develop better and more interactive relationships, including improved recognition by supervisors of each worker’s skills.

Increasing Recognition

Direct-care workers often feel that they do not receive adequate recognition for their work or for the contributions that they make toward quality patient care. Studies looking at the implementation of empowered CNA teams at skilled nursing facilities found that giving CNAs added decision-making responsibilities led them to become more competent and also to develop better attitudes about their jobs. This approach also takes advantage of the fact that CNAs have the most direct knowledge about the preferences of nursing home residents and as a result are often in the best position to make decisions relating to day-to-day care (Yeatts and Cready, 2007). Efforts to increase the involvement of direct-care workers in decision-making have also been linked to increased overall job satisfaction and, ultimately, decreased turnover. One study, for example, found that turnover among nursing home aides was significantly reduced when they were involved in interdisciplinary care-plan meetings (Banaszak-Holl and Hines, 1996). In a study of Pennsylvania’s direct-care workforce, increased involvement of direct-care workers in care planning was associated with decreased rates of staff shortages and fewer job vacancies (Leon et al., 2001).

The Wellspring nursing home quality improvement model is one example of an effort to improve the recognition of CNAs as important members of the care team by enabling them to become leaders in continuous quality improvement. The program encourages individual staff members to acquire knowledge and skills in particular clinical areas (e.g., incontinence and pressure ulcers) so that they can lead care-resource teams in the care-planning and decision-making processes for residents (Wellspring Institute, 2005). (See the next section on career lattices for more on the development of specialty areas among direct-care workers.) These areas of training are based on best practices determined by the guidelines of both the Agency for Healthcare Research and Quality and the American Medical Directors Association as well as on other national standards of best practices (Wellspring Institute, 2005).

Evaluation of the program has shown that its training and organizational change methods have had measureable impact on retention and job satisfaction among its staff, as well as on resident satisfaction. Turnover rates were lower than at comparable facilities in the area; staff was more actively involved in assessing resident needs and providing care; and there was observational evidence of improved quality of life and interactions with staff among residents (Stone et al., 2002).

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