Description

The Center for Nursing and Rehabilitation (CNR) developed an eighteen-month program to train certified nursing assistants (CNAs) as ''CNA Person Centered Care (PCC) Mentors.'' The PCC mentors have since gone on to orient and mentor new employees as well as share person-centered skills with other staff.

Sponsoring Organization

The Center for Nursing and Rehabilitation is a member of the Beth Abraham Family of Health Services, a voluntary, nonprofit organization delivering a range of continuing care services through out New York City. These include adult day health care, long term home health care, short-term rehabilitation, and nursing home care.

Setting

Nursing aides were selected from the Penthouse Gardens, an 80-resident neighborhood focused on caring for residents with dementia, at the Center for Nursing & Rehabilitation. The Penthouse Gardens has been the site of workplace and environmental changes since 1999. Since the training has been implemented, aides have been deployed to other resident neighborhoods throughout the facility.

Target Group

A cadre of certified nursing assistants was selected from within the Penthouse Gardens suite of CNR.

Start Date

Training began in October 2003; the CNA Person-Centered Care Mentor job title was instituted in August 2005.

Objectives

The primary objectives of the program were 1) to train a core of CNAs in person-centered care, with a focus on dementia care; and 2) for that core of CNAs to mentor new employees and provide leadership on their floors with other CNAs.

Key Components

Selection:

Of twenty applicants, thirteen CNAs were selected for an 18-month training to become mentors. To qualify for the position, nursing aides were required to have a high school diploma or equivalent, a current CNA certification, above average performance assessments, a minimum of two years of employment at CNR, and no history of disciplinary action within the past year. The selection process included a group interview and sumbission of writing samples. CNAs were also expected to understand and articulate the principles of ''culture change.''

Training:

The training content was divided into two components. One was a formal training conducted by a project manager and the Paraprofessional Healthcare Institute, which covered 1) increased knowledge and skill in caring for residents with dementia; 2) mentoring skills with newly-hired staff; and 3) leadership skills related to ''culture change'' activities throughout the organization. The second was an informal training conducted by the project manager in conjunction with CNR nurses and directors. This part of the training developed the aides' clinical skills and preparation for grief and bereavement.

The role of the CNA person-centered care mentor:

The PCC mentors assist in the hiring and orientation of new CNAs, serve as a resource for other staff, and provide leadership to select projects relating to person-centered care. Each new CNA is paired with a mentor for two to three weeks. The mentors teach routines, skills, time management, and also serve as a liaison between the nurse or neighborhood director and the new CNAs. While the mentors are not supervisors, they do assist in the identification and reporting of the skills performance of CNAs in their departments. PCC mentors participate in constructing care plans and in teaching bathing, nutrition, feeding, and communication skills. In particular, they have enhanced the process of bathing dementia residents. They also give a lead in developing person-centered changes, such as a welcoming committee, which was revitalized after the program was implemented, and changes to the decor of the bathrooms and resident rooms.

The mentors have three days of regular assignments, and usually work two days a week as mentors. The PCC mentors are now dispersed in all neighborhoods and floors of the facility.

Results, Outcomes, Evaluation

Surveys taken in 2003 and 2005 (before and after the program's implementation) showed signs of improvement in staff satisfaction and turnover rates. During this time, while all nursing staff turnover decreased from 10.5% to 7.6%, the staff at the ''Penthouse Gardens'' site, where the program was implemented, decreased from 5.6% to 0%. Furthermore, all PCC mentors still work at the facility.

Job satisfaction and commitment also increased. For instance, the 2005 survey found that 37% of staff felt they had an opportunity to participate in decision-making in their ''neighborhood'' based worksite, as opposed to 20% in 2003. 61% agreed or strongly agreed with the statement: ''Being involved in decisions about my neighborhood and choices of uniform gives me a sense of pride and loyalty,'' up from 43% in 2003.

Anecdotally, residents, families, and staff have all expressed increased satisfaction with environmental changes since the program's implementation. These include redesigned spas for bathing and a dining room that supports restaurant-style dining. Peer mentors also developed and implemented other projects—adding heat lamps in bathrooms, decorations in residents' living spaces, using shadow boxes, and creating welcome baskets—that were well received by residents and families.

The most dramatic changes, according to the program participants, occured in relation to staff team building and communication. Mentors and administrators alike agree that the hierarchy of the nursing department broke down significantly as a result of the program. There is now a direct line of communication between CNAs and the administration as well as between PCC mentors and other staffing departments (building operations, dietary department, director of environmental services, etc.). Administrators find that the mentors consistently offer insight and useful suggestions about how care ought to be implemented, and they are able to react quickly and directly when there are problems or suggestions.

The mentors also express an increased confidence in their own knowledge of dementia, feel invested in the process of developing person-centered care, and feel they are better at problem-solving and communicating with co-workers and residents.

According to the Penthouse Gardens' neighborhood director: ''The mentors feel empowered, feel they are making a difference. They ask to do more now that they are not stuck in a box. They speak well, they have knowledge, make suggestions, are intelligent... they are a plain asset.''

Lessons Learned

Administrators and mentors discussed three main challenges in the program: 1) recruiting CNAs to submit applications for the program, 2) initial suspicion on the part of other CNAs to the new mentor roles, and 3) hitting a plateau in translating knowledge from mentors across to other CNAs.

One of the main reasons cited by the mentors as to why they were initially hesitant to join the program was that they had seen many programs come and go and were not convinced that this was a serious initiative.

Administrators felt they had to market the program and provide incentives in order to recruit CNAs to apply. Work needed to be done to clarify to other CNAs what the new mentor roles were. According to the mentors, some CNAs initially saw them as supervisors or even ''spies.'' This initial suspicion broke down over time as mentors were able to share skills that other CNAs saw work in practice.

Now staff regularly seek out mentors for help needed. Mentors overwhelmingly expressed a need for patience and periodic check-ins with each other in order to weather the difficulties in adjusting to their new roles.

The challenge now is to translate the knowledge learned by the mentors to other CNAs. Mentors and administrators expressed a dynamic in which PCC mentors do more of the work than they are able to effectively share.

Costs and Funding

The program was developed out of a grant from the Department of Health that was to address educating staff on Dementia and improving the environments for residents with dementia. They spent $108,000 on staff replacement during the training period; $202,000 on consultant and trainers fees; and approximately $30,000 on program supplies, mentors' travels to seminars and conferences, and other staff development costs.

The grant started on 1 July 2003 and ended on 31 October 2005. Any costs incurred after the life of the grant are CNR's responsibility. These include $1.50/hr raises for PCC mentors upon completion of the training and any new policies and systems implemented.

Contact Information

Joyce Lusan
Director of Certification, Education, Research, and Training (CERT)
CNR Health Care Network
520 Prospect Place
Brooklyn, NY 11238

t: 718-636-1000, ext. 313
f: 718-789-9212
e: jlusan@cnrhealthcare.org
Website: www.cnrhealthcare.org

Other Resources

Introducing peer mentoring in long-term care settings

Bathing without a battle: Creating a better bathing experience for persons with alzheimers disease and related disorders

Peer mentoring: A workshop series for direct-care workers in home and residential care

The well-rounded CNA: How a mentoring program improved our whole facility