An Introduction to the

National Nursing Assistant

Survey

Series 1, Number 44 March 2007
Copyright information

All material appearing in this report is in the public domain and may be

reproduced or copied without permission; citation as to source, however, is

appreciated.

Suggested citation

Squillace MR, Remsburg RE, Bercovitz A, Rosenoff E, Branden L. An

Introduction to the National Nursing Assistant Survey. National Center for Health

Statistics. Vital Health Stat 1(44). 2007.

Library of Congress Cataloging-in-Publication Data

An introduction to the National Nursing Assistant Survey.

p. ; cm. -- (DHHS publication ; no. (PHS) 2007-1320) (Vital and health

statistics. Ser. 1 ; no. 44)

‘‘February 2007.’’

Includes bibliographical references.

ISBN-13: 978-0-8406-0614-3

ISBN-10: 0-8406-0614-1

1. Nurses’ aides--United States. 2. Nursing homes--United States--Employees.

3. Health surveys-- United States. I. National Center for Health Statistics (U.S.)

II. Series. III. Series: Vital and health statistics. Ser. 1, Programs and collection

procedures ; no. 44.

[DNLM: 1. National Nursing Assistant Survey (U.S.) 2. Nurses’ Aides--

United States. 3. Nursing Homes--manpower--United States. 4. Data

Collection--methods--United States. 5. Health Surveys--United States. 6.

Research Design--United States. W2 A N148va no.44 2007]

RT84.I58 2007

614.4.’273--dc22

2006038116

For sale by the U.S. Government Printing Office

Superintendent of Documents

Mail Stop: SSOP

Washington, DC 20402-9328

Printed on acid-free paper.
Series 1, Number 44

An Introduction to the

National Nursing Assistant

Survey

Programs and Collection Procedures

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Hyattsville, Maryland

March 2007

DHHS Publication No. (PHS) 2007-1320
National Center for Health Statistics

Edward J. Sondik, Ph.D., Director

Jennifer H. Madans, Ph.D., Acting Co-Deputy Director

Michael H. Sadagursky, Acting Co-Deputy Director

Jennifer H. Madans, Ph.D., Associate Director for Science

Jennifer H. Madans, Ph.D., Acting Associate Director for

Planning, Budget, and Legislation

Michael H. Sadagursky, Associate Director for

Management and Operations

Lawrence H. Cox, Ph.D., Associate Director for Research

and Methodology

Margot A. Palmer, Director for Information Technology

Margot A. Palmer, Acting Director for Information Services

Linda T. Bilheimer, Ph.D., Associate Director for Analysis

and Epidemiology

Charles J. Rothwell, M.S., Director for Vital Statistics

Jane E. Sisk, Ph.D., Director for Health Care Statistics

Jane F. Gentleman, Ph.D., Director for Health Interview

Statistics

Clifford L. Johnson, Director for Health and Nutrition

Examination Surveys

Division of Health Care Statistics

Jane E. Sisk, Ph.D., Director

Robin E. Remsburg, Ph.D., Deputy Director

Lauren Harris-Kojetin, Ph.D., Chief, Long-Term Care

Statistics Branch
Contents

Acknowledgments ......................................................................................... iv

Introduction .............................................................................................. 1

The Demand for Nursing Assistants......................................................................... 2

The Move toward Enhancing the Direct Service Workforce...................................................... 3

Report Organization ..................................................................................... 3

Methodology ............................................................................................. 3

Research Goal and Objectives ............................................................................. 3

Participant Inclusion and Exclusion Criteria .................................................................. 4

Sample Design and Selection .............................................................................. 4

Response Rate .......................................................................................... 5

Instrumentation ......................................................................................... 5

Pilot Test .............................................................................................. 6

Procedures ............................................................................................. 7

Combining Establishment and Worker Surveys.................................................................. 10

Advantages of Combining Establishment and Worker Surveys ................................................... 10

Expanded 2004 National Nursing Home Survey ............................................................... 11

Uses of Survey Data and Data Publication ..................................................................... 11

Potential Uses of the National Nursing Assistant Survey ........................................................ 11

Potential Uses of the NNAS Data Linked with the NNHS and Other Data Sources .................................. 13

Data Publication and Availability ........................................................................... 15

Summary and Future Directions.............................................................................. 15

References ............................................................................................... 15

Appendixes

I. Promotional and Contact Information ................................................................... 19

II. List of Survey Items................................................................................. 27

Text Tables

A. National Nursing Assistant Survey Response Rate......................................................... 5

B. Key subject areas on the National Nursing Assistant Survey questionnaire ..................................... 6

C. Contents of advance packets .......................................................................... 8

D. Important policy and practice issues associated with paraprofessional workers .................................. 12

E. Examples of research questions that may be addressed by the National Nursing Assistant Survey .................. 12

F. Potential analyses of the National Nursing Assistant Survey with the National Nursing Home Survey and other data

sources............................................................................................ 13

iii
Acknowledgments

The National Nursing Assistant

Survey (NNAS) was sponsored and

funded by the Office of the Assistant

Secretary for Planning and Evaluation

(ASPE).

The survey was conducted by the

Centers for Disease Control and

Prevention’s National Center for Health

Statistics. The project director was

Robin Remsburg. Design, production,

and analysis assistance for this project

was provided by Abigail Moss,

Genevieve Strahan, Alvin Sirrocco,

Sarah Gousen, and Iris Shimizu.

The interview was developed with

the assistance of Mathematica Policy

Research, Inc. Westat and their

subcontractors conducted all interviews

for the project.

We gratefully acknowledge the

contributions of Andreas Frank,

previously with ASPE, and William

Marton of ASPE. We are indebted to

our national advisory group members

who were most giving of their time and

expertise: Marilyn Biviano, Barbara

Bowers, Joseph DuBois, the late Susan

Eaton, William Eschenbacher, Mary

Harahan, Mark Hatch, Graham Kalton,

Peter Kemper, D.E.B. Potter, Edward

Salsberg, Anita Schill, Robin Remsburg,

Robyn Stone, and David Zimmerman.

iv
Objectives

This report provides an introduction

and overview of the National Nursing

Assistant Survey (NNAS), the first

national probability survey of nursing

assistants working in nursing homes.

The NNAS was designed to provide

national estimates and to allow for

separate estimates to be calculated for

nursing assistants by geographic

location of the agency and for workers

by tenure at the sampled facility.

This report includes a description of

relevant research that led to federal

interest in sponsoring the NNAS, types

of data collected, methodology, linkage

between the NNAS and the 2004

National Nursing Home Survey (NNHS),

advantages of combining establishment

and worker surveys, and potential uses

of the data.

Methods

The NNAS was conducted as a

supplement to the 2004 National Nursing

Home Survey. The design was a stratified,

multistage probability survey. Nursing

facilities were sampled and then nursing

assistants were sampled within the

facilities. Telephone interviews were

conducted with nursing assistants using

Computer-Assisted Telephone Interviews

(CATI). The survey instrument consisted of

sections on recruitment, training and

licensure, job history, family life,

management and supervision, client

relations, organizational commitment and

job satisfaction, workplace environment,

work-related injuries, and demographics.

Results and Conclusions

A total of 3,017 interviews were

completed from September 2004 to

February 2005. The overall response

rate was 53.4 percent. A public-use

data file has been released that

contains the interview responses and

sampling weights. The file also includes

ownership, bed size, and geographic

location of the facility where the nursing

assistant was sampled. Estimates

based on the sampling weights can be

used to produce national estimates.

Keywords: National Nursing

Assistant Survey c National Nursing

Home Survey c nursing assistant c

job satisfaction c turnover

An Introduction to the National

Nursing Assistant Survey

By Marie R. Squillace, Ph.D., Department of Health and Human

Services, Office of the Assistant Secretary for Planning and

Evaluation; Robin E. Remsburg, Ph.D., and Anita Bercovitz, Ph.D.,

National Center for Health Statistics, Division of Health Care

Statistics; and Emily Rosenoff, M.P.A., Department of Health and

Human Services, Office of the Assistant Secretary for Planning and

Evaluation; and Laura Branden, Westat

Introduction

Since the 1990s, the Office of the

Assistant Secretary for Planning

and Evaluation (ASPE), the U.S.

Department of Health and Human

Services (HHS), has made the long-term

care workforce a major focal point of its

policy research agenda. The largest and

most visible of its research initiatives in

this area is the National Nursing

Assistant Survey (NNAS), the first

national probability sample survey of

nursing assistants employed in nursing

homes. The NNAS was designed to

provide an evidence base for

understanding what draws individuals to

careers as nursing assistants and to work

in nursing homes, and what contributes

to their satisfaction and likelihood of

staying in their jobs. This report

provides a historical perspective on the

federal government’s involvement in

creating the NNAS as an example of the

federal role in enhancing the availability

and capabilities of the direct service

workforce. Specifically, this report

describes relevant research that led to

federal interest in sponsoring this

survey; introduces the NNAS, including

the types of data collected, the methods

undertaken, including the linkage

between the NNAS and the 2004

National Nursing Home Survey

(NNHS); the advantages of combining

establishment and worker surveys and

the potential uses of these data; and

highlights the expanded and improved

NNHS.

The immediate antecedents of the

NNAS can be found in Senate Report

107–84, Departments of Labor (DOL),

Health and Human Services, and

Education, and Related Agencies

Appropriation Bill. In fiscal year 2002,

Congress requested that the Secretaries

of Health and Human Services and

Labor identify the causes of labor force

imbalances among frontline caregivers,

including registered and licensed

practical nurses, certified nurse aides,

and other direct care workers in

long-term care settings such as nursing

homes, assisted living, and home health

care. In addition, Congress requested

that HHS and DOL make

comprehensive recommendations to the

House and Senate Appropriations

Committee to address the increasing

demand of an aging population (1).

The report, The Future Supply of

Long-Term Care Workers in Relation to

the Aging Baby Boom Generation:

Report to Congress, is a collaboration

between HHS and DOL in response to

the requests from the U.S. Congress.

One recommendation from this report

was to support research activities to

inform policymakers at all levels of

government on the quality and

availability of the long-term care

workforce, including such issues as

wage and benefit trends among frontline

caregivers, understanding the effect of

training and workplace culture on

Page 1
Page 2 [ Series 1, No. 44

worker retention, and understanding how

worker characteristics relate to

recruitment and job satisfaction (2).

Although widely used in the research

and policy literature, the concepts of

recruitment and retention have not been

measured in consistent ways, making it

difficult to compare the effects of

interventions designed to improve

retention (3).

In 2003, ASPE contracted with an

independent research organization to

develop a series of design options for a

national survey of paraprofessional

workers in institutional and communitybased settings. As work progressed,

ASPE decided to fund one of the

emerging design options, a National

Survey of Certified Nursing Assistants

in Nursing Homes. The objectives of the

survey were to describe nursing

assistants’ work experiences and reasons

for entering the field; to find out what

changes in working conditions, wages,

benefits, and career growth for nursing

assistants would make the job more

attractive; and to provide a better

understanding of why nursing assistants

leave the field. The survey of nursing

assistants was fielded as a supplement to

the 2004 NNHS at a subsample of

nursing homes participating in the

NNHS. Ultimately, survey results will

strengthen federal, state, and provider

efforts aimed at recruiting a qualified

and committed workforce. ASPE is the

sponsor of the NNAS; its design and

implementation were made possible

through collaborations with two

independent research organizations, a

national advisory group, private

consultants, and a sustained partnership

with the Centers for Disease Control

and Prevention (CDC), National Center

for Health Statistics (NCHS).

The Demand for Nursing

Assistants

The total number of Americans in

need of long-term care is projected to

more than double from 13 million in

2000 to 27 million in 2050 (2).

Long-term care providers face

tremendous challenges each day trying

to provide high-quality care to clients.

One of the greatest challenges is staff

retention among direct care workers—

nursing assistants, personal care

attendants, and home health aides—who

provide hands-on services to clients.

These frontline caregivers provide the

majority of paid assistance to persons

with disabilities (of all ages) in the

formal long-term care delivery system

(4). Nursing assistants working in

nursing facilities make up an estimated

24.7 percent (593,490) of the over 2.4

million paraprofessional workers (5,6).

Since nursing assistants primarily

provide hands-on assistance to clients

with activities of daily living (ADLs),

they are key players in determining the

quality of paid long-term care.

Turnover among direct care workers

is high and can reach rates of over

100 percent in some organizations,

although the definition of turnover may

affect the rate calculation by as much as

47 percent (7–10). The nursing home

industry, in particular, has been plagued

for decades by an inability to recruit and

retain nursing assistants (7,11).

Long-term care providers are reporting

national average nursing assistant

turnover rates at 71 percent and more

than 52,000 vacant nursing assistant

positions (12). Gaps in staffing may

disrupt the continuity of patient care (7),

worker morale (13), worker safety (14),

and quality of care (15–22).

Turnover of direct care workers has

other repercussions as well: it is costly

to the provider and to the payer (13,19,

23–26). Both direct costs (recruiting,

training new employees, and hiring

temporary staff) and indirect costs

(reduced productivity, deterioration in

organizational culture, and morale)

associated with turnover can

compromise the quality and continuity

of clients’ care (13,23). Further, costs

for recruiting and training new direct

care workers may be reflected in the

demand for higher government

reimbursement rates to maintain

adequate care quality.

Turnover and high vacancy rates of

direct care workers have implications

for family caregivers as well. The

inability to recruit and retain direct care

workers places more pressure on

informal (unpaid) family caregivers to

provide care and exacerbates the

challenge of arranging for formal care

(27).

While the significance of the direct

care worker’s role in the provision of

long-term care has become more

recognized by long-term care

professionals and researchers, these

workers experience stressful working

conditions, little career mobility, and are

among the lowest-paid workers in the

health care field (4,21,24,28,29).

Long-term care organizations, therefore,

face considerable difficulty in recruiting

and retaining direct care staff. As the

demographics shift toward a larger

aging population and greater demand for

direct care workers, the recruitment and

retention problem is likely to intensify.

If left unaddressed, this emerging care

gap could severely restrict the ability of

providers to deliver adequate long-term

care (30,31).

The ability to understand and

replicate programs that reduce turnover

can improve continuity of care while

reducing the need for higher levels of

reimbursement, yet evidence on what

long-term care organizations and federal,

state, and local policymakers can do to

reduce job turnover is quite limited.

While wage and benefit increases have

been deemed as possible solutions to the

direct care worker turnover problem

(32), impending Medicaid cuts render

these solutions unlikely (33) and suggest

the need for alternative solutions such as

peer mentoring, career ladders, enhanced

staff-family communication, alternative

labor pools, multi-faceted initiatives

(public awareness campaigns, career

enhancements, quality improvement

initiatives), and culture and managerial

changes. These are the primary

strategies currently being employed by

providers and states (34–38). Moreover,

supporting data to demonstrate the

efficacy of the wage pass-through as a
Series 1, No. 44 [ Page 3

tool to reduce worker vacancies and

turnover are lacking. A study of 12

states that had implemented wage

pass-through programs found that three

programs had no impact on recruitment

and retention; three could not determine

whether there was any measurable

effect; and four either had a positive

impact or ‘‘probably had some positive

impact’’ (39).

Adequate wage and benefit levels

are important in recruiting and retaining

committed and high-quality workers for

direct care jobs (40); however, increased

benefits cannot solely resolve

recruitment and retention problems (32).

Studies have shown that factors other

than wages and benefits can have an

impact on intent to stay on the job and

worker satisfaction (36,37).

Employees’ attitudes about various

aspects of their jobs, for example, affect

their overall job satisfaction, their

commitment, and the likelihood that

they will remain with their employer

(41–43). Survey research can reveal the

most important drivers that positively or

negatively impact job satisfaction,

thereby informing targeted retention

efforts in areas of supervision, skill

development, or advancement

opportunities (44). While the U.S.

Bureau of Labor Statistics (BLS)

provides employment estimates to

monitor the labor force, no nationally

descriptive information is collected

directly from the paraprofessional

workforce to evaluate what motivates

individuals to choose careers as direct

care workers in long-term care settings,

and what contributes to the likelihood

that they will continue in these positions

based on their job satisfaction,

environment, training, and advancement

opportunities. Studies have collected

such data from these workers, but they

are state or community specific (45–49)

or focused on a specific segment of the

workforce, such as older workers (50).

The Move toward

Enhancing the Direct

Service Workforce

With widespread current shortages

that are likely to increase as the demand

increases, industry and policy leaders

recognize the urgency that direct service

workforce development plays for

staffing the continuum of care outlined

in the President’s New Freedom

Initiative (51–53). The goal of providing

consumers with choices that maximize

their independence can only occur if

there are enough capable caregivers to

provide such services. The DOL

projections continue to list these jobs

among those with the highest growth

rate. The number of nursing assistants,

orderlies, and attendants are expected to

increase by 22.3 percent (from 1.455

million to 1.781 million); the number of

personal and home care aides is

expected to grow by 41 percent (from

701,000 to 988,000); and the number of

home health aides is expected to grow

by 56 percent (from 624,000 to 974,000)

between 2004–14 (6). The communitybased approaches that are supported by

the New Freedom Initiative require

many more direct services workers than

are currently in the field. It is, therefore,

critical that industry and policy leaders

have access to information that is useful

in improving the attractiveness of

care-giving jobs and in reducing

turnover. The NNAS provides a

framework for future evidence-based

policy, practice, and applied research

initiatives to address the long-term care

direct care workforce shortage.

Report Organization

The remainder of this report

includes the following sections:

+ Methodology—including study goals

and objectives, participant

inclusion/exclusion criteria, an

overview of the study sample and

response rate, and detailed sections

on instrumentation, procedures, and

study limitations.

+ Combining establishment and

worker surveys—including an

overview of the expanded NNHS

and advantages of combining

establishment and worker surveys.

+ Uses of survey data and

publication—including uses of the

NNAS and the NNAS linked to the

NNHS and other data sources, and

guidelines for data access.

+ Summary and future directions—

including key issues and next steps.

Methodology

Research Goal and

Objectives

The goal of the study is to provide

industry and policy leaders with

information that is useful for improving

the attractiveness of long-term

paraprofessional care-giving jobs and in

reducing turnover. In addition, the study

sought to:

+ Describe nursing assistants’ work

experience and reasons for entering

the field.

+ Determine what changes in working

conditions, wages, benefits, and

career growth will make nursing

assistants’ jobs more attractive.

+ Provide a better understanding of

why nursing assistants leave the

field.

+ Provide a framework for future

evidenced-based policy, practice,

and applied research initiatives to

address the long-term direct care

workforce shortage.

The survey was conducted as a

supplement to the 2004 NNHS. The

2004 NNHS is part of a continuing

series of nationally representative

sample surveys of United States nursing

homes, their services, their staff, and

their residents. The NNHS was first

conducted in 1973–74 and repeated in

1977, 1985, 1995, 1997, 1999, and most

recently in 2004. Although each survey

has emphasized different topics, they all

provide basic information about nursing

homes, the services they provide, their

staff, and their residents. The nursing

home survey was preceded by a series

of surveys from 1963 through 1969

called the Resident Places Surveys.

Data for the NNHS are collected

via on-site interviews with

administrators and staff who are familiar

with sampled residents and use facility

and medical records to respond to the

survey. For the NNAS, nursing

assistants were sampled from a subset of
Page 4 [ Series 1, No. 44

nursing homes participating in the

NNHS.

Participant Inclusion and

Exclusion Criteria

The target population for the NNAS

is nursing assistants who work in

nursing homes and assist residents with

ADLs, including eating, transferring,

toileting, dressing, and bathing. The

nursing assistants must be certified by

the state to provide Medicare or

Medicaid reimbursable services.

Certification, required by the Omnibus

Budget Reconciliation Act (OBRA) of

1987 (P.L. 100–203) (54), mandates that

nursing assistants complete 75 hours of

training and a written certification test.

This study includes nursing assistants

currently in the process of certification

and those who started working as a

nurse aide prior to 1987, when the

certification process was implemented.

Participants must be an employee of

the nursing home either full or part

time, work at least 16 hours per week,

and must be paid to provide ADL

assistance. The survey instrument was

translated into Spanish for nursing

assistants who were unable to participate

in English.

The NNAS specifically excludes

nursing assistants who are not certified

(unless they are currently in the process

of certification or started working as a

nurse aide prior to 1987 when the

certification process was implemented),

are employed through contractual

arrangements, and only provide

assistance with instrumental ADLs—

such as transportation, shopping,

housekeeping, meal preparation, or

medication administration. Nursing

assistants who did not speak English or

Spanish were excluded because

providing interpretive services for other

languages was cost prohibitive. Nursing

assistants who worked less than 16

hours per week were excluded from the

survey to ensure that respondents would

have had enough exposure and

experience in the nursing home to

accurately report on organizational

culture and work policies. In addition,

since the NNAS sample was selected

from facilities participating in the

NNHS, any workers in facilities

excluded from the NNHS were in turn

excluded from the NNAS (those with

fewer than three beds, not certified by

Medicare or Medicaid, or did not have a

state license to operate as a nursing

home).

Although the NNAS was designed

to allow for a better understanding of

organizational culture and how it relates

to worker satisfaction, it is known that

many nursing assistants hold down

multiple jobs and may actually work in

several nursing homes. To avoid

potential confusion, contract workers

and nursing assistants who worked less

than 16 hours per week were excluded

from the survey to ensure that

respondents would have had enough

exposure and experience in the nursing

home to accurately report on

organizational culture and work policies.

Contract workers and those employed

fewer than 16 hours per week may have

different needs and work challenges

than full-time employees. Moreover,

facilities with a high percentage of these

employees are likely to have a different

work environment and organizational

culture than those with fewer contract

and part-time employees.

Only certified nursing assistants

providing help with ADLs were eligible

for the survey. Certified nursing

assistants working in other roles—such

as medication aides, or activity

coordinators, and other noncertified

direct care workers providing ADL

assistance (such as feeding assistants)

were ineligible for the survey.

Undoubtedly, these workers face similar

work challenges, yet the range of their

workload, duties, and responsibilities are

fundamentally different than certified

nursing assistants delivering help with

ADLs.

Sample Design and

Selection

The sample design for the nursing

assistant survey was developed with the

primary goal of preparing nationally

representative and reliable estimates of

nursing assistants. As such, the NNAS

involved a stratified, multistage

probability design in which nursing

facilities were sampled and then nursing

assistants were sampled within the

facilities. The sample design allows for

separate estimates to be calculated for

workers by the Core Based Statistical

Area (CBSA) geographical location of

the nursing facility (metropolitan,

micropolitan, or neither), and for

workers by tenure at the sampled

facility (less than 1 year working at the

sampled facility or more than or equal

to 1 year working at the sampled

facility).

Sampling Frame for Selection

of Nursing Homes

For the 2004 NNHS, 1,500 nursing

facilities were selected from a sampling

frame of nursing homes in the United

States. The sampling frame for the

NNHS was drawn from two sources: the

Centers for Medicare and Medicaid

Services (CMS) Provider of Services

(POS) file of nursing homes, and state

licensing lists compiled by a private

organization. These two files contained

approximately 17,000 nursing homes.

The combined files were matched and

unduplicated, resulting in a final

sampling frame of 16,628 nursing

homes.

Selecting Nursing Facilities for

the NNHS and NNAS

Each nursing facility was placed

into a stratum comprised of bed-size

category and CBSA status (metropolitan,

micropolitan, or neither). To permit

implicit stratification within these

broader sampling strata, nursing

facilities were arrayed by certification

status, hospital-based and nonhospitalbased, ownership, geographic region,

state, county, and ZIP code. Facilities

were then selected using systematic

sampling with probability proportional

to their bed size. A total of 1,500

facilities were selected for the NNHS. A

random subsample (n=790) of these

selected facilities was then selected to

participate in the NNAS.
Series 1, No. 44 [ Page 5

Selecting Workers from Each Table A. National Nursing Assistant Survey Response Rate

Sampled Facility Category Number Percent

At the time of the in-person

interview with the facility administrator

during data collection for the NNHS, the

facility provided a list or lists of nursing

assistants for sampling purposes. The

interviewer cleaned and numbered the

lists so that the nursing assistants were

divided into the two tenure groups: all

nursing assistants employed by the

facility for less than 1 year, and all

nursing assistants employed by the

facility for 1 year or more as of

midnight the day before the interview.

Interviews were conducted between

September 2004 and February 2005.

The interviewer entered the total

number of nursing assistants employed

for less than 1 year into a computerassisted personal interview system

(CAPI); the CAPI program randomly

selected up to four nursing assistants.

The process was repeated for the

nursing assistants employed for 1 year

or more.

Response Rate

The response rate for the NNAS is

a function of the response rate for

nursing homes and the response rate

among nursing assistants. For the 2004

NNAS, a random subsample of 790

facilities was selected from the 1,500

nursing facilities selected for the 2004

NNHS. Of these, 21 facilities were

determined to be out of scope. Facilities

were considered out of scope for one or

more of the following reasons: it had

gone out of business; it was a duplicate

of another facility in the sample; or it

failed to meet the definition used in this

survey by having either fewer than three

beds, not being certified by Medicare or

Medicaid, or not licensed by the state to

operate as a nursing home.

Of the 769 eligible facilities, 164

did not participate in any aspect of the

NNHS and 23 others elected not to

participate in the NNAS portion of the

survey. This resulted in a facility

response rate of 75.7 percent. From the

582 eligible facilities that agreed to

participate in the NNAS, 4,542 nursing

assistants were sampled. Of these, 4,274

were eligible and 3,017 completed an

Total CNAs1 in responding facilities ................ 4,542 100

Ineligible2 ............................... 268 6

Total eligible ............................. 4,274 94

Total eligible .............................. 4,274 100

Nonresponse3 ............................. 1,257 29

Refusal ................................ 143 3

Unable to contact .......................... 919 22

Other nonresponse ......................... 195 5

Complete interviews4 ......................... 3,017 71

1

Certified nursing assistants.

2

CNAs who did not meet the eligibility criteria for inclusion in the study or were sampled in error.

3

Totals do not add to 100 due to rounding.

4

Approximately 50 interviews were completed in Spanish.

NOTE: The percent of completed interviews is calculated as the number of completed interviews divided by the total number

eligible.

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, NNAS (2004).

interview. This yielded a response rate

of 70.6 percent among eligible nursing

assistants, with an overall NNAS

response rate of 53.4 percent (eligible

nursing assistants (0.71) x facility

response rate (0.76) (Table A).

Overall, the major reason for

nonresponse was inability to contact the

nursing assistants. Although 74 percent

of nursing homes provided contact

information (for example, home phone

number and address), 22 percent of the

eligible nursing assistants could not be

located. Only 3 percent of contacted

nursing assistants refused to participate

in the NNAS. For refusals who returned

their postcard, the reason for refusal is

unknown. (Postcards were provided to

nursing assistants in Advance Packets,

designed to encourage participation.

Nursing assistants indicated their

willingness to participate in the survey

and provided their name, address, phone

number, and the best time and day to

reach them to participate in the survey.

See ‘‘Advance Packets for Nursing

Assistants’’ section for additional

information.)

Reasons for refusals among those

contacted by phone included no time to

do an interview, concern over

confidentiality, compensation was not

adequate, and poor English skills.

About 6 percent (n=268) of the

nursing assistants were ineligible for the

survey. Of the ineligible cases, 227

completed the screener questions and

were determined to be ineligible for the

NNAS; 41 were determined ineligible

based on information obtained from the

NNHS interviewer or the facility about

a sampling error (that is, were not

nursing assistants or did not work at the

facility at the time of the survey). The

majority of those deemed ineligible

were working fewer than 16 hours per

week, a criterion for exclusion. Other

nursing assistants were deemed

ineligible because they had not

completed a formal nursing assistant

course and passed a test in nursing

assistant training.

Instrumentation

The survey instrument was designed

with input from ASPE and members of

the technical advisory panel, as well as

representatives from the National

Institute for Occupational Safety and

Health, the Occupational Safety and

Health Administration, and CMS. The

NNAS was designed to measure job

satisfaction and organizational culture,

as well as to provide basic information

on job history, family life, and intention

to continue to work as a nursing

assistant.

The final survey instrument,

designed to be administered by

telephone, consisted of 10 primary

sections:

1. Recruitment (7 items).

2. Education, training, and licensure

(19 items).

3. Job history (17 items).

4. Family life (17 items).

5. Management and supervision (10

items).
Page 6 [ Series 1, No. 44

Table B. Key subject areas on the National Nursing Assistant Survey questionnaire

B. Recruitment ........... ........... How nursing assistant found out about the job. Reasons for working in field, source of job.

C. Education, training, and licensure .... .... Circumstances of training, nature of initial training. Continuing education, on-the-job training.

D. Job History ........... ........... Current and previous jobs, current job benefits.

E. Family Life ........... ........... Transportation. Family size and makeup, family care needs. Public assistance.

F. Management, supervision ...... ...... Job title of supervisor, quality of supervision.

G. Client relations .......... .......... Distribution of work time, acknowledgement of work.

H. Organizational commitment, job satisfaction . . Reasons for continuing job. Opportunity to perform different types of work. Satisfaction. Problems on the

job. Future prospects in the field.

I. Workplace environment ................ Attitude toward management/supervision. Cooperation among workers. Job-related problems.

J. Work-related injuries ......... ......... Nature of injuries, needle sticks, facility prevention.

K. Demographics .......... .......... Age, race, marital status, income, education, citizenship status, language, gender.

L. Facility leavers .......... .......... Why separated. Current working arrangements. Likelihood of working again. Likelihood of recommending

facility to family/friend.

SOURCE: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, NNAS (2004).

6. Client relations (8 items).

7. Organizational commitment and job

satisfaction (14 items).

8. Workplace environment (8 items).

9. Work-related injuries (14 items).

10. Demographics (10 items).

Eligible nursing assistants who were

no longer working at the facility when

contacted were asked to complete a

separate facility leaver section of the

survey (11 items). Table B provides an

overview of key subject areas on the

NNAS questionnaire. A detailed listing

of variables is located in Appendix II.

Content validity of the final

instrument was established by means of

a technical advisory panel with expertise

in survey methodology and sample

design, long-term care paraprofessional

workforce issues, health policy, and

evaluation. Question formats that

allowed for the survey to be conducted

as expeditiously as possible were used

(that is, closed-ended questions,

checklists).

The instrument was tested using a

convenience sample of nursing assistants

in English (n=9) and Spanish (n=8) for

timing, basic comprehension, and flow,

and was refined based on the results.

The interviews were completed in

stages, with a few interviews being

completed, followed by changes being

applied for the next group of interviews.

Telephone interviewers conducted these

preliminary interviews.

The approach used for translating

and testing the Spanish-language version

of the questionnaire utilized guidelines

from the U.S. Census Bureau. Rather

than back-translating, the Spanish

instrument was adapted from English.

This process of adaptation allowed for

parts of a question to be altered from

the source document to capture

cross-cultural differences across

languages. The translation team included

translators, translation reviewers, and

translation adjudicators. Because this is

a national survey, the translation was

targeted to the general Spanish-speaking

population of the United States, rather

than to dialects from specific regions,

such as Mexico, Puerto Rico, or South

America. The final translation captured

all items from the source document; no

new or extraneous items were added

(55).

Overall, both the English and

Spanish interviews with nursing

assistants were conducted with few

problems. Respondents were able to

understand the intent of the questions,

and there were very few instances of

item nonresponse due to question

sensitivity. Interviewers displayed little

difficulty in administering the

questionnaire due to skip patterns or

question wording; as a result, there was

a limited number of missed skips and

interviewer errors.

Pilot Test

A pilot test was conducted from

March through April 2004, to assess the

effectiveness of advance materials and

contact procedures; procedures for

selecting the sample; instrument

administration time and question

wording; and the collection, quality, and

processing of contact information. The

NNAS pilot test consisted of two

phases: training and data collection for

field interviewers (who made in-person

visits to the facility to gather contact

information) and training and data

collection for telephone interviewers

(who conducted the NNAS).

Nursing assistants for the pilot test

were defined in the same way they were

defined for the national sample, and the

pilot sample was also stratified by

tenure (less than 1 year or more than or

equal to 1 year). A sample of 63 nursing

assistants was selected from eight

facilities from a sample of 12 facilities

that had also participated in the NNHS

pilot test. While the nursing facilities

used in the pilot test for the NNAS had

also participated in the NNHS pilot test,

the pilot data collection for the NNHS

and the NNAS were not conducted at

the same time. Of these eight facilities,

only one nursing home administrator

(12.5 percent) provided contact

information for the sampled nursing

assistants. Since the majority of nursing

home administrators did not provide

contact information for nursing

assistants, improvements were made in

the advance materials and a decision

was made to create a stand-alone

recruitment packet. To assist in

developing these materials, two focus

groups and two cognitive interview

sessions were held in June 2004 with

nursing assistants to elicit feedback on

the various versions of advance

materials proposed for the NNAS. Final

advance materials were developed based

on the feedback provided by the nursing

assistants.
Series 1, No. 44 [ Page 7

Procedures

This section describes the

procedures used for the NNAS data

collection, including those used for

informing the facilities about the NNAS,

selecting the sample, contacting the

selected nursing assistants, and

follow-up procedures to increase

response rates. This section concludes

with an overview of survey limitations.

Advance Materials for Facilities

The NNHS facilities selected for the

NNAS were informed about the survey

as part of the advance contact materials

sent to the nursing home administrator

that included an advance letter,

appointment call, appointment

confirmation letter, and an appointment

confirmation call. The appointment

confirmation letter explained that up to

eight nursing assistants would be

selected in the facility and that contact

information would also be collected.

Facilities were asked to provide a list of

nursing assistants employed by the

facility with an indicator of whether

their tenure was less than 1 year or 1

year or more at the time of the

in-person interview at the facility.

In the appointment confirmation

packet, the facility administrator

received a copy of letters provided by

three professional nursing assistant

organizations endorsing the NNAS,

including the National Association of

Geriatric Nursing Assistants, the

National Network of Career Nursing

Assistants, and the Paraprofessional

Healthcare Institute. The appointment

confirmation packet also included a

NNAS flyer (Exhibit 1) and an advance

letter (Exhibit 2) for the administrator to

present to all nursing assistants

employed by the facility to provide

information about the survey. The

NNAS flyer was designed to be posted

in an area of the facility where nursing

assistants would most likely see it. It

alerted the nursing assistants that the

NNAS was coming and that they might

be chosen to participate. The flyer

incorporated the NNAS logo and color

theme and addressed the purpose of the

survey, the $35 incentive payment, the

voluntary nature of the survey, that the

interviews would be conducted by

telephone, and assurance of the

confidential nature of the survey. It also

included HHS and CDC logos, the

NNHS website address, and the NNAS

toll-free number. Each facility received

two copies of the flyer. The NNAS

advance letter contained similar

information to the flyer. It was printed

on NNAS letterhead and designed to be

distributed to all of the nursing

assistants in the facility, either with their

paycheck or in a mailbox at work or in

whatever manner the administrator

decided to use to distribute the letters.

Activities to Contact Nursing

Assistants

Contact information—During the

on-site interviews for the NNHS, eight

nursing assistants were selected to

participate in the NNAS. The NNHS

field interviewers then prepared packets

(described in the following text) for

distribution by the facility. The

interviewers also asked facility

administrators to provide contact

information for each of the selected

nursing assistants. Contact information

requested included the nursing

assistant’s first and last name, home

address, home phone number and other

number (if available), and shift the

nursing assistant usually worked. NNAS

pilot test results indicated that fewer

than 15 percent of the nursing homes

provided contact information for the

selected nursing assistants, therefore the

primary strategy planned for contacting

nursing assistants was through advance

packets distributed by the facility. These

packets included a postcard nursing

assistants could complete if they wanted

to participate in the survey. The advance

packets were personalized by the NNHS

field interviewers during the on-site

interviews and distributed by a facility

contact person designated by the facility

administrator (for example, the

administrator, director of nursing, or

staff from the human resource office).

This individual signed a receipt form

acknowledging receipt of the packets

and was usually the person who was

contacted later for follow-up activities.

Although the pilot test indicated

that most facilities would not provide

nursing assistant contact information,

approximately 74 percent of facilities

participating in the NNAS did provide

contact information for the sampled

nursing assistants. Having contact

information proved extremely important.

Telephone interviewers used this

information as an additional means to

contact nursing assistants to solicit

participation in the survey.

Advance packets for nursing

assistants—The NNAS advance packets

were designed to provide information

about the survey in a variety of formats

and to encourage the nursing assistants

to open the packet and explore the

materials (Table C).

The advance materials detailed the

purpose of the survey and its voluntary

and confidential nature. Respondents

were informed that the telephone

interview would take about 40 minutes

and would collect information on topics

including training, supervision, job

history, work setting, wages, education,

and benefits. In addition to the $5

prepaid incentive included in the NNAS

advance packet, nursing assistants were

told they would receive a $30 check

mailed after the interview was

completed.

Telephone interviewer training—

Survey staff involved in data collection

for the NNAS participated in formal

training sessions. Telephone Research

Center (TRC) team leader, support staff,

and supervisor training included an

introduction to the NNAS, an overview

of the advance contacting procedures

and materials for the NNAS, and

detailed information on telephone

contact procedures for the nursing

assistants. Interviewers and TRC staff

were shown the DVD that was included

in the nursing assistant advance packet

to provide an overview of the

importance of the survey. Interviewers

participated in formal in-person training

sessions on collecting the NNAS data

using the computer-assisted telephone

interview (CATI). In addition, two

Spanish bilingual interviewers and team

leaders were trained and participated in

data collection using a Spanish version

of CATI.

The training program included a

detailed overview of the NNAS, the

survey purpose and importance, and the
Page 8 [ Series 1, No. 44

Table C. Contents of advance packets

Introductory letter (English/Spanish) . . . . Described the survey and frequently asked questions, signed by the Director of the National Center for Health Statistics

(NCHS) (Appendix I).

$5 Bill clipped to the Introductory letter . . Bill attached with a large, colorful plastic paper clip to the Introductory letter signed by the Director of NCHS.

Welcome letter........ ........ From NCHS project officer on NNAS letterhead (Appendix I) with the Spanish version printed on the back of the letter.

Fact sheet ......... ......... 1-page, colorful (Appendix I).

Pen ............ ............ Gift pen with the survey name, survey sponsors, the NNAS 800 number, and website embossed on the pen barrel.

Return postcard ................ Used by the nursing assistant to indicate their willingness to participate in the survey and to provide their name, address,

phone number, and the best time and day to reach them. The postcard also had a box to check for the nursing assistant

to request a report on the results of the NNAS (Appendix I).

Postage paid return envelope .... .... To return the NNAS postcard.

DVD ........... ........... A 5-minute DVD explained the survey and the importance of participation.

SOURCE: U.S. Department of Health and Human Services, National Center for Health Statistics, and the Office of the Assistant Secretary for Planning and Evaluation, NNAS (2004).

advance materials sent to nursing

assistants. In addition, training sessions

included lectures, interactive sessions,

and role-play. The interactive exercises

were designed to familiarize

interviewers with the screening process,

the different interview pattern for

nursing assistants who were no longer

working at the sample facility, and how

to record the nursing assistant’s job

history. Interviewers were trained to

read all questions verbatim to the

respondent. Supervisors and team

leaders also participated in the

interviewer training sessions, providing

coaching on interviewer telephone skills,

and use of the CATI. Team leaders

monitored the interviewers throughout

the field period for quality assurance

(56).

Nursing Assistant Data Collection

Activities—The telephone interviews

began in September 2004, about

1-month after the NNHS data collection

began, and ended February 2005,

approximately 1-month after data

collection for the NNHS ended. To

participate in the NNAS interview,

nursing assistants either called the

NNAS 800 toll-free line or were

contacted by a TRC interviewer using

the telephone number provided by the

facility or information provided on the

postcard nursing assistants completed

and mailed. Some nursing assistants

returned the postcard and called the

toll-free number. If the nursing assistant

could not complete the interview at the

time they called the toll-free number or

when the telephone interviewer

contacted them, an appointment was set

to complete the interview at a later time.

The telephone interviewers read a

consent statement as part of the

introductory script and at the beginning

of the CATI interview to which NNAS

respondents had to respond affirmatively

to before the interview could continue.

This consent statement adhered to the

informed consent principles of the

NCHS Institutional Review Board

(IRB). To meet IRB guidelines for this

project, the English version of the

informed consent was written at an

eighth-grade reading level. This was

verified by the Grammatik feature in

Microsoft Word, which uses the Flesch

method. There is less certainty in the

literature on verifying Spanish

readability. Since the survey was judged

to involve minimal risk, signed

informed consent was not obtained.

Telephone interviews were

conducted using a CATI instrument.

Most of the TRC staff selected to

conduct the NNAS interviews had

previous CATI experience. Interviewers,

reading from a computer screen, asked

each question as it appeared on the

screen. Interviewers entered responses

directly into the CATI system. This

process eliminated the need for separate

data entry and automatically guided the

interviewer through questionnaire skip

patterns. The interviews were conducted

during nonworking hours (56).

Supervisors monitored

approximately 10 percent of all

interviewers’ work for adherence to the

study protocol. Clarification of issues

and problems identified during

monitoring was provided to the

interviewers and team leaders in memos.

TRC supervisors were also available

throughout the data collection to

respond to interviewer questions or

other issues that arose.

Follow-up activities—There were

three types of follow-up activities for

participating NNAS nursing home

facilities. The first, about 1 week after

the NNHS visit, the NNAS facility

contact was sent a cover letter and

reminder letters to distribute to the

selected nursing assistants. The purpose

of the reminder letters was twofold: it

served as a reminder for the nursing

assistants to participate in the survey,

and it served as a reminder to the

NNAS facility contact to distribute the

NNAS advance packets if he or she had

not done so already. At this time, a few

of the NNAS facility contacts reported

that they were unable to deliver the

NNAS advance packets to a selected

nursing assistant or reported a problem

with the selection of a particular nursing

assistant (that is, a nursing assistant

selected was not eligible for the survey).

The second follow-up activity was a

call to the NNAS facility contact if none

of the selected nursing assistants

returned a postcard or called the NNAS

toll-free number to participate in the

survey within 3 weeks of when the

facility interview was completed. The

third follow-up activity was a call to the

NNAS facility to get additional contact

information for nursing assistants who

were difficult to reach. This follow-up

activity was implemented approximately

2 months after the survey began. Both

TRC interviewers and field interviewers

contacted facilities that had provided

contact information for the selected

nursing assistants to get additional

contact information. If the facility could

not provide any additional contact

information for a nursing assistant, the

interviewer requested that the NNAS

facility contact nursing assistants to
Series 1, No. 44 [ Page 9

remind them about the survey and

provide the toll-free number for the

nursing assistants to call to participate.

Tracing activities—Cases for which

there was contact information, but either

no telephone number or the telephone

number provided was wrong, not in

service, or no answer were traced by six

specially trained NNAS TRC

interviewers, supervised by an

experienced TRC tracing specialist.

Tracing activities were limited attempts

to contact the selected nursing assistant

or relatives of the selected nursing

assistant and involved calling directory

assistance and searching Internet

databases. Cases that the TRC had

difficulty reaching after eight call

attempts or cases for which there was

no viable telephone number were sent a

letter if a mailing address was available.

Two months after the survey began,

follow-up for pending tracing cases was

initiated with facilities that provided

contact information for the selected

nursing assistants. If the facility was

unable to provide new or additional

contact information for the selected

nursing assistant, the standard tracing

activities were implemented for the case.

Data Processing, Weighting,

and Survey Estimates

Data processing (coding and

editing)—Data processing for the NNAS

included coding of ‘‘other specify’’ text

strings, open-ended items, and

self-reported occupational information;

reconciling interviewer remarks and

calls to the telephone hotline from

NNHS field interviewers regarding the

NNAS; and periodic reviews of the

database to identify skip pattern, valid

range violations, and any other coding

or keying anomalies. Data were verified

and de-duplicated (as needed) so that

each verbatim response coded was

unique (coded only once).

+ Other specify—Responses were

coded by assigning a code for one

of the established response

categories when appropriate and by

adding additional codes for

responses that did not fit into an

established category.

+ Open-ended items—Items were

coded by applying new codes

(categories) to the extracted

responses. An electronic

Classification Table was established

for each item, consisting of the

precodes from the original interview

questions and any new categories

established by the coding supervisor.

Coding was verified in monthly

batches and reviewed in frequency

tables.

+ Self-reported occupation

information—Information was coded

using standard industry and

occupation codes. The job’s industry

was coded using the North

American Industry Classification

System industry coding

classification, assigning the full six

digits, as published by BLS

www.bls.gov/ces/cesnaics.htm. For

occupation coding the Bureau of

Labor Statistics 2000 Standard

Occupational Classification, ISBN

0–934213–77-1 was used

www.bls.gov/soc/home.htm. The

structure of this code is also six

digits.

+ Remarks—Comments, questions,

and additional data are keyed as text

into the CATI instrument by

interviewers during the interview.

These entries were reviewed by

coding staff, trained in the flow and

content of the NNAS, to determine

if data entered in various fields

required editing.

For many of the NNAS items,

editing occurred during data collection.

Hard and soft range checks were built

into the CATI system, as well as hard

and soft consistency checks between

multiple variables. Hard edits required

the interviewer to fix the discrepant data

before the interview could continue. Soft

edits resulted in a prompt for the

interviewer who could either correct the

data or suppress the edit. All items were

reviewed extensively to ensure that

individual responses were accurate,

consistent, logical, and complete. When

necessary, records were reviewed to

resolve inconsistencies, and in some

cases responses were recoded (56).

Survey Weighting Procedures

Because the NNAS is designed to

produce national estimates for nursing

assistants, the data must have weights to

inflate the sample numbers to the

national estimates. Each record on the

data file has a weight for this purpose.

By aggregating these weights, counts for

national data can be obtained.

To create unbiased national

estimates, statistics for nursing assistants

are computed using a weight associated

with each sampled nursing assistant. The

weight is constructed to reflect the

design of the sample: a multistage

probability proportional to size,

systematic random design. The

following are components to the weight:

1. Inverse of the probability of

selecting the nursing assistant—The

probability of selection of a nursing

assistant is a product of the three

selection probabilities: the

probability of selecting a facility to

the NNHS sample; the probability a

facility was sampled in the NNAS;

and the probability the nursing

assistant was selected within the

sample NNAS facility. The inverse

of the product of these probabilities

is used in weighting.

2. Adjustment for nonresponse—The

second component for calculating

the weight is adjustment for

nonresponse. There are three types

of nonresponse. The first two types

are facility level and the third is

person level. The first type occurs

when in-scope facilities did not

respond to the NNHS. The second

type occurs when an in-scope

facility does not provide the number

of nursing assistants employed. The

third type occurs when the

individual nursing assistants sampled

fail to respond.

3. Ratio adjustment and weight

smoothing—The final components

of calculating weights involve ratio

adjustment and smoothing. Ratio

adjustments are made within each of

the groups defined by region to

adjust for over- or under-sampling

of facilities reported in the sampling

frame. This adjustment is a

multiplicative factor whose
Page 10 [ Series 1, No. 44

numerator was the number of

facilities in the sampling frame

within each region and whose

denominator was the estimated

number of facilities for that same

group. Ratio-adjusted weights are

smoothed only if there are

disproportionally large weights. In

smoothing, totals are preserved.

Survey Estimates

Because data are based on a

sample, they will differ somewhat from

data that would have been obtained if a

complete census had been taken using

the same instruments, instructions, and

procedures. The standard error is

primarily a measure of the variability

that occurs by chance because only a

sample, rather than the entire universe,

is surveyed. The standard error also

reflects part of the measurement error,

but it does not measure any systematic

biases in the data or other nonsampling

errors. The chances are about 95 in 100

that an estimate from the sample differs

from the value that would be obtained

from a complete census by less than

twice the standard error. Standard errors

for this survey need to be computed

using statistical software programs that

take into account the complex survey

design (for example, SUDAAN, SAS,

and STATA) (57–59).

Confidentiality of Data

Participation in surveys conducted

by NCHS is voluntary, and information

on individuals or facilities is

confidential. Strict procedures are

utilized to prevent disclosure of

confidential data in survey operations

and data dissemination. The NNAS was

conducted as a supplement of the

NNHS, which is authorized by Congress

in Section 306 of the Public Health

Service Act (42 USC 242K). In

accordance with Section 308(d)(42

U.S.C. 242m) of the Public Health

Service Act, no information collected in

this survey may be used for any purpose

other than the purpose for which it is

collected. Such information may not be

published or released in any form if the

individual or establishment is

identifiable unless the individual or

establishment has consented to such

release. The information provided by

nursing homes and nursing assistants is

used solely for statistical research and

reporting purposes.

Survey Limitations

Insufficient sample sizes for items

with low prevalence in the population

are a limitation common to all sample

surveys. For example, making accurate

estimates of responses to many survey

items for male nursing assistants may

not be possible since the prevalence of

male nursing assistants working in

nursing homes is about 8 percent.

Another limitation of the survey is the

use of ‘‘other specify’’ response options

for many of the questionnaire items.

Although many of these open-ended

responses could be back coded to

established response categories or new

response categories could be created

when a sufficient number of nursing

assistants provided the similar responses,

many of the responses could not be

coded into a meaningful category or

were of low prevalence and hence will

not produce reliable estimates. Some

information was collected on nursing

assistants who reported that they

terminated employment between the

time they were sampled and the time

they completed the survey (facility

leavers). This included reason for

termination; whether nursing assistants

were still working as nursing assistants;

whether they were working in long-term

care or the health care field, reasons for

leaving, and what, if anything would

have encouraged them to stay at their

job. However, usefulness of this

information is limited. First, the sample

size is small (n=120), limiting many

analyses. Second, the cohort of facility

leavers may not be representative of all

leavers. The NNAS was designed to

select a national probability sample of

current workers and not of facility

leavers. Collecting some information on

facility leavers was judged useful for

future research efforts to understand

nursing assistant turnover.

Combining

Establishment and

Worker Surveys

This section focuses on the

methodological benefits of

combining the NNAS and NNHS.

First, the methodological benefits of

combining establishment and worker

surveys in general is presented, with

specific examples from combining the

NNHS and NNAS. Next, an overview

of the 2004 NNHS, including new

content areas and data collection

methods, is presented.

Advantages of Combining

Establishment and Worker

Surveys

Developing a list or sampling frame

of all eligible direct care workers is

impractical and costly. Although some

workers are self-employed, the vast

majority are employed by nursing

facilities, home and hospice care

agencies, and other alternative

residential care facilities such as board

and care homes or assisted-living

facilities. Surveying workers in various

long-term care settings through the

establishments where they work is an

efficient way to construct a sampling

frame and select a sample of workers.

Moreover, combining the surveys

increases the likelihood of getting

contact information on the workers. In

this case, contact information was

secured from 74 percent of the facilities

in a national survey where the two

surveys were combined, versus

12.5 percent in the pilot survey where

the two surveys were not combined.

Using an established survey like the

NNHS reduces the time, effort, and

costs involved in reaching nursing

assistants and soliciting their

participation in the survey.

The direct care workforce consists

largely of low-income workers.

Low-income populations are among the

most difficult groups to locate and

interview, and they may be less
motivated to participate in surveys

compared with other income groups

(60). They are extremely mobile. Many

are suspicious of attempts to interview

them because they associate the

interview process with government and

authority. They are more likely than

most populations to be without a

telephone, less likely to have established

credit histories, and are seldom included

in mailing lists and other databases that

provide information to commercial

locating databases. Hence, these

populations are difficult to trace using

conventional methods (61). Contacting

workers through their employers could

provide additional legitimacy for the

survey and a way to follow up with

nonresponders and workers who initially

may be reluctant to participate.

Other advantages to combining a

telephone survey of workers with an

establishment survey of their employers

include the ability to reduce field costs,

reduce respondent burden, improve

response rates, and increase the analytic

potential of both surveys. The costs of

contacting the nursing homes,

recruitment activities, and travel to the

facility to collect data could be covered

by the establishment survey. Nursing

home administrators would only be

asked to participate in one survey. Many

facilities are already working under

constrained staffing conditions and are

regularly expected to respond to

extensive federal and state regulatory

requirements. Pairing a survey of

nursing homes and a survey of their

workers could reduce respondent burden

and improve response rates. Combining

the two surveys eliminates potential data

collection duplication that occurs if the

surveys were conducted independently.

Finally, by linking data collected from

the workers to data collected on the

establishment, the analytic potential of

both surveys is enhanced. Linked data

sets enable researchers to explore the

relationship among facility practices,

worker characteristics and perceptions,

and resident outcomes.

Expanded 2004 National

Nursing Home Survey

Like its predecessor surveys

conducted periodically since 1973, the

2004 NNHS uses a national probability

sample of nursing homes to collect data

on facility characteristics, including

information about staffing and their

residents. All nursing homes included in

2004, the most recent survey, had at

least three beds and were certified by

Medicare, Medicaid, or had a state

license to operate as a nursing home.

Based on interviews with the

administrators and staff, the survey

collects data on facility bed size,

ownership, staffing, number of residents,

certification status, services provided,

and basic charges. For residents, data

are obtained on demographic

characteristics, functional and health

status, diagnoses, services received, and

sources of payment.

The 2004 NNHS was redesigned

and expanded to better meet the data

needs of researchers and health care

planners working to ensure that quality

long-term care will be available for the

nation’s growing senior population. New

content areas include:

+ Medications

+ Medical, mental health, and dental

services offered or provided

+ End-of-life care and advance

directives

+ Education, specialty credentials, and

length of service of key staff

+ Turnover and stability of nursing

staff, use of contract or agency staff,

overtime shifts worked, wages and

benefits and

+ Facility practices for immunization,

dining, and use of mechanical lifting

devices.

For the first time, the survey was

conducted using CAPI. The CAPI

system makes it easier for respondents

to participate in the survey and speeds

the processing of data so that

information can be released on a timely

basis. The 2004 NNHS also included a

self-administered questionnaire sent to

the facility prior to the on-site interview

to obtain more in-depth information on

staffing characteristics. The NNHS

provides information on

nursing homes from two perspectives:

the nursing home and the care recipient.

The addition of the NNAS to the 2004

NNHS provides a new perspective, that

of the direct care worker.

Series 1, No. 44 [ Page 11

Uses of Survey Data

and Data Publication

Potential Uses of the

National Nursing Assistant

Survey

The NNAS represents a major

advance in the data available about

nursing assistants and has the potential

for numerous studies to improve

understanding of the direct care

workforce. One of the many benefits of

the NNAS is that it allows researchers

to focus on nursing assistants as a

subset of the larger, broader group of

long-term care direct care workers.

Findings from this survey will be of

great interest to a range of stakeholders,

including federal and state policymakers,

federal agencies, provider organizations,

workforce experts and researchers,

professional worker associations, and

labor market analysts. There are several

topics addressed in the NNAS that will

inform policy and practice (Table D).

The NNAS will provide the first

estimates of the nursing assistant

population based on a national

probability sample of a cross section of

certified nursing assistants employed in

nursing homes. Results from this survey

will create a framework for future

evidence-based policy, practice, and

applied research initiatives to address

long-term care direct care workforce

shortages. Although the major focus of

the NNAS is to provide descriptive data,

the survey also has exploratory,

confirmatory, and developmental

aspects. Specifically, the NNAS is

designed to:

1. Support descriptive analyses of

individual and workplace

characteristics of nursing assistants

working in nursing homes.

2. Support analyses of relationships

that exist between why individuals

enter or leave direct care work and

what contributes to job satisfaction

and retention.

3. Examine patterns and effects of

various independent variables such

as wage and benefit levels, training,
limited, yet anecdotal evidence suggests

Page 12 [ Series 1, No. 44

Table D. Important policy and practice issues associated with paraprofessional workers confounders, thereby clarifying possible

How workers are recruited

Use of public benefits

Reasons for turnover (separation)

Compensation

Benefits: health insurance access/coverage

Reasons for becoming a nursing assistant

differences among subgroups of nursing

assistants. For example, because both

nursing assistants who have completed

Citizenship status

Extent and type of occupational injuries

Working conditions

Finding new sources of workers

Contributors of satisfaction

Contributors of likelihood of staying in job

Role of initial and continuing education and training

Advancement

SOURCE: U.S. Department of Health and Human Services and Department of Labor (2003) (2).

the OBRA mandated training and

nursing assistants who were

grandfathered in were included in the

survey, responses for both types of

nursing assistants can be analyzed. In

addition, because researchers have

speculated that average direct care

management practices, that the quality of the worker has a worker tenure in long-term care settings

organizational characteristics, and significant effect on various outcomes is bimodal, with a portion of the

career advancement opportunities on (35). workforce that turns over frequently and

recruitment, retention, job Research has also revealed that a portion of workers with a long tenure

satisfaction, and turnover. predictors of job satisfaction and (69), one design objective of the NNAS

4. Correlate facility characteristics with turnover (66) established linkages included selecting enough short and

key policy and practice issues of between inadequate training and long stayers to be able to sufficiently

interest. satisfaction and retention (67), and compare these groups. Using NNAS

5. Identify where the nursing home clarified the nature of working data, separate estimates can be

industry has been successful in conditions (68). Yet few seminal calculated by the CBSA location

addressing certain labor issues. research studies have had large enough (formerly MSA status) of the nursing

6. Identify methods that are likely to samples to sufficiently examine the facility or by tenure (less than 1 year,

be effective in reducing turnover and recruitment, retention, job satisfaction, more than or equal to 1 year). It is also

increasing staff retention. and turnover of certified nursing possible to examine factors associated

Empirical research on nursing assistants in greater detail. with specific response categories, for

assistants has revealed associations The NNAS, in contrast, allows for example, the environmental

testing of various assertions through characteristics that are associated with between job satisfaction and turnover

(62) and intent to leave (63), established both simple and complex analyses using intent to leave, while controlling for

linkages between job satisfaction and a large sample of nursing assistants other potential confounders such as

quality of care (64), staff turnover and (n=3,017, which, when weighted, wages.

quality (3,15), and human resource represents 702,500 nursing assistants). Following are a few specific

management and quality of care (65). The survey allows for an in-depth examples of how these data can be used.

Evidence documenting the causal link description of nursing assistant In many cases, the availability of linked

between the quality of workers and the characteristics and attitudes. data (detailed later in this section) will

Additionally, the sample size permits enhance the usefulness of the quality of care/life for consumers is stratification by variables that may be information highlighted here (Table E).

Table E. Examples of research questions that may be addressed by the National Nursing Assistant Survey

Characteristics of certified nursing assistants in nursing homes

c What are the motivations or key characteristics of nursing assistants recruited into their job?

c What are the motivations or key characteristics of nursing assistants who stay in their job?

c What level of interest and desire do nursing assistants have toward additional training and education, as well as career advancement?

c What family/lifestyle demands are related to a nursing assistant’s ability to work?

c What is the nature and prevalence of worker injuries?

c What is the likelihood that nursing assistants will continue in their present positions and what are the factors that affect those decisions?

c What reasons do nursing assistants give for leaving the industry?

c What factors or motivations most contribute to nursing assistant job satisfaction?

c What are the key characteristics of nursing assistants who experience more or less job satisfaction?

Characteristics of certified nursing assistants’ employment status

c What is the relationship between employee benefits and job satisfaction?

c What effects do training approaches and workplace culture have on job satisfaction and retention?

c What effects do supervisor-worker relationships have on job quality and turnover?

Framework for evidence-based policy, practice, and applied research

c How do results compare with existing research? Do results support, contradict, or advance contemporary thinking? What are the policy implications?

c What strategies might be pursued to enhance the recruitment and retention of nursing assistants in nursing homes?

c What strategies might be pursued to enhance job satisfaction and retention of nursing assistants in nursing homes?
Series 1, No. 44 [ Page 13

Potential Uses of the NNAS

Data Linked With the

NNHS and Other Data

Sources

A major advantage of using the

NNHS as a vehicle to conduct a survey

of nursing assistants is the ability to

combine data from both surveys. Both

surveys obtain data from probability

samples, which means the data provide

a comprehensive picture of United

States nursing homes, residents, and the

nursing assistant workforce. Combining

data from the NNAS with data from the

NNHS enables three types of analyses:

1. Measures of association between the

characteristics of nursing facilities

and nursing assistants’ perceptions

and outcomes

2. Measures of association among the

characteristics of nursing facilities,

nursing assistant perceptions and

outcomes, and resident outcomes

3. Measures of association between

facility and nursing assistant

responses on similar experiences

The two surveys include measures

of structure and process for the facility

and outcome measures for nursing

assistants and residents. Thus it is

possible to look at relationships between

facility characteristics and nursing

assistant outcomes, and facility and

nursing assistant characteristics and

resident outcomes. For the purpose of

the following description, the definition

of outcomes was broadened to include

outcomes pertinent to nursing assistants,

such as job satisfaction.

Table F illustrates various measures

of structure, process, and outcomes

available from combined analyses of the

NNHS, NNAS, and other data sources.

The structure-process-outcome

framework used in Table F is based on

the work of Avedis Donabedian on

quality of care (70). Structural measures

are ‘‘attributes of the settings in which

care occurs,’’ process ‘‘denotes what is

actually done in giving and receiving

care,’’ and outcomes are ‘‘the effects of

care on the health status of the

population.’’

Some variables are listed as both

process and outcome variables, for

example, CNA satisfaction and turnover.

These two variables may be considered

outcomes when the unit of analysis is

the CNA. They may also be considered

process variables when the unit of

analysis is the resident’s quality of care.

These variables affect the interpersonal

process of care, which may in turn

affect the resident’s quality of care or

outcome. Empirical studies have

established linkages between these

variables and quality of care (3,15,64).

Use of the linked NNAS and NNHS

data sets will allow researchers to

determine the role of these variables

while controlling for other structural and

process variables.

Because both surveys collect

identical information from two

perspectives, that of the facility

administrator and that of the nursing

assistant, such things as wages and

benefits and the congruence of facility

and nursing assistant responses can be

compared as well.

Additional analyses are also

possible, as the 2004 NNHS can be

linked to other data sources such as the

CMS’s Minimum Data Set (MDS),

facility quality indicator reports, the

Online Survey and Certification

Automated Record system, and

Medicare claims files. These data

sources provide additional information

on clinical status and outcomes for

residents, facility quality measures,

facility characteristics, health services

utilization, and care costs. NNHS data

can also be linked to the Area Resource

File to provide information on market

characteristics that can affect how

nursing homes operate and the care they

provide.

Survey data and administrative data

can be useful by themselves in

answering many policy questions.

Table F. Potential analyses of the National Nursing Assistant Survey with the National Nursing Home Survey and other data sources

Structural variables Process/Intervening variables Outcomes

NNAS National Nursing Assistant Survey (NNAS) NNAS

Availability of and training for use Adequacy of training. Perceived need for continuing CNA1

satisfaction. Intention to stay/leave job. CNA injuries. CNA

of mechanical lifts. education. CNA satisfaction. Perceptions of supervisor. immunizations.

Perceptions of the nursing home. Intent to stay/leave job.

Working multiple jobs.

NNHS National Nursing Home Survey (NNHS) NNHS (Resident component)

Ownership. Facility size. Number Permanent assignments. Staff to resident ratios. Turnover/ Emergency department visits. Hospitalizations. Medication use.

of mechanical lifts. Benefits. stability rates. Overtime shifts. Temporary/ agency staff use. Pain management. Accidents. Weight change. Pressure ulcers.

Wages. Retention strategies. Restraints.

Tenure of key personnel. Vacancy

rates. Advance practice nurses.

Nurses with specialty certification.

Minimum Data Set (MDS) Facility Quality Indicators2,3

Prevalence of pressure ulcers. Prevalence of daily physical

restraint use. Prevalence of urinary tract infection. Incidence in

decline in late loss ADL.4

1

Certified Nursing Assistant.

2

Selected MDS Facility Quality Indicators. The Center or Health Systems Research and Analysis (CHSRA). http://www.chsra.wisc.edu/chsra/qi/matrix.htm. Accessed March 9, 2006.

3

MDS Version 2.0, Center for Medicare and Medicaid Services, http://www.health.state.ok.us/program/qies/mds/mds0900b.pdf. Accessed April 3, 2006.

4

Activities of daily living.

NOTE: The structure/process/outcome framework is based on the work by Avedis Donabedian on quality of care. Structural measures are ‘‘attributes of the settings in which care occurs’’; process

‘‘denotes what is actually done in giving and receiving care’’ and outcomes are ‘‘the effects of care on the health status of the population’’ (70).

SOURCE: The U.S. Department of Health and Human Services, National Center for Health Statistics, NNHS (2004) and the Office of the Assistant Secretary for Planning and Evaluation, NNAS (2004).
Page 14 [ Series 1, No. 44

However, a much wider range of

questions can be addressed by linking

multiple data sets. For example, the use

of large data sets in long-term care has

the potential to be used to improve

quality of care, both directly and

indirectly. As Ryan and colleagues point

out, ‘‘there is a critical need to design

new methods and longitudinal

experiments that bring together clinical

and organizational (administrative)

databases [large data sets offer the

potential] to develop, test, and explicate

theory about the causal relationships

between structure and process variables

and related outcomes of long-term care’’

(71).

Nursing Facility

Characteristics, Nursing

Assistant Perceptions, and

Outcomes

Previous research demonstrates that

various nursing home structural and

process characteristics such as facility

ownership and chain membership,

staffing levels, top management and

registered nurse turnover, staffing

patterns, resident case mix, and

Medicaid census influence nursing

assistant perceptions of job satisfaction

as well as nursing assistant turnover and

retention (15,69,72,73). Linking data

from the NNHS and the NNAS can

provide additional insight into how these

and other structural and process

variables such as membership in a

union, benefits, use of advance practice

nurses, use of contract/temporary staff,

and overtime shifts may affect nursing

assistants’ perceptions of their jobs,

supervisors, work environment, and their

intention to continue employment.

Nursing facility structural and

process measures in the NNHS include

ownership, certification, chain

membership, facility size, and payer

mix. The NNHS also contains numerous

structural and process measures related

to staffing, including wages, benefits,

and retention strategies for nursing

assistants, nursing staff mix, use and

percentage of staff who are contract

workers, turnover, stability, specialty

certification, and specialization of the

director of nursing and nursing staff,

and use of mid-level practitioners. The

NNHS includes measures of facility

practices, such as nursing assistant

involvement in resident care planning,

use of permanent assignments, and the

number of overtime shifts worked that

provide additional information on

nursing assistant work environment. By

linking facility data to information from

nursing assistants, researchers will be

able to identify structural and process

characteristics that affect nursing

assistant satisfaction, perceptions of their

supervisors, adequacy of continuing

education, and their perception of their

initial and ongoing training, for

example.

Facility and Nursing Assistant

Characteristics, Resident

Outcomes, and Quality of Care

Analysis of the linked surveys can

also be useful in examining the

association of facility and nursing

assistant characteristics with resident

outcomes and quality of care in nursing

homes (71,74). Comparisons across

important provider structural

characteristics can be used to address

issues that are of key concern to

policymakers and providers, such as

care outcomes and quality of care

provided by nursing homes (72,75–81).

Although previous studies have explored

how nursing home structural and

process characteristics affect resident

outcomes and quality of care provided

by nursing homes, these data sets have

not included information from the

workers who are providing care in the

facility. The combination of information

on the facility, their residents, and the

characteristics and perceptions of the

nursing assistants who provide care

presents a unique opportunity to

understand the role paraprofessional

workers play in resident outcomes.

Resident outcome measures in the

NNHS include the number of

emergency department visits,

hospitalizations, and pain management.

Data from residents from the survey can

be linked to MDS information to expand

the range of outcomes available and to

create episodes of care. Additional

resident outcome information available

by linking to the MDS includes restraint

use, number of falls, weight changes,

and pressure sores. Descriptive

information on residents can also be

obtained from the MDS, including

broader measures of cognitive

functioning and disruptive behaviors that

can be used to further understand how

level of impairment affects caregivers

and outcomes of care. In addition,

linkages to other data sources such as

Medicare claims data and the Area

Resource File will allow exploration of

how care costs, resource allocation, and

local area market factors such as

hospital bed supply affect care outcomes

(82–85).

Nursing Facility and Nursing

Assistant Responses

Linking nursing facility

characteristics to nursing assistant

responses about the facility provides a

unique opportunity to explore the extent

to which employer and employee

experiences are similar. Data on staff

turnover, immunization practices, wages

and benefits, and availability of patientlifting devices were collected from both

the facility participating in the NNHS

and nursing assistants participating in

the NNAS. Staff turnover in the nursing

home can be compared with nursing

assistants’ perceptions of high or low

turnover and whether turnover is

perceived as disruptive to caregiving.

The extent to which nursing assistants

are knowledgeable regarding the

availability of benefits provided by the

facility can be assessed as well. These

types of analyses, for example, can

inform providers on employee

knowledge of benefits and reasons

nursing assistants do or do not subscribe

to various benefits.

Finally, the evidence on the use of

mechanical patient-lifting devices

indicates that many lifting-related

injuries in health care workers can be

prevented (86–90). Although many

nursing homes make these devices

available to workers, the extent to which

nursing assistants use them is largely

unknown. Analyses in this area can

reveal the extent to which nursing

assistants experience injuries related to

lifting residents.
Series 1, No. 44 [ Page 15

Data Publication and

Availability

Data from the NNAS will be

available through public-use files and

analytical reports published by ASPE

and NCHS. Publications and public-use

data files will be available through the

ASPE (www.aspe.hhs.gov) and NCHS

(www.cdc.gov/nchs) websites.

Information will also be made available

in journal articles and in papers

presented at professional meetings.

The public-use files will contain

information from the NNAS, edited to

ensure protection of confidentiality, and

will include some variables on nursing

home characteristics. Researchers who

wish to link data from the NNAS to the

facility or patient questionnaires of the

NNHS will need to work through the

NCHS Research Data Center (RDC).

The RDC allows researchers meeting

certain qualifications, and, under strict

supervision, to access confidential

statistical micro data files. To qualify,

researchers must submit a proposal for

review and approval. Researchers can

use one of three access methods:

1. Direct on-site access

2. A remote program submission

system through which researchers

can submit work to be done in the

RDC with the output returned by

e-mail

3. Programming services for outside

researchers provided by RDC staff

Additional information on the

NCHS RDC and procedures for access

to linked data files is available from:

www.cdc.gov/nchs/data/

GuidelinesRDC11–8-05.pdf.

NNAS Public-Use File Release

If you are interested in receiving

notification of the release of the NNAS

public-use file, we encourage you to

join our listserv at:

+ U.S. Department of Health and

Human Services, Office of the

Assistant Secretary for Planning and

Evaluation, aspe.hhs.gov/info/

maillist.shtml.

+ U.S. Department of Health and

Human Services, Office of

Disability, Aging, and Long-Term

Care Policy (DALTCP),

aspe.hhs.gov/daltcp/contact.shtml.

+ U.S. Department of Health and

Human Services Centers for Disease

Control and Prevention, National

Center for Health Statistics

www.cdc.gov/nchs/nnhs.htm.

Summary and Future

Directions

DOL projections continue to list

direct care worker positions

among those with the highest

growth rate. While it is clear that

turnover of formal (paid) caregivers is

costly to the care recipient, the payer,

and the provider, evidence to date has

been limited on what can be done to

stabilize and improve the workforce

within the reimbursement constraints

that are likely to continue. It is critical

that industry and policy leaders have

access to information that is useful in

improving the attractiveness of

caregiving jobs and in reducing

turnover. The NNAS represents a major

advance in the data available about

nursing assistants working in nursing

homes and provides a framework for

future evidence-based policy, practice,

and applied research initiatives to

address the long-term care workforce

shortages.

ASPE is currently building on the

work of the NNAS to improve its

understanding of another segment of the

direct care workforce—home health

aides. ASPE’s National Home Health

Aide Survey (NHHAS) will provide the

first national estimates of this population

based on a national probability sample

of a cross section of workers. The

NHHAS will be fielded as a supplement

to the 2007 National Home and Hospice

Care Survey in partnership with NCHS,

CDC. Like the NNAS, the NHHAS has

numerous benefits, among these, the

potential for future comparisons of

worker characteristics, skills, and

training across settings to see if workers

are similar and could be affected by

similar initiatives in the future.

References

1. Senate Report 107–84. Departments of

Labor, Health and Human Services, and

Education, and Related Agencies

Appropriation Bill. 2002.

2. HHS: Department of Health and

Human Services & DOL: Department

of Labor. The future supply of

long-term care workers in relation to

the aging baby boom generation:

Report to Congress. Washington, DC:

HHS and DOL. [http://aspe.hhs.gov/

daltcp/reports/ltcwork.htm]. 2003.

3. Castle N, Engberg J. Staff turnover and

quality of care in nursing homes. Med

Care 43(6):616–26. 2005.

4. Stone R, Wiener J. Who will care for

us? Addressing the long-term care

workforce crisis. Washington, DC:

Office of the Assistant Secretary for

Planning and Evaluation, U.S.

Department of Health and Human

Services. [http://aspe.hhs.gov/daltcp/

reports/ltcwf.htm]. 2001.

5. American Health Care Association.

Estimates of current employment in the

long-term care delivery system.

Washington, DC. 2004.

6. Bureau of Labor Statistics. National

industry-specific occupational

employment and wage estimates.

Washington, DC: U.S. Department of

Labor. 2004.

7. GAO: General Accounting Office.

Nursing workforce: Recruitment and

retention of nurses and nurse aides is a

growing concern. Testimony before the

Committee on Health, Education,

Labor, and Pensions. GAO-01–750T.

Washington, DC: U.S. Senate. 2001.

8. Decker F, Dollard K, Kraditor K.

Staffing of nursing services in nursing

homes: Present issues and prospects for

the future. J Seniors Housing and Care.

Baltimore, MD: Johns Hopkins

University. 2001.

9. Cohen-Mansfield J. Turnover among

nursing home staff: A review. Nursing

Management 28(5):59–64. 1997.

10. Castle N. Measuring staff turnover in

nursing homes. Gerontologist

46(2):210–9. 2006.

11. HRSA: Health Resources and Services

Administration. Nursing aides, home

health aides, and related health care

occupations—National and local

workforce shortages and associated data
Page 16 [ Series 1, No. 44

needs. Washington, DC: U.S.

Department of Health and Human

Services. 2004.

12. AHCA: American Health Care

Association. Results of the 2002 AHCA

survey of nursing staff vacancy and

turnover in nursing homes. Washington,

DC. 2003.

13. Noelker L, Ejaz F. Final report:

Improving work settings and job

outcomes for nursing assistants in

skilled care facilities. Cleveland, OH:

The Margaret Blenkner Research

Center, the Benjamin Rose Institute.

2001.

14. Bureau of Labor Statistics. Workplace

injuries and illnesses in 2001.

Washington, DC: U.S. Department of

Labor. 2002.

15. Castle N, Engberg J. Organizational

characteristics associated with staff

turnover in nursing homes.

Gerontologist 46(1):62–73. 2006.

16. Centers for Medicare and Medicaid

Services. Appropriateness of minimum

staffing ratios in nursing homes.

Baltimore, MD. 2002.

17. Kramer A, Eilertsen T, Lin M, Hutt E.

Effects of nurse staffing on hospital

transfer quality measures for new

admissions. In: Health Care Financing

Administration Report to Congress:

Appropriateness of Minimum Nurse

Staffing Ratios In Nursing Homes.

Baltimore, MD: Health Care Financing

Administration (now the Centers for

Medicare and Medicaid Services).

2000.

18. Harrington C, Kovner C, Mezey M,

Kayser-Jones J, Burger S, et al. Experts

recommend minimum nurse staffing

standards for nursing facilities in the

United States. Gerontologist (40):5–16.

2000.

19. Straker J, Atchley R. Recruiting and

retaining frontline workers in long-term

care: Usual organizational practices in

Ohio. Oxford, OH: Scripps

Gerontology Center, Miami University.

1999.

20. Kayser-Jones J, Schell E. The effect of

staffing and the availability of care at

mealtime. Nursing Outlook 36(7):267–

70. 1997.

21. Bowers B, Esmond S, Jacobson N.

Turnover reinterpreted: Certified

nursing assistants talk about why they

leave. J Gerontological Nursing

29(3):36–43. 2003.

22. Mercer SO, Heacock P, Beck C.

Nurses’ Aides in Nursing Homes:

Perceptions of training, work loads,

racism, and abuse issues. J

Gerontological Social Work 21(1/2):95–

112. 1993.

23. Seavey D. The cost of frontline

turnover in long-term care. Washington,

DC: Institute for the Future of Aging

Services, American Association of

Homes and Services for the Aging.

2004.

24. NGA: National Governor’s Association,

Center for Best Practices. Rescuing the

health workforce: Options for state

action. Issue Brief. Washington, DC.

2004.

25. Stone R. The direct care worker: The

third rail of home care policy. Annu

Rev Public Health 25:21–37. 2004.

26. Pillemer K. Solving the frontline crisis

in long-term care. Cambridge, MA:

Frontline Publishing Co. 1996.

27. Stone R. Long-term care workforce

shortages: Impact on families. Policy

Brief No. 3. San Francisco, CA: Family

Caregiver Alliance. 2001.

28. BLS: Bureau of Labor Statistics. State

occupational employment and wage

estimates. Washington, DC: U.S.

Department of Labor. 2001.

29. Callahan J. Policy perspectives on

workforce issues and care of older

people. Generations. Spring 12–16.

2001.

30. Friedland R. Issue Brief. Caregivers

and long-term care needs in the 21st

century: Will public policy meet the

challenge? Washington, DC:

Georgetown University. 2004.

31. Stone R. Long-term care for the elderly

with disabilities: Current policy,

emerging trends, and implications for

the 21st century. New York, NY:

Milbank Memorial Fund. 2001.

32. HHS: Department of Health and

Human Services. State wage

pass-through legislation: An analysis.

Washington, DC: Office of the

Assistant Secretary for Planning and

Evaluation, U.S. Department of Health

and Human Services. [http://

aspe.hhs.gov/daltcp/reports/

wagepass.htm]. 2002.

33. NGA: National Governor’s Association

& NASBO: National Association of

State Budget Officers. Fiscal Survey of

States. Washington, DC. 2005.

34. Harmuth S, Dyson S. The National

Clearinghouse on the Direct Care

Workforce and the Direct Care Workers

Association of North Carolina. Results

of the 2005 national survey of state

initiatives on the long-term care

direct-care workforce. Brooklyn, NY:

Paraprofessional Healthcare Institute.

2005.

35. Stone R. The direct care worker: A key

dimension of home care policy. Health

Care Management and Practice

16(5):339–49. 2004.

36. Harris-Kojetin L, Lipson D, Fielding J,

Kiefer K, Stone R. Recent findings on

frontline long-term care workers: A

research synthesis 1999–2003.

Washington, DC: Office of the

Assistant Secretary for Planning and

Evaluation, U.S. Department of Health

and Human Services. [http://

aspe.hhs.gov/daltcp/reports/insight.htm].

2004.

37. McGuire M, Houser J, Jarrar T, Moy

W, Wall M. Retention: It’s all about

respect. Health Care Manager,

22(1):38–44. 2003.

38. PHI: Paraprofessional Healthcare

Institute & IFAS: Institute for the

Future of Aging Services. State-based

initiatives to improve the recruitment

and retention of the paraprofessional

long-term care workforce. Washington,

DC: Office of the Assistant Secretary

for Planning and Evaluation, U.S.

Department of Health and Human

Services. [http://aspe.hhs.gov/daltcp/

reports/pltcwf.htm]. 2003.

39. PHI: Paraprofessional Healthcare

Institute & IFAS: Institute for the

Future of Aging Services. State wage

pass-through legislation: An analysis

workforce strategies No. 1. Washington,

DC: Office of the Assistant Secretary

for Planning and Evaluation, U.S.

Department of Health and Human

Services. [http://aspe.hhs.gov/daltcp/

reports/wagepass.htm]. 2002.

40. Howes C. Wages, benefits, and

flexibility matter: Building a

high-quality home care workforce.

Washington, DC: Institute for the

Future of Aging Services, American

Association of Homes and Services for

the Aging and Connecticut College.

2006.

41. Kuokkanen L, Katajisto J. Promoting or

impeding empowerment? Nurses’

assessments of their work environment.

J Nurs Adm 33(4):209–15. 2003.

42. Burke, RJ. Hospital restructuring,

workload, and nursing staff satisfaction

and work experiences. Health Care

Management 22(2):99–107. 2003.

43. Laschinger H, Finegan J, Shamian J,

Wilk P. Impact of structural and

psychological empowerment on job

strain in nursing work settings. J Nurs

Adm 31(5):260–72. 2001.

44. Kiefer K, Harris-Kojetin L, Brannon D,

Barry T, Vasey J, Lepore M. Measuring

long-term care work: A guide to
Series 1, No. 44 [ Page 17

selected instruments to examine direct

care worker experiences and outcomes.

Washington, DC: Office of the

Assistant Secretary for Planning and

Evaluation, U.S. Department of Health

and Human Services, and the Office of

the Assistant Secretary for Policy, U.S.

Department of Labor. [http://

aspe.hhs.gov/daltcp/reports/

dcwguide.htm]. 2005.

45. Brannon D, Barry T, Angelelli J,

Weech-Maldonado R. Pennsylvania

long-term care survey workforce

surveys: A report to the Pennsylvania

Intra-Governmental Council on

Long-Term Care. University Park, PA:

The Pennsylvania State University.

2005.

46. Wyoming Department of Health.

Report to the Joint Appropriations

Committee on study of direct care staff

recruitment, retention, and wages.

Cheyenne, WY. 2002.

47. Onondaga County Department of

Long-Term Care. Employer/employee

survey in home care agencies and

nursing homes. Onondaga County, NY.

2001.

48. Kopiec K. The work experiences of

certified nursing assistants in New

Hampshire. Concord, NH: The New

Hampshire Community Loan Fund.

2000.

49. Salmon J, Crews C, Reynolds-Scanion

S, Weber S, Oakley M. Nurse aide

turnover: Research, policy, and

practice. Tallahassee, FL: Florida

Department of Elder Affairs. 1999.

50. Hwalek M, Essenmacher V. Older

workers in direct care: A labor force

expansion study. Detroit, MI: SPEC

Associates. 2005.

51. U.S. House of Representatives

Concurrent Resolution 94. Direct

Support Professional Recognition

Resolution. Washington, DC. 2003.

52. U.S. Senate Concurrent Resolution 21.

National Direct Support Recognition

Act. Washington, DC. 2003.

53. HHS: Department of Health and

Human Services. Report to the

President on Executive Order 13217 in

Delivering on the Promise: Compilation

of Individual Federal Agency Reports

of Actions to Eliminate Barriers and

Promote Community Integration.

Washington, DC. 2002.

54. The Federal Nursing Home Reform Act

from the Omnibus Budget

Reconciliation Act of 1987. Public Law

100–203.

55. DesRoches D, Santos B, Stapulonis R.

Pretest report on the English and

Spanish questionnaires for the National

Survey of Nursing Aides and

Assistants. Washington, DC: Office of

the Assistant Secretary for Planning and

Evaluation, U.S. Department of Health

and Human Services. 2004.

56. Edwards B, Tourangeau K, Branden L,

Lohr B, Vincent C. 2004 National

Nursing Home Survey: Final Report.

Rockville, MD: Westat. 2005.

57. SUDAAN®. Release 9.0.1. Research

Triangle Park, NC: Research Triangle

Institute. 2005.

58. SAS Institute. SAS/STAT Software:

Release 9.1.3. Cary, NC: SAS Institute.

2003.

59. StataCorp. Stata Statistical Software:

Release 9. College Station, TX:

StataCorp LP. 2005.

60. Singer E, Kulka RA. Paying

respondents for survey participation. In

Studies of Welfare Populations, Data

Collection and Research Issues,

National Research Council.

Washington, DC: National Academy

Press. 2002.

61. Sinclair M, Stapulonis RA, DesRoches

D, Clusen N. Design options report:

Nursing home component. Washington,

DC: Office of the Assistant Secretary

for Planning and Evaluation, U.S.

Department of Health and Human

Services. 2003.

62. Feldman P, Sapienza A, Kane N. Who

cares for them? Workers in the home

care industry. Westport, CT:

Greenwood. 1990.

63. Parsons S, Simmons WP, Penn K,

Furlough M. Determinants of

satisfaction and turnover among nursing

assistants: The results of a statewide

survey. J Gerontological Nursing

29(3):51–8. 2003.

64. Chou S, Boldy D, Lee A. Resident

satisfaction and its components in

residential aged care. Gerontologist

(42):188–98. 2002.

65. Eaton S. Beyond ‘‘unloving care,’’

linking human resource management

and patient care quality in nursing

homes. J Human Resource

Management 11(3): 591–616. 2000.

66. Waxman H, Carner E, Berkenstock G.

Job turnover and job satisfaction among

nursing home aides. Gerontologist

24(5): 503–9. 1984.

67. Pillemer K, Hegeman CR, Albright B,

Henderson C. Building bridges between

families and nursing home staff: The

Partners in Caregiving Program.

Gerontologist 38(4):499–503. 1998.

68. Tellis-Nayak V, Tellis-Nayak M.

Quality of care and the burden of two

cultures: When the world of the nurse’s

aide enters the world of the nursing

home. Gerontologist 29(3): 307–13.

1989.

69. Brannon D, Zinn J, Mor V, Davis J. An

exploration of job, organizational, and

environmental factors associated with

high and low nursing assistant turnover.

Gerontologist 42(2):159–68. 2002.

70. Donabedian A. The quality of care:

How can it be assessed? J Am Med

Assoc 260(12):1743–8. 1988.

71. Ryan J, Stone R, Raynor C. Using

large data sets in long-term care to

measure and improve quality. Nursing

Outlook 52(1):38–44. 2004.

72. Burgio LD, Fisher SE, Fairchild JK,

Scillley K, Hardin JM. Quality of care

in the nursing home: Effects of staff

assignment and work shift.

Gerontologist 44(3):368–77. 2004.

73. Harrington C, Swan J. Nursing home

staffing, turnover, and case mix. Med

Care Res Rev 60(3):366–92. 2003.

74. Harrington C. Quality of care in

nursing home organizations:

Establishing a health services research

agenda. Nursing Outlook 53(6):300–4.

2005.

75. Krichbaum K, Pearson V, Savik K,

Mueller C. Improving resident

outcomes with GAPN organization

level interventions. Western J Nursing

Research 27(3):322–37. 2005.

76. Swagerty DL, Lee RH, Smith B,

Taunton RL. The context for nursing

home resident care: The role of leaders

in developing strategies. J

Gerontological Nursing 31(2):40–8.

2005.

77. Adams-Wendling L, Lee R. Quality

improvement nursing facilities: A

nursing leadership perspective. J

Gerontological Nursing 31(11):36–41.

2005.

78. Intrator D, Zinn J, Mor V. Nursing

home characteristics and potentially

preventable hospitalizations of

long-stay residents. J Am Geriatrics

Soc 52:1730–6. 2004.

79. Zimmerman S, Gruber-Baldini AL,

Hebel JR, Sloane PD, Magaziner J.

Nursing home facility risk factors for

infection and hospitalization:

Importance of registered nurse turnover,

administration, and social factors. J Am

Geriatrics Soc 50(12):1985–87. 2002.

80. Castle N. Administrator turnover and

quality of care in nursing homes. The

Gerontologist 41(6):757–67. 2001.

81. Dellefield ME. Predictors of quality

care in California nursing homes.

Abstract and Executive Summary of
Page 18 [ Series 1, No. 44

Dissertation. California University, Los

Angeles. Rockville, MD: Agency for

Healthcare Research and Quality. 1999.

82. Decker FH. Nursing staff and the

outcomes of nursing home stays.

Medical Care 44(9):812–21. 2006.

83. Konetzka RT, Norton EC, Sloane PD,

Kilpatrick KE, Stearns SC. Medicare

prospective payment and quality of care

for long-stay nursing facility residents.

Med Care 44(3):270–6. 2006.

84. Weech-Maldonado R, Shea D, Mor V.

The relationship between quality of

care and costs in nursing homes. Am J

Med Qual 21(1): 40–8. 2006.

85. Castle N. Does quality pay for nursing

homes? J Health and Soc Policy

21(2):35–51. 2005.

86. Chhokar R, Engst C, Miller A,

Robinson D, Tate RB, Yassi A. The

three-year economic benefits of a

ceiling lift intervention aimed to reduce

health care worker injuries. Appl Ergon

36(2):223–9. 2005.

87. Edlich RF, Hudson MA, Buschbacher

RM, Winters KL, Britt LD, Cox MJ,

Becker DG, et al. Devastating injuries

in health care workers: Description of

the crisis and legislative solution to the

epidemic of back injury from patient

lifting. J Long Term Effects of Medical

Implants 15(2):225–41. (2005).

88. Hudson MA. Texas passes first law for

safe patient handling in America:

Landmark legislation protects health

care workers and patients from injury

related to manual patient lifting. J

Long-Term Effects of Medical Implants

15(5):559–66. (2005).

89. Pellino TA, Owen B, Knapp L, Noack

J. The evaluation of mechanical devices

for lateral transfers on perceived

exertion and patient comfort.

Orthopedic Nursing 25(1):4–10. 2006.

90. Engst C, Chhokar R, Miller A, Tate

RB, Yassi A. Effectiveness of overhead

lifting devices in reducing the risk of

injury to care staff in extended care

facilities. Ergonomics 48(2):187–99.

2005.
Series 1, No.

44[ Page 19

Appendix I.

Promotional and

Contact Information

In the appointment confirmation

packet,the facility administrator

receiveda copy of letters provided by

threeprofessional nursing assistant

organizations endorsing the NNAS (the

National Association

of Geriatric

Nursing Assistants, the National

Network

of Career Nursing Assistants,

and the Paraprofessional Healthcare

Institute). The appointment confirmation

packet also includeda NNAS flyer

(Exhibit

1) and an advance letter

(Exhibit

2)for the administratorto

present to all nursing assistants

employed by thefacility to provide

information about the survey. The

NNAS advance packets, given to all

sampled nursing assistants, provide

information about the survey ina

variety of formats and encourage

nursing assistantsto open the packet and

to explorethe materials (Exhibits 3–6).

Each advance packet also includeda$5

bill clipped to the

Introductory Letter

anda

5-minute DVD that explained the

survey and theimportance of

participation(not displayed).
Page 20 [ Series 1, No. 44

EXHIBIT 1: National Nursing Assistant Survey Flyer
Series 1, No. 44 [ Page 21

EXHIBIT 2: Advance Letter
Page 22 [ Series 1, No. 44

EXHIBIT 3: Introduction Letter
Series 1, No. 44 [ Page 23

EXHIBIT 3 (continued)
Page 24 [ Series 1, No. 44

EXHIBIT 4: Welcome Letter
Series 1, No. 44 [ Page 25

EXHIBIT 5: Fact Sheet
Page 26 [ Series 1, No. 44

EXHIBIT 6: Postcard
Series 1, No. 44

[ Page 27

Appendix II.

List of Survey Items

SectionA was completed by all

nursing assistants contacted and was

used to establisheligibility. Eligible

nursing assistants who were working at

the facility on the date of the interview

also completed SectionsB through K.

SectionsD through D6d,

K through

K7a, and SectionL were completed by

eligible nursing assistants who were

sampled for the survey but were no

longer working at the facility when

contacted.

Response values are indicated in

parentheses after or under each variable

description.

Variables with multiple

sub-questions under one stem are

indicated in bold; other sub-questions

are identified by letters. Open-ended

responses are italicized, and underlined

multiple response variables are labeled ‘‘check all that apply.’’ Some variables

were recoded for ease of analysis or due

to low sample frequencies for item or

category responses. Changes are noted

in footnotes to the variables.

The final instrument is available at

http://aspe.hhs.gov. It may also be

accessed in the following ASPE

publication: Measuring Long-Term Care Work: A Guide to Selected Instruments

to Examine Direct CareWorker

Experiences and Outcomes [http://aspe.hhs.gov/daltcp/reports/

dcwguide.htm].
Page 28 [ Series 1, No. 44
Series 1, No. 44 [ Page 29
Page 30 [ Series 1, No. 44
Series 1, No. 44 [ Page 31
Page 32 [ Series 1, No. 44
Series 1, No. 44 [ Page 33
Page 34 [ Series 1, No. 44
Series 1, No. 44 [ Page 35
Page 36 [ Series 1, No. 44
Series 1, No. 44 [ Page 37
Page 38 [ Series 1, No. 44
Series 1, No. 44 [ Page 39
Page 40 [ Series 1, No. 44
Series 1, No. 44 [ Page 41
Page 42 [ Series 1, No. 44
Series 1, No. 44 [ Page 43
Page 44 [ Series 1, No. 44
Series 1, No. 44 [ Page 45
Page 46 [ Series 1, No. 44
Series 1, No. 44 [ Page 47
Page 48 [ Series 1, No. 44
Series 1, No. 44 [ Page 49
Page 50 [ Series 1, No. 44
Series 1, No. 44 [ Page 51
Page 52 [ Series 1, No. 44
Series 1, No. 44 [ Page 53
Page 54 [ Series 1, No. 44
Vital and Health Statistics

series descriptions

SERIES 1. Programs and Collection Procedures—These reports

describe the data collection programs of the National Center

for Health Statistics. They include descriptions of the methods

used to collect and process the data, definitions, and other

material necessary for understanding the data.

SERIES 2. Data Evaluation and Methods Research—These reports

are studies of new statistical methods and include analytical

techniques, objective evaluations of reliability of collected

data, and contributions to statistical theory. These studies

also include experimental tests of new survey methods and

comparisons of U.S. methodology with those of other

countries.

SERIES 3. Analytical and Epidemiological Studies—These reports

present analytical or interpretive studies based on vital and

health statistics. These reports carry the analyses further than

the expository types of reports in the other series.

SERIES 4. Documents and Committee Reports—These are final

reports of major committees concerned with vital and health

statistics and documents such as recommended model vital

registration laws and revised birth and death certificates.

SERIES 5. International Vital and Health Statistics Reports—These

reports are analytical or descriptive reports that compare U.S.

vital and health statistics with those of other countries or

present other international data of relevance to the health

statistics system of the United States.

SERIES 6. Cognition and Survey Measurement—These reports are

from the National Laboratory for Collaborative Research in

Cognition and Survey Measurement. They use methods of

cognitive science to design, evaluate, and test survey

instruments.

SERIES 10. Data From the National Health Interview Survey—These

reports contain statistics on illness; unintentional injuries;

disability; use of hospital, medical, and other health services;

and a wide range of special current health topics covering

many aspects of health behaviors, health status, and health

care utilization. They are based on data collected in a

continuing national household interview survey.

SERIES 11. Data From the National Health Examination Survey, the

National Health and Nutrition Examination Surveys, and

the Hispanic Health and Nutrition Examination Survey—

Data from direct examination, testing, and measurement on

representative samples of the civilian noninstitutionalized

population provide the basis for (1) medically defined total

prevalence of specific diseases or conditions in the United

States and the distributions of the population with respect to

physical, physiological, and psychological characteristics, and

(2) analyses of trends and relationships among various

measurements and between survey periods.

SERIES 12. Data From the Institutionalized Population Surveys—

Discontinued in 1975. Reports from these surveys are

included in Series 13.

SERIES 13. Data From the National Health Care Survey—These

reports contain statistics on health resources and the public’s

use of health care resources including ambulatory, hospital,

and long-term care services based on data collected directly

from health care providers and provider records.

SERIES 14. Data on Health Resources: Manpower and Facilities—

Discontinued in 1990. Reports on the numbers, geographic

distribution, and characteristics of health resources are now

included in Series 13.

SERIES 15. Data From Special Surveys—These reports contain

statistics on health and health-related topics collected in

special surveys that are not part of the continuing data

systems of the National Center for Health Statistics.

SERIES 16. Compilations of Advance Data From Vital and Health

Statistics—Advance Data Reports provide early release of

information from the National Center for Health Statistics’

health and demographic surveys. They are compiled in the

order in which they are published. Some of these releases

may be followed by detailed reports in Series 10–13.

SERIES 20. Data on Mortality—These reports contain statistics on

mortality that are not included in regular, annual, or monthly

reports. Special analyses by cause of death, age, other

demographic variables, and geographic and trend analyses

are included.

SERIES 21. Data on Natality, Marriage, and Divorce—These reports

contain statistics on natality, marriage, and divorce that are

not included in regular, annual, or monthly reports. Special

analyses by health and demographic variables and

geographic and trend analyses are included.

SERIES 22. Data From the National Mortality and Natality Surveys—

Discontinued in 1975. Reports from these sample surveys,

based on vital records, are now published in Series 20 or 21.

SERIES 23. Data From the National Survey of Family Growth—These

reports contain statistics on factors that affect birth rates,

including contraception, infertility, cohabitation, marriage,

divorce, and remarriage; adoption; use of medical care for

family planning and infertility; and related maternal and infant

health topics. These statistics are based on national surveys

of women of childbearing age.

SERIES 24. Compilations of Data on Natality, Mortality, Marriage, and

Divorce—These include advance reports of births, deaths,

marriages, and divorces based on final data from the National

Vital Statistics System that were published as National Vital

Statistics Reports (NVSR), formerly Monthly Vital Statistics

Report. These reports provide highlights and summaries of

detailed data subsequently published in Vital Statistics of the

United States. Other special reports published here provide

selected findings based on final data from the National Vital

Statistics System and may be followed by detailed reports in

Series 20 or 21.

For answers to questions about this report or for a list of reports published

in these series, contact:

Information Dissemination Staff

National Center for Health Statistics

Centers for Disease Control and Prevention

3311 Toledo Road, Room 5412

Hyattsville, MD 20782

1-866-441-NCHS (6247)

E-mail: nchsquery@cdc.gov

Internet: www.cdc.gov/nchs
COVER 4

PRINTER: ADJUST SPINE TO FIT

PRINTER:

POSITIVE ART FOR BACK COVER (cover 4): PRINT SOLID PMSNEGATIVE ART FOR FRONT COVER (cover 1): PRINT SOLID PMS

07-0014 (03/2007)CS108770T27552DHHS Publication No. (PHS) 2007-1320, Series 1, No. 44