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Geriatric Nursing 38 (2017) 146e151

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Geriatric Nursing

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Feature Article

Perspectives on caregiving: A qualitative evaluation of certified nursing assistants

Nancy Kusmaul, PhD, LMSWa,b,*,d, Morgan Bunting, BS c

a The College at Brockport, State University of New York, USA bUniversity of Maryland, Baltimore County, USA cUniversity of Maryland, Baltimore, USA

a r t i c l e i n f o

Article history: Received 6 May 2016 Received in revised form 12 September 2016 Accepted 19 September 2016 Available online 12 October 2016

Keywords: Long term care Nursing assistants Quality

Conflicts of interest: None Funding: This study was funded by a New York State Individual Development Grant. * Corresponding author. State University of New Yo

MSW Program, 55 St. Paul Street, Rochester, NY 1460 E-mail address: [email protected] (N. Kusmau

d Present/permanent address: University of Maryl Hilltop Circle, Baltimore, MD 21250, USA.

0197-4572/$ e see front matter � 2016 Elsevier Inc. http://dx.doi.org/10.1016/j.gerinurse.2016.09.004

a b s t r a c t

This study sought Certified Nursing Assistants’ (CNAs) perspectives on the activities that compose quality care. CNAs provide the majority of hands on care in nursing homes positioning them to have a unique perspective on factors that constitute good quality care. Using semi-structured interviews, 23 CNAs from New York State nursing homes were asked to identify factors they felt were components of good care. Interviews were recorded, transcribed verbatim, and coded using open coding. Three themes emerged: (1) technical aspects of care; (2) care of the environment; and (3) a little bit more. Our results emphasize the complexities of providing care that go beyond items that can be regulated. Assessments of quality care should incorporate the voices of CNAs.

� 2016 Elsevier Inc. All rights reserved.

Introduction

The residents are the center of care in nursing homes. An indi- vidual resident spends more time with a certified nursing assistant (CNA) than any other care provider in the nursing home, as CNAs provide more than 80% of the hands on care.1 Therefore the care provided by CNAs is an important part of overall quality of care. If we want to measure this aspect of care, more needs to be under- stood about it. CNAs are uniquely positioned to describe what makes up quality direct care and the barriers to providing that care well, based on their ongoing contact with residents. Researchers, providers, and regulators need this information to be able to best assess care and best support CNAs in their work.

Jean Watson’s theory of human caring defines professional caring “as activities that promote healing, preserve dignity, and respect the nature of holistic nursing practice.”2 This study explored how CNAs describe the activities that make up quality care. The primary research questions were: (1) How do CNAs

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rk, College at Brockport, GRC 4, USA. l). and, Baltimore County, 1000

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describe their role in caring for nursing home residents; and (2) How do CNAs conceptualize quality care behaviors? The study was conducted in New York because the primary researcher was located in New York at the time of the study.

Factors that influence quality of care provided by CNAs

Studies on quality of care often consider CNAs. A literature search in CINAHL of articles published in the last 10 years using the search terms “CNAs þ Quality of Care” revealed 45 results. The last 10 years are significant because they represent 20 years since the passage of the Nursing Home Reform Act3 which fundamentally changed expectations for care activities in nursing homes and created the survey and certification process. The studies that are conducted with CNAs focus primarily on retention,4 work envi- ronment,5,6 and job satisfaction.7

Job retention is a critical issue for quality of care because of the interpersonal aspects of caregiving. CNAs that work consistently with residents learn individual preferences and personal charac- teristics about them. It is knowledge of these that allows CNAs to provide individualized care. Turnover is consistently high in the CNA population, and when a CNA departs, so does their knowledge of individual residents. Lower rates of turnover are associated with better quality of care and fewer deficiencies.4

In a traditional, hierarchical nursing home, CNAs occupy the positions of lowest power. Others dictate when, where, and how they care for residents. They also dictatewhether their observations

Table 1 Sample employment characteristics.

Where employed Expressed interest

Participated in study

Nursing home # 1 7 2 Nursing home # 2 10 5 Nursing home # 3 32 12 Nursing home # 4 1 1 Nursing home # 5 2 0 Unable to determine 7 3

N. Kusmaul, M. Bunting / Geriatric Nursing 38 (2017) 146e151 147

and opinions on resident needs are acknowledged or heeded, and whether they feel appreciated.7 It is not surprising, then, that the type and quality of the supervision they receive plays a critical role in their retention and job satisfaction. One of the most common reasons CNAs cited for job dissatisfaction and leaving their job is lack of appreciation and lack of respect from supervisors.4 While all members of an organization influence organizational culture, managers/supervisors play a critical role in establishing a person- centered environment.6 Though individual CNAs may gain satis- faction from providing good care, this is not enough to create satisfaction in the shadow of a manager who does not care or listen.6 Workers identified listening, appreciation, and respect as three areas in which changes by their employers would improve their jobs.8

CNAs feel conflicted in cases when they are expected to nurture residents but do not feel cared for by their work environments.5

CNAs identified that when they work in traditionally structured nursing homes, they are considered expendable and not valued and organizational change to a person-centered model for residents does not always extend to staff.9,10 Participants identified the need for both physical and emotional components of care, but when CNAs were not valued, it impeded their ability to provide the emotional part of caregiving.5

Supportive supervision is one area that is shown to increase job satisfaction.4,5 In the absence of good supervision, job satisfaction is derived from making meaning of their work. Some CNAs define their roles as doing good work, or God’s work, describing it as a calling.11 CNAs also came to value residents as like family or friends.12 This allowed them to find satisfaction despite other job challenges.

Qualitative methods or open ended questions allow research participants to tell their stories in their own words. Since CNAs are in devalued positions that often give them little voice, qualitative methods are particularly important to ensure that their perspec- tives are incorporated into quality of care research. Overall, few of these studies used such methods. Notably, Chung13 used a groun- ded theory approach to understand how CNAs conceptualized good care. She found that good care consisted of outcomes and pro- cesses; that is, care leads to particular desired results such as cleanliness, and it also consists of attitudes and mindsets that are demonstrated through the care delivery process. This study used qualitative methods to capture the CNAs perspectives on what direct care behaviors make up quality care.

Total Respondents 59pp 4 Phone 1 Walk-in 54 In Wri�ng

12 messages le� 7 unable to reach 2 did not meet criteria 29 interviews scheduled

9 not contacted due to satura�on reached

23 interviews completed

6 no-shows

Fig. 1. Diagram of participant flow.

Methods & analysis plan

CNAswho participated in this studyworked at nursing homes in a medium sized metropolitan area in Upstate New York. Since this was a descriptive qualitative study, sampling procedures were purposive and designed to ensure access to the population of in- terest. A letter was sent to every Nursing Home Administrator and Director of Nursing of the 33 homes in the county inviting them to advertise the study to the CNAs at their facility. Eight nursing homes (24%) agreed to distribute study information. Half the participating homes were in the city, half were elsewhere in the county. CNAs at the participating facilities were provided with a study description and a recruitment formwith contact information for the primary investigator (PI) if they were interested in partici- pating. Respondents were not asked at which nursing home they worked, but were asked for a work phone number, and from these we know that at least 5 of the 8 facilities were represented in the responses. Table 1 includes information about facilities in sample. Study procedures were approved by the Institutional Review Board at the State University of New York, College at Brockport.

Inclusion criteria were (a) New York State certified nursing as- sistant, (b) currently employed as a nursing home CNA, (c) over age 18, and (d) English speaking. While each state certifies their own nursing assistants, all states require training that meets or exceeds federal minimum standards of 75 hours on a prescribed array of topics.14 Nursing assistant responsibilities are similar throughout the country. New York State requires CNAs to receive 100 hours of training prior to certification.15

CNAs were contacted in the order in which they responded. Interviews were conducted at public places, such as fast food res- taurants and public libraries, and at times that were convenient to participants. The locations outside of their workplace were chosen to allow the CNAs to answer questions without feeling pressured. Privacy was maintained by the overall busyness of the environ- ments. In libraries that were quieter, the PI used corner tables or isolated areas. CNAs were recruited until saturation was reached, meaning that no new information was being added.16 Participants received $20 in cash after completing an interview. Interviews took place in the Spring of 2014. Fifty nine CNAs expressed interest in participating. Of those, twenty nine scheduled interviews and 23 interviews were completed. See Fig. 1 for full description of sam- pling procedure.

The interviews focused on what CNAs do for residents in a typical day and asked respondents to compare good and bad care. This study sought to understand the experiences of individuals who care for others in a professional setting. Since we were looking at the experience of CNAs caregiving, we chose a phenomenological stance.

Measures

The interview guide was developed based on the principles of caring behaviors outlined in Watson’s Caritas Theory.2 The

Table 2 Sample description.

Characteristic Percentage

Sex (female) 91% CNA experience Less than 5 years 30% 5e10 years 17% 11e15 years 9% 16e20 years 17% More than 20 years 26%

Setting employed Urban 35% Suburban 52% Unable to determine 13%

N. Kusmaul, M. Bunting / Geriatric Nursing 38 (2017) 146e151148

interviews included both open and closed ended questions. Re- spondents were also asked to picture and consider a favorite resi- dent and describe how their care for that resident was the same or different from other residents, to see what role relationship had in caring. Respondents were encouraged to add additional informa- tion they thought was relevant to the research questions. A panel of researchers reviewed the survey questions prior to initiation of the interviews to see if they were relevant to the study’s aims. The first author conducted all interviews. Interviews lasted between 20 and 80 min and were recorded and transcribed verbatim.

Data analysis

Qualitative inquiry is used to understand more about perspec- tives on a phenomenon or idea,17 and phenomenology is used to explore the common elements of a single kind of human experi- ence.17,18 Phenomenology is both a philosophy and a research method used in nursing research to describe a phenomenon, or first person experience. Phenomenology allows researchers to create accounts of human relations, as they are experienced by the in- dividuals in question. This philosophy requires researchers to identify preconceived notions and potential biases.19 In this case, both authors had worked in nursing homes. This bias was reduced by journaling about assumptions and prejudices throughout the interview and analysis process.20 By identifying our biases, the authors were able to look for confirming and disconfirming evi- dence in the responses. Using phenomenology as a guiding phi- losophy allowed us to explore the lived experience of the CNAs.21

Following a phenomenological philosophy, we analyzed the data using a multi-step content analysis method to create a “condensed and broad definition of a phenomenon.”20 First, tran- scripts were read in their entirety to get an overall sense of them. Then each transcript was coded line by line to identify the meaning CNAs placed on aspects of their jobs and to search for shared themes. Statements were identified as significant if they were repeated by multiple respondents or emphasized by respondents and were collated to begin to create a unified definition of the experience of caring.17 Areas of disagreement between respondents were identified. Journals were referenced throughout data analysis to ensure that different perspectives were identified and consid- ered. The authors analyzed the data separately, met to compare results, and reached consensus on the findings presented.

Results

CNA characteristics and experience

A purposive sample of 23 currently employed CNAs participated in this study. Most were female (91%), reflecting the composition of this workforce.22 CNA experience ranged from less than a year to 49 years. See Table 2 for a more complete description of the sample. CNAs represented all shifts (7ame3pm, 3pme11pm, 11pme7am), though most worked days.

Respondents were asked what brought them to the job of CNA. One frequent reason was that they saw CNA as a stepping stone to nursing. For example, one CNA who saw herself on the path to registered nurse was doing this “for now.” Others talked about a desire to go into nursing, but chose CNA due to an inability or perceived inability to achieve nursing’s academic requirements. In most cases, these individuals reported having previously struggled in school.

Many also described a desire to work with people or care for others. Most respondents had cared for aging or dying relatives before pursuing this career. For some, this act of caring for a relative taught them that caregiving was something at which they excelled.

Others were the family member who cared for the older or ill relative because they had always been the one within the family who was “the caregiver” and thus, identified with the role of CNA.

CNA perceptions of giving care

Respondents were asked to describe their role as a CNA. Every respondent used terminology that captured a sense of physical care they provided for residents. These responses ranged from value- neutral “Total care givers (CNA #4),” to positive “Helping people who can’t help themselves (CNA #17),” to negative or self- deprecating “Professional Ass Wiper (CNA #8)” and “Hiney Shiner (CNA #20).” One CNA gave a longer, value-neutral response:

I feel like I’m support, I’m there to care for them. Not to baby them, I’m just there to help where they need.is it comfort or going back home.is it staying safe? You know, I’m there for them. That’s what I feel like I do (CNA # 12).

Study participants used three themes to define the care they provide: thorough physical care, care for the environment, and a concept that one of our respondents described as “a little bit more.”

Physical aspects of care CNAs in this study all began describing their job by talking about

the physical care they provide. Throughout the interviews, they emphasized the comprehensive nature of the tasks, as well as the importance of doing the tasks thoroughly. One simply stated, “..I don’t take shortcuts (CNA #1).” Another provided a longer response:

Yeah, we do everything they need. Like we start from the bed to the chair, we feed, we bathe, we do the nail care, dressing.you know, what I do every day for me, I am doing for them. (CNA # 11)

CNAs described responsibilities such as washing the individual, getting them up, getting them dressed, setting them up for meals, and feeding them. “We get the people up, we take care of them, we clean them. We dig in, we get our hands dirty (CNA #21)”. They discussed the comprehensive nature of the physical tasks. “..we as CNAs are total caregivers. We take care of everything that needs to be taken care of for the residents there (CNA #4).” This speaks to the idea of residents having ongoing needs that require direct contact.

They understood their tasks as things that people would do for themselves if they could. “I think it is common sense because I take care of myself. The way I take care of myself, I take care of them (CNA #19).”

Just to take care of the basic needs of residents, help them out as much as I can, make it comfortable for what they are doing. They’re in a very vulnerable position. You have to clean them up

N. Kusmaul, M. Bunting / Geriatric Nursing 38 (2017) 146e151 149

and they’re just kind of lying there, so you want them as comfortable as possible. (CNA #3).

Both the comparison of the residents to themselves and the comment about vulnerability are evidence of their empathy to- wards residents.

An interesting component to this discussion about the physical nature of the task was how the CNAs viewed the older adults for which they provided care. Several compared their job re- sponsibilities to child care, stating that they do for their residents that which you would do in caring for a baby. Others studies have linked the fact that impaired older adults need help with all aspects of care to the sometimes unconscious infantilization of residents by CNAs, a dignity issue.13 The CNAs in this study used the comparison to illustrate the multiple aspects of the care, and the common sense nature of the tasks that needs to be done. However, it was not clear from their comments as to whether this perspective impacted their sense of empathy regarding residents’ vulnerability.

Care of the environment Another theme of good care included care for the environment.

“The single most important part of my job is to take care of my residents and make sure they are clean and their surroundings are clean (CNA #22).” Multiple CNAs cited the importance of cleaning up the resident’s room as part of the process of care and leaving the environment neat and clean. “At the end of it all, you want to make sure that the room is a reflection on who you are as a caregiver. I always do a look-back and look and see how tidy my room is (CNA #5).” This component seemed to reflect both a desire to leave the resident in a clean place and a good situation, and the idea that the resident’s environment was reflective of the type of care they provided. There was the sense that an aide who left her rooms messy was not providing good caring.

A little bit more The third themewas a sense of meetingmore than the resident’s

physical and environmental needs. “It’s more than just cleaning them up. It’s good to know them a bit (CNA #3).” CNAs said good care includes “a little bit extra” “a little bit more” “above and beyond.” “I sometimes put in a little extra in than I should, but I know I’m doing some good for somebody (CNA #2).”

In response to the question “what do you think is the single most important part of your job?,” one CNA said “To love these people, do everything I can for them, and think if it was my parent, or it could be me, you know (CNA #23)?” Another said,

Making the residents smile. Making them happy. Giving them something to look forward to. Letting them know when you are there, they are going to be taken care of. When you are not there they sure notice it when you come back (CNA # 18).

These quotes suggest that the CNAs in this study identify rela- tionship as an important part of caring, as Watson hypothesized.23

They suggest that the relationship includes emotional caring, love, and empathy beyond the physical tasks of caring.

A comparison of good caring vs bad caring In order to illustrate the themes described, respondents were

asked to describe the difference between good and bad caring. CNA # 7 described CNAs who provided good caring in this way:

You won’t see them just sitting down. You will always see them either walking around and checking on the residents or in the lounge with the residents, interacting, doing activities, nails, playing games. Or if you see a light go off they will go answer that light even though it is not their resident. Just go answer the

light. You never know. They could have fallen or something. Pretty much if the residents call out, you are there to check on the residents. Even if it is something they are always doing.calling out all the time, you still go and check on the resident. You never know. I think that’s it. You always see them want to interact with all the residents and not just sitting down waiting..like it’s 3:00 so now I have to go do something. Al- ways just moving and going for the residents.

Respondents provided examples of poor care in all of the areas listed above. Examples of poor physical care given included skip- ping body parts when washing a resident or providing care with a phone in hand. This would be visible if that person’s resident was messy or disheveled. Poor environmental care is leaving beds messy, not emptying garbage cans, leaving laundry and linens in the resident’s room.

CNAs who do not participate in teamwork, have attitudes, or do not have conversations with residents were considered to be just going through the motions, or just there for the job. The CNAs in this study expected their co-workers to provide a certain level of caring to their residents: “You get them a certain way; we expect you to pass them on to the next person that same way (CNA #16)” “You have to have a passion for it (CNA # 12).”

Respondents felt they were different from other CNAs with whom they worked who were “just there for the paycheck” or for whom “it was only a job”. “I ammore caring. I am the one that goes above and beyond (CNA #14)” “[It’s] not just physically taking care of them but caring about what you are doing (CNA #17).” This suggests a pride in one’s work, and the recognition that good caring is important.

CNA perceptions of their place in the nursing home

CNAs described themselves as the staff members who provide themajority of care and know the residents best. This is reflective of what the literature says about nursing home care. Participants said, “I know my people (CNA # 14),” “I can usually spot when there is something going on wrong (CNA #10),” and “We are the ones that are the front line. We are the ones that see them every day and know what they need (CNA #8).” This suggests that CNAs have a knowledge base and a skill set that is often unrecognized.

Whether they are listened to often depends on the nursing staff with which they work. The respondents in this study were divided on whether their contributions were valued.

I have been fortunate to work with some good nurses but some of the nurses, they can be real nasty. You know, they feel that they are higher than the CNA. I feel like some of the nurses aren’t on board (CNA #6).

Structurally, almost none were formal parts of their care teams, but many said their nurse managers would make care card changes or follow up on their recommendations.

Discussion

This research identified three themes of CNA caregiving: (1) technical/physical aspects of care; (2) care of the environment; and (3) a generalized something more which included relational com- ponents. Research suggested that CNAs would talk about relation- ship as the base of good care.8 The results revealed that relationship is but one part. Every CNA began their description of caringwith the physical components of care. They emphasized the importance of providing good physical care to residents. The physical aspects of care are the essential building blocks that make caring good or bad.

N. Kusmaul, M. Bunting / Geriatric Nursing 38 (2017) 146e151150

The difference is subtle. While in theory, one could provide thor- ough physical care without the “something more,” the larger message was that those who make the effort to provide thorough physical care are also those who “go above and beyond.” Without a base of good physical care, other aspects are not as important.

By their descriptions, continued education on technical aspects of caregiving could influence the overall quality of nursing home care. However, given the other components of good caring, it is unlikely that education alone would create the caring improve- ments that are continuously sought. CNAs in other studies have described their work as a chance to do good work, or God’s work11

or a chance to respond to a higher calling.9 These concepts cannot be taught. They suggest the importance of finding the right people for professional caregiving jobs.

Beyond the physical care of residents, many interviewees identified good environmental care as a factor impacting good quality caring. For many CNAs, this was a source of personal pride with which they identified. They expressed that others could tell who had cared for a resident by what the environment looked like when they were done.

The component of a little bit more refers to building relation- ships with residents, a concept that is difficult to quantify and thus nearly impossible to measure. This theme has been found before, as others have described the residents they care for as being like family members or friends.12 CNAs in this study differentiated themselves from other CNAs who were “just there for the paycheck,” suggesting that ability is not enough to provide good care and passion may be more important. This leads to questions of self-selection bias. This study did not include an observational component. It is unclear whether the CNAs who participated were as caring as they reported and whether they were different than these “others” to whom they refer.

Together these themes in our results that emphasize the importance of human relationships in caregiving. Organizations must support the development of those relationships through appropriate, responsive supervision4,8and empowerment.7 CNAs are the largest group of employees in a nursing home, and each spends more time with residents than any other single staff member. In a traditional nursing home hierarchy, CNAs have the least control and influence over information and procedures. The Department of Labor recognizes that there is no clear definition of low-wage worker, but the job of a CNA includes many of the typi- cally cited components: wages that average not more than 45% of minimum wage, little in the way of upward mobility, and some- times irregular hours.24,25 Many CNAs in this study acknowledge that others did not perceive their contributions as important. They took pride in their work and did their best to advocate for the needs of their residents, but recognized that their role was limited to whether others listening to their contributions. In general, the CNAs perceived their role in the care team as less significant than other team members. However, acknowledgment of their contributions, or lack thereof, was a factor in feeling as part of the team. When nurse managers did not recognize CNA contributions, CNAs felt disconnected and unappreciated. In this regard, perhaps more training is needed for all team members on communication. CNAs need to be recognized as a formal part of the care team to have their contributions universally recognized.

Limitations

As a qualitative study, the sample was not designed to be representative. Of note, the sample was skewed in terms of level of experience towards the outliers - the newest and the very experi- enced. It is impossible to knowwhether this was due to the general make-up of the CNA population, or how participants chose to be in

the study. Participants were self-selected, which likely resulted in higher levels of participation by those who had strong opinions about care and caregiving. Perspective of those who did not respond is missing. Half of the participants were employed at the same nursing home, which could also explain some of the simi- larities between respondents, though it is important to note that their responses were consistent with those from other nursing homes as well.

Also, most participants felt they provided good care, and differentiated themselves from those who were “just there for the job.” This study had neither a way to evaluate the care provided by participants, nor a way to compare it to care provided by others. When conducting research with marginalized groups it is impor- tant that the research not further marginalize them. Providing an observational component of CNAs’ work could potentially increase a sense of vulnerability in a population already disempowered by their status in the workplace.26

Conclusion

Overall, our findings provide insight into components that factor into caregiving from the perspectives of CNAs. Care is more com- plex than items that can be regulated (i.e. physical care). Although physical care is a major base of caring, it is not the only component. In a similar study conducted by Chung,16 CNAs conceptualized good care by equating it to desirable outcomes of their care such as comfort. CNAs in the current study also identified components of caregiving, but the desirable resident outcomes they mentioned were things like smiling and happiness, which are harder to quantify than pain.

This study raises the need to increase the voices of CNAs in assessment of the quality of care. Future research should consider effective ways to increase the voices of individual CNAs in the nursing home structure.

Acknowledgments

We thank Paul Sacco, Corey Shdaimah, and John Cagle for their critical feedback and guidance. We would also like to recognize the CNAs who participated and gave their time and perspective.

Appendix.

Supplementary data

Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.gerinurse.2016.09.004

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