Certified Nursing Assistants' Wellbeing

U.S. nursing homes (NHs) serve 1.6 million older persons, all of whom have significant
physical and/or cognitive impairment, and the majority of whom have Alzheimer's disease or a
related cognitive disorder. In these settings the vast majority of hands-on care is provided
by an estimated 634,000 certified nursing assistants (CNAs) - paraprofessional caregivers who
are racially diverse, largely female, and an annual income equivalent to the poverty
threshold for a family of four. Despite the crucial role of CNAs in providing care for the
long-term care population and efforts to recruit and retain a stable workforce, absenteeism
rates are high and annual turnover averages 65%, with adverse impact on the quality of care
provided to NH residents, making CNA retention a policy priority.

CNAs have significant life stressors that affect their ability to work, such as single
parenthood, poor physical health, difficulty finding childcare, and transportation problems.
They also face emotionally and physically demanding job tasks, particularly when working with
persons with Alzheimer's disease and related dementias, and many lack helpful strategies for
dealing with stress, negative feelings, and burden.

A newly developed, standardized Mindful Self-Compassion (MSC) intervention may have
particularly high impact and relevance for the high-stress lives of NH CNAs. MSC training has
been shown to increase wellbeing, compassion for others, and stress-coping skills. However,
little is known about the impact, feasibility and acceptability of MSC training in
low-educated, stress-burdened paraprofessional populations such as CNAs, or whether it can
impact outcomes such as burnout, absenteeism, and turnover.

This preliminary study will modify, refine, and test a MSC training intervention for CNAs who
care for nursing home residents. The researcher teams' goal is to increase CNA coping skills
and well-being, thereby reducing absenteeism and intent to leave the job, reducing burnout,
and improving job satisfaction and attitudes toward people with dementia. The proposed
research will be conducted in 3 similarly rated and structured community NHs. In aim 1 the
investigators will assess intervention feasibility and acceptability in one NH, using the
knowledge they gain to tailor an evidence-based MSC program specifically for CNAs. In Aim 2
the investigators will pilot test the MSC training program with 30 CNAs who work in 2
similarly rated and structured NHs, evaluating the fidelity of the revised training and
exploring trends in immediate, 3-month, and 6-month outcome measures in order to inform power
calculations for future trials.

The specific aims are:

Aim 1. Determine the feasibility, acceptability, and necessary adaptations of MSC training
needed to meet the diverse cultural background, limited literacy, and job and family
challenges of the nursing home CNA workforce, including the unique challenges of caring for
persons with dementia, and of the data collection methods.

1. Conduct a field trial of the standardized 8-week MSC training program with 15 CNAs
within a single community NH. Evaluation will focus on: (a) participation (including
home practice adherence); (b) attendee evaluation of the training; (c) barriers to and
facilitators of participation; (d) use and retention of class material by participants;
and (e) recommendations for improvement of training.

2. Field test the feasibility and acceptability of our study recruitment and evaluation
strategy.

3. Use data collected from the field test to modify recruitment strategies, protocols, and
course structure, content and materials so as to be maximally feasible, acceptable and
effective in a CNA population.

Aim 2. Conduct a pilot test of the adapted protocols and intervention in a sample of 30 CNAs
from 2 similarly rated and structured community NHs to reexamine feasibility and
acceptability, identify trends in key intermediate and long-term outcomes, and estimate
effect size in preparation for a future randomized trial.

1. Evaluate the fidelity and immediate impact of the modified training by measuring (a)
training attendance; (b) satisfaction with the training; and (c) pre-and post-training
measures of self-compassion, perceived stress, job satisfaction, job burnout symptoms,
and attitudes towards persons with dementia.

2. Evaluate the sustained impact of the training by comparing baseline, 3-and 6-month
post-training measurements of: absenteeism, intent to leave job, self-compassion,
perceived stress, job satisfaction, job burnout symptoms, and attitudes towards persons
with dementia.

Inclusion Criteria:

- Certified Nursing Assistant employed by 3 partnering Nursing Homes

- Aged 18 and over

- Speak English

- Work at least 20 hours as a CNA at one of our proposed Nursing Homes

- Expect to attend at least 75% of the intervention classes

- Expect to stay at least 8 weeks on the job

- Score in the top 50% on the PSS-10 (Perceived Stress Scale)

Exclusion Criteria:

- Younger than 18

- Working fewer than 20 hours a week

- Unable to attend at least 75% of the intervention classes

- Expect to leave their position during the 8 weeks of the intervention