Occasional LTC Policy Paper Series
Duke Long Term Care Resources Program Paper No. 9
Recruitment and Retention of Nursing
Assistants: Community Perspectives on a National Issue
Patricia J. Capehart, BSW, MPA
In this Occasional Policy Paper, Patricia Capehart reviews the
outcomes of a focus group, a survey, and a dialogue in Beaufort
County, North Carolina, sponsored by the Duke Long Term Care
Resources Teaching Communities Program and the Mideast Commission
Area Agency on Aging in December 1997 to
explore how communities can approach the challenge of the recruitment
and retention of nursing assistants. Capehart is an alumna
of Greensboro College, East Carolina University and the Senior
Leadership Enhancement Initiative of the Duke Leadership in
an Aging Society Program. From 1987 to 1996, she was the director
of the Beaufort County Department of Social Services. Now retired,
she is active in county, regional and state volunteer activities
related to aging and long term care.
The Challenge: Recruiting and Retaining
Nursing Assistants
One of the most pressing problems in meeting the long term care
needs of older adults is recruitment
and retention of nursing assistants, the caregivers who
provide 90% of direct patient care. It
is estimated that over one million additional frontline workers
in long term care will be needed by the year 2005. (Monthly
Labor Review, November, 1993). The demand for long-term care
services will far outstrip the supply of those aides who, through
training, have been certified (CNAs). Unless we find new solutions,
large numbers of people in need of long-term care will have
no one to provide it. Providers are already experiencing the
effects of rapid turnover with nursing assistants which affects
quality of care and significantly increases costs for recruitment
and training. Various dimensions of this problem were identified
in a recent discussion in Eastern North Carolina in which participants
shared experiences and considered recommendations for action.
The Cross-Cutting Nature of the Challenge
Recruitment and retention of certified
nursing assistants is a national, state and local problem which
cuts across multiple agencies and impacts both public and private
sector providers. This is how the CNA problem looked
in December, 1997, when the Duke Long
Term Care Resources Teaching Communities Program and the Mideast
Commission Area Agency on Aging co-sponsored a preliminary
discussion of the issues surrounding CNA recruitment and retention
in Beaufort County. The dialogue was initiated to help frame
the CNA recruitment and retention issue for policy makers and
to provide a fruitful sounding board for future local and statewide
discussions.
Representatives from public and private
sector home care agencies; hospitals, nursing and adult care
homes; DSS aging services and WorkFirst programs; regional workforce
development, community college NA training program, secondary
industrial education and the AAA ombudsman participated in the
dialogue. Also attending were Bonnie Cramer, Long Term
Care Policy Unit, North Carolina Department of Health and Human
Services; Sandy Crawford Leak, Duke LTC Resources Program; John
Frank, Kate B. Reynolds Charitable Trust; Louisa Cox, Director,
Mideast Area Agency on Aging; and Patricia Capehart, facilitator.
Specifying the Challenge at the County
Level: Context and Common Ground
Beaufort County, located in the eastern part of N.C., is a large, rural county divided by
the Pamlico River. Its population is 42,283 (1990 census). Adults over sixty-five years of
age constitute 15.6% of the population. The challenges identified in Beaufort County
around the issue of CNA recruitment and retention reflect many of those identified in the
national literature and by state policy makers:
- Low pay and lack of benefits for CNAs and related rapid turnover;
- Third party reimbursement rates which affect salary and benefits;
- Shrinking pool of certified nursing assistants actively seeking employment;
- Competition among providers in recruitment of aides, resulting in movement of aides from
provider to provider;
- High number of part-time positions which results in aides working multiple jobs in order to
earn a living;
- Heavy caseloads in institutional settings which causes stress and burnout;
- Physical demands of job which can result in injuries and Workman Compensation claims;
- Lack of career path for CNAs and lack of advocacy to upgrade the CNA profession.
Given the problems cited above, the task at the community level was to identify what
could be done to address the overall challenge.
Quantifying the Challenge: Need for an
Adequate Reporting System
The first step to evaluating and recommending solutions to the
CNA recruitment and retention problem involves documenting the
characteristics of the target group and the overall dimensions
of the problem. The discussion group determined that there
is no system for data collection regarding the number
of CNAs needed in the county, how many are trained but not working,
or how many CNAs are drawing unemployment compensation. Yet
another factor is the number of aides who are in private pay
arrangements as caregivers for individuals for whom there are
no formal reporting mechanisms to government agencies. Without
accurate reporting systems for the workforce patterns of CNAs,
it is impossible to anticipate the needs, and to identify the
distinct needs of different geographic locations and long term
care (LTC) settings (nursing homes, adult care homes,
home care).
Two current data collection systems were
identified which might be expanded to provide more specific
information: the Employment Security
Commission and the Nurse Aide
Registry. The Employment Security Commission (ESC) automatic
tracking system collects data by code numbers for job categories.
Current job orders for CNAs can be tracked; however, CNAs are
grouped with other service sector job categories in the database.
Therefore, there is no cumulative data for CNA job orders or
unemployment claims. The only data collection system which gives
information about the number of CNAs is the
Nurse Aide Registry maintained by the N.C. Division of Facility
Services. In February 1999, the Registry listed 84,415 CNAs
in active status with 92,205 in inactive status in North Carolina.
The information is not available on a county basis. The Registry
does not reflect whether those CNAs classified as active are
full-time or part- time employees. Also, active status may be
misleading as CNAs need only one day of supervised work during
a twenty four month period to maintain active status on the
Registry.
A Word about Nomenclature
This policy paper addresses generally the topic of recruiting
and retaining a frontline paraprofessional workforce across
long term care settings. In general, in North Carolina and around
the nation, workers trained at that level are referred to as
"aides" but also are often called nursing assistants and, where
a certain competency level has been met, certified nurse's aides
or CNAs. For the purposes of this paper,
the CNA acromyn is being used as a general designation for this
workforce with the realization that training levels and terminology
do vary.
Training for CNA's:
What Works and What Needs to Change in
Beaufort County
When issues of recruitment and retention of CNAs are presented, the discussion
inevitably leads to training for nurse assistants. The central question is are there enough
accessible and affordable training opportunities available to meet the demand for
trained aides. In Beaufort County, the general answer to that question is yes, but the
dialogue highlighted important issues about what works and what does not work
regarding aide training.
What Works:
- Current funding sources (Pell Grants, TANF, NAFTA, JTPA) appear to meet local training
needs for CNAs.
- There exists a good relationship between providers and the Beaufort County Community
College (BCCC) NA Training Co-ordinator. Providers contact BCCC regularly as part of
ongoing recruitment efforts.
What Needs to Change:
- BCCC is training a large number of nursing assistants relative to the 541
active aide positions in Beaufort County (from an informal
telephone survey of providers in November, 1997). In 1997,
308 individuals completed the nursing assistant program
and in 1998, there were 227 completions. The problem is
that only a low percentage of those
who complete the training seek employment as CNAs.
There are no records available to track the number of graduates
who actually begin work as aides and stay employed.
- There is sometimes a perceived difference between the training and "real world"
CNA experiences among both providers and employees. An informal
poll of providers revealed that approximately
50% of CNA positions in Beaufort County are home-based;
however, training is geared toward institutional care.
Coordination with WorkFirst Efforts: A Relevant Discussion.
Training for one pool of potential CNAs, WorkFirst participants,
was specifically addressed in the dialogue. Experience with
training WorkFirst recipients
to be CNAs in Beaufort County indicates that while the potential
exists for recipients to be an important source of CNAs, issues
related to job skills development need special attention and
mentoring. WorkFirst, North Carolina's employment program for
TANF (Temporary Assistance for Needy Families) recipients has
time limited benefits and cash benefits are no longer an entitlement.
The goal is to assist welfare recipients with securing unsubsidized
employment. Efforts are being made at both the local and state
levels to use TANF funds to train WorkFirst participants to
be CNAs. Employers, employment counselors and the training coordinator
identified the need for additional training/mentoring
for this population.
Retaining CNAs: The Central Issue of
the Challenge
In general, the consensus of the dialogue
participants was that recruiting and training to create a pool
of CNAs can be better refined; however, the most critical challenge
is retaining trained workers in the work force. As discussed
above, the existing data to quantify this problem indicates
that at any given time there are more CNAs in North Carolina
who are not working than those who are actively employed.
A substantial amount of time was spent
during the dialogue and related activities sharing approaches
that local agencies are using to improve retention rates for
trained workers. Incentives and strategies which were discussed
included:
Care Focus, a local for profit home care agency (now a part
of Beverly Enterprises) has established a Caregiver
Award Program which rewards and honors in-home employees
by giving cash bonuses to Caregiver of
the Quarter and of the Year. Care Focus also reimburses
tuition costs for CNA training for employees. Additional
incentives include a bonus to
an employee who refers a CNA applicant who becomes employed
by Care Focus and who remains with the Agency at least 90 days.
Although the results of these policies have not been statistically
measured, the agency director states that they have experienced
less turnover and CNA morale is higher since the policies were
enacted.
The Beaufort ESC manager reports that he receives a high number
of job orders for full and part-time nursing assistants; however,
the positions are difficult to fill due to low starting pay.
In an effort to compensate for this, Beaufort County DSS reclassified
ten of its 50+ CNA positions from part-time
to full-time status which made those employees eligible for
health insurance and retirement benefits. There is some
indication that this incentive has helped with retention of
CNAs. Although the overall turnover rate for CNAs employed by
Beaufort DSS was 34% in 1997, only one of the seventeen CNAs
who left the DSS Aging Services Unit was a full-time employee.
Participants discussed the need to change
the perception of the CNA position.
Most of the agencies represented at the Dialogue recognized
National Nursing Assistant Day last year as a means of expressing
appreciation for CNAs and of enhancing
their professional status.
Inclusion of CNAs in the care planning
team was also presented as a means to further enhance
professional status among CNAs. Pungo District Hospital, a small
private hospital located in Belhaven, now includes CNAs as members
of care teams. Pungo sent a team of two RNs and a CNA to the
"Partners in Caring: Visions for the Future" Conference in March,
1998. This conference was the first major event in North Carolina
to include nursing assistants as team participants with registered
nurses.
Other Initiatives to be Considered at
the Community Level
The Beaufort County Dialogue and a follow-up meeting with a focus group of
participants (Ombudsman, representatives from DSS and Care Focus with Pat
Capehart as facilitator) highlighted the need for continued thought and research around
the following issues:
1. Identifying "inactive" CNAs to determine
numbers and to better understand why they are not working
as nursing assistants. (Transportation? Family problems? Other
employment?) Could an additional field be added to the Nurse
Aide Registry database to give county specific numbers of active/inactive
aides?
2. Would an apprenticeship help?
Development of an additional work-study or apprenticeship component
to the regular CNA training for WorkFirst participants, which
would assist with transition to the workplace and re-enforcement
of a positive work ethic, should be considered. The new federally
funded Welfare-to-Work program provides an opportunity for more
intensive mentoring and job coaching services for WorkFirst
recipients.
3. What are the most likely sources of
future CNAs? Target new groups for employment as CNAs;
i.e. physically able, low-income older adults (both male and
female) or high school students through JobReady and Industrial
Education Programs. Strengthen linkages between employment programs
(Welfare-to-Work, WorkFirst, First Stop, Workforce Development
and the Title V Program of the Older Americans' Act) and Community
College Nursing Assistant training programs.
4. Is compensation the heart of the matter?
Increase advocacy efforts to raise awareness for funding of
long term care which acknowledges the need for adequate salary
and benefits for CNAs. Salary increases are perceived to be
directly related to third party reimbursement rates.
5. Tracking CNA job movement.
Advocate for CNA positions to be given a separate code in the
ESC system in order to track cumulative numbers of job orders
and unemployment insurance claims.
Listening to the Workers
In order to obtain the worker's perspective on recruitment and retention issues, Pat
Capehart as facilitator, met with a focus group of five CNAs representing three
agencies. A survey of Department of Social Services nursing assistants was also taken
by the supervisor during a quarterly training session. Training sessions are a
requirement for continued certification as a licensed home care agency. Forty-six CNAs
participated in the voluntary and anonymously recorded survey.
Demographics of CNA Respondents.
All of the participants in the survey and in the focus group
were female. About three-quarters (78%)
were aged 4l or older. The majority had more
years of experience as home care providers than in institutions.
All but five were trained in a Community
College nursing assistant program. When CNAs were asked,
"What attracted you to the NA profession?", the dominant answer
focused on caring and self-fulfillment. Only a few responded
"Need a job" or "Want part-time work".
Concerns About CNA Working Conditions:
In expressing concerns about working conditions, the responses
differed for aides working in home care and those working in
institutional care. These concerns identify issues which must
be addressed in any attempt to change current problems in recruitment
and retention. Encouragingly, a number
of these issues are modifiable by leadership at the local level;
others represent less tractable issues which will require broader
policy or societal change.
Responses regarding home care working
conditions:
- Working in isolation
- Lack of clear understanding of care plan and family's responsibilities
with patient care which sometimes results in conflicts with family members
- Exposure to unsafe and unsanitary conditions resulting from substandard housing
- Not being allowed to use skills learned in CNA training
- Being perceived as "maids" which is considered demeaning
- Frequent changes in caseload assignments
- Confidentiality policies which were perceived to be restrictive
and prohibit sharing of information that could be helpful in
caring for patients
Responses regarding working conditions in institutions centered around:
- Heavy caseloads which causes stress and affects quality of care
- Confusion about CNA role which differs from setting to setting
- Not being considered part of the team
Responses regarding working conditions/job expectations which cut across both the
home care and institutional settings reflected that many CNAs feel they:
- Are not given a clear picture of the patient's status (not participating in development of care
plan nor being provided a copy of the care plan, no explanation of patient's nutritional needs
or medical status);
- Receive multiple or conflicting orders from supervisory staff; and
- Need to work two jobs in order to make a living. (Currently, CNAs are paid from $5.15 to
$6.50 per hour in Beaufort County.)
Issues of Recruitment. When asked about recruitment
considerations, certified nurse assistants in both the focus
group and survey responded that they needed
more job security with a better salary, benefits and guaranteed
hours. All were concerned about benefits, especially
health insurance. A number of CNAs cited transportation and
hours compatible with family responsibilities as factors in
decisions to work full or part-time. Interestingly, the focus
group members had a good understanding of third party reimbursements
for health care services and its impact on salaries, benefits
and use of part-time staff.
Issues of Retention. Discussion
and responses around retention issues also centered around salary
and benefits. CNAs expressed a desire for "the
perfect job" described as having smaller
caseloads (home care), more status
(institutional care), and job security
(decent salary with benefits).
Staff Turnover
Primary reasons given by respondents for leaving the CNA profession,
and similarly what would make the work
of a CNA more satisfying for those desiring to stay included:
- "salary"
- "want responsibilities compatible
with CNA training"
- "to be able to use CNA skills"
DEVELOPMENTS AT THE STATE LEVEL: A SPECIAL INITIATIVE
Since the Beaufort County Dialogue was
held in December of 1997, the North Carolina Department of Health
and Human Services has received a grant from the Kate B. Reynolds
Charitable Trust to work on the issue of nurse aide and related
paraprofessional aide recruitment and retention. Current
efforts include developing a data tracking system for the workforce;
piloting various incentives to improve recruitment and retention;
revising the nurse aide curriculum to give a more realistic
introduction to the work to be performed; and developing and
implementing a public awareness campaign about what workers
do. A summary of the grant activities is available on the Division
of Facility Services website at http://facility-services.state.nc.us/.
Up-dates on grant activities will also be posted on that site.
Emerging Insights at the Local Level
Faced with the documented need for a stable and well-trained
CNA workforce, insights emerged from
the Teaching Communities experience in Beaufort County
which may be helpful to other communities as they address the
challenge of nursing assistant recruitment and retention:
1) The importance of listening to the
workers themselves in developing a more informed understanding
of the issues and formulating responses.
2) Awareness that cooperative efforts
at the local level can lead to both a better understanding
of the challenge and specific strategies for addressing the
challenge.
3) Making CNA recruitment and retention a priority issue for
attention at local and state levels. Specific components of
the issue which need addressing include:
a) Development of an information system
for planning;
b) Increased coordination with training
institutions;
c) Reimbursement issues related to salary/benefits;
and
d) Increased interactions with workforce
planners and health care industry.
4) Provision of quality continuing education
opportunities by linking community resources. For example,
the Mideast and Albemarle Regional Ombudsman Programs sponsored
a workshop "Specialist in the Art of Caring" for CNAs on June
24, 1998. This was a win-win event with CNAs receiving job related
training as well as dealing with job-related stress. Agencies
gave the staff paid time to attend the workshop and received
the benefit of meeting training requirements. Regional Ombudsmen
continue to receive positive feedback from the CNAs who report
increased feelings of professionalism and acceptance.
While nurse aide recruitment and retention
is a national problem, one of our greatest strengths in finding
solutions may well lie with community involvement. Beaufort
County was very receptive to the opportunity to dialogue about
this critical issue through the Teaching Communities initiative.
From the outset, providers and agency leaders responded positively
to the need to discuss the issue of recruitment and retention
of nurse aides. The increased awareness of the problem in Beaufort
County has led to further sharing of information and pooling
of resources such as the Ombudsman training for CNAs described
above. To whom can we look to solve the problems of adequate
long term care? Some of the answers lie within our communities.
Acknowledgments: On behalf of
the Duke Teaching Communities Program, the author wishes to
express appreciation to each of the Beaufort County participants
in the Dialogue, focus groups and survey as well as to the staff
of Mideast Commission Area Agency on Agency. The Teaching Communities
Program is made possible through the generosity of the Kate
B. Reynolds Charitable Trust.
Occasional LTC Policy Paper Series
Paper 9 / July 1999
Duke University Center for the Study of Aging and Human Development
DUMC 2920
Durham, NC 27710
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