The role of certified nursing assistants and nursing home assessments is critical. Typically, nursing assistants provide the “raw data” to nurses, including pain observations, behavior patterns, and treatment preferences. But how is the CNA role different from the RN or the LPN? Why is training important? In this week’s episode, we welcome Dr. Elizabeth Halifax to discuss the importance of CNAs in nursing home care.
Schenk: Hey out there. Welcome back to the podcast. My name is Rob. I’m going to be your host. This week, we’re going to be talking about the role of the CNA in nursing home care, what they do, how CNAs are different from nurses, and then we’re going to talk a little bit into how CNAs play a critical role with regard to pain management of nursing home residents, and that all starts with being able to observe the signs and symptoms of pain in residents that are unable to vocalize that.
But we’re not doing that alone. We have a fantastic guest today – Dr. Elizabeth Halifax. With a career focus on healthcare for older adults, Dr. Halifax has held leadership positions in hospital administrations in the UK, in U.S. nursing homes and as a research specialist at the University of California – San Francisco, where she is an assistant clinical professor in the Department of Physiological Nursing – say that three times fast.
She has taught and mentored graduate and pre-licensure nursing students at California State University and trains long-term care ombudsmen. Her education includes an undergraduate degree in economic and social history and qualifying as a registered nurse in the UK. She graduated with her PhD from UCSF in 2013. Dr. Halifax has specialized in qualitative research, and her interests are focused on nursing home care, including palliative care, access, understanding pain in people with dementia and the role of staff and staffing levels in providing quality care.
She currently serves as a board member for the National Consumer Voice for Quality of Long-Term Care, an organization that provides national education, advocacy and policy analysis for long-term care residents. She also volunteers as a long-term care ombudsman in San Francisco. We here at the Nursing Home Abuse Podcast, we love the Consumer Voice. We’ve had at least a few episodes of our time at the Consumer Voice annual conference and we’ve had other members of the Consumer Voice on the program as guests, but we are so happy we’ve been able to get Dr. Halifax on to talk about CNAs and their role in nursing home care. Dr. Halifax, welcome to the show.
Halifax: Well thank you very much for inviting me.
Schenk: All right. So I was just talking before we came on the air about an article about CNAs and their abilities or non-abilities to conduct pain assessments and how that’s done in a nursing home setting, and that’s actually how I got your information. I feel like I’m one of these science nerds so I’m reading papers, I’m trying to educate myself, but I’m like, “Let’s just have Dr. Halifax on the show,” you know what I mean, instead of me trying to read your paper and trying to educate people on this, so I like to have you on the show. So we’re really happy that you’re on.
But just from kind of an introduction – when I say “CNA,” when someone hears the word “CNA,” when someone says, “certified nursing assistant,” “certified nursing aide,” can you explain just from a broad level what are we saying? What does that mean?
Halifax: Well CNA stands for certified nursing assistant, and they’re people who generally work in nursing homes and they do a lot. I mean they’re very busy people. They provide about 80 to 90 percent of the direct care to nursing home residents and most of their work comprises of giving personal care, so it’s really hands-on stuff. And they give assistance with activities of daily living. Should I explain what activities of daily living are?
Schenk: Please do so.
Halifax: Okay, so sometimes they’re referred to, if you’re visiting a nursing home, people talk about ADLs. That’s what they’re talking about. They’re talking about activities of daily living. And these are things we normally do independently like wash our hair, get dressed, stand up, you know, very basic things. So they include things like eating and drinking, using the bathroom, either being helped to go to the bathroom or being given incontinence care if they’re incontinent, and then personal hygiene like shaving, hair washing, showers, bathing, all those kinds of things, teeth cleaning, mouth care, getting dressed and undressed. And then importantly, mobility. Most people who live in nursing homes are having mobility issues because of disability or because of the functioning or pain that they have. And so nursing assistants really do help them. Some people need help even turning over in bed. I mean they literally cannot turn themselves, reposition themselves in bed. And as you know, if you’ve ever sat in a plane for any lengths of time, your butt gets really numb and uncomfortable if you can’t move. So these people are very important.
Schenk: Right. So if I understand correctly, then, and that’s a really staggering statistic, that upwards of 80 percent…
Halifax: 80 to 90.
Schenk: …80 to 90 percent of the care that if you have a loved one in a nursing home, 80 to 90 percent of the care they’re receiving is being done by the CNA.
Schenk: So if I understand it correctly, most of the hands-on care being provided is what you refer to as the activities of daily living. It’s helping them eat, helping them groom, hygiene, brushing teeth, that type of thing.
Halifax: Exactly. And they do have other roles. I mean they’re there also as a social connection. They’re there to look after mental health and social needs like just talking to, interacting. These people are pretty isolated in nursing homes. And they’re responsible too for maintaining residents’ dignity and their rights within the nursing home. Nursing homes are very institutional settings, and just simply doing things like ensuring residents get the choices that are available to them, that they don’t say, “You’re having a shower at 10 o’clock.” You say, “Would you like a shower today? We have a slot at 10 o’clock. Would that work for you?” So treating them with dignity and respect. And then really helping them – while they’re there to assist and help, it’s very important that CNAs understand that they need to help maintain the resident’s level of independence, so helping them with assistance, with – what am I trying to say? – things like moving their arms and legs if they’re unable to do it, then the CNA will help them move their joints, so range of motion. Helping them relearn things – so maybe they have had a stroke, they can’t use their right hand any longer, so they’re having to retrain them to clean their teeth with their left hand, things like that. So this is just one of the things they do.
Schenk: Right, and I feel like that’s so interesting because we’ve talked about different types of care provided by different types of staff at a nursing home, but it’s so wonderful that you’re pointing out that the CNA is not just there for ADLs. They’re not just there maybe to observe things but they’re there to interact for the purposes of maintaining the dignity and the happiness and the wellbeing of these residents. So something as simple as being like, “Ms. Johnson, I see that you watched ‘America’s Got Talent.’ What did you think about how it turned out?” That conversation, that goes to the wellbeing of the resident in some ways just as much as, “Ms. Johnson, make sure that you’re turned every two hours.” It’s very rare that I hear anybody say something along those lines in terms of interpersonal care is important as well, so that was great. I cut you off.
Halifax: Yeah, relationships with your certified nurses…
Schenk: I’m sorry, I cut you off. Go ahead, I’m sorry.
Halifax: No, your relationship with your CNA is often – it reflects the quality of your life.
Schenk: That’s right. That makes sense. You’re in a home, like this is literally your residence. You live here. These are individuals, although they’re tasked with providing you care, it’s human interaction. You need that for your wellbeing and your psychosocial wellbeing as I guess the regulations would say. It’s very important.
Halifax: I don’t know whether this is appropriate to speak to, but one of the issues that I really feel strongly about is that CNAs are given this huge task. If you’ve dressed a baby, if you’ve had children, you know how long it takes to bathe and dress people, and yet there really isn’t sufficient staffing. You know, the average assignment for a CNA during the day in the afternoon are seven to 10 residents that they’re caring for, so they’re doing all the things I just described for that many people. And obviously some of those residents are much more dependent than others, and many states don’t have a minimal staffing requirement. There is a federal staffing requirement, but it’s pretty low and research has generally found that that’s not adequate. And even with that minimum federal requirement, 50 percent of nursing homes are not hitting that and 25 percent of those 50 percent are really at low staffing levels. So that’s an issue that CNAs are dealing with day to day in trying to provide good care.
Schenk: Absolutely. And not just CNAs, everybody out in the audience understands this is an issue that CNAs and nursing, like in fact, nursing, you can argue is even worse, but yes. So speaking of that in terms of the staffing and how that directly relates to positive outcomes, can you kind of – how is the CAN different from the nurse from just a general standpoint? Like why – is it bad that 80 percent or 90 percent of the face-time for an individual at a nursing home is done by a CNA as opposed to a nurse or attending physician or an LPN?
Halifax: The roles are quite distinct. There’s three types of nursing staff in a nursing home. There’s the RNs, the registered nurses, and there’s the LPNs, which are the licensed practical nurses – they’re sometimes called LVNs in places like Texas and California, and then there are the CNAs. And so the RNs are really an overseeing kind of position, but they also do the treatments and make the medications, do a lot of the scheduling and they do the – they oversee and manage the other staff as well.
And the LPNs, they have more extensive education and training than CNAs, but they have to have high school diploma and they have to do a full year of coursework. But they have a more comprehensive role in the sense that they assess the residents, which CNAs are not considered to do even though they do do it in a basic way. They’re taught to assess residents and understand their needs and to plan the response to those needs and the treatments that are needed.
Schenk: So that’s interesting because that’s always an issue that we address on this show, which is that’s kind of the driver of the overall care is in the hands of the registered nurse, who depending on what state you’re in, I guess, but most states, their main duty is to assess, create plans and revise plans as needed, whereas the CNA, aside from the ADLs, is basically one of observation rather than assessment. So I guess that’s the big difference between what the nurse is doing and what the CNA is doing in terms of the long-term health of every resident there
Can you speak to – what I find interesting in this, and hopefully you can kind of elaborate on this, but the criteria, the education requirements of nurses I feel are state to state. It’s not a federally regulated position. A nurse in Nevada might have a different educational background and different compliance requirements than a nurse, a registered nurse in Georgia. However, CNAs, that is federally regulated. To call yourself a CNA in a nursing home means something. Am I wrong about that?
Halifax: Well the training for CNAs is regulated by the 1987 OBRA Act, which was the act that brought a lot of nursing home reforms in, and it does state that a CNA has to have a minimum of 75 hours training. At least 16 hours of those have to be in a clinical setting, so they have to have some kind of hands-on experience. And that experience has to be supervised by a registered nurse.
So in every state, trainees have to attend a state-approved training program and a licensing exam, but those training programs, those licensing exams are not standardized. They vary across states. And then from state to state, there are differences in other requirements that might be made. So for example, in some states, there’s a minimum age of 16 years. In some states, you have to have a criminal record check. And then in some states, I think there’s about 12 of them altogether, they require more training than the minimum 75 hours set out in the federal law. And that amount of training ranges from 85 and 180 hours, and so the average training of those 12 states that require more training is 118 hours, which is like considerably more than the 75 minimum. So when you say it’s standardized, it is, but it isn’t, because it does vary by state.
Schenk: It’s almost like it’s the absolute bottom floor, and maybe you can speak to this too, but at least in Georgia, I feel like it’s not like CNAs are going to an academy that’s University of CNAs. They’re being trained under these federal minimum requirements by these nursing homes themselves. Is that what you’re seeing? So it’s almost like garbage in, garbage out if the nursing home is not complying with that law.
Halifax: Well that’s a real problem when the coursework is based in the nursing home because there’s very low oversight. But in some states, the majority of coursework is done by community colleges and then in other states, there are also private organizations and nonprofit organizations. In fact some unions offer courses on CNA training. So there’s a variety of places you can get that training.
Schenk: That’s interesting. So I wasn’t aware of tat. Is there a union of CNAs?
Halifax: The SEIU represents some CNAs.
Schenk: Oh, I see. I see. Well we’re in Georgia, so unfortunately, that’s not a big lobbying group here or union here in Georgia. Well that’s interesting. I’m sorry, go ahead.
Halifax: I just wanted to say one thing about the exam, just to tell you about the variety from state to state. In some states, the knowledge part of the exam as opposed to the skills part, which is the thing you do like practically, you can do that test orally. So you’re not even checking for literacy. So somebody does that test as an oral test, it’s to help people with English as a second language or people who are not completely literate. Then you’ve got people working in your nursing home that are expected to document at the end of the time, but you don’t check for literacy skills. So that’s kind of an interesting piece. It’s very basic.
Schenk: Yeah, I guess I’d never considered that. So like do you have any thoughts about like how can we make that better? Would you be an advocate for more federal regulations with regard to training and compliance with CNAs? Like is that something?
Halifax: Yeah, I would. And I would also think it would be sensible to standardize the exam as a national exam and really make the course teach to that test, which is not always a good way to do things, but it would ensure people have a good way of doing things.
Schenk: That makes sense. I feel like that in this country, we embrace federalism to our detriment sometimes. There should be absolutely no difference between a pressure injury in Arizona and a pressure injury in Maine, right? Why would we care what our local legislators think about a medical issue or medical care versus the one that’s a couple states over. I understand for some issues, like that’s the cake that we baked, but when it comes to that, I don’t know. I think a federal regulation is good so you know what you’re going to get regardless of where you go. But I digress.
Halifax: You know, you might be interested to know actually that in California, for example, where a CNA only needs 100 hours of supervised training, a manicurist, somebody who can paint your nails, has at least 400 hours, and a cosmetologist needs 1,600 hours, and a barber needs 1,500 hours.
Schenk: Well we know where the priorities are in California, apparently. It’s the Hollywood industry. You’ve got to have…
Halifax: Oh, that’s right. We care what we look like.
Schenk: What is it? You’ve got to get your nails right, your hair tight. No, nails tight, hair right.
Halifax: You need 15 times more training to be a barber than you do a CNA.
Schenk: That’s insane.
Halifax: And then the other point I was going to make is during the pandemic, I don’t know if you’re aware, but there’s been a federal waiver for training for CNAs, so that nursing homes can now pick people up and bring them in and give them minimal practical training and they are doing the job of the CNA.
Schenk: It’s kind of like deputizing people in an emergency. I think along with the other regulations being relaxed during COVID, like we’re not going to fine you for PPE failures unless it was something out of your control and no visitation and all this stuff, it’s just a perfect storm of problems.
So let me ask you this then, because now I think we kind of have a basis of who CNAs are, what they do, their role versus the role of the nurse, can you talk to me about this particular paper that we mentioned in the beginning where it’s about the importance of CNAs being able to observe the signs and symptoms of pain in residents that might not be able to express themselves verbally?
Halifax: Well, you know, if you’ve ever had pain, you know it really doesn’t fill your quality of life. I mean it’s something that affects everything about you. It affects your thinking process. And I started thinking about this issue because my mom had dementia and she had fallen and cracked a knee, and I would say to her, “Mom, you should take this medication to help the pain.” And she’d be sitting comfortable in her favorite chair and she’d say, “Oh, I don’t have any pain.” But then of course when she went to stand up, she couldn’t because it hurt so bad. And so she stopped moving, which was a real problem for someone who was older. And so what I learned from that, even though I’d been a nurse for many years, I learned that we couldn’t trust what she was telling us because she was living just in the very moment you were speaking to her about.
And so this brought me to this problem, and persistent pain affects 80 percent of people in nursing homes. And by persistent pain, I mean like chronic pain, pain that goes on for months and months. And it’s often under-recognized and undertreated because, as you know, if 80 percent to 90 percent of care is being delivered, these nursing home residents don’t see a lot of the licensed nurses. So understanding that pain is what people tell us it is, that’s the gold standard of how we assess pain, and so the best way is to ask someone to describe it, but of course, in nursing homes, at least 60 percent of nursing home residents have dementia and then other people have had strokes or CVAs and their speech has been impaired or they’ve lost speech for other reasons. And so that becomes really difficult.
And so this is why CNAs and their knowing the residents, their being with them so much and observing the way they behave really helps us understand those residents’ pain. So they have a number of behaviors that they were able to observe when I asked them, you know, “What kind of things were the things that clued you in as to whether this person was having pain?” And the sorts of things they talked about were things like facial expressions. You can really see if someone is grimacing and feeling anxious.
Another thing is that people who can’t express themselves with words might shout out or make a lot of noise. People might move less because it hurts now to move. They don’t want to move around, but at the same time, they might become fidgety and they might not settle well, so body movement is another thing they look for.
And then another thing is changes in routines, so you know, somebody might stop eating. They might stop going to activities. Their mood can change. They might become teary or aggressive or irritable.
There are all these things that CNAs describe to me that they saw in their residents and they immediately thought, their first thought was, “Has this person got pain?” And as you know, often when people exhibit behaviors like irritability and shouting, the first line of attack is, “Let’s prescribe them with medication to calm them.” And often that’s not necessary. What’s needed is to prophylactically try to treat the pain. Give them two Advil – well not two Advil, two Tylenol, whatever it is – and see if that helps first. Are they going to settle down because they’ve not got the pain now? So that’s why it’s so important what CNAs do.
Schenk: It’s so interesting that you say that because we’ve had a couple episodes about essentially chemical restraints and there is a sad tendency in some nursing homes to medicate problem behaviors. But as you mentioned, the problem behaviors, there’s lots of triggers, but one of them could be the chronic pain, and I feel like that’s often a problem from the very beginning. When the resident enters a nursing home, they should be assessed for pain, and I think oftentimes the first failure is that initial assessment, let alone the training and understanding of the CNAs of seeing the symptoms of it. Yeah.
Halifax: Yeah, that should be your first thought. If somebody’s behavior changes, I’m needing to explain to you what’s happened to them, you think to yourself, “Are they having pain?” and you do a full pain assessment. That should be the first thing you do.
Schenk: So is there any bits of advice, just general advice, if an audience member has a loved one in a nursing home with regard to noticing pain and trying to educate themselves on that topic of assessing pain?
Halifax: Well I think the most important thing is especially as we age, we sometimes expect pain and think it’s okay to have it, and it’s not. I mean no level of pain is acceptable. Obviously we can’t always treat every single pain completely, but we can alleviate it. And what the CNAs were telling me was, “We’re not just relying on medications.” One of the biggest techniques they had for helping pain was distracting people, so they’d tell me stories like, “I’d go into the room and she’s looking really miserable, and I’d say to her, ‘Have you seen your grandchildren this week?’ Like, ‘How tall is the oldest now?’” She’d talk to them about things that she loves, or as you mentioned earlier, “Hey, have you seen ‘Dancing With The Stars?’ Who’s on this week? What’s going on?” So real distraction is a help. And as a visitor, you can do that.
And one of the things, this is from personal experience with my mom, I would take a small tube of hand cream in and she wasn’t really conversational, but I would sit and I would rub her hand with the hand cream and her upper arm and sometimes her feet if it was possible, and we would connect through that. And I think that was very soothing for her. I really believe that eased her pain. It was kind of something she really enjoyed and she would just make noises like, “Ooh. Ooh. Lovely.” So just right there, there are things you can do with someone without speaking or having conversation and other ways like that.
And there are things outside of medication like the usual things we use at home, like hot and cold packs, although you do have to be real careful with people who are older with frail skin using those. And then changing position – somebody looking unhappy, do they want to go lie on the bed for a while? Do they want to get up from the bed? Do they need to walk around the block? Is this something that you can do? So those sorts of things, as a visitor, you can intervene with, and these are things that the CNAs often do. And you’re their advocate. You can really go and say to the nurses, “She doesn’t look good. Have you assessed her pain? When was the last time you assessed her pain?” Nail them down.
Schenk: That’s right. And that’s a recommendation I feel like we, it’s every other episode is to if you are the individual who has the appropriate authority and is the personal representative of your loved one in the nursing home, get a copy of the care plan at minimum. You can get the whole chart if you want to, but you have the right to review the care plan and take part in the care plan process. So having the care plan with you, it’ll tell you, “Here’s the prescription medications. Here’s if there’s any interventions for pain. Have you done these?” that type of thing. So it’s really important to be involved as Dr. Halifax had said.
So Dr. Halifax, this has blown by. This has been fantastic. One last question though before we cut the episode off is what was the result of the study? What was the alternate finding, if there was one?
Halifax: Well it is. First of all, CNAs, work very hard and a lot of them care deeply about their residents and what we need to do, what I would recommend is the licensed nurses in the facility talk to the CNAs when they do pain assessment. Include that as part of their pain assessment. They should include them in the MDS assessment, and this is another place they should be included, because they have this knowledge but quite often they don’t have the confidence to talk to the nurses about it. They might report acute pain, but they don’t always report what they describe as everyday pain.
Schenk: Right, the chronic pain.
Halifax: So that’s something the nurses should be talking to the CNAs about.
Schenk: Got you. Okay. Well very good, Dr. Halifax. Thank you so much for being on the show. This has been very fun, very fantastic, very informative.
Halifax: Okay, well thank you for having me.
Schenk: All right.
Halifax: Appreciate it.
Schenk: What’s funny is that before we went on air, Dr. Halifax asked if her accent was okay, if she was understandable, and I was like, “Not only is it understandable, but it’s probably one of the more delightful accents we’ve had on this program. So Dr. Halifax, do not worry about that. You sound lovely.
If you found this podcast interesting, then please by all means like and subscribe. Check us out on YouTube if you’re more of a visual learner. We have a lot of videos on our YouTube channel, the Nursing Home Abuse Podcast, and new episodes come out every other week on Monday, that is two times a month. So that’s where you can check us out, again, wherever you get your podcast from, or on YouTube. And with that, we’ll see you next time.