The nursing home reform provision of the 1987 Omnibus Reconciliation Act (OBRA '87) (Public Law 100-203) enacted major advancements in the provision of rights to residents. For the first time in history, it mandated that nursing homes provide residents with choices and respect in their everyday lives. In light of these requirements, long-term care ombudsman programs have been strengthened nationwide, and quality of life issues are now addressed as part of the survey process.
The federal regulations, however, do not mandate that there be formal training regarding resident rights. Most state regulations suggest that staff training occur annually and that resident rights be included as part of the inservice education provided for staff. National advocacy groups and state and local ombudsmen express concern that the level and type of training received by the nursing staff is not always adequate to promote resident rights and the quality of care envisioned by OBRA (Migdail, 1992). Typically, staff members learn resident rights information by rote methods. In the day-to-day life of the facility, they can become lost when working under a task-oriented medical model. The purpose of this study was to compare the knowledge and perceived implementation of resident rights by nurses (RNs and LPNs) and certified nursing assistants (CNAs) working in long-term care facilities.
NURSING HOME RESIDENTS
The profile of the typical nursing home resident suggests that the majority of residents are white women, 75 years of age or older, and not married. In addition, residents are likely to have multiple chronic conditions, difficulty performing two or more activities of daily living, and some degree of cognitive impairment (Hooyman & Kiyak, 1996). There is, however, much diversity among residents in the manifestations of their physical limitations, cognitive abilities, and personalities. All nursing home staff members are expected to respect and promote these individual differences while providing care within a fairly structured and uniform environment (Fischer, 1993; Kane, Freeman, Chaplan, Aroskar, & Urv-Wong, 1990).
The basic rights of nursing home residents as presented under OBRA '87 (RL. 100-203) indicate that all individuals have a right to:
* Dignified and respectful treatment.
* Responsiveness to individual needs.
* Consideration of personal interests.
* Be a decision maker.
More specifically these rights are interpreted or defined as the right to privacy (e.g., knocking before entering residents' rooms) and choice (e.g., what residents eat or who they spend time with). Residents also have the right to be informed about their medical conditions, to choose health care consistent with their interests, and to be free from physical and chemical restraints. By acknowledging and abiding by these rights, nursing homes meet OBRA's goal of "maintaining or enhancing the quality of life of each resident" (Omnibus Reconciliation Act, 1987, RL. 100203).
CARE PROVIDERS IN NURSING HOMES
The nursing staff comprises the largest segment of personnel working in long-term care facilities. Members of this staff include all professionally licensed nurses (i.e., RNs, LPNs), CNAs, and unlicensed aides who are responsible for tasks associated with nursing services. In many nursing homes, the most highly educated nurses (e.g., RNs) often spend less time on direct resident care activities than on providing staff supervision and completing the documentation required by federal and state regulations (Burgio, Engel, Hawkins, McCormick, & Scheve, 1990). It is the CNAs and nursing aides who provide the vast majority of handson daily care to the residents. It has been estimated that they provide approximately 80% of the direct care provided to residents (Waxman, Carner, & Berkenstock, 1984).
Current law requires that CNAs have a minimum of 75 hours of training and pass a certified test before they can be employed as CNAs in a long-term care facility. The CNAs are taught skills needed to transfer residents, take vital signs, make beds, and provide personal care. The majority of the training focuses on the technical skills needed to provide nursing care and services, including delegated medical tasks. Little training occurs on the psychosocial aspects of caring for residents. Although these technical training requirements have improved the knowledge base of the front line staff, limited attention is given to incorporating resident rights with the provision of nursing care.
RESIDENT RIGHTS AND CARE DELIVERY
Resident rights is the context in which the provision of care for nursing home residents should be delivered. The nursing staff must not only be knowledgeable about resident rights, but they also must understand how to protect the rights of the residents as they provide medical care. Although inservice education provides the nursing staff with information about the provisions contained in resident rights regulations, complaints to long-term care ombudsmen and the outcomes of state surveys suggests there is a gap between knowing about those rights and knowing how to implement them during the delivery of care. Therefore, the purpose of this study is to assess the differences between nurses' and CNAs' (referred to collectively throughout the rest of this paper as the "nursing staff) level of knowledge and perceived implementation of resident rights.
Background Characteristics of the CNAs and Nurses
The following questions guided the research:
1) What is the nursing staff's level of knowledge about resident rights?
2) Is there a difference between CNAs' and nurses' knowledge of resident rights?
3) Are there differences in the knowledge of resident rights of CNAs and nurses and their perceptions of how resident rights are carried out within their long-term care facilities?
4) Are years of education and work experience predictive of CNAs' and nurses' knowledge and implementation of resident rights?
CNAs1 and Nurses1 Knowledge and Implementation of Resident Rights*
The sample for this study consisted of 83 CNAs and 62 nurses (i.e., RNs and LPNs) from five nursing homes located in one large, frontrange county in Colorado (Table 1). A questionnaire was distributed to all people attending one of the ongoing inservice training sessions provided at each facility during the spring and summer of 1995. Attendees were told the purpose of the study and that their participation was totally voluntary; there were no incentives offered for completing the questionnaire. Administrative personnel from the individual facilities were not present when data collection took place, and attendees were asked not to put their names on the questionnaires. Of the approximately 300 members of the nursing staff who attended the inservice programs, 145 completed the questionnaire for a response rate of 48%.
A self-report questionnaire was designed specifically for use in this study. It consisted of two parts. Part one gathered background information about the respondents (e.g., gender, age, years of education, work experience). Part two consisted of Il case scenarios developed to assess the respondents' perceptions of working with residents living in long-term care facilities. Each scenario focused on a specific issue relevant to resident rights (e.g., privacy, choice, right to information about health status). For each scenario, respondents were directed to answer the following two questions:
* Based on your understanding of resident rights, how should the situation be handled?
* Based on your understanding of resident rights, how is the situation being handled?
There were 5 possible responses for each scenario; 1 correct response (as defined by OBRA '87, P.L. 100-203), 3 incorrect but common responses (derived from the experiences of the ombudsman and nursing homes' administrative staffs), and 1 "other," which allowed the respondents to write in their own response. The participants were instructed to respond to each question based on their knowledge and daily work experiences; they could give the same response to both questions. An example of one of the scenarios used in this study is provided in Appendix A. It focuses on the right of privacy. See Appendix B for a brief explanation of the additional scenarios.
Knowledge of Resident Rights
For 9 of the 1 1 scenarios, at least 75% of the nursing staff gave the correct response to the "How should the situation be handled?" question (Table 2). Chi-square analyses revealed significant difference between CNAs and nurses for 3 of the 1 1 scenarios. These scenarios focused on the use of physical restraints, chemical restraints, and respect. In all three cases a greater percentage of nurses answered correctly than CNAs (Table 1). It should be noted, however, that for the "respect" scenario 93% of the CNAs (compared to 100% of the nurses) did give the correct response.
Knowledge Versus Perception of Implementation
Differences between the knowledge and perceived implementation of resident rights between CNAs and nurses were examined in two ways. First, a comparison of the CNAs and nurses' responses to "How is the situation being handled?" revealed significant differences for three scenarios illustrating the use of chemical restraints, refusal of medications, and participation in activities. In all situations, a greater percentage of nurses answered that the situation was being handled correctly than CNAs (Table 2).
Next, the responses of the CNAs and nurses were examined separately using a series of McNemar tests to detect significant changes in the proportion of the respondents who responded correctly to question one (i.e., what should happen) compared to question two (i.e., what is happening). For CNAs, significant changes were found for 8 of the 1 1 scenarios (Table 3). In 5 of the cases (privacy, choices-bathing, voice concerns, respect, and activities), the responses of the CNAs suggested that although they knew what the appropriate response was, it was not the typical response to that type of situation within their facilities. For the other three scenarios (physical restraint, chemical restraint, and roommates), the CNAs were more likely to give incorrect knowledge responses. A similar pattern emerged for the nurses. Significant changes were found for 7 of the 1 1 scenarios (Table 3). In 5 of the cases (privacy, choices - bathing, physical restraints, voice concerns, and respect) they indicated correct knowledge but perceived less appropriate implementation. For the other 2 scenarios (awareness of health status and roommates), the nurses were more likely to give incorrect knowledge responses.
Comparison of Responses of "What Should Happen" and "What is Happening" with Resident Rights
Predictors of Knowledge and Perceptions
Multiple regression analyses were used to determine if the background of the nursing staff was predictive of their knowledge and perceptions of resident rights. Two independent variables were entered in the equation: years of education and years of work experience in long-term care. The dependent variables were composite scores of the number of correct knowledge (what should) and perceptions (what is) responses. For CNAs, neither years of education nor years of work experience were predictive of the number of correct responses given in the "what should" situations (F[2,45] = 1.39, p > .05). Both variables, however, were predictive of the total number of correct "what is" responses (/-[2,45J = 3.84, ? < .05; r2 (adj) = .11); CNAs with lower educational levels (Beta = -.34) and few years of experience working in long-term care facilities (Beta = -.16) gave fewer correct responses. For the nurses, no significant predictors were found for either the "how should" (F[2,34] = 2.35, p > .05) or the "how is" responses (iT2,34] = . 77, /»>. 05).
DISCUSSION AND NURSING IMPLICATIONS
The results of this study indicate that members of the nursing staff working in long-term care facilities are knowledgeable of resident rights.
For 9 of the 1 Í situations presented, the majority of respondents answered correcdy. Providing residents with information about their health status (Scenario 2) and choices about food (Scenario S) were the two areas in which the greatest percentage of both CNAs and nurses responded incorrectly. Nursing staff need to be taught strategies for dealing with these types of situations so they can uphold resident rights while maintaining professional boundaries and responsibilities. For example, although it is usually doctors or family members who provide resident information about their medical condition, some nurses may have authority to provide specific information about residents' health status. It is generally not appropriate for CNAs to discuss detailed diagnostic information with the resident. However, CNAs should not be put in a position where they cannot be truthful when a resident asks them a question, as competent residents have the right to know about their health conditions (OBRA '87, RL. 100203). One strategy for handling situations related to the health or diet of the resident may be to refer questions to the charge nurse or physician overseeing the care of the resident. Previous research suggests that CNAs who have an understanding of the lives of the residents report more positive attitudes toward residents (Boyd, 1994; Pietrukowicz & Johnson, 1991), thus it is also important to share the residents' conditions and rationale behind their treatment regimes with all members of the nursing team.
A few differences were found in the accuracy of responses between CNAs and nurses. In particular, nurses were more likely to respond correctly to situations concerning the use of physical and chemical restraints than were CNAs. These findings may be because nurses frequently are responsible for implementing physical and chemical restraints. They tend to receive more intensive education about the use of medicaand tions to participate on chemical and physical restraint review committees more than CNAs. However, the findings do show the need to increase CNAs' knowledge and understanding of restraint issues. In addition to designing training to enhance their awareness of restraints, the CNAs' involvement in care planning and participation on restraint review committees should increase. Such involvement helps CNAs better integrate the information into their daily work, encourages greater autonomy and decision-making among staff members, and subsequently improves the quality of resident care (Caudill, 1989; LeSar, 1987).
For all members of the nursing staff, actually implementing resident rights appears to be a difficult task. For almost one half of the scenarios, both CNAs and nurses perceived that resident rights were not upheld within their facilities. This finding suggests that although staff members can recite the resident rights, the constraints of the environment and the demands placed upon the staff may impede their ability to implement what they have learned (Kane et al., 1990). This appeared particularly evident for CNAs with fewer years of education and work experience. Years of education, however, did not appear to be an influencing factor for the nurses. Because we did not ask participants about the specific amount of education they had received in the area of resident rights, we can only speculate on the reason education did not consistently influence responses. It may be that within their formal academic training, the nurses received more education directly (i.e., in the classroom) and indirectly (i.e., supervised clinical experiences) about resident rights. The CNAs receive information about resident rights as part of their training, but this usually consists of one or two sessions in which the rights are explained. One way to address this dilemma is that inservice coordinators and other nurse educators within facilities should consider new training modalities to help all members of the nursing staff better apply their knowledge to day-to-day situations. For example, case-based training brings to life the issues that residents and staff encounter in the nursing home setting. This type of training encourages group discussions and facilitates problem identification and resolution. The use of this approach can help members of the nursing staff make the transition from the theory to putting the concepts into practice.
Another possibility for the differences found between knowledge and perception of implementation may be that the nursing staff are not finding the support within their facilities to follow through with the correct action. Given the structure and functioning of most nursing homes, the nursing staff and CNAs in particular may feel they are receiving mixed messages from their supervisors and advocates for resident rights. For example, respecting the rights and autonomy of the residents may mean spending time with them as they select clothing and prepare to leave their room. Yet, if they do not get residents to where they need to be on time they will likely be reprimanded for being behind schedule or not completing their assigned duties. In addition, CNAs often work short-staffed and report feeling that they have too much work and too many residents needing care (Wacker, 1996). This suggests that nurse educators may need to focus their inservice training, at least in part, on the development of timemanagement skills to help staff prioritize work duties and find areas where they can make better use of their time. Time-management training asserts that no matter how well individuals manage their time, there will always be issues that arise that cannot be anticipated. The key is to teach the nursing staff to remain flexible but focused. In addition, the inclusion of team-building strategies may be helpful so that each member of the nursing staff may obtain a greater awareness of one another's roles and the responsibilities of each member of the team.
The CNAs who find that a resident has a special need may be uncertain about their authority to respond (e.g., a request for chocolate by a diabetic resident - Scenario 8; wanting make-up on before going to breakfast - Scenario 9). Education and experience levels of the CNAs may apply here. Academic and inservice training programs need to focus on the improvement of communication skills, critical thinking, and problem-solving methods. Nurse educators need to teach CNAs ways of actually offering choice, giving self-worth, and providing for resident dignity (Erickson, 1987). In addition, participation in organized support groups may be beneficial. This type of training and support may help empower CNAs to identify problems and develop creative, thoughtful solutions to the barriers that prohibit nursing home residents from exercising their rights.
The findings of this study show the disparities between what should occur and what does occur with regard to the rights of individuals living in long-term care facilities. However, the findings are limited by the nature of the research design. The authors relied on a volunteer sample that provided self-reports of what actually occurred within facilities and thus were not able to verify respondents' subjective perceptions of what actually occurred or the frequencies in which such violations of rights transpired. It is also possible that respondents gave socially desirable responses to what actually happened within their facility. Future studies employing multiple means of data collection (i.e., observation, record reviews) and random samples are warranted. Also, specific demographic information was not collected that would have allowed comparison of the responses of nurses who were RNs compared to those who were LPNs. In addition to differences in education and training, we do not know how other factors such as the perceived personality or mental status of the resident influences the responses of the participants. These and other demographic, psychosocial, and environmental variables need to be assessed in future studies.
Overall, the findings from this study suggest that although the nursing staff of long-term care facilities have accurate knowledge of resident rights, they have some difficulties in implementing these rights in their everyday work. As suggested by others (Fischer, 1993; Kane et al., 1990) the structure of the nursing home environment is a complex set of intervening variables that makes the execution of knowledge complicated. Although OBRA '87 (RL. 100-203) initiated changes that have led to improved standards for quality of care and greater recognition of resident rights than in previous decades, there remains an unfinished agenda for achieving goals of improved quality of life for nursing home residents (Vladeck & Feuerberg, 1995/1996). As efforts continue in the transformation of the nursing home environment, the nursing staff will play a significant role in protecting and enhancing the rights of residents while assuring the quality of care provided.
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Background Characteristics of the CNAs and Nurses
CNAs1 and Nurses1 Knowledge and Implementation of Resident Rights*
Comparison of Responses of "What Should Happen" and "What is Happening" with Resident Rights