NURSE AIDE TRAINING: PREPARING FOR THE FUTURE
On February 4, 2002, a conference for nursing home staff was held in New York City. The conference, held at the Greater New York Hospital Association offices in Manhattan, was co-sponsored by the Nursing Home Community Coalition of New York State (NHCC), the Centers for Medicare & Medicaid Services (CMS, formerly HCFA), the New York Health Care Alliance and Southern New York Association, the New York State Department of Health and the Greater New York Hospital Association. It was a follow-up to NHCC’s 1999 conference where nurse aides, residents and family members met to discuss nurse aide training. [1]   This new conference recapped the findings from the earlier conference and highlighted practices from three facilities that are training aides in ways discussed at the 1999 conference.  Eighty-two participants from 36 nursing homes attended.

Welcome
Scott Amrhein from Greater New York and Neil Heyman from NY Health Care Alliance and Southern New York welcomed the participants and discussed how important nurse aides are to the working of the nursing home and to staff –resident interactions.

Judy Berek, Administrator of CMS Region II said she believed conferences such as these are very important.

 “Retention of good staff is one of the most important issues in delivering quality in nursing homes. If you have a constant turnover of nurse aides, you cannot deliver good care. Training is one of the things that plays an enormous role in retention. It does two things—one, it is a way of making direct-care staff better. But it is also a way of letting people know that they’re valued. People who come into this field come to us because they care about people, and it is our job to find ways of making sure that we reward them for that in every way that we can. People want to go home at the end of the day feeling good about their work.“

Anna Colello, Director, Division of Quality and Surveillance for the New York State Department of Health,  discussed the fact that this conference brought regulators, providers and consumers together by saying that you don’t have to agree with someone to respect their motives. In addition, the fact that three nursing homes will be presenting their training programs will help, “…by listening to others’ best practices, you can get an idea of how to develop your own.”

Introductory Remarks

Cynthia Rudder, director, Nursing Home Community Coalition of New York  State, moderated the event. She opened by summarizing the findings of the 1999 conference.  The participants, nurse aides, residents and relatives felt that nurse aide training and education should involve learning how to:

• Be part of a care team
• Understand care planning
• Allow their natural compassion and understanding to be revealed
• Assess individual needs, values and differences
• Understand the value of autonomy and choice—not only for residents, but for themselves
• Build relationships with resident’s families and other workers
• Understand more about cultural diversity and cultural differences, including sexual orientation
• Mentor

Perspectives from the Front Line
Cynthia Rudder introduced three front-line members of the nursing home community who were at the 1999 conference to discuss their perspectives on the need for change in nurse aide training.

Woody Wilson, president of the board of the Coalition of the Institutionalized Aged and Disabled (CIAD) spoke on behalf of nursing home residents. Mr. Wilson opened the eyes of many attendees to the stake that residents have in their relationship with CNAs, and that this can often add stress to the aides that administrators are shielded from. “Residents get mad at CNAs rather than blaming the administration when things go wrong," Mr. Wilson explained. But that’s because, “You get more angry with a friend that you feel has let you down than you do with someone you don’t know.”

Mr. Wilson went on to echo many themes stated throughout the day, including the need to better train aides in cultural sensitivity. “Most of all," he concluded, "We need a better understanding between the nurses’ aides and the administration about what the residents need. And nobody knows better than the aides what residents need.”

Antonia Pena, a member of Friends and Relatives of Institutionalized Aged, (FRIA) spoke on behalf of relatives of nursing home residents.  She discussed the need, broached by Cynthia Rudder, for aides to be given more autonomy in directing residents' care. "The CNA is, in fact, the frontline soldier in preventive care for each resident," Pena advised. "They must be seen, and see themselves, as more than a person responsible for seeing to it that residents are free of feces and urine.”

Ms. Pena called for drastic increases in training hours and continued in-servicing. She cited an example of a nursing home partnering with a local community college to provide this training at little charge as proof that administrators are capable of facilitating this training.

Ms. Pena also addressed the public stigma that many aides and potential aides perceive as attached to long-term care work. She called for a career track that “publicly recognizes their centrality to the quality of care and the quality of life for frail elderly, and their centrality to care planning.” She concluded: “It is my position that we have no shortage of workforce in New York. We have a large reservoir of people steeped in respect for elder relatives. Go to them to improve retention.”

Williemae Young, a nursing assistant in Far Rockaway, and a long time delegate from 1199/SEIU, spoke on behalf of CNAs, discussing their cries for increased and enhanced training. “With more training we will have more knowledge to give our residents better care.” Ms. Young also repeated earlier calls for CNA involvement in "care planning, and any other committee" that impacts on residents' quality of life.

Presentations on Best Practices

Cobblehill Nursing Home: CNA Autonomy – CNAs Involved in Care Planning
Janice Dabney, CSW, Director of Social Work, Cobble Hill Nursing Home, opened by stating that “the work we do today will lay the foundation for what the future will be.”

Ms. Dabney discussed the organic movement within Cobble Hill that led to reform of the way it trained its CNAs. In 1990, shortly after Cobble Hill switched from for-profit to non-profit status, the administration canvassed the facility's entire staff and came up with the notion of an Alzheimer’s program. Ms. Dabney reported of Cobble Hill's collaborative environment in which all employees were stakeholders. "We were all students. We all had to learn about this together. And I think that’s an approach that has continued to direct us as we move beyond Alzheimer’s.” She then spoke of the role creative administrating can play in effecting innovations in CNA training. She said the administration reexamined the DOH code and its union contracts with the aim of not seeing them as shackles but as parameters within which to be innovative.

What resulted was an Alzheimer's unit in which CNAs had unprecedented levels of autonomy and strongly-encouraged relationships with residents and their relatives. The administrative structure is based largely on accepting input from CNAs on the personal and medical needs of residents -- thus giving CNAs a prime role in directing residents' care. The facility also changed the dynamic between CNAs and their supervisors, so CNAs felt less threatened by supervisors and that their decisions were more highly valued. One of the innovations Cobble Hill has introduced to promote both pride in CNAs’ career and a tool that passes wisdom from experienced to inexperienced aides is a booklet called "Speaking From Experience". This publication contains the words and perspectives of the facility's experienced CNAs. By putting something like this in print, Dabney said, "You show respect for the CNAs. You really immortalize them.” Dabney closed by advising administrators to listen to CNAs on how to enhance their training programs. Her belief is that CNAs know best what training they are lacking.

Lawrence Nursing Home: Eden Alternative - Team Building
Barbara Young, administrator and Felicia Stephen, director of nursing of Lawrence Nursing Home discussed how they trained their staff for a transition to the Eden Alternative. This model of care addresses the three plagues that haunt residents of all facilities: helplessness, hopelessness and boredom. Employee training and empowerment is central to the Eden concept.

The training began by bringing all staff together and asking them what a nursing home is and what they think a nursing home should be.  The goal was to develop an ideal of what a nursing home should be. 

“At the beginning they realized that none of them wanted to go to a nursing home. Even though we all worked at a nursing home, none of us wanted to be here if we needed to be at a nursing home.  We wanted to make Lawrence nursing home a kind of home where, when we got old, we’d all be fighting for a bed.”

The Eden Alternative is based largely on building mini-communities of residents within facilities and creating teams of employees to service those communities. “The Eden philosophy of employee empowerment fit right in," she said. "It includes team-building, teaching people how to work in teams and the importance of each member."

Teams of residents and CNAs to build these mini-communities were developed to determine what animals and plants they would import and to work out how they would be cared for and exercises were developed to work on team-building. In addition, committees were created to make sure that everything that was done would be code compliant. A major concept at Lawrence today is that,  “We operate as a team; we rise together and we fall together.”

Center for Nursing and Rehabilitation (CNR): Resident-Directed Care
Joan Skyers, Director of Nursing, and Clare Creese, Director of Compliance, Education, Research and Training, Center for Nursing Rehabilitation (CNR) spoke about innovative techniques for nurse aide training and education in a resident-directed care environment.

CNR is making a journey from:

• “units” to “neighborhoods;”
• traditional medical models to social models
• routinized, staff directed care to resident-directed care that promote staff-resident-family interactions
• structured activities to a nurturing of the human spirit
• compliance driven nurse aide training programs to an environment that promotes and supports the nurse aide’s continuous growth through dynamic learning experiences

In order to make this transition, its CNA training had to be modified. CNR looked at what it believed CNAs needed to learn; what resources were available; how they should be taught; why they should learn these things; and federal, state and other standards and rules. It expanded mandatory in-services with other topics such as customer courtesy, cultural diversity, the neighborhood concept, age-specific conduct; resident-directed care; respect with a smile; dignity with compassion; caring with empathy by integrating resident’s customary routine in the daily care of the resident.

Aides were given education in clinical issues such as falls, weight loss and dehydration and the tools to help solve some of these problems as a respected member of the care team.  They were helped to creatively think of solutions by imagining problems visually, thinking “out of the box” and brainstorming solutions, e.g., why did residents fall?  CNAs are encouraged to attend classes for licensed staff if they would like to such as MDS assessment or care planning. In addition, CNR has introduced a self-directed learning program that nurse aide can do independently. This not only helps solve the problem of how to find the time to in-service nurse aides, but encourages independence.

Final Comments: Judy Berek
“Creativity is incredibly important, and it is really wonderful to listen to those of you who have taken the risks and been creative and are trying to move the system forward. I will try to do everything I can from the bit of a bully pulpit I have to encourage that creativity and to find ways for those of us working within the regulatory structure to get better care for the residents…. I think the three homes that presented to us today are all doing terrific work. I have a cousin at the dementia unit at Cobble Hill and when her family filled out the form, they said all the things about she wouldn’t do this and she’d hate that, and she is doing all those things now and is very happy…. As a regulator and a family member, I want to thank you all, and to say Cynthia, you are a national treasure, to keep us all from forgetting what it is all about. Those of you who are in the nursing homes can’t forget; the rest of us need people like Cynthia to remind us.”

Thanks
Very special thanks go to CMS for its work on making this event a success and distributing these proceedings, Greater New York Hospital Association for hosting the conference and providing refreshments, and to the Healthcare Alliance and Southern NY for funding the printing of these proceedings, to DOH for helping make sure that administrator credit was offered.