Ms. Harahan is Independent Consultant and Senior Advisor, Ms. Sanders is Senior Research Associate, and Dr. Stone is Executive Director, LeadingAge Center for Applied Research, Washington, DC. Dr. Bowers is Professor, Ms. Nolet is Outreach Specialist, Dr. Krause is Faculty Associate, and Ms. Gilmore is a doctoral student, University of Wisconsin-Madison, Madison, Wisconsin.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This project was funded by the California HealthCare Foundation. Predoctoral funding for project member Melanie Krause is supported by the National Institutes of Health National Research Service Award (5F31NR010039-03). The project team thanks Aging Services of California and Anne Burns Johnson for consultation and assistance throughout the project.
Address correspondence to Alisha Sanders, MPH, Senior Research Associate, LeadingAge Center for Applied Research, 2519 Connecticut Avenue, NW, Washington, DC 20008; e-mail: email@example.com.
While evidence suggests that the primary supervisors of direct care staff in nursing homes are often licensed practical nurses (LPNs)—also called licensed vocational nurses (LVNs)—little research has focused on these LVN supervisors or their supervisory skills. Researchers have found that supervisory and leadership training are rarely included as part of LVN educational programs or continuing education (Noelker & Ejaz, 2001; Reinhard & Reinhard, 2006; Riggs & Rantz, 2001; Seago, Spetz, Chapman, Dyer, & Grumbach, 2004) and that LVNs in particular lack self-awareness regarding their limited supervisory and leadership skills (Siegel, Young, Mitchell, & Shannon, 2008).
The purpose of this article is to describe the development, implementation, and evaluation of a supervisory skill education program for LVNs. Project LVN LEAD (Leadership, Enrichment, and Development) is a curriculum designed to increase LVNs’ leadership and supervisory capacities. This project was developed collaboratively by the LeadingAge Center for Applied Research (formerly known as the Institute for the Future of Aging Services), the University of Wisconsin-Madison School of Nursing, and Aging Services of California. The project had four objectives: (a) develop and pretest a leadership and supervisory training program for LVNs in four California nursing homes; (b) assess the feasibility of implementing and evaluating the program on a broader scale; (c) identify barriers to widescale implementation and how they might be resolved; and (d) evaluate the program’s impact on participants. The development of the curriculum and its implementation and evaluation were funded by the California HealthCare Foundation.
Although RNs are ultimately responsible for supervising and delegating in long-term care settings, this work often falls to the LVNs, who are usually the nurses in charge of units. According to 2008 data collected by the National Council of State Boards of Nursing, 62% of LPNs/LVNs working in long-term care facilities reported they are charge nurses, directing and supervising the work of certified nursing assistants (CNAs) (Wendt, 2009). Another 7% reported they are team leaders. Anecdotal evidence suggests there are times when LPNs/LVNs are the only nurses in the nursing home, other than the director of nursing (DON). In California, the overwhelming majority of nurses in nursing homes are LVNs (Harrington & O’Meara, 2004). During the course of this project, it was clear few RNs were employed in the four participant homes and that the LPNs/LVNs had primary responsibility for supervising frontline workers.
Numerous studies have found that the nursing home work environment—particularly the relationship between charge nurses and CNAs—is an important factor in CNA job satisfaction, turnover, and quality of care (Bowers, Esmond, & Jacobson, 2003; Dellefield, 2008; Eaton, 2000; Kemper et al., 2008; McGilton, Hall, Wodchis, & Petroz, 2007; Tellis-Nayak, 2007). Prior research (Bishop, Squillace, Meagher, Anderson, & Wiener, 2009; Bowers et al., 2003; Harahan et al., 2003; Kemper et al., 2008; McGilton et al., 2007) has documented the pervasive experience of CNAs as feeling disrespected, under-appreciated, and generally excluded from resident care decisions, particularly by LVN supervisors. Lack of respect by their supervising nurse has also been repeatedly identified by CNAs as an important factor in their organizational commitment (Bishop et al., 2008) and their desire to leave their job (Brannon, Barry, Kemper, Schreiner, & Vasey, 2007; Parsons, Simmons, Penn, & Furlough, 2003).
A prior study conducted by the current research team (Harahan et al., 2003) suggested that licensed nursing staff routinely dismissed the importance of supervisory skills and seemed largely unaware of the CNAs’ generally negative perception of nurses’ supervisory ability. Despite the well-documented importance of supervisory and leadership skills and the pervasive lack of such skills, few studies have investigated the supervisory roles performed by LVNs in nursing homes or the impact of supervisory training on themselves or the people they supervise.
A review of nurse management training and leadership development programs found few targeted at nurses in long-term care settings (Reinhard & Reinhard, 2006). An extensive review of the research on nurse leadership training in nursing homes concluded that effective programs must include four elements: interpersonal, clinical, organizational, and management skills (Harvath et al., 2008). The authors were not able to identify any programs for LVNs that met all of these criteria.
Six key activities were undertaken during the period prior to delivering the LVN LEAD training program (Table 1). These activities were designed to inform development of the LEAD curriculum and training implementation. The institutional review board determined this project was for curriculum development and evaluation, thus exempting it from federal human subject research regulations; however, the highest ethical standards to protect those involved with the project were followed.
Table 1: Data Collection Methods and Purpose Prior to LEAD Training
Stakeholder Views of LVNs
Nine stakeholders were interviewed by telephone and through in-person interviews (Table 1). There was agreement that LVN education programs did not include preparation in leadership and supervision of CNAs. When asked to describe LVN work, stakeholders mentioned medication pass, clinical treatments, and monitoring patient conditions. Only one comment included supervising CNAs. One stakeholder suggested that, often coming from the ranks of CNAs themselves, LVNs found it difficult to act in a position of authority over individuals who had previously been their peers. One administrator described LVNs as lacking a professional identity and was consequently unclear about their role in motivating, teaching, and coaching CNAs.
CNA Focus Groups
Two focus groups were convened with CNAs who were not employed in the pilot sites. CNAs identified the following “ideal charge nurse” characteristics/activities:
- Sharing information about residents, particularly at admission and between shifts.
- Performing direct care tasks appropriately and on time (not making residents wait).
- Listening to residents and responding to their needs.
- Helping with call lights and vital signs and working as part of a team.
- Treating CNAs fairly.
- Speaking in a language other staff and residents can easily understand.
- Coaching CNAs.
- Acknowledging CNAs and their work.
LVN Focus Groups
Two focus groups were held with LVNs. Initially, several LVNs said they were too busy to handle supervisory tasks in addition to their patient care and regulatory responsibilities and suggested it might be the director of staff development’s responsibility to educate CNAs about proper patient care techniques. Later in the focus group, several LVNs began to express a lack of confidence about engaging in supervisory and leadership activities, saying it was hard to teach CNAs the proper way to do things because CNAs became defensive. LVNs also expressed discomfort with trying to resolve conflicts among staff and believed this was the role of the DON or other supervisor.
Four northern California nursing homes perceived as high performing, on the basis of annual survey results and active participation in state quality improvement initiatives, were selected to pilot the leadership curriculum. These included two for-profit and two not-for-profit facilities, ranging in size from 59 to 174 beds. One of the sites was dropped from the study after the first round of training when administrator turnover became a barrier to participation.
Pilot Site Management Interviews
As part of the planning process, the project team asked managers (administrators, DONs, and staff development directors) at pilot sites to identify topics they believed should be addressed in the leadership program. Several managers mentioned coaching and mentoring skills as well as the importance of identifying “teachable moments” that provide an opportunity for them to mentor CNAs. Improving communication skills was identified as a high priority, along with problem-solving and critical thinking skills. Managers also wanted more LVNs to devise their own solutions to problems rather than referring them on to managers.
Pilot Site Surveys
Prior to training implementation, pilot site CNAs and nurses were surveyed about aspects of their jobs regarding satisfaction and supervision. Details on the survey and sample can be found in the Results section below.
LVN LEAD was designed to provide charge nurses with skills, knowledge, and competencies that enable them to:
- Understand the importance of their role as leaders and role models.
- Better communicate with all levels of personnel within a facility, but particularly with the staff they directly supervise.
- Develop skills in coaching and mentoring CNAs.
- Enhance critical thinking skills.
- Develop strategies for resolving conflict in the workplace.
- Understand how culture can influence their own leadership style and skills and how others’ culture affect work styles.
- Work more effectively with management.
LVN LEAD was developed as a series of seven 1-hour modules on the above topics that could be taught in 1 day or over several time periods, along with companion “booster” materials to be given as a follow-up post-module. Thirty-seven nurses, predominantly LVNs, from four nursing homes participated in the program.
The curriculum was grounded in adult learning theory and guided by previous research (Harahan et al., 2003; Harvath et al., 2008; Scott-Cawiezell et al., 2004), as well as feedback from interviews and focus groups with administrators, CNAs, LVNs, and pilot site managers. The learning exercises were carefully tailored to be consistent with the participating nurses’ daily practice, and participants were provided opportunities to discuss the exercises and how they might apply the knowledge to their daily work.
On the basis of the project team’s past research and published literature on the importance of administrative involvement in practice change, the project team included administrative staff in the planning and implementation. Project staff met first with administrators to discuss the project and to decide how administrators would support the staff in their implementation efforts.
Evaluation of the project focused on the following questions:
- How did CNAs in the pilot sites view the skills of their supervisors?
- Did CNAs believe that charge nurses were supportive and helpful to them?
- Did the CNAs believe that charge nurses promoted their learning?
- How did charge nurses view their own leadership capabilities?
- Did charge nurses believe it was their role to coach and mentor CNAs?
- Did charge nurses change their behavior following the program?
- What implementation obstacles were encountered?
As previously stated, one of the four participating facilities could not sustain participation beyond Session 1 of training and did not complete posttraining surveys or interviews.
Data Collection and Instruments
Quantitative data were collected through baseline and follow-up surveys with the CNAs and nurses in the four pilot sites, along with a satisfaction survey with the nurses who attended the LVN LEAD training sessions. Qualitative data were collected through baseline and posttraining interviews with management in the pilot facilities and posttraining interviews with LVN participants in the training program.
CNAs and LVNs were surveyed at baseline and posttraining to evaluate impact. CNAs were asked about job satisfaction, satisfaction with charge nurse supervision and support, communication patterns within the facility, and issues raised by the cultural diversity of staff. Charge nurses were surveyed about their supervisory roles, supervisory skills, communication, cultural competency, and workplace support. Survey items were taken from the 2004 National Nursing Assistant Survey/Nursing Assistant Questionnaire (Centers for Disease Control and Prevention, 2004), the General Job Satisfaction Scale derived from the Job Diagnostic Survey (Hackman & Oldham, 1980), the Better Jobs Better Care Survey of direct care workers (Kemper et al., 2008), and the Readiness Assessment Tool for Nursing Homes developed by the LeadingAge Center for Applied Research (Agency for Healthcare Research and Quality, 2007). One hundred CNAs in three pilot sites and 18 nurses completed the survey approximately 6 months posttraining.
In addition to the survey data, in-person and telephone interviews were conducted with 10 LEAD participant LVNs at 1 month postprogram and with 20 participants 6 months post-program to assess perceived changes in their working relationships with CNAs, what they had learned in LVN LEAD, and their ability to apply what they learned. Thirteen CNAs were also interviewed approximately 8 weeks after the LVNs completed the program to gain their perceptions of any changes in charge nurse behavior. Finally, the leadership teams were interviewed via telephone multiple times posttraining to identify any changes in work environment that could be associated with the training program.
The survey results were analyzed using descriptive statistics. Due to the small sample and exploratory nature of this analysis, facilities were aggregated for the analysis. The means and medians for specific items were calculated. Cross tabulations and chi-square tests were used to determine whether any statistically significant differences existed between baseline and follow up. The interview and focus group transcripts were analyzed using qualitative thematics by senior members of the project team (A.S., B.J.B., K.A.N.). Results from statistical analysis were compared with the qualitative themes.
Comparisons of perceptions of working relationships between LVNs and CNAs before and after the leadership program revealed some consistent differences between LVN and CNA perceptions of LVN leadership ability. The pre-/postprogram comparison also suggested some project impact on LVN charge nurses’ coaching and mentoring skills, although few comparisons were significant at alpha = 0.05.
Pre-Training Survey Sample. The pre-training survey sample included 130 CNAs and 57 LVNs. Of the CNAs surveyed, 80% were women with a median age of 44 and a median length of employment in their current facility of 3 years. The majority of CNAs identified themselves as Asian (61.6%) or Black (24%). Of the nurses surveyed, 89.5% were women with a median age of 43.5 and a median length of employment in their current facility of 4 years and 8.5 months. The majority of nurses identified themselves as Asian (77.2%) or Black (12.3%). Pilot site management acknowledged that staff who identified themselves as Asian were primarily Filipino.
Posttraining Survey Sample. The posttraining survey was administered to a total of 100 CNAs and 26 LVNs. Of the CNAs surveyed, 83% were women with a median age of 44 and a median length of employment in their current facility of 3.5 years. The majority of CNAs identified themselves as Asian (74.5%) or Black (13.3%). Of the nurses surveyed, 92% were women with a median age of 49.5 and a median length of employment in their current facility of 4 years. The majority of nurses identified themselves as Asian (76.9%).
LVN Survey. Charge nurse descriptions of their supervisory skills were consistently high both before and after the leadership program. Before and after the program, charge nurse respondents agreed with statements: “I provide clear instructions when assigning work” (100% and 100%, respectively), “I treat all nursing assistants equally” (100% and 100%), “I help CNAs with their job when they need it” (100% and 100%), “I listen to CNAs when they are concerned about a resident’s care” (100% and 100%), “I tell CNAs when they are doing a good job” (100% and 100%), and “I discipline or remove CNAs who do not do their job well” (83% and 80%).
CNA Survey. In contrast to the LVNs’ perception of their supervisory skills, CNAs rated LVN supervisory skills consistently lower both before and after the leadership program. However, most CNA ratings of LVN supervisory skills improved following the training program. Both before and after the program, most CNA respondents agreed with the statements: “My charge nurse listens to me when I am worried about a resident’s care” (86.7% and 87.2%, respectively), “My charge nurse provides clear instructions when assigning work” (85.3% and 93.9%), “My charge nurse helps me with my job tasks when help is needed” (83.7% and 80.7%), “My charge nurse tells me when I am doing a good job” (82.8% and 83.3%), “My charge nurse is open to new and different ideas, such as new or better ways of dealing with resident care” (77.9% and 88.3%), “My charge nurse is supportive of progress in my career, such as further training (77.1% and 89%), and “My charge nurse disciplines or removes other nursing assistants who do not do their job well or share of their work” (63.7% and 57.7%). Two items from baseline survey data, “My charge nurse provides clear instructions when assigning work” and “My charge nurse is supportive of progress in my career, such as further training,” showed statistically significant differences after the training program (Table 2).
Table 2: CNA Strongly Agree/Somewhat Agree Responses to Selected Measures of Charge Nurse Support
Prior to the implementation of the training program, 51% of nurses and 45.6% of CNAs agreed with the statement that “Sometimes there are problems between staff of different races and cultures.” Posttraining, more nurses (68%) and CNAs (46.3%) agreed with this statement. This could indicate nurse participants were more aware of cultural differences. Prior to the program, more than 44% of CNA respondents reported that some staff members had a hard time doing their jobs because of language and/or reading difficulties. After the program, 47.9% of CNA respondents agreed with this statement.
The research team was unable to make a more meaningful comparison of self-reported changes in nurse behavior between the baseline and follow-up surveys because of ceiling effects. Charge nurses rated themselves so highly at the baseline on the items designed to measure their relationship to CNAs that it was not possible to detect changes after the program was completed. CNAs also rated their charge nurses very highly at baseline, making it impossible to discern a measurable change.
Postprogram Interviews with LVNs. Subjective experiences shared by LVNs have provided some sense that the program had a positive impact. Twenty of the 32 nurse participants were interviewed 6 months after the end of the training program to find out whether they were able to apply what they learned, and if so, how. Almost all nurses said they had never before received any training in leadership and supervision. The majority said the training program helped them become better at listening to and soliciting CNAs’ input regarding patient care needs, consistently communicating patient status and care planning with CNAs, and providing feedback to CNAs. One LVN stated, “I listen to their ideas now and I didn’t before. Before, I said ‘You need to do it this way.’ I didn’t realize that they could have good ideas, because they deliver so much of the care.” Another LVN observed, “I try to be more assertive than before; I try to talk to CNAs. I asked them ‘What are your suggestions?’” These LVNs transitioned from viewing their role solely as a nurse in charge of patient care to viewing themselves as leaders who have the capacity to teach and mentor.
The module on mentoring and coaching seemed to make a significant impression. One nurse expressed a new understanding of her teaching and coaching roles, capturing its essence when she said, “You are teaching them all the time, especially the new ones. It opened my eyes. I now tell them ‘I’ll show you and you watch, and then you try it and I’ll watch.’” Several other nurses also pointed out they were now more conscious of the importance of explaining to CNAs why particular clinical tasks were important and sharing outcomes with them.
Managers’ Perceptions of Training Impact. Managers at the three pilot sites that remained in the project were interviewed after each training session. They described many concrete examples of behavior changes they attributed to the training program. For example, a DON in one site required all nurses to select a goal they want to work on as part of their annual performance review. She said for the first time many of her nurses picked coaching, telling her they had learned they needed to be more respectful of the CNAs. An administrator at another site stated the project helped him understand that supervising staff was more of a coaching process than a punitive one.
A director of staff development observed, “I see a couple people out on the floor who would never go out on the floor before and are now working with CNAs and answering lights.” Another director of staff development mentioned she had seen a particularly quiet charge nurse coaching a CNA for the first time.
Implementation Barriers. Upper management instability posed a particular challenge to successful implementation of strategies learned during the program. The loss of an administrator in one facility led to the withdrawal of the entire facility from the training program. The DONs at two of the remaining sites also vacated their positions during the course of the study. This was a consequential loss for the training program, as the research team expected them to play a major role in motivating and reinforcing staff participation in the training program and implementing skills on the job.
In the judgment of the project team, evaluation findings supported program goals. The data affirmed the need for a training program to help build the leadership and management capacity of the LVNs in California nursing homes. One of the major successes of the pilot was the recognition by many LVNs that they were leaders and had a responsibility to manage their units, to communicate with and mentor the CNAs, and to develop a team approach to service delivery.
While leadership instability did not interfere with gaining the requisite participation of LVNs among the three organizations that remained in the study, it may have contributed to less ownership of project goals and less probability of lasting effects from the intervention. At the beginning of the program, each leadership team was asked to develop a plan to sustain the program in the future. Many discussions were held with upper management to identify strategies for institutionalizing project goals. However, little guidance was provided by the project team, as the scope of the project and timeline did not permit this activity. In addition, none of the managers set any real expectations for LVNs prior to their attending the training program and few prompted concrete follow up. A cognitive dissonance seemed to exist between what upper management thought they were doing and what they actually did to support the program. As a result of this project, the research team has concluded that any replication of the training program must include more specific guidance for and involvement from the facility’s upper-level management.
During the training sessions, a number of “natural mentors” were observed helping other participants. Efforts to expand and replicate the training program should carefully consider how to formally use these natural mentors in an effective and encouraging manner. The directors of staff development in the project sites maintained important relationships with both CNAs and LVNs, and, in most cases, seemed respected by both groups of staff. Therefore, it may be advantageous to use directors of staff development as supports for the LVN training program to create a pivotal link between the LVNs and upper management.
The project team also learned from many individuals involved that cultural orientations are believed to create conflict and misunderstanding among staff. The research team observed how the cultural orientation of these nurses influenced their behavior and found that some tensions at the pilot facilities appeared to be a product of differences in cultural orientation. Because of this, the researchers believe this project underscored the importance of including cultural competence in leadership training and the application of this knowledge in daily practice.
Implications for Nursing Practice, Education, and Research
The responsibilities of nursing home LVNs in the supervision and management of CNAs have been largely understudied. While there is a need to recruit and retain more RNs as part of the effort to improve nursing home quality, the reality of the role of LVNs as charge nurses and team leaders should also be acknowledged, strengthened, and supported. The following recommendations for next steps in research and continuing education for LVNs have emerged from this pilot study:
- Create a broader awareness of the role the LVNs play in quality long-term care delivery.
- Modify education and competency requirements to assure that new LVNs are prepared to assume leadership and supervisory responsibilities.
- Integrate supervisory and leadership training and support into continuing education requirements for LVNs.
- Revise the scope of responsibilities of the director of staff development to support LVNs in their leadership and supervisory roles.
- Evaluate the impact of leadership and supervisory training on LVN and CNA job satisfaction, turnover, and quality of care.
Poor supervision by charge nurses is an important contributor to turnover among CNAs, which in turn, negatively influences quality of care. Unfortunately, charge nurses often do not recognize themselves as leaders. Nursing homes must not only clearly spell out their expectations for charge nurses, but also establish systems, policies, and practices to support LVNs’ supervisory role. Because LVNs receive little supervisory training during their formal education, training programs such as LVN LEAD are crucial to help charge nurses develop their supervisory skills. This program evaluation demonstrated that LVNs are interested in strengthening their supervisory skills and perceive an improvement in their work relationships when they use those skills. Nursing homes that offer supervisory training such as LVN LEAD and cultivate systems to support LVNs’ role as supervisors are likely to realize important increases in staff satisfaction, reductions in staff turnover, and improvements in quality of care.
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Data Collection Methods and Purpose Prior to LEAD Training
||Review evidence based on nurse leadership and supervision in long-term care and adult learning techniques.
|Stakeholder interviews (n = 9)a
||Obtain input on the role of charge nurses and what is needed to strengthen their leadership and supervisory capacities.
|CNA and LVN focus groups (CNAs, n = 23; LVNs, n = 16)
||Obtain feedback on what makes a good charge nurse and the areas in which charge nurses need training.
|Telephone and in-person interviews with pilot site management team members (administrators, directors of nursing, directors of staff development)
||Solicit perspectives on their concerns about the performance of charge nurses in the facility and the areas in which they need to strengthen leadership/supervisory abilities.
Identify the organizational structures necessary to help implement and sustain the knowledge and skills acquired by participants in the training program.
|Baseline survey of CNAs in four pilot facilities (n = 130)b
||Gather CNA perspectives on their job satisfaction, support received from charge nurse, communication across staff, and issues with cultural diversity within their facility.
|Baseline survey of charge nurses in four pilot facilities (n = 57)c
||Obtain nurse perspectives on their supervisory responsibilities and skills, support received from facility leadership, communication across staff, and issues with cultural diversity within their facility.
CNA Strongly Agree/Somewhat Agree Responses to Selected Measures of Charge Nurse Support
||% Baseline (n= 99)
||% Follow Up (n= 100)
|My charge nurse listens to me when I am worried about a resident’s care.
|My charge nurse provides clear instructions when assigning work.
|My charge nurse helps me with my job tasks when help is needed.
|My charge nurse tells me when I am doing a good job.
|My charge nurse is open to new and different ideas, such as new or better ways of dealing with resident care.
|My charge nurse is supportive of progress in my career, such as further training.
|My charge nurse disciplines or removes other nursing assistants who do not do their job well or share of their work.