The rapidly growing aging population has led to an increasing demand for long-term care facilities and staff (Scanlon, 2001). Despite efforts to improve the quality of care in nursing homes, consumers and providers continue to be dissatisfied with various aspects of resident care (Scalzi, Evans, Barstow, & Hostvedt, 2006). Previous culture change interventions aimed at improving the quality of resident care have had mixed results or effected temporary improvements (Forbes-Thompson, Leiker, & Bleich, 2007). Consequently, researchers have begun to explore other factors that influence the quality of resident care and institutions’ ability to sustain improvements (Forbes-Thompson et al., 2007).
A naturalistic design using qualitative methods guided the data collection and analysis procedures (Patton, 1990). The naturalistic design allowed the researchers to observe CNAs’ activities and interactions in their natural work environment. The project was reviewed and approved by the university institutional review board.
Setting and Sample
Three nursing homes, all belonging to a not-for-profit chain, comprised the setting. Each home was located in a metropolitan area of the midwestern United States, had more than 100 beds, and was dually certified by Medicare and Medicaid. Sampling from three homes reduced the burden on any one home related to having researchers onsite observing and interviewing CNAs. In addition, using three homes allowed for potential variability among the CNAs’ experiences, thereby enriching the data collected.
Each director of nursing (DON) was asked to inform his or her staff about the study and invite participation. DONs were also encouraged to elicit participation from CNAs who performed at different levels and who had held their positions for varying amounts of time. Eligibility criteria for this convenience sample included being able to comprehend and speak English and to provide informed consent.
Qualitative data collection methods included participant observation, document review, and formal and informal interviewing. Participant observation was used to describe the context in which the CNAs worked, primarily the physical and social environment. Observations occurred in common areas, such as hallways, dining rooms, sitting areas, staff break rooms, activities rooms, and courtyards, and were documented in field notes (Patton, 1990). Approximately 28 hours of participant observation occurred in each of the three homes. Documents such as CNA job descriptions and policies and procedures were reviewed; resident medical records were not part of the data collection activities.
Formal and informal interviews were used to explore CNAs’ perceptions of their roles and experiences. Each CNA participated in two formal, audio-recorded interviews. The first interview included a consistent set of five broad, open-ended questions/statements for each CNA:
- What led you to become a CNA?
- Please describe what a typical day is like for you.
- What do you like most about your job?
- What do you like least about your job?
- If a friend told you he or she was thinking about becoming a CNA, how would you respond?
Each interviewer spontaneously used probing questions to gain clarity and encourage elaboration (Rubin & Rubin, 2005).
During the second interview, the researchers incorporated follow-up questions to gain depth and clarity, to explore emerging themes, and to test premises (Rubin & Rubin, 2005). These follow-up questions were developed for each CNA on the basis of their answers from the first interview. Informal interviews occurred spontaneously during two 4-hour blocks in which researchers “shadowed” the CNAs. Shadowing allowed the researchers to experience the CNAs’ day-to-day activities, and informal interviewing allowed the researchers to be discovery oriented and responsive to changing circumstances.
The research team was composed of 12 doctoral students involved in a two-course, two-semester qualitative research experience. Each student received training in participant observation and interviewing, as well as training and supervision during data analysis, as part of this experience.
Qualitative content analysis—a process of reflection, deconstruction of data into codes, and reconstruction into interpretive themes and patterns—was used to analyze the data (Coffey & Atkinson, 1996; Patton, 1990). Credibility of the study was maintained by triangulation of data sources, peer debriefing, and member checking.
Eleven CNAs from three nursing homes completed the study. Seven CNAs were Caucasian, 3 were African American, and 1 was Hispanic. The CNAs ranged in age from 22 to 54, and their years of experience ranged from 2 to 34. The three homes were in the process of implementing the neighborhood philosophy. The term neighborhood is often used interchangeably with culture change and resident-centered care as a philosophical orientation to care. The neighborhood philosophy represents a movement away from the hierarchical management structure of the traditional nursing home, where care is task oriented, to one that is resident centered. Resident-centered care represents a more homelike atmosphere and attitude. Accordingly, the staff members, especially CNAs, are empowered to be more involved in resident care planning and decision making.
Several CNAs described the neighborhood concept as innovative care that allows residents to make choices. One CNA summarized the neighborhood concept this way: “It is not task oriented; it is not driven by a certain time frame.” The overall goal of resident-centered care was referred to as “helping residents get through their day” and “giving them the best care.” When asked the meaning of the neighborhood concept, another CNA stated that it “allows CNAs’ ideas to be welcomed and values everyone’s ideas.”
Between the time the nursing homes agreed to participate in the study and the initiation of the study, all three nursing homes were incorporating culture change values and either starting or moving toward a neighborhood concept. This philosophical orientation was reflected in many of the CNAs’ responses. Although all three homes claimed to have adopted the neighborhood concept, each was in a different stage of transition.
The newest home, built based on the neighborhood concept, was made of brick and sat on several manicured acres. The décor inside created a comfortable homelike feeling. Residents lived in four uniquely named neighborhoods, such as Southern Heights (pseudonym). The living and dining rooms served as the central gathering place for the residents. French doors in each living area opened to an outdoor patio. Nurses used a small desk located in a corner of the living room to chart and make telephone calls. The medication carts resembled kitchen cabinets on wheels, with sides composed of stained wood panels.
The second home, built in the 1960s, was a four-story brick building facing a large parking lot. Inside, nurses’ stations on each of the three floors connected two long hallways or units. The nurses’ stations were traditional, containing books, chart racks, red medicine carts, and locked medication rooms. Each neighborhood was named similarly to the newer nursing home, although it lacked the small, congregate living spaces of the newer home.
The third home was similar to the second home in age and design. However, this home was undergoing remodeling to remove the nurses’ stations and large medication rooms to create central living and dining spaces for the residents. The neighborhoods were not given unique names but were instead referred to simply as Neighborhood A or Neighborhood B.
Four themes emerged from the observations and interviews that epitomize the experience of being a CNA in these three nursing homes: Transitioning Between Two Worlds, Responding to the Call, Living the Job, and Transcending the Job (Table).
Table 1: CNAS’ Experience in the Nursing Home: Major Themes, Characteristics, and Examples
Transitioning Between Two Worlds
The CNAs’ experiences reflected transitioning between two worlds. In one world, the institution provides care to numerous frail older adults, while meeting state and federal regulations. In this world, CNAs are replaceable workers. In the other world, the home offers a sense of community and a homelike environment where the residents’ individual needs and preferences are attended to. In this world, CNAs are considered valued members of the team and the community.
When asked, the CNAs described their work environment in terms of the neighborhood concept as, “more relaxed,” “less rigid and structured,” and “it allows you time and space to just slow things down…. A shower can be left off for today.” Yet, they also had to balance the need for efficient completion of necessary tasks with the desire to meet the unique needs and requests of each resident. One said:
It’s just that somehow, somewhere in the day, it’s up to you…how you’re going to implement and find the balance and not yet be so frazzled and burned out and disappointed that you didn’t get a task done. If they [the residents] say, perhaps tomorrow, then perhaps tomorrow. It’s a fine balance.
Although each home was in some phase of transition toward the neighborhood philosophy, there were definite reminders of a traditional institution. For example, staff break rooms were separated from the resident living areas, stark in appearance, and contained signs of rules and admonishments. Remnants of the nursing home staff hierarchy were also evident, such as when charge nurses ignored resident call lights and one DON was observed publicly scolding a CNA. When licensed staff did not help, the CNAs felt disempowered and were unable to attend to the individual needs of their residents. The CNAs expressed their feelings: “Some nurses don’t feel we’re important,” and “We’re at the bottom of the food chain.”
When teamwork was present, CNAs had contrasting perceptions. One CNA, describing the charge nurse, said, “She’s good. She’s here for the residents too. And if you tell her something…she comes and looks at it right away; she don’t put you off.” In summary, the CNAs’ experience of transitioning between two worlds was evident in the discrepancies between the neighborhood philosophy and the physical appearance of the homes, as well as in the behaviors of some of the staff.
Responding to the Call
Overwhelmingly, the CNAs revealed a yearning to care for others and to make a difference in someone’s life. Some referred to previous caring experiences when describing how they became a CNA. One participant shared, “I helped take care of my aunt when she was with us…. She was a quadriplegic, and I helped care for her, like give her baths and put her to bed, and things like that, and I decided that’s what I wanted to do.” One CNA explained why she had decided to become a CNA, rather than a nurse: “If you are a nurse, you do the paperwork, you don’t have hands-on care. I want to care for people, and I don’t live to do paperwork, and this is what I chose to do.”
In contrast to those who were drawn by their desire to care for others, one CNA was attracted by an image. Chuckling, she remembered, “I had a friend who…was all dressed up in his scrubs and had his stethoscope, and I said…‘He looks so important…’ [and] looks like you’re a doctor, or somethin’.” For some, the desire to become a CNA was manifested as a spiritual longing, a higher calling to serve humankind. Another CNA reflected, “I just felt led to it…you seem to brighten their [residents’] day, you know; just being able to serve was a self-gratification. I was giving back to someone, and it was gratifying to me.” Another CNA responded, “I see Him here in everyone, and especially this little man I was talking about. It was about something I could see in his face. I wanted to help him, help him with anything that he needed.” Finally, some participants referred to the reciprocal nature of serving the residents: “God put the resident here, so that I can learn from the resident, but also make a difference in that person’s life. That person helped me deal with some issues in my life.”
Whether the CNAs expressed a desire to care, an attraction to the image, or a wish to serve, the calling provided motivation to train as a CNA. Responding to the call was the first step; living the job came next.
Living the Job
The CNAs possessed a set of skills that went far beyond their technical training. They demonstrated flexibility in their management of numerous interruptions, critical thinking as they constantly reprioritized tasks, and discernment regarding residents’ individual needs. Finally, they demonstrated tremendous physical and emotional strength.
The CNAs’ days were filled with numerous repetitive tasks, such as getting residents up and laying them down, dressing, bibbing, feeding, toileting, wheeling, walking, assisting, grooming, bathing, passing water pitchers, putting in hearing aids and dentures, setting alarms, and answering call lights. They maintained a constant flow of movement from one resident to another, repeating the same tasks over and over throughout the day. The days were exhausting, yet rewarding. One CNA said:
You feel exhausted, but yet you feel proud because you’ve accomplished all that stuff in a short time…. You feel like you’ve done something, you know; you feel like you’ve accomplished something. Like you’ve taken care of somebody that can’t take care of themselves…. You’ve been there for them, and it makes you feel good…another day done. They’re happy.
Although the CNAs performed the same tasks every day, their work can be described as predictably unpredictable. Frequent interruptions challenged their ability to complete essential tasks efficiently. One CNA referred to the challenge this way: “When a resident has diarrhea five times in a row, and you have to change the bed, clean them up, give them a shower, plus get all your other things done.” They often demonstrated flexibility in managing the numerous interruptions in the daily routine. While moving deftly from one resident to another, they reprioritized tasks repeatedly on the basis of new information, such as a resident’s changing health status or personal requests, family requests, or staffing changes. One CNA appreciated the flexibility that was expected as part of the neighborhood philosophy of resident-centered care: “You have more options to where it is you’re going to get your tasks done.” But she also noticed less experienced CNAs struggling to find a balance between completing the necessary tasks and accommodating interruptions in the routine: “It’s a balance…still yet I hear my coworkers struggle with finding the balance. They struggle with finding a balance.”
The CNAs knew their residents very well, having learned their behavior patterns and their likes and dislikes. One CNA said, “You take care of them every day, and you know…every little move that they’re gonna make.” Knowing the residents enabled the CNAs to discern when it was necessary to encourage them to do a task for their own well-being. For example, the CNAs understood when they could allow a resident to miss exercise class versus when they needed to push the resident to attend.
Several CNAs verbalized the importance of slowing the pace with the residents to ensure their health and safety. One noted that “taking it slow feeding them [was important so] that they might not get choked and they’re getting the fluids in between the different bites.” Another CNA asserted, “If you’re going too fast, you don’t want to give them a skin tear, so you have to slow down.”
The CNAs demonstrated a level of intuition and discernment regarding changes in the residents’ health status. Recognizing subtle changes prompted early treatment for serious problems, such as urinary tract infections and pneumonia. One CNA declared, “I know my residents really well. Just looking in their eyes, we can tell when something is not right. You know that they don’t have the gloss in their eyes that they used to.”
Being a CNA required enormous strength, both physically and emotionally. A strong stomach was essential. One CNA gave advice for those who were considering becoming a CNA: “I mean you’ll run into all [kinds of] incontinence, accidents, where people get sick to where they vomit, or even death. If you can’t tolerate that…I mean if you don’t have the stomach for that, you really shouldn’t be doing it.” Another described the CNA’s job as “hard work. Got to be willing to do what you need to do to help out that resident, regardless of what it is. If you get queasy to your stomach, it doesn’t matter. You have got to help that resident out.”
The work was physically demanding, particularly on floors where residents needed complete assistance. Years of heavy lifting, despite good body mechanics, had taken a toll on many of the CNAs. Several described their own back, neck, and arm injuries that had occurred while lifting residents and have considered making changes to prevent further injury. One said, “Going to nights [shifts] would be easier on my back.” Another used her own injury to teach other CNAs about proper body mechanics: “And I hurt my back…that’s why I keep telling them ‘That’s why you raise that bed up when you turn them…don’t bend that back. Use your head, save your back.’”
Emotional strength was also necessary. Death was inevitable and often difficult, depending on the CNA’s relationship with the resident. The loss was personal and real. One CNA reflected, “Seeing…one you really really cared for…[who] just lit up the room when you walked in…[having] passed on; the heartbreak.” Remembering the living helped put death in context. One CNA said, “You know you’re going to miss ’em, but you have other people to take care of.” Some drew on their spiritual beliefs for emotional strength. One CNA pondered, “God has allowed them so much time in the earth and…seeing death upon them… I have to come to the conclusion it’s time to let them go.”
Transcending the Job
Transcending the job represented the ability to move beyond performing the day-to-day routine and involved integrating caring behaviors with the essential tasks. The CNAs who transcended the job developed relationships with residents that were deeper than feelings of responsibility. One CNA reflected, “I know they love me as much as I love them. That’s why I stay.” Their connections were intimate and cherished, extending beyond feeling valued by the residents to include valuing the residents themselves: “When a resident says ‘thank you,’ it’s like they feel the love that you have for them in the care.”
The wisdom of those who transcended the job did not necessarily reflect their age or expertise in the field, but rather an insightful worldview that included valuing relationships and service to humanity. In fact, a few young participants, with fewer than 5 years of experience, displayed tremendous innate wisdom. In the words of one young, new, and perceptive CNA:
Being a CNA speaks to the person’s integrity. These residents have families; they are loved by someone…. You are caring for a real person. They cannot tell you everything they need, so we have to know [italics added] them and…know what they need all the time…. We provide for their physical, psychosocial, spiritual, the whole person…. The caring involves a lot of touch…just being present around them, I think, is one important thing…. A caring touch, you know, just for comfort…for emotional support.
The CNAs often referred to the daily tasks as more of an offering of service for the purpose of giving to and being with the residents, rather than just doing for them. Acts of sharing became a treasured part of the experience—sharing space, moments, stories, photographs, advice, laughter, tears, and hugs. One CNA remembered tearfully, “The resident was needin’ me, and she was depressed. Her family never came to see her, and I was all that she mainly seen, so I sat down and gave her a manicure. It enlightened me to see her smile.” Another CNA spoke fondly of her experience: “You feel you are a part of the family, you know…. If someone has a problem and is not happy, you notice this lady, she has changed…you see they become part and parcel of one another…. We become one family.”
The CNAs who integrated the job into their own sense of self understood the true context of the work as one that included developing significant relationships and connections with residents and other staff members. As one young CNA of 2 years so wisely stated, “Without the connection, it’s just a job.” Another wise CNA reflected on why she was still a CNA after 10 years: “I still have the passion…it’s in my soul.”
Many of the CNAs in this study felt called to the job and expressed a heartfelt passion for what they did. They described their job as physically difficult and mentally challenging, necessitating various kinds of strength to complete the daily tasks. The unpredictable nature of the job often required flexibility and quick action. The CNAs understood the importance of their role as the staff members who worked most closely with the residents. They cherished their intimate relationships with certain residents, which provided motivation for them to return to work each day. However, remnants of an institutional model combined with staff hierarchy affected CNAs’ ability to care for residents. In addition, CNAs knew they were experts on the residents, yet their knowledge was not always elicited or valued.
CNAs who transcended the job moved beyond difficult daily care tasks and staff hierarchy. They revealed a profound wisdom that allowed them to honor the process of connecting with their residents, not as objects of care but as valuable human beings. Findings from this study offer suggestions for improving CNAs’ work environment and daily experience, thereby potentially reducing turnover and improving resident care.
Identifying and Nurturing the Passion for the Job
Passion for the job and a longing to make a difference are desirable qualities in any employee. These qualities, coupled with an adequate skill set, can generate CNAs who are committed to enhancing residents’ lives. Hiring practices can be developed that identify the individuals who have a similar caring passion. Pennington, Congdon, and Magilvy (2007) found that second-career CNAs tend to have altruistic intentions and are more influenced by relationships and the desire to make a difference than by money. In addition, second-career CNAs expressed their values and ideals through their work and sought to transform nursing home care. Recruitment strategies that target second-career CNAs may also increase the number of potential mentors who can serve as role models for new CNAs.
Supporting the Balancing of the Daily Tasks with Relationships and Sense of Community
For CNAs, the day-to-day work is physically and emotionally difficult. They struggle to find and maintain a balance between the task-oriented needs of residents (e.g., bathing, feeding, toileting) and developing relationships and building community. The ability to find a balance is a skill that cannot be taught in an 8-week CNA program or a brief job orientation. New CNAs need support systems that teach them how to balance the essential care tasks with the development of human connections. Longer orientations, followed by preceptorships with seasoned CNAs, would allow them to observe and rehearse ways to maintain that balance. This kind of mentored on-the-job training allows model CNAs to impart their wisdom and knowledge on, and develop relationships with, new CNAs. Further, experienced CNAs need opportunities to feel empowered and valued. Having the role of an expert mentor highlights their importance in the care of residents and the organization. In addition, career ladders might be created, allowing for the advancement and recognition of expert CNAs.
Spending consistent time with residents helps CNAs become familiar with residents’ patterns of health and behavior and their likes and dislikes. Familiarity with their residents promotes the development of relationships, as well as the CNAs’ expertise in making care decisions on the residents’ behalf. In one study, when CNAs were allowed to care for familiar residents on days they were short staffed, they found ways to combine cares that were not harmful to the residents (Bowers et al., 2000). In contrast, CNAs who were unfamiliar with the residents were more likely to take detrimental shortcuts with their care. Consistent CNA-to-resident interactions are essential for the development of relationships and, ultimately, the improvement of resident care.
Valuing the CNAs’ Knowledge of the Residents and Their Contributions to the Care Team
Researchers have documented that CNAs’ decisions to leave their jobs were influenced less by hard work and low pay than by feeling devalued by administration (Bowers et al., 2003). Successful nursing home communities have demonstrated that they value CNAs by seeking their input on resident care planning, providing mentoring activities, and respecting their work (Pennington et al., 2003). Important, then, is the adoption of policies and practices that create an atmosphere of valuing and appreciating CNAs’ contributions. Personal gestures of appreciation such as recognizing birthdays or organizational gestures such as offering career ladders can make a difference in CNAs’ morale (Forbes-Thompson et al., 2007). Further, CNAs must be empowered and then allowed to make decisions regarding resident care tasks. The culture change movement, or the neighborhood philosophy, views the empowerment of CNAs as one of its central tenants. However, many homes have yet to adopt this philosophical orientation to care. RNs, including advanced practice nurses, must learn about culture change movements and foster the implementation of these care strategies in the homes where they work.