
told what the regulations are.
"They get the certification course, but that doesn't speak specifically to regulations," says Lori Porter, a former
CNA who is now the Executive Director of the National Association of Geriatric Nursing Assistants (NAGNA). "Somewhere
in the facility they may know there is a regulation book, but they don't know where it is and wouldn't know how to read
it."
This lack of information is the root cause of a lot of frustration for CNAs across the country. The kicker? As a
CNA, says Porter, you don't even know what you're missing. "I understood nothing and was told none of this until I began
studying for my administrator's exam... and learning the regulations which nursing assistants have no real access to."
After eight years as a CNA, Lori passed her administrator's exam and in 1990 took the reins of a nursing home in
Kansas. After five years in this role, she joined forces with Lisa Cantrell, also a former CNA, and founded NAGNA.
Lisa was a Director of Nursing at the time, and the two combined their knowledge as administrators with their years
of experience as CNAs to create an organization that would help people in both roles bridge the gap in education and
responsibility that lay between them.
Individual CNAs can join NAGNA to educate themselves about regulations and keep abreast of industry news that may
affect them. The bulk of their work, however, is done through facility memberships. NAGNA offers four levels of
membership to nursing homes which include benefits such as quarterly in-house workshops, training courses and
personalized programs designed to address key issues such as staff recruitment, retention and morale.
Anyone in the nursing home business knows that one of the major problems facing the industry is staff turnover.
National estimates place staff turnover at about 90% or 100% yearly in an average nursing home, but among CNAs
specifically the rate is often double that or more. "The turnover in other departments is low enough to bring down the
overall facility percentage," says Porter, "but it's not uncommon to find a facility that's hired and lost well over 100
nursing assistants in a 12-month period."
This high rate of turnover further contributes to the lack of information available to CNAs, because administrators
are less likely to invest the time and effort it takes to train and educate someone who might not even be around next
week, let alone next year. NAGNA works with homes to address these problems, but Lori warns that it is not a quick
fix. "A lot of facilities will buy a membership [into NAGNA] for their nurses' aides because they think we are some
kind of magical cure, but we are not. This is a process which takes six months in some cases or a year, or five years
in others... it just depends on what the situation is in the facility."
Part of the issue here is that CNAs are in a position where they need to make countless decisions as a part of their
daily job, but they're not given the authority to do so. At CultureChangeNow, we've always advocated increasing the
decision-making powers of CNAs, but we also believe that this sort of staff empowerment must go hand in hand with
increased knowledge and new skills. Giving your staff the authority to make decisions is important, but giving them
the knowledge required to make the right decisions is critical.
Lori agrees. "We can't put [CNAs] into situations where they will fail because of a lack of knowledge. If nursing
assistants are going to take on decision-making and more empowered roles, then they need access to the informational
and educational resources that the current decision makers have."
It's important for administrators to realize that the burden of responsibility lies not just on the CNAs and their
ability to do their jobs, but also on the administration and their ability to help the CNAs do their jobs effectively.
Those who don't realize this, Porter says, often fall into the trap of simply writing off CNAs as disposable and
unreliable without looking at the work environment to see why they aren't staying. She tells of one nursing home she
visited recently.
"I asked, 'How many openings do you have today for nursing assistants?' The DON said that there were nine. Then I
asked, 'How many people have you hired and lost in the past four months?' Their guess was 120. So I said, 'You've
had 120 opportunities to develop nine professionals.' And they were just blown away by that. They had never thought
about it in those terms."
So how does NAGNA help nursing homes deal with the turnover problem? "The continuing education programs that we
provide in our member facilities are team-building, communications, dealing with change, survey preparedness and
regulations and the whole gamut of soft skills," Lori explains. They also offer correspondence courses and materials
for individuals to continue honing their skills.
Lori believes that NAGNA's most important program, however, is their preceptor training. This is an intensive
16-hour program that helps CNAs grow from nursing assistants into teachers, guides and mentors for new employees.
Facilities are then encouraged to use these preceptors to guide all new CNAs through a three-hour mentoring program
to help orient and acclimate them to the job and the environment, instead of just throwing them in the water and
seeing if they can swim.
The mentoring program is key, because while the administrator or DON may hire new CNAs, they'll be turned over
almost immediately to other nursing assistants who will give them what orientation they can in the midst of their
usual duties. If these nursing assistants are trained preceptors, Porter believes, new CNAs will come away from
their first few days at work feeling better prepared and more highly valued, and will be likely to stay on longer.
But does it work? "It's being met with a lot of success. Where there are preceptors, there is reduced turnover."
In fact, of the approximately 3500 CNAs trained by preceptors since the program's inception, 80% remained at the
facility for 180 days or more, over three times as long as the average new hire. And that's a good first step
towards breaking that circle of frustration for both CNAs and administrators.
