Accepted on 10 Oct 2021 Submitted on 09 Jun 2021
In response to persistent nursing shortages and to maintain financial solvency for the U.S. healthcare system, some care that was previously the responsibility of licensed nurses (LNs) is now performed by certified nurse aides (CNAs).1 This change has been apparent across acute and post-acute settings and was particularly impactful in long-term care (LTC), where CNAs perform 80–90% of all direct resident care (Institute of Medicine Committee on Nursing Home Regulation, 1986). In the nursing home, the LN and CNA must follow scope of practice and state Board of Nursing regulations (National Council of State Boards of Nursing, 2019) while working together in a team nursing model (Siegel et al., 2018). Despite the critical nature of teamwork and the emphasis placed on collaboration (Agency for Healthcare Research and Quality, 2019a; IOM Committee on Nursing Home Regulation, 1986), challenges to LN/CNA collaboration in the nursing home raise concern regarding its functional application (Cammer et al., 2014; Caspar et al., 2017; Madden et al., 2017; Prentice et al., 2017). Our aim was to identify LN/CNA caregiving pairs who operationalize collaboration and explore their lived experience of working together in the nursing home. This paper focuses specifically on participant experience with the collaborative element termed mutual support (Agency for Healthcare Research and Quality, 2019b).
The current nursing home workforce in the United States is comprised of individuals with various levels of education and preparation. Licensed nurses include registered nurses (RNs) and licensed practical nurses (LPNs). Despite substantial differences in educational preparation, LPNs and RNs are often grouped in nursing home research due to similarities in their job descriptions and because of the small number of RN/LPNs in a facility to avoid inadvertent identification of participants by the study sites (Dwyer, 2011; Siegel et al., 2008).
The requirements for licensure as a registered nurse include graduation from an accredited nursing program and passing the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Accredited nursing programs have historically offered three different degree options: associate degree (2-year program), diploma (3-year program), and Bachelor’s degree (4-year program; Nursing Explorer, 2019). Graduates from all three of these programs qualify by passing the same licensing exam and practice with RN licensure.
Accredited CNA certification and training programs follow guidelines in the Omnibus Budget Reconciliation Act of 1987, and individual states may add to these regulations (U.S. Congress, H.R.3545, 1987). Thus, there are state variations in the number of required classroom and clinical training hours (PHI National, 2018). Some LTC facilities offer to provide and pay for training, and prospective employees can complete the CNA training process in as little as four weeks (American Red Cross, 2018). Under LN direction, CNAs assist residents with feeding, bathing, dressing, and mobility (U.S. Department of Labor, 2019b) and provide almost all hands-on resident care (Harris-Kojetin et al., 2019). CNAs frequently incur occupational injuries, including cuts, bites, and back injuries as the recipient of residents’ combative behavior (Walter, 2012). They are also at risk for injuries from sharps and exposure to disease, including blood-borne pathogens (Quinn et al., 2009) and the novel Coronavirus (COVID-19; Chatterjee et al., 2020). Seventeen percent of CNAs are under 25 years old. While 43.8% of CNAs have a high school diploma and 18.2% received a high school equivalency certificate, 12.4% do not have either (U.S. Department of Labor, 2019b). One-third have a family income of less than $20,000, and only 9.6% reported a family income of $50,000 or more. Turnover of CNA staff is high; the most common employment length is 2–5 years (26.2%), with 12.4% having worked as a CNA for more than 20 years (U.S. Department of Labor, 2019b).
These findings are part of a broader study that explored the lived work experience of collaboration in four nursing homes in the Western United States (Beynon et al., manuscript in review). The study sample included 24 participants: 12 LNs (six registered nurses and six licensed practical nurses) and 12 CNAs who work together in the delivery of bedside care. The study had Institutional Review Board approval. Semi-structured interviews were conducted with the caregiving pair as well as the individual LN and CNA, using a cross-over study design (see Table 1). This combination of paired and individual interviews has been considered the most useful approach by some experts in qualitative research (Morgan, 2016); however, for logistical reasons, studies that include both are rare, and none were previously identified in nursing home literature. We conducted pair interviews to allow concurrent reflection by two participants, potentially increasing recall reliability and allowing the researcher to observe the interaction between the LN and CNA as the story unfolded. Individual interviews provided an opportunity to interview the participants privately and allow them to share feelings or perspectives that may have been uncomfortable in the presence of their coworker.
Table 1 Cross-over Interview Design. Note: A crossover design was incorporated to mitigate response bias by balancing out both the influence of the paired interview on the individual responses and the influences of the individual responses on the paired interview. Individual interviews included prompts asking each participant about their interaction with their coworker (LN or CNA). They were asked to talk about the intersection or connection of their own role with that of their coworker and identify what does or does not work well in that relationship (See Appendix A). Pair interviews included the use of a vignette (Jenkins et al., 2010) and the critical incident technique (Gremler, 2015), allowing participants to recall a real situation they faced together and plan the care of a theoretical resident. Pairs were prompted to share challenges as well as most enjoyable aspects of their working relationship (See Appendix B). The focus of the interviews was to allow participants to share their experience of working together, both in coalition with their LN/CNA partner and individually. Participants were recruited with purposive sampling using a Partner Selection Questionnaire designed for this study. LN and CNA coworkers mutually identified one another as effective partners in providing high-quality resident care and were interviewed individually and as LN/CNA caregiving pairs. Participants included 12 CNAs and 12 LNs. Participant race included Asian (8%), American Indian (8%), multiracial (4%), Black or African-American (4%), and White (63%). Twenty-five percent of participants reported Hispanic ethnicity. The mean age of CNA participants was 32 (range 18–57 years), and the mean age of LN participants was 46 (range 23–66 years). Participant experience in long-term care (LTC) ranged from 6 months to 11 years, with an average of 9 years of experience among participants. Interviews lasted between 30 and 60 minutes and were all conducted by the primary researcher. Interviews were recorded and transcribed verbatim, and data were coded for meaning using NVivo12 software. Thematic analysis was used to allow meaning to emerge through the subjective experience of the participants. Descriptive and in-vivo coding were used during first-cycle coding, and pattern coding was used during second-cycle coding (Miles et al., 2014). The first author conducted data analysis with oversight and code-checking by two experienced researchers. As participants shared the lived work experience of collaboration in individual and pair interviews, it was noted that both LN and CNA participants described multiple ways CNA caregivers are supported by their LN coworkers. Although mutual support was previously identified as an element of successful collaboration, our research found support was primarily expressed in participant descriptions of LN support for CNAs.
In individual and pair interviews, participants described various expected and unexpected ways LNs support their CNA coworkers. Findings were consistent across LN interviews, CNA interviews, and pair interviews. These LN and CNA insights are presented in the following nine categories: listen and respond, show respect, help with resident care and answer call lights, teach and explain, provide feedback and encouragement, adjust and divide workloads, protect the CNA, support physical needs, and provide emotional support. These categories blend and overlap, but each has value and meaning in support of the critical work of CNAs. Each category will be described using examples from qualitative data.
Because CNAs know the residents well, they can guide the LN to “approach the resident from the other side” or “put the pills in chocolate pudding.” As one LN put it, “[I listen to the CNAs because] they know when I’m going to get whacked!” LN participants also emphasized that CNAs play a critical role in resident safety by communicating resident condition changes to the LN. Primarily, CNAs support the LN by doing their job and doing it well. One nurse said it takes stress off her “…to have a CNA I can trust to get her job done …It’s just super helpful.”
Without exception, CNA participants reported they provide the best care they can regardless of the nurse’s collaboration or investment. Still, they are limited if something goes wrong such as the resident needing medication or requiring a change in orders. In contrast, each LN expressed a complete reliance on CNAs to care for residents. The LNs in this sample expressed an understanding and recognition of the vital contribution CNAs make to nursing home residents’ care. For many reasons—the well-being of residents, concern and genuine regard for the CNAs, and their own work interests—these nurses expressed a willingness to go to great lengths to support their CNAs. One LN put it this way: “I know they work so hard, and if I didn’t have them, I couldn’t do my job. If they weren’t here, I would fail.” These LNs understood and readily acknowledged that when it comes to resident care and quality of life, it’s all about the CNAs. LN and CNA insights regarding ways LNs support CNAs are presented in the following nine categories: listen and respond, show respect, help with resident care and answer call lights, teach and explain, provide feedback and encouragement, adjust and divide workloads, protect the CNA, support physical needs, and provide emotional support. These categories are interconnected and overlapping, but each contributes to our understanding of LN support for their CNA coworkers.
CNA participants expressed appreciation for LNs who listen to their concerns, respond promptly, and follow through. Several LN participants emphasized the value of listening and responding to their CNA coworkers as a way to build trust and demonstrate respect. One RN said, “[My CNAs] know I will drop everything if they asked me to come and help.” She added it promotes resident safety and “It’s less work actually to go and help than to risk having something bad happen.” In this same pair interview, the CNA shared a time when a different nurse did not listen and respond helpfully.
LN and CNA participants emphasized the importance of showing respect by valuing the CNA’s knowledge and experience to build a collaborative relationship. One nurse advised other nurses to avoid “separating yourself or acting like your work is so much more important.” Another nurse stressed the value of asking the CNAs’ opinion when they come to him with concerns:
One LN gave an example of seeking CNA input in making care decisions. “We have this lady that was not sleeping. For me, it’s helpful to shoot ideas off the CNAs about what [to do]. ‘Is that what you’re seeing? What do you think?’” Many CNAs expressed appreciation for the respect shown by their LN interview partners. One said, “she doesn’t make me feel like I’m just a CNA.”
When the residents’ needs exceed the CNA’s human capabilities, LNs provide support by helping with the workload. Nurses emphasized the importance of being willing to help provide care when the CNA is spread too thin to safely meet resident needs. CNA participants described help they received from nurses, such as answering lights, helping with resident transfers, and getting vital signs. One CNA shared a time when she felt overwhelmed, and the LN help prevented her from quitting.
Another CNA explained why her helpful LN partner makes such a difference at the facility:
Another CNA said the difference in collaboration is “pure and simple” – a nurse who is “willing to help.” All nurse participants emphasized the importance of helping CNAs:
Another LN described digging in to help as the key to collaborative care: “[Nurses should] just not think that they’re above the caregivers – Bottom line! They can clean up poop, too.”
Nurses also support CNAs by answering questions and educating them. One nurse said, “with teaching, you’re empowering [CNAs] to make decisions, you know, then they can make decisions, and then they do better.” She further described it this way:
A CNA participant expressed appreciation for the teaching she received from her LN interview partner.
Nurses stressed the value of being positive, appreciative, and commending CNAs when they do a great job. One nurse talked about it this way:
One LN said, “You have to constantly be giving [the CNAs] feedback. As nurses, we don’t feel appreciated. Well, we can do that with the aides.”
One nurse had three CNAs working on the floor, and two of them were cousins. The nurse observed the cousins provided help and support to one another but were not as quick to help the third CNA. “You could hear her on the radio asking for [help] and they wouldn’t come. Sometimes I would step in and say ‘[The CNA] needs help down there – It’s not safe.’ I mean, you can’t do that alone. It’s dangerous. [The resident] is combative.” Other situations require adjustments in workloads. One CNA said, “I try to come into work and leave all my problems at the door and come in with a smile and everything.” However, at the end of an afternoon shift, he received a text from his significant other with devastating family news.
During a weekend shift, a resident’s family member came in and was unhappy about the resident’s laundry situation. The family member began to yell at Lori,3 the CNA. As she related this story in the pair interview, Lori turned to her LN interview partner, Andy, and said she wished he had been the nurse working that day “cause they yelled at me right in front of Chris [the LN working], and Chris just stood there and walked away. If that would have been you, you would have intervened.” Andy elaborated:
In another facility, a different nurse stepped in to protect a CNA from sexual harassment.
One CNA, Jade, had several years of experience as a nurse in another country before coming to the United States. When she first started working at the facility as a CNA, Jade had a very difficult day.
Jade decided she was going to walk off the job, and she made multiple attempts to tell the nurse.
Jade continues,
When one of the CNAs looked extra tired, the LN pulled her aside and asked if she was okay. Initially, she said she was fine, but then admitted she was not. She confided that her phone had been shut off and she didn’t have anything to eat. “So I was like—We’re going to feed you. Okay, let’s get take-out.” The nurse said similar things happened with other CNAs, and she felt part of her job was “making sure they know that I care. You’re fed, you’re okay … Keeping your body well-nourished is huge.” Another nurse shared a story of a CNA who worked for almost a month with a medical ailment.
One CNA expressed appreciation for the emotional support she gets from her LN interview partner.
A nurse related the following story:
One CNA feels supported because the nurses “always know where we are.” She added, “Many nurses encourage you to go break if we, you know, [are] frustrated or something… She’ll be there when I’m burn[ed] out.” Another nurse shared how she builds teamwork with the CNAs she works with:
Collaborative LNs undergird their CNAs in a variety of ways based on the situation. These nurses make the CNA needs and concern a priority and seek and value their input in resident care. Such LNs feel and demonstrate respect for the demanding and challenging CNA tasks and roles. They answer call lights and help with resident care as necessary, assuming some of the CNA’s responsibilities. These LNs empower the CNAs through on-the-job education, providing encouragement, and expressing appreciation for effort and tasks well done. Similarly, these LNs adjust and divide workloads in response to team dynamics and individual needs of the residents and CNAs. They observe and accommodate when one CNA is overwhelmed, or when the particular circumstance requires additional help. At times, these LNs run interference with residents, family members, or other staff when necessary to protect the CNA’s time, dignity, and safety. Finally, these collaborative LNs are aware of and supportive of physical or emotional needs that impact the CNA’s ability to provide their best care. While some LN support level for CNAs was anticipated, these findings exceeded the researcher’s expectations and the support reflected in nursing home literature prior to this study. To describe the holistic support provided by collaborative LNs, we applied the term undergirding. Undergirding is defined as an approach that “gives support underneath; strengthens or secures” (Merriam-Webster, 2020). Bridges have undergirding to stabilize them and keep them from collapsing under the weight of their burden. The structural undergirding is inconspicuous but essential. The purpose and design of the undergirding vary depending on the structure’s location, size, and purpose (K. Watts, Architectural Designer, Bountiful, Utah, personal communication, January 20, 2019). Undergirding in this context is depicted in Figure 1. Each pillar represents a way undergirding was described by LN and CNA participants. Not all structures require nine pillars, and the themes of LN support are not equally common or essential in all cases. Additionally, the pillars are interconnected and overlapping.  Figure 1 Collaborative LNs Describe Types of Undergirding That Support CNA Coworkers. These findings build on existing literature. In addition to their own responsibilities, RNs are expected to have competency in the LPN and CNA role and assist in those roles when necessary (Montayre and Montayre, 2017, p. 47). LNs who help with resident care and answer call lights (Pillar 3) understand this expectation and realize that they are ultimately responsible for resident care. The undergirding pillar educate and explain (Pillar 4) speaks to appropriate LN to CNA delegation. As part of their scope of practice, the RN oversees nursing staff under their charge and, as applicable, delegates aspects of care to the LPN and/or CNA. This approach to delegation of care helps break down barriers in effective delegation identified in previous literature, such as attitudinal barriers and poor partnerships (Corazzini et al., 2010). Mutual support has been defined as “the essence of teamwork” by the Agency for Healthcare Research and Quality (2019b). TeamSTEPPS® describes mutual support as “1) assisting one another; (2) providing and receiving feedback; and (3) exerting assertive and advocacy behaviors when patient safety is threatened.” This research builds on the TeamSTEPPS® definition of mutual support and provides rich narrative examples of that support. Additionally, it may guide the reframing of “mutual” support as further research could explore how that support is or is not balanced or reciprocal. This research underscores CNAs’ challenges, touches on ways they are a vulnerable population, and offers concrete ways LNs can support CNAs. It presents examples of the CNAs’ need for protection and support from LNs who respect their care and depend on them to be successful. The examples shared here complement the work of Hewko et al. (2015) who conducted a scoping review on health care aide (HCA) literature and concluded HCAs are “invisible and ubiquitous” (p. 1) and undervalued. In 2002, Teal wrote, “The simple truth is that the only way to provide high-quality care for adults who cannot live independently is to provide a high-quality job for the direct care worker” (p. 102). She went on to identify direct care workers as “the number one quality indicator in long-term care” (p. 102). For the past three decades, nursing homes have been encouraged to implement culture change models of care with a renewed commitment to collaboration and teamwork (White-Chu et al., 2009). To fully realize the benefits possible in the culture change model, we must foster collaborative care practices by providing the needed support to CNAs as they provide the majority of hands-on care to residents. The collaborative front-line LNs in this study valued the contribution of the CNAs with whom they work. They recognized their reliance on compassionate, dependable CNAs, and responded by providing holistic support as needs arose. From the perspective of CNA participants, this undergirding made a difference in CNA job satisfaction, promoted CNA retention, improved the workplace attitude, and ultimately, elevated the care CNAs provided for the residents. Thus, the bottom line of these holistic support strategies is to improve resident care by undergirding those who provide that care.
There is always some concern when one analyzes a particular component of a more extensive study, yet the fundamental nature of mutual support between LN and CNA and the depth of information that emerged during data analysis merited in-depth analysis. A limitation for generalizability is that the overall staff report of these four facilities was described as highly collaborative and may not represent the broader spectrum of nursing homes. The emphasis of this study was to determine what is effective rather than problematic, so highly collaborative pairs were selected for interviews. Findings were based on self-report and were not subject to objective measures. We did not distinguish between LN levels of licensure, so differences in mutual support provided by licensed practical nurses, associate degree-prepared RNs, and baccalaureate-prepared RNs were not assessed. Future research could further explore LN undergirding concerning boundaries, burden, and sustainability. This sample was purposively selected to reflect high collaboration levels and likely represented the “top-performers” in collaboration and effective teamwork. Additional effort to support, study, or correct “underperformers” is needed. Further research could also explore the phenomenon of undergirding in the broader range of LNs and CNAs across levels of collaborative staff members. Another suggestion for additional research is to explore how residents and their family members perceive collaboration between nursing home caregivers and the role and expectations of the CNAs who provide their care. One strength of the study was the inclusion of the CNA voice. Additionally, it was unique in focusing on what is working in nursing home LN/CNA teams. Each participant expressed their commitment to providing quality resident care, a deeply held value voiced by both LNs and CNAs interviewed.
Education and training for both LNs and CNAs should include collaborative work approaches and team building. Role play of collaboration and communication skills could include: task delegation, asking questions, providing constructive criticism, requesting assistance, and expressing appreciation for the team member. It would be helpful for students to increase their understanding of the roles of the other team member and have opportunities to interact in a clinical or simulation setting. Administrators and nursing directors can advocate for CNAs through their own Nursing Home policies and procedures. This may be reflected through their expectations of CNA training programs or their own onboarding procedures. CNS could benefit from additional recognition of their valuable work and treatment as full team partners rather than mere subordinates. This research has many implications for long-term care policy. Internal facility efforts to foster teamwork and mutual support are, at best, part of the solution. Understanding ways LNs are providing unobtrusive undergirding should speak most powerfully to policymakers. CNAs need more support, including adequate pay and benefits, to provide for themselves and their families if nursing homes hope to decrease turnover, improve retention, and elevate the quality of care for nursing home residents.
These findings provide a glimpse into hard-working, compassionate, resident focused LNs and CNAs who value collaboration and share their conviction that effective collaboration improves the quality of resident care. These caregivers deserve our respect, our appreciation, and our support. For decades, there have been ongoing concerns regarding improving outcomes for nursing home residents—particularly regarding the quality of care and resident safety. Supporting the CNAs who provide that care is fundamental. The LNs they work with know that—it’s time for us to recognize it as well.
Caregiving Pair Selection Questionnaire (CNA)
Caregiving Pair Selection Questionnaire (Licensed Nurse)
1In this article, the term certified nurse aide (CNA) is used as the title for nurse aides certified through state-approved programs in the US. Additional designations for this position, including nursing assistant, healthcare aide, and unlicensed assistive personnel, are also used throughout the broader NURSING HOME literature. 2In California and Texas, nurses who pass the NCLEX-PN are called licensed vocational nurses (LVNs), but for the purposes of this study, they are referred to collectively as LPNs. 3All names in this paper have been changed.
The authors have no competing interests to declare. References
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