key: cord-0995160-ttyozvl2 authors: Franzosa, Emily; Mak, Wingyun; R. Burack, Orah; Hokenstad, Alene; Wiggins, Faith; Boockvar, Kenneth S.; Reinhardt, Joann P. title: Perspectives of certified nursing assistants and administrators on staffing the nursing home frontline during the COVID‐19 pandemic date: 2022-03-10 journal: Health Serv Res DOI: 10.1111/1475-6773.13954 sha: 3c6ed2a5bb149d5f113c70cfc231b06a8d028f4a doc_id: 995160 cord_uid: ttyozvl2 OBJECTIVE: To identify best practices to support and grow the frontline nursing home workforce based on the lived experience of certified nursing assistants (CNAs) and administrators during COVID‐19. STUDY SETTING: Primary data collection with CNAs and administrators in six New York metro area nursing homes during fall 2020. STUDY DESIGN: Semi‐structured interviews and focus groups exploring staffing challenges during COVID‐19, strategies used to address them, and recommendations moving forward. DATA COLLECTION: We conducted interviews with 6 administrators and held 10 focus groups with day and evening shift CNAs (n = 56) at 6 nursing homes. Data were recorded and transcribed verbatim and analyzed through directed content analysis using a combined inductive and deductive approach to compare perceptions across sites and roles. PRINCIPAL FINDINGS: CNAs and administrators identified chronic staffing shortages that affected resident care and staff burnout as a primary concern moving forward. CNAs who felt most supported and confident in their continued ability to manage their work and the pandemic described leadership efforts to support workers' emotional health and work–life balance, teamwork across staff and management, and accessible and responsive leadership. However, not all CNAs felt these strategies were in place. CONCLUSIONS: Based on priorities identified by CNAs and administrators, we recommend several organizational/industry and policy‐level practices to support retention for this workforce. Practices to stabilize the workforce should include 1) teamwork and person‐centered operational practices including transparent communication; 2) increasing permanent staff to avoid shortages; and 3) evaluating and building on successful COVID‐related innovations (self‐managed teams and flexible benefits). Policy and regulatory changes to promote these efforts are necessary to developing industry‐wide structural practices that target CNA recruitment and retention. Certified Nursing Assistants (CNAs) are the cornerstone of nursing homes, providing the majority of hands-on care and gaining intimate knowledge of residents and their needs. [1] [2] [3] While their work is physically and emotionally demanding in the best of times, the COVID-19 crisis added extraordinary personal and professional stressors. 1, 4, 5 Emerging research shows that the pandemic led to widespread CNA staffing shortages, threatening resident care and nursing home viability. 6, 7 Lower staffing ratios, increased use of temporary agency staff, and lack of adequate sick leave were associated with COVID-19 outbreaks and resident death. [8] [9] [10] While COVID-19 may have exacerbated the nursing home workforce crisis, the pandemic did not create it. Nursing homes have long suffered from inadequate staffing and difficulty recruiting and retaining CNAs due to low pay and poor job quality, potentially undermining care quality. [11] [12] [13] [14] [15] Prior to the pandemic, national surveys of nursing home administrators and CNAs consistently showed that staffing shortages were a top concern, and CNA positions were the most difficult to fill. 15, 16 Ensuring the future viability of the nursing home industry and meeting the need for safe, high-quality long-term care requires stabilizing the existing direct care workforce while building a pipeline of Our approach drew from directed content analysis. 20 Study team members independently reviewed two interviews and two focus groups, noting key themes, issues, debates, and questions, and met to compare findings and develop an initial codebook. The authors separately coded the remaining interviews and reviewed each other's codes. We maintained rigor via in-depth writing and weekly discussion of key findings and accuracy of code definitions. 21 We compared findings between and within roles, sites, and shifts (day/evening) to surface concordant and divergent perspectives. Data were analyzed using Dedoose qualitative software. 22 Results presented here include data from all participating sites, but due to the sensitive topic and small sample, we did not tie them to specific facilities to maintain confidentiality. However, groups at three nursing homes generally reported feeling more supported and confident in their ability to manage pandemic stressors than the two others, and we stratified our results by these two environments. This study was approved by the institutional review board at The New Jewish Home. We interviewed 6 administrators and held 10 focus groups with 56 CNAs (See Tables 1 and 2 for site and CNA characteristics). Administrators and CNAs both identified staffing as their greatest concern (See Table 3 T A B L E 3 Certified nursing assistants' perceptions of challenges and strategies to support frontline workers Experience of staffing gaps Note: both "more-supported" and "less-supported" groups reported staffing as their primary challenge If we have enough staff, we could give the level of care [dying residents] really need… maybe some extra time to hold their hands to go through the traveling process or just give them the comfort that is needed, that we would want in their position. If you work Friday short, Saturday short, Sunday short, Monday on or short, you expect for us to come for the next day because we are overwhelmed, right. Then we better stay home instead of coming in and drop somebody or injure ourselves. One of our co-workers, she [fell] sick and when she called me and I said, "oh, we are only two on the floor", she [canceled] the sick call. I see all the sacrifice I gave [the facility] during the COVID. And leave my kid to come just work here. Now I'm being laid off because they said they are struggling with income. Groups reporting more supportive work environments Groups reporting less supportive work environments contributed to severe shortages during the initial COVID-19 surge, generating concerns around safety, care quality, and staff burnout as they worked without time off because "residents are relying on us." CNAs across groups worried short-staffing increased COVID-19 risk for residents and staff (e.g., "floating" staff between COVID and non-COVID units), and difficulty meeting isolated residents' physical and emotional needs, particularly during the dying process. Administrators attempted to bring in part-time and temporary workers to fill gaps, often at "astronomical rates" which were "almost unsustainable." However, CNAs in most groups felt agency aides and nurses were not an adequate solution as they required training and were unfamiliar with facility workflows or residents' needs and preferences. As one CNA noted, "it's like you're doing your job and you're also doing the person's job." Administrators also employed creative staffing strategies, sometimes supported by state and federal emergency waivers of licensing and certification requirements. 23, 24 Administrators reassigned staff from closed adult day centers, used administrative and social work staff to help change beds and feed residents, and created positions such as an unlicensed "unit assistant" to answer phones and facilitate virtual family visits. Despite ongoing shortages, CNAs and administrators worried funding pressures and a low patient census might force facilities to further reduce staff. An administrator noted that "it's a personal source of conflict for me to have to potentially lay off the people who worked really hard…it's horrible." One CNA participant also revealed that she had just been laid off. CNAs in many groups said employers seemed more aware of their need for flexibility and support to balance the intense emotional toll of their work and juggle personal and job responsibilities. Workers appreciated new accommodations for child care, transportation, or caring for sick family members. CNAs in one group described working with supervisors to adjust their team's work schedules around child care, while others suggested flexible or staggered shifts would be useful in the future. Child care services were also an important new benefit for many workers. CNAs wanted these benefits to continue and be equally accessible to night and weekend shift workers. CNAs also noted the importance of paid time off. While most had vacation time, they either had not been able to use it or did not want to use it for mental health purposes. Several groups mentioned that administrators tried to give them time off to recuperate, with one facility providing an extra week of paid leave and others allowing days off when the resident census was low, although it was unclear if this was paid time. All administrators also described conscious efforts to provide mental health and coping resources, from support groups and meditation classes to quiet spaces. Several facilities partnered with the CNAs' union to offer telehealth counseling and connect staff to mental health benefits through the union health plan, which was appreciated by the CNAs who used these services. Both administrators and CNAs in more supportive facilities described an "all-hands-on-deck" approach across hierarchical lines. CNAs were particularly appreciative when other staff pitched in to help change beds, distribute meals, and perform care tasks. Administrators similarly stressed the importance of making staff "feel that they're not in it alone." However, CNAs in several groups were frustrated that management was rarely visible. While some CNAs felt supported and appreciated by unit nurses, others felt left out of care decisions. CNAs also relied on peer support, "rallying together" to hand-off care tasks, remind each other of COVID-19 protocols, and provide emotional support. Many workers appreciated the visible recognition and appreciation of CNAs, which some felt was a change from usual practice. Administrators described efforts to recognize staff, offering meals and gifts, greeting staff at the door, and creating a labor-management staff recognition committee including union delegates. However, both CNAs and administrators acknowledged these modest supports were inadequate. "The reality was, people were working double shifts, seven days a week," shared one administrator. "It was like being in a war zone, and you're on the frontline (saying) 'well, here's a pizza.'" CNAs in groups describing more supportive work environments cited open-door policies and direct access to supervisors, managers, and administration that made them feel heard and valued. This included avenues to request training, support, and mental health services. However, not all CNAs felt they had access to facility leadership. One group expressed frustration over the hierarchical reporting structure, noting CNAs were often "not heard" and discouraged from reporting problems not directly related to resident care. Across groups, CNAs emphasized that clear, direct, "real-time" CNAs. However, ongoing staff shortages continued to be administrators' and CNAs' greatest concern, consistent with other research in this area. 25 Our sample represented nursing homes that were already actively engaged in workforce retention efforts yet still experienced severe staffing challenges, suggesting that these issues may have been greater for other facilities. The continued financial impacts of COVID-19, including low nursing home admissions and ongoing funding challenges, may further threaten the stability of the workforce and resident care. 26 While our results suggest nursing homes and researchers can and should further explore these organizational adaptations, stabilizing the workforce long-term will also demand more fundamental policy and regulatory efforts, including appropriate financing for those who need institutional-level care. Collaborative practices and "open-door" policies made CNAs in our study feel recognized and valued, while also helping manage an unsustainable workload. With this support, CNAs in many of our focus groups felt empowered to work closely together to coordinate staff schedules and patient hand-offs. Our findings suggest an opportunity to further test self-managed teams, [27] [28] [29] although these efforts will also require adequate support and compensation for CNAs to take on these new roles without creating additional job strain. [30] [31] [32] Trust in leadership alongside transparent, real-time communication of rapidly changing information was also essential to CNAs in our study. Open, accurate communication has been shown to reduce CNA turnover 33 COVID-19 placed the nursing home industry and its workforce under extreme and unprecedented strain. However, it also provided an opportunity for facilities to explore more collaborative, compassionate workplace practices. Rather than return to "business as usual," the industry now has the opportunity to further study and build on these lessons. These strategies must also go hand in hand with policy and regulatory efforts to stabilize the nursing home industry, its workforce, and the older adults they serve. The authors thank the Ladders to Value Workforce Investment Organization (WIO) for funding this work, especially Georgina Weyhe and Kathryn Santos for their assistance in identifying sites. We also thank the 56 CNAs and six administrators who generously shared their experiences during a uniquely challenging time and the staff at each facility who helped coordinate and facilitate our focus groups. Emily Franzosa https://orcid.org/0000-0002-7590-0316 Nursing assistants employed in nursing homes: key facts. 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NBC News Web site Now, I'd like to move on to talking about your facilities' COVID experience What were the biggest challenges your facility faced during the COVID-19 surge in the spring? How did you manage them? In terms of staffing, what helped you the most to deal with COVID-19 in the nursing home? What was most challenging? What are the barriers to accomplishing this [reference answers to #5]? How might those be addressed? What are the most important lessons you've learned from the past six months? Do you have any questions for me? That's all of my questions. Thank you so much for your time! If there's anything else you think of later that you want to add, or if you have any other questions for me CERTIFIED NURSING ASSISTANT (CNA) FOCUS GROUP GUIDE Let's go around the room, and please share your name and how long you've been working at B.1. | Core questions We realize that COVID-19 has put us all through challenges we've never faced before at work and in our personal lives. In terms of your work over the past 6 months On a scale of 1-10, how helpful would you find: a. Training and preparation: Things like training on infection prevention/safe work practices, care of patients with COVID, grief and loss, working with residents' families b. Benefits: Things like paid time off, sick leave, "hero" pay c. Work-life support: Things like meals/groceries, child care support, help with transportation, flexible scheduling d. Emotional support: Things like mindfulness training Which of these would be most important? Why? Are there other supports you'd want that I didn't mention? Of everything we've talked about, what is the single most important thing your employer could do to support you on the job? 11. Is there anything we didn't ask, but should have? Thank you so much for your time! All of the information you shared with us today is incredibly helpful. I know our time was short, so if there's anything else you would like to add