| CNAs and Vaccination: An Issue of Trust | <p>Although COVID-19 vaccination rates for certified nurse assistants (CNAs) have increased significantly since the beginning of the year, many CNAs remain unvaccinated, for a variety of reasons.<br></p><p>As someone who worked for many years as a CNA and who now heads the largest professional association for CNAs, I believe that doctors who serve as medical directors for nursing homes hold the key to persuading those CNAs who are persuadable to get vaccinated and protect residents, their co-workers, their loved ones, and themselves.<br></p><p>Why do I say that? Because trust is a huge issue for CNAs, and they are more likely to trust the medical directors at their facilities to give them accurate, honest information about the vaccines than just about anyone else.</p><h2>Medical Directors are Local Experts</h2><p>According to a <a href="https://www.ahrq.gov/nursing-home/materials/prevention/vaccine-trust.html" target="_blank">new guide</a> from the federal government for building CNAs’ confidence in the COVID-19 vaccines, CNAs who are most resistant to getting vaccinated also tend to trust their employers the least. Among those they trust most: local medical experts. This is critical, because CNAs get a lot of their information—and misinformation—on social media, especially Facebook.<br></p><p>Not only do CNAs view their medical directors as their local medical experts, but many also see them as their personal physicians. This is especially common in rural areas that are short on doctors.<br></p><p>CNAs typically have good working relationships with their facility medical directors, who respect their hands-on experience and expertise, as well as their compassion for the residents they care for. This respect is greatly appreciated by CNAs, who are among the lowest-paid workers in health care and who often feel underappreciated. In addition, medical directors aren’t nursing home employees, and CNAs see them not only as credible but also as more independent than other nursing home leaders.</p><h2>COVID Ups the Stakes</h2><p>CNAs have a tough time, and COVID-19 has made it tougher. Even before the pandemic, they worked long hours, often at multiple jobs. But this past year has been hell for them. Many have been sick themselves; they’ve also lost residents they cared for and co-workers as well. Their jobs have been incredibly stressful and demanding, even as the demands on them at home have increased.<br></p><p>There are many reasons why CNAs aren’t getting vaccinated. Some have taken a “wait and see” attitude, while others harbor fears and concerns that they feel haven’t been addressed. Some would like to get vaccinated, but they can’t afford to take unpaid time off from work, especially if they get sick from side effects, or they don’t have transportation or child care.<br></p><p>And remember: CNAs have been on the front lines of battling this virus and watching it unfold for over a year. Either they’ve gotten it and survived, or they haven’t gotten it at all.  The way they see it, they don’t need the vaccine. If they’ve gotten this far without it, why would they need it now?</p><h2>Meeting Early, Lingering Concerns</h2><p>I myself was wary of getting vaccinated at first. I thought those first vaccines came out too fast. They couldn’t be safe. But then my organization did a <a href="https://www.youtube.com/watch?v=QJhk71PLRBk" target="_blank">vaccine education webinar</a> with AMDA, which represents medical directors serving long term care facilities and whose panelists were not only credible but open and respectful. They answered all my questions, so I came out in support of the vaccine and made my declaration to our members.<br></p><p>That’s who CNAs need to hear from: trusted medical experts at their facilities who will listen to their concerns about the vaccines and address them fully and respectfully. Very few administrators have time to do that—and I know, because I used to be a nursing home administrator, too.<br></p><p>I believe that the best way to persuade CNAs is to appeal to their desire to do good and protect others, especially their residents and co-workers. But they need to be heard out, and some of them may need logistical help as well.<br></p><p>Medical directors can play a strong role here. They can do one-on-ones with CNAs, either in person or virtually. They can speak at staff meetings or give webinars. They can be the go-to contact person at the facility for workers who have questions about the vaccines and respond via email or phone or in person.<br></p><p>To fully protect nursing home residents and workers against COVID-19, we need to vaccinate more CNAs. Medical directors of America, we trust you to answer our questions. When can we talk?<br></p><p><em><strong>Lori Porter </strong>is co-founder and chief executive officer of the National Association of Health Care Assistants (NAHCA). She can be reached at</em> <a href="mailto:lporter@nahcacna.org" target="_blank">lporter@nahcacna.org</a>. <br></p> | 2021-06-29T04:00:00Z | <img alt="" src="/Topics/Guest-Columns/PublishingImages/LoriPorter.jpg" style="BORDER:0px solid;" /> | COVID-19;Workforce | Lori Porter | Although COVID-19 vaccination rates for certified nurse assistants (CNAs) have increased significantly since the beginning of the year, many CNAs remain unvaccinated, for a variety of reasons. |
| National Assisted Living Week Theme Revealed for September Celebration | <p>The National Center for Assisted Living (NCAL) said “Compassion, Community, Caring" is this year's theme for National Assisted Living Week<sup>®</sup>. The annual, national observance—officially sponsored by First Quality in 2021—provides a unique opportunity for residents, their loved ones, staff, volunteers, and local communities to celebrate the individuals who live and work in assisted living and learn more about this sector of long term care.</p><p>“This year's National Assisted Living Week is special because of everything we have faced over the past year," said NCAL Executive Director Scott Tittle. “'Compassion, Community, Caring' reflects the hard work and dedication of all the essential caregivers in assisted living communities during the COVID-19 pandemic. It also represents the importance of family and remaining connected, even when we could not physically be together."</p><p>Established by NCAL in 1995, National Assisted Living Week (NALW) will be held Sept. 12-18. “Compassion, Community, Caring" encourages assisted living communities around the country to host a variety of events that honor the individuals who reside, work, and volunteer in these communities while adhering to infection control requirements and precautions in place for COVID-19.</p><p>“First Quality is honored to be the official sponsor of National Assisted Living Week in 2021," said Shelley Bache, First Quality Healthcare Leader. “After one of the most challenging years ever, it is imperative to remember and celebrate those in assisted living communities who did so much in the midst of so many unknowns. This week is a time to come together in a safe way and recognize the 'Compassion, Community, Caring' that could not be stopped by a pandemic."</p><p>In the coming months, NCAL said it will issue a planning guide and products centered on ways to celebrate the week's theme. Participants are asked to share their celebrations throughout the week on social media with the hashtag #<strong>NALW</strong>.</p><p>Visit <a href="http://www.ahcancal.org/NALW" target="_blank">www.ahcancal.org/NALW</a> for updated information and resources.<br></p><p></p> | 2021-05-17T04:00:00Z | <img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/nalw_2021.jpg" style="BORDER:0px solid;" /> | Caregiving;Workforce | Patrick Connole | Week to reflect the hard work and dedication of all essential caregivers in assisted living during the COVID-19 pandemic. |
| Teamwork Carries the Day During Pandemic | <p>During the pandemic, it hasn’t been unusual to see a director of nursing (DON) in the kitchen, human resources staff making beds, maintenance staff picking up or dropping off employees, and administrators feeding patients. There’s an “e” in teamwork, and in the past year, that’s stood for “everyone helps everyone else.” <br></p><p><img src="/Monthly-Issue/2021/April/PublishingImages/Oguin.jpg" alt="Jennifer Oguin, RN, DON" class="ms-rteImage-3 ms-rtePosition-1" style="margin:5px;width:144px;height:177px;" />As Jennifer Oguin, RN, DON, at Trinity Care Center in Round Rock, Texas, says, “My title went out the window. When it comes down to it, we are a team that pulls together without even asking. People just jump in and do what needs to be done. It’s embedded in our culture.”<br></p><p>Teamwork has taken on new meaning during the pandemic. Facilities have implemented new strategies for communication, collaboration, and innovation. Transparency, resilience, and empathy are not buzzwords but essential elements of daily work life.<br></p><p>Getting past the pandemic and the politics of 2021 calls for renewed efforts to focus on the residents and what it takes to keep everyone safe and engaged, as well as building and strengthening cultures that will weather any storm or crisis. </p><h2>Head of the Class: Education Moves Up<br></h2><p>Team education has always been essential in post-acute and long term care. However, during the pandemic, it’s taken on a new level of urgency. It’s also been more challenging, as guidance, recommendations, and clinical evidence regarding COVID-19 have changed constantly. Keeping up with this has been challenging. <br></p><p>How challenging? Well, according to Ohio State University researchers, there have been more than 87,000 scientific papers alone on the coronavirus since the pandemic started. <br></p><p>“You have to communicate frequently and have one-on-one conversations,” says Oguin. “You have to discredit misinformation before it spreads and is embraced as fact.” At first, she says, people were often confused and frightened.<br></p><p>However, she says, “We have kept staff informed as new evidence and information arises. As they saw positive results from guidance and protocols, it lessened their fears and increased their confidence and trust.”<br></p><p>Keeping everyone on the same page when they are getting different information from several sources is “a constant battle,” Oguin says. “As the CDC [Centers for Disease Control and Prevention] put out new guidance, we were regularly updating protocols and recommendations.” <br></p><p><img src="/Monthly-Issue/2021/April/PublishingImages/JBB.jpg" alt="Jeffreys Barrett, RN" class="ms-rtePosition-2" style="margin:5px;width:150px;height:192px;" />When change is this constant, it is important to acknowledge that it’s frustrating and challenging, she says. “You need to say, ‘We’re doing this, too; we’re there with you. We know this is new and different, but it’s the right thing to do.’ You need to have a team that trusts you, and this helps build trust.”<br></p><p>Jeffreys Barrett, RN, MHA, NHA, executive director of Wellsprings of Gilbert in Arizona, says, “Early on, there were some people who didn’t believe COVID was a real virus, and others who were terrified of it. I would post emails once a week and constantly communicate information we received from the CDC and department of health.”<br></p><p>At some point, he suggests, “You can only educate people until they stop listening. But you can build a level of trust between yourself and others and deal with what is happening without being bombastic or threatening.”<br></p><p>As the pandemic wore on and the holidays approached, team leaders wanted to ensure that staff resisted the urge to attend large parties and family gatherings. “We provided a lot of staff education leading up to the holidays talking about ways to safely celebrate with family and friends,” Barrett says.<br></p><p>Buster Peter, administrator of Park Bend Health Center in Austin, Texas, says, “Then we gave staff take-home kits with PPE [personal protective equipment], hand sanitizer, and other items. We got the most positive response we’ve ever gotten for a staff gift. They appreciated getting something that they needed.”</p><h2>Hiring for Character</h2><p><img src="/Monthly-Issue/2021/April/PublishingImages/Buslovich.jpg" class="ms-rtePosition-1" alt=" Steven Buslovich, MD," style="margin:5px;width:145px;height:186px;" />Hiring during the pandemic was challenging. It was difficult to vet job candidates to determine if they’d be a good fit for the organizational culture. Yet, it’s important to communicate that “if you are devoted to the residents and this patient population, you will do everything possible to protect the resident,” says Steven Buslovich, MD, CMD, MSHCPM, a New York-based geriatrician and chief executive officer of software producer Patient Pattern. “If you’re doing it solely for the paycheck, this isn’t likely the place for you.”<br></p><p>Staffing is always challenging. However, Oguin says, “It is important to have a back-up plan in advance for how you will maintain adequate staffing in a crisis.” Cross-training can help, she says. Training everyone on basic tasks such as feeding, monitoring the dining room, making beds, and basic infection control can make it easier to enable people to fill in when there are shortages on the front lines.</p><h2>Nurse Aide Adaptions<br></h2><p>In many communities, “People stepped up and helped others,” says Alice Bonner, PhD, RN, FAAN, senior advisor for aging, Institute for Healthcare Improvement. “Nursing homes worked with area agencies on aging, senior centers, etc. Administrators and others connected with high schools and community colleges to help fill job openings. Everyone came together, and that made a big difference.”<br></p><p>During the COVID-19 public health emergency, the Centers for Medicare & Medicaid Services (CMS) waived the federal nurse aide training and competency evaluation requirements for newly hired nurse aides, with the exception of requirements that nurse aides be competent to provide needed services. CMS issued this waiver “to assist in potential staffing shortages seen with the COVID-19 pandemic.”<br></p><p>The American Health Care Association/National Center for Assisted Living stepped in to help by offering free eight- and 16-hour online courses for a temporary nurse aide (TNA) able to provide services and supports such as assistance with dining, ambulation, and other activities of daily living. After successfully completing the online training, TNAs then go through a competency evaluation by the provider before beginning work. <br></p><p>Currently, the program is permitted under special waivers, exceptions, or flexibilities for TNA roles in several states. To make the transition to become licensed/certified nurse aides/nurse aides included in state CNA/LNA/NA registries, TNAs need to complete additional certification requirements in accordance with federal and state regulations.<br></p><p>While this solution has filled a need during the pandemic, the National Association for Health Care Assistants (NAHCA) recommends that CMS reinstate the nurse aide training and competency evaluation standards as soon as possible, and no later than the end of March 2021.<br></p><p>NAHCA also suggests that the agency require that temporary nurse aides (those employed under the waiver) complete the training and competency evaluation set forth in federal regulations, since CMS has no authority to extend a waiver beyond a declared emergency period.<br></p><p>Elsewhere, callouts have been an issue. While these were problematic, Peter says, “We always put the safety of our residents and staff at the forefront. We recognize that short-term staffing strategies lead to long-term infection control success. We had nurses covering shifts as CNAs [certified nurse assistants], and we had people working double shifts. But we wouldn’t let people come to work when they didn’t feel good.”</p><h2>From Fear to Firefighters</h2><p>“Some people ran from the fire, but many were firefighters,” Buslovich says. “People with COVID often stop eating and drinking, and they need support and encouragement. We started systematic fluid hydration protocols, and anytime anyone went in the room, they would offer the patient a drink.” Everyone, including therapists, activity staff, administrators, and others helped hydrate and feed patients, he says.<br></p><p>“You might have one or two brave aides on a COVID unit with 20 residents. We don’t have the luxury of relying on them to adequately feed or hydrate everyone,” he says. “It takes a team to enable residents to recover from COVID and, whenever possible, stay out of the hospital.”<br></p><p>These types of efforts were significant, Buslovich says. “We have some of the frailest patients, yet our mortality rate has been remarkably low. Our teams have been a great commodity, and their efforts saved lives.”<br></p><p>Many team members made significant sacrifices to protect residents and co-workers. For instance, Buslovich says, “I moved out of my house and rented an apartment so staff could protect our families and be available 24/7 to the facility. We didn’t know enough about the virus early on, and you had to make a choice to fight the fire or stay back. This way, we could be present and available.”</p><h2>Small Fish, Big Pond</h2><p>One key to reducing turnover is to support staff when they get sick. “For staff who are out, it’s easy to feel like you don’t matter, like you’re a small fish in a big pond,” Peter says.<br></p><p>“When our people call in to staffing coordinators, they get a call from the administrator—not to find out when they’re coming back but to let them know we’re thinking about them and are genuinely concerned about their well-being. They appreciate that,” he says.<br></p><p>“The wheels would fall off without staff. We made sure we expressed appreciation for people’s efforts.”<br>Barrett agrees. “When people were out sick, we sent flowers and food from Door Dash. We made sure we covered people’s wages while they were out. We take caring for our people seriously. It’s not just lip service.”<br></p><p><img src="/Monthly-Issue/2021/April/PublishingImages/JJG.jpg" alt="Jefferson Gerodias, RN" class="ms-rtePosition-2" style="margin:5px;width:150px;height:188px;" />Jefferson Gerodias, RN, BSN, director of clinical services at Wellsprings of Gilbert, says, “We took care of employees and their families. We sent them food. Other staff would go grocery shopping and leave them on the doorstep for families.” <br></p><p>Gerodias knows this from experience. He contracted COVID in January and was out sick for two weeks. “Every day I woke up to 50 text messages asking how I was doing. And my floor staff got together and brought me groceries.”<br></p><p>Bonner adds, “When people are out sick, managers can call and check on them. There should be a buddy system where colleagues check on each other. People who are out with COVID shouldn’t feel forgotten or unsupported.”<br></p><p>Moving forward, empathy is key. “You need to understand what everyone is feeling. Everyone has obstacles they are dealing with,” says Oguin. “While everyone is doing their best, you can’t expect them to always drop everything. Managers need to be flexible and understand that their employees are juggling lots of responsibilities and challenges.” <br><br><em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></p> | 2021-04-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/April/PublishingImages/0421-CS1.jpg" style="BORDER:0px solid;" /> | COVID-19;Workforce | Joanne Kaldy | Teamwork has taken on new meaning during the pandemic. Facilities have implemented new strategies for communication, collaboration, and innovation. |
| How to Improve Administrator and DNS Relationships | <p><img src="/Monthly-Issue/2021/April/PublishingImages/AmyStewart.jpg" alt="Amy Stewart" class="ms-rtePosition-1" style="margin:5px;width:157px;height:200px;" />The relationship between the administrator and director of nursing services (DNS) has never been more important. Pandemic stress, coupled with increased regulatory scrutiny, has further strained what was already fraught; often, these stressors lead to turnover in one or both positions. <br></p><p>This critical relationship, often compared to a marriage, drives many aspects of care delivery. It affects facility culture because staff want to work on a cohesive team. It eases certification or complaint surveys by providing support. It generates financial benefits when these two collaborate on budget and census goals. And it improves the environment for residents and staff alike when communication between the two is transparent and truthful. <br></p><p>Achieving these results takes focus on the DNS-administrator relationship itself. When time and skill are invested in cultivating the relationship, it can withstand adversity, but if neglected, there can be far-reaching consequences. </p><h3>Improvement on Both Sides</h3><p>Consider this scenario: Joe, who recently started as the administrator, just told Nancy, the long-time DNS, she will need to cut her nursing budget this month. Nancy immediately became defensive, assuming he was saying she must make staffing changes. But, while Joe said she had to lower expenses, he hadn’t said to cut staff. In fact, Joe had wanted to review options with Nancy, but she jumped to conclusions. <br></p><p>Clearly, this does not create a cohesive team. If Nancy had listened carefully before responding, she would have known Joe wasn’t referring specifically to staffing. If Joe had built trust and established clear expectations, or communicated his wish to weigh options together, he could have avoided Nancy’s overreaction.<br></p><p>This scenario is far too common. When such conflicts occur frequently, they create irreparable damage. Below are five ways to improve the DNS-administrator relationship, regardless of tenure in each role.<br></p><h3 class="ms-rteElement-H3B">1. Teamwork Makes the Dream Work</h3><p>A solid foundation is necessary for a long-lasting, trusting relationship. Commit to working together as a team. Although each role has different responsibilities, the two must work together to meet patient outcomes and budgetary goals. <br></p><p>Yet teamwork goes both ways. Connect daily to discuss challenges, successes, and expectations. Start meetings by sharing what was done well before exploring what needs attention. Use reflective listening to understand what the other is saying before responding.<br></p><p>This takes practice. It is easy to let emotions take over, but reflection on the words used is more productive than reaction. Take time to learn each other’s strengths and weaknesses; use those strengths to improve care delivery and the work environment. A foundation of commitment and collaboration between the administrator and DNS will also reinforce teamwork within other departments and their staff. </p><h3 class="ms-rteElement-H3B">• Case in Point</h3><p>When Liz joined a small facility as the new DNS, tensions were high: The facility had recent survey issues, and census was low. Renee, the administrator, met with Liz daily. Renee discussed expectations and reviewed budget and census goals while Liz shared clinical improvements and concerns. By working to understand one another, Liz and Renee built trust and respected each others’ roles. </p><h3 class="ms-rteElement-H3B">2. Healthy Communication Every Time</h3><p>Learn each other’s preferred communication style and use it when possible. Some people prefer face-to-face communication, while others are perfectly happy with email. Whatever the style, remember that words are very powerful, so choose them wisely. Communicate frequently and honestly. Don’t hide issues to keep the conversations “nice and polite.”<br></p><p>Prioritizing communication requires a safe space to discuss tough situations that inevitably arise. Candid conversations are often necessary to improve care. Being truthful and having respect for each other avoids a negative work environment and supports the other’s efforts. </p><h3 class="ms-rteElement-H3B">• Case in Point</h3><p>When Mrs. Smith’s daughter arrived angry and demanded to speak to the administrator about care delivery concerns, Jen, the administrator, was already aware of the situation. She explained measures that had been initiated to improve care, and Mrs. Smith’s daughter felt reassured about how it was being handled. This confrontation could have gone differently if the DNS and administrator didn’t communicate regularly and transparently. </p><h3 class="ms-rteElement-H3B">3. Conflict Resolution that Works</h3><p>It is unrealistic to think that two people will always agree. Be prepared with a plan to overcome conflicts that will arise. It is best to disagree behind closed doors and work together toward resolution. Brainstorm options and discuss them until an agreement is reached. Sometimes, there isn’t a resolution; when that occurs, agree to disagree and move on.<br></p><p>Because the administrator and DNS are the two top leaders in a facility, staff watch the relationship closely. If staff observe disagreements, they may feel compelled to take sides. Don’t let conflict interfere with the facility’s mission and goals. </p><h3 class="ms-rteElement-H3B">• Case in Point</h3><p>Brenda, the administrator, and Amy, the DNS, discussed changing the uniform policy. Brenda wants nurses to wear one color uniform and nurse assistants another so patients know if the person entering the room is a nurse or assistant. Amy doesn’t agree.<br></p><p>Unhappy staff later question Amy about the change. Although Amy doesn’t like it, she explains the rationale fairly. Staff don’t need to know she disagreed, because it won’t change the policy, but could harm the work environment.</p><h3 class="ms-rteElement-H3B">4. Support Each Other</h3><p>There will be days when the stress level is so high that each person cannot be their normal self. Long term care has many stressful challenges, such as surveys, staffing, census, and regulatory change. When stakes are high, be a support system. Recognize when stressors are taking a toll.<br>Many of these challenges are unique to long term care, and no one can understand like the administrator or DNS. When things get tough, lean on each other. Occasionally, share a small token of gratitude to show you value one another. </p><h3 class="ms-rteElement-H3B">• Case in Point</h3><p>Already stressed about staffing, DNS Mike has just been told the survey team has arrived. Soon after, a surveyor asks Mike about an incident, and the conversation goes poorly. Administrator Tom recognizes that Mike’s stress level is increasing and checks on him, bringing a favorite coffee, moral support, and a sympathetic ear. This leaves Mike feeling heard, valued, and appreciated. </p><h3 class="ms-rteElement-H3B">5. Be Goal-Getters </h3><p>It’s easy to set goals, but the DNS and administrator must collaborate to achieve them. Being goal-getters requires a cohesive team. Offer to help one another with individual and mutual goals. When goals are not aligned, attainment becomes more difficult, and both parties become frustrated. However, when the two work together, goals are more easily achieved. And don’t forget to recognize and celebrate successes. </p><h3 class="ms-rteElement-H3B">• Case in Point</h3><p>Kathy, the DNS, proposes an annual goal of being deficiency-free with no complaint surveys. Bob, the administrator, recognizes that this is an ambitious goal and asks Kathy if she might want to consider a more realistic goal, such as fewer complaint surveys and two fewer deficiencies than last year. <br></p><p>Bob shares his census and budget goals and discusses how Kathy could help meet them. He asks her to include goals that increase the staff’s ability to care for medically complex patients, to help meet budget and census goals.<br></p><p>Cohesiveness in the administrator-DNS relationship has many benefits for a facility. Studies have shown that tenure of the two roles is associated with less staff turnover and lower survey deficiencies. It also enables better patient outcomes, as expectations, goals, and communication remain central to the working relationship. When both parties work together to provide the best care in a transparent manner, they can improve this critical relationship. <br><br><em>Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, is vice president of education and certification strategy at the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at <a href="mailto:astewart@aapacn.org" target="_blank">astewart@aapacn.org</a> <br></em></p><p style="text-align:center;"><a href="http://www.aapacn.org/" target="_blank"><img src="/Monthly-Issue/2021/April/PublishingImages/AAPACN.jpg" class="ms-rtePosition-3" alt="" style="margin:5px;width:200px;height:58px;" /></a> </p><p><em></em></p> | 2021-04-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/April/PublishingImages/0421-mgmt.jpg" style="BORDER:0px solid;" /> | Management;Workforce | Amy Stewart, RN | The relationship between the administrator and director of nursing services has never been more important. |