Long-Term Care Survey Alert

Published on Mon Apr 21, 2008 PDF

Find out why you should try this approach -- and tips to make it work.

Looking for a way to promote quality of care and life for residents -- and boost job satisfaction for certified nursing assistants, to boot?

Consider implementing a primary CNA team approach, which is actually one of the Advancing Excellence in Nursing Home goals, suggests Steven Littlehale, MS, APRN, BC, chief clinical officer for LTCQ Inc. in Lexington, MA.

Primary nursing doesn't work in long-term care due to the ratios of licensed nurses to residents, Littlehale says, whereas primary care CNA teams "absolutely do work -- in fact, they work quite well."

Choice is key: When Littlehale created such teams in the past, he allowed CNAs to select their own residents for primary care assignments. If the resident agreed to work with the nursing assistant, the assignment became an ongoing one.

Littlehale facilitated the assignments by having CNAs first identify their criteria for evaluating the "difficulty" of caring for a resident, which included ADL dependencies, behaviors, challenging families, toileting, and "messy rooms."

To ensure equitable workloads overall, each CNA used the selected criteria to evaluate all of the residents on a five-point scale. Averaging their evaluations helped to ultimately ensure that CNAs received a fair assignment.

Next step: The CNAs were required to tell each resident they selected, "I chose to work with you. I want to work with you. Would you like to work with me?"

Even those residents who were initially somewhat cautious about the primary assignments ultimately loved it, Littlehale reports.

"They no longer worried about who was going to walk through their door to care for them."

"With primary care teams, the CNA develops a completely different relationship with the resident. The 'problems' seem to disappear as both the CNA and resident commit to the relationship," says Littlehale.

Expect some bumps in the road: Implementation wasn't all roses. Littlehale notes that some CNAs initially were looking to have his "head on a platter" for changing the usual way of doing things. But after the "dust settled," they later told him that the change had enhanced their job satisfaction. "They knew long in advance whom they'd be taking care of for that day, week, and month."

The consistent assignments allowed the CNAs to better manage their time and invest more in the relationship with the resident. They also had more flexibility to work with the resident to select which day the resident wanted to take a shower, as one example.

"CNAs realized they were in control of their schedule and could make those kinds of changes without seeking permission from the licensed nurse," Littlehale says.

More perks: A primary caregiver who really gets to know a resident's likes and dislikes can improve his care experience -- and prevent negative outcomes, such as weight loss. For example, "one of the most important dietary interventions is to make sure the resident gets what he requests," says Annette Kobriger, a registered dietitian and nutritional consultant in Chilton, WI.

CNAs who really get to know a resident's baseline functional status and behavior can also be the first to identify a subtle change in condition that may herald the onset of delirium or acute life-threatening illness.