BEST PRACTICES: Center for Nursing and Rehabilitation

ABSTRACT: The Center for Nursing and Rehabilitation (CNR) developed an 18-month program to train certified nursing assistants (CNAs) as ''CNA Person-Centered Care (PCC) Mentors.'' The PCC mentors orient and mentor new employees as well as share person-centered skills with other staff. (February 2011)

Person-Centered Care Mentors

The Center for Nursing and Rehabilitation (CNR) in Brooklyn, New York, has operated as a 320-bed skilled nursing facility since 1978. Its mission is to provide quality health care services to under-served populations in an environment that promotes individuality, dignity, and independence.

In 1997, CNR’s administration began a culture change journey to transform their facility from a traditional institution to a more home-like environment.

Nursing units were changed to "neighborhoods," department silos were reduced, and neighborhood teams created. Environmental changes included the creation of living rooms, dining rooms, a library, computer area, more accessible teamwork stations, spas, and additional spaces for activities. Live animals and plants were integrated into the everyday life of residents and staff.

Managers discovered they were overlooking a valuable resource--their workforce.

But the managers soon discovered that they were overlooking a valuable resource -- their direct-care workforce. With turnover high among newly hired staff, management suspected that CNAs did not feel the same level of respect that they were being asked to show in relation to residents and their families.

Thus, they decided to try a new approach—implementing a peer mentoring program that would support new employees in learning the skills and values associated with person-centered care.

The facility used a grant from the New York State Department of Health to develop a peer mentoring program. A group of 13 certified nursing assistants (CNAs) were chosen to undergo training to become peer mentors, with a focus on spreading the idea of person-centered care throughout CNR.

Training was therefore focused largely on leadership development skills and person-centered practices: The goal was to get trainees to see themselves as representatives of -- and models for -- person-centered change, able to use their interpersonal skills to influence other CNAs in a positive way.

Much of the peer-mentor training was geared toward dementia care, since the mentors would end up doing most of their work within Penthouse Gardens, CNR’s dementia-focused neighborhood. At the end of the training, graduates would receive a new job title -- "CNA Person-Centered Care (PCC) Mentor" -- along with a higher salary.

Selection

In 2003, CNR administrators selected 13 CNAs from a pool of 20 applicants to become mentors. To qualify for the position, nursing aides were required to have a high school diploma or equivalent, a current CNA certification, above average performance assessments, a minimum of two years of employment at CNR, and no history of disciplinary action within the past year. The selection process included a group interview and submission of writing samples. CNAs were also expected to understand and articulate the principles of ''culture change.''

Training

The training content was divided into two components. One training component was conducted in-house by CNR’s project manager in conjunction with CNR nurses and directors. This training was focused on bolstering trainees’ clinical skills and was largely informal in nature.

The other training consisted of a more formalized training curriculum, conducted by a CNR project manager and PHI trainer. The formal training focused on three areas: 1) information and skills related to caring for residents with dementia; 2) skills for mentoring newly hired staff; and 3) leadership skills related to ''culture change'' activities throughout the organization.

This part of the training combined formal classroom instruction with on-the-job practical application. Trainees would develop various person-centered skills within the classroom -- individualized bathing, for example -- then returned to the facility to introduce the new skill to their neighborhood.

The training sessions were spread out over the course of 18 months, the length of the grant period. Upon successful completion of the training, PCC mentors received a wage increase.

The role of the CNA person-centered care mentor

The PCC mentors assist in the hiring and orientation of new CNAs, serve as a resource for other staff, and provide leadership to select projects relating to person-centered care. Each new CNA is paired with a mentor for two to three weeks. The mentors teach routines, skills, and time management, and also serve as liaisons between the nurse or neighborhood directors and the new CNAs. While the mentors are not supervisors, they do assist in identifying and reporting on whether CNAs successfully perform the newly learned skills in their departments.

In their role as leaders of CNR’s transition to person-centered care, PCC mentors participate in constructing care plans and in teaching bathing, nutrition, feeding, and communication skills. In particular, they have helped to improve the process of bathing dementia residents. They also take the lead in developing person-centered changes, such as revitalizing the welcoming committee and implementing changes to the decor of the bathrooms and resident rooms.

The mentors have three days of regular assignments, and usually work two days a week as mentors. The PCC mentors are now dispersed to all neighborhoods and floors of the facility.

Outcomes

Surveys have shown signs of improvement in staff satisfaction and turnover rates. In 2003, before the peer-mentor program was initiated, nursing staff turnover was 10.5 percent. By the third quarter of 2010, the turnover rate was down to 3.4 percent. Furthermore, all PCC mentors still work at the facility, save for a couple mentors who have since retired.

Anecdotally, residents, families, and staff have all expressed increased satisfaction with environmental changes that have been introduced by the PCC mentors. These changes include redesigned spas for bathing and a dining room that supports restaurant-style dining. Peer mentors also developed and implemented other projects—adding heat lamps in bathrooms, decorating residents' living spaces, and creating welcome baskets—that were well received by residents and families.

The hierarchy of the nursing department broke down significantly.

The most dramatic changes, according to the program participants, occurred in relation to staff team building and communication. Mentors and administrators alike agree that the hierarchy of the nursing department broke down significantly as a result of the program.

There is now a direct line of communication between CNAs and the administration as well as between PCC mentors and staff in other departments (building operations, dietary department, director of environmental services, etc.).

Administrators find that the mentors consistently offer insight and useful suggestions about how care ought to be implemented, and they are able to react quickly and directly when there are problems or suggestions.

The mentors also express an increased confidence in their own knowledge of dementia, feel invested in the process of developing person-centered care, and believe they are better at problem-solving and communicating with co-workers and residents.

"The peer mentors have knowledge, make suggestions, are intelligent. They are a plain asset.”Ginger Wilson-Hew, Associate Director for Clinical Services

''The mentors feel empowered, feel they are making a difference,” said Ginger Wilson-Hew, CNR’s associate director for clinical services. “They ask to do more now that they are not stuck in a box. They speak well, they have knowledge, make suggestions, are intelligent... they are a plain asset.''

Indeed, Wilson-Hew notes that the PCC mentors represent a previously untapped source of ideas about person-centered care delivery.

For example, the mentors introduced the concept of “shadow boxes” to CNR’s dementia care unit. The shadow boxes -- plastic wall-mounted display cases positioned outside each resident’s room -- contain photographs and other small artifacts that have special meaning to each individual resident. The shadow boxes help residents with dementia easily find their way back to their own rooms, Wilson-Hew says.

They are just one of many ways that PCC mentors have improved the facility, she adds: “Their ideas are just as good as an idea coming from an administrative person.”

Lessons Learned

Administrators and mentors discussed three main challenges in the program:

Recruiting CNAs to submit applications for the program.One of the main reasons cited by the mentors as to why they were initially hesitant to join the program was that they had seen many programs come and go and were not convinced that this was a serious initiative. Administrators felt they had to market the program and provide incentives in order to recruit CNAs to apply. Work needed to be done to clarify to other CNAs what the new mentor roles were.

Patience and check-ins helped mentors weather the difficulties of adjusting to their new roles.

Initial suspicion of the new mentors on the part of other CNAs. According to the mentors, some CNAs initially viewed PCC mentors with skepticism. “Initially, they would say, ‘Who are you to tell me what to do -- you’re just a CNA like me,’” Wilson-Hew says. Some CNAs even viewed the mentors as spies, working on behalf of CNR management.

This initial suspicion broke down over time as mentors were able to share skills that other CNAs had seen work in practice. Now staff regularly seek out mentors for help when needed; they recognize that “the role of the peer mentors enhances the care process,” Wilson-Hew said.

Mentors overwhelmingly expressed a need for patience and periodic check-ins with each other in order to weather the difficulties of adjusting to their new roles.

Hitting a plateau in translating knowledge from mentors to other CNAs. Mentors and administrators say that, in certain cases, they have faced difficulties in transferring the mentors’ newly acquired knowledge to CNAs. Consequently, some peer mentors have been burdened with a greater overall workload than before – that is, unable to successfully teach their new skills to CNAs, some mentors have had to compensate for that by executing the new skills themselves. Wilson-Hew says that this problem has diminished considerably in recent years, but it can remain a challenge.

Sponsoring Organization: The Center for Nursing and Rehabilitation (CNR) is a member of the Beth Abraham Family of Health Services, a nonprofit organization delivering a range of continuing care services throughout New York City.

Best Practice: The Center for Nursing and Rehabilitation developed an 18-month program to train certified nursing assistants as ''CNA Person-Centered Care (PCC) Mentors.'' The PCC mentors have since gone on to orient and mentor new employees as well as share person-centered skills with other staff.

Setting: CNR is a 350-bed skilled nursing facility in Brooklyn, New York. Nursing aides were originally selected from the Penthouse Gardens, an 80-resident neighborhood focused on caring for residents with dementia. The program has since deployed mentors in each of the resident neighborhoods throughout the facility.

Start Date: Training began in October 2003; the CNA Person-Centered Care Mentor job title was instituted in August 2005.

Costs & Funding: The program was developed out of a grant from the Department of Health educating staff on dementia and improving the environments for residents with dementia. They spent $108,000 on staff replacement during the training period; $202,000 on consultant and trainers fees; and approximately $30,000 on program supplies, mentors' travels to seminars and conferences, and other staff development costs.

The grant started in July 2003 and ended in October 2005. Any costs incurred after the life of the grant are CNR's responsibility. These include maintaining the wage increase for PCC mentors and the costs of any new policies and systems that arise from the mentors.

Additional Resources:

  • Bathing without a battle: Creating a better bathing experience for persons with alzheimers disease and related disorders, Barrick, Ann Louise, Phil Sloane and Joanne Rader, 2003, University of North Carolina at Chapel Hill.
  • Peer Mentoring: A Workshop Series for Direct-Care Workers in Home and Residential Care, Paraprofessional Healthcare Institute, April 2006.
  • Introducing Peer Mentoring in Long-Term Care Settings, Paraprofessional Healthcare Institute, May 2003, Workforce Strategies, No. 2.

Contact Information:

Ginger Wilson-Hew, Associate Director for Clinical Services
CNR Health Care Network
520 Prospect Place
Brooklyn, NY 11238
www.cnrhealthcare.org

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