Certified Nursing Assistants' Wellbeing

Certified nursing assistants (CNAs), who provide the majority of care to persons with chronic disease and/or cognitive impairment from Alzheimer's disease and related dementias, face tremendous job and home stress, and as a result absenteeism and job turnover are high. This is a preliminary study that will tailor Mindful Self-Compassion (MSC) - a promising new program designed to cultivate greater self-care, and strengthen resilience and coping skills - for the CNA population and study its effectiveness. If results are favorable, MSC could be incorporated into CNA training programs, thereby helping contribute to a more effective and stable long-term care workforce.

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

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

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

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

The specific aims are:

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

1. Conduct a field trial of the standardized 8-week MSC training program with 15 CNAs within a single community NH. Evaluation will focus on: (a) participation (including home practice adherence); (b) attendee evaluation of the training; (c) barriers to and facilitators of participation; (d) use and retention of class material by participants; and (e) recommendations for improvement of training.
2. Field test the feasibility and acceptability of our study recruitment and evaluation strategy.
3. Use data collected from the field test to modify recruitment strategies, protocols, and course structure, content and materials so as to be maximally feasible, acceptable and effective in a CNA population.

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

1. Evaluate the fidelity and immediate impact of the modified training by measuring (a) training attendance; (b) satisfaction with the training; and (c) pre-and post-training measures of self-compassion, perceived stress, job satisfaction, job burnout symptoms, and attitudes towards persons with dementia.
2. Evaluate the sustained impact of the training by comparing baseline, 3-and 6-month post-training measurements of: intent to leave job, self-compassion, perceived stress, job satisfaction, job burnout symptoms, and attitudes towards persons with dementia.

Eligibility Criteria:
Inclusion Criteria:

* Certified Nursing Assistant employed by one of 3 study Nursing Homes
* Aged 18 and over
* Speak English
* Work at least 20 hours as a CNA at one of our proposed Nursing Homes
* Expect to attend at least 75% of the intervention classes
* Expect to stay at least the course of the intervention on the job
* Score in the top 50% on the PSS-10 (Perceived Stress Scale) (if more than 20 participants interested)

Exclusion Criteria:

* Younger than 18
* Working fewer than 20 hours a week
* Unable to attend at least 75% of the intervention classes
* Expect to leave their position during the intervention