Exploring Variation in Certified Nursing Assistant Assignments From the Perspective of Nursing Home Residents: A Comparison of Adopters and Nonadopters of Consistent Assignment

Abstract

Objective: To describe and compare certified nursing assistant (CNA) staffing between adopter and nonadopters of consistent assignment. Data sources: One month of preexisting CNA assignment and scheduling sheets from a purposive sample of 30 homes. Study design: A descriptive comparative study was conducted to calculate and compare numbers of CNAs assigned per resident across homes. Data extraction: Resident names and CNA assignments were abstracted from assignment records and entered into the Advancing Excellence consistent assignment tool to calculate numbers of CNAs assigned per resident. Principal findings: Both variation and overlap existed in the number of CNAs per resident within and between homes. Adopters assigned significantly fewer CNAs per resident. Conclusion: Research is needed to determine how assignment variations affect resident perceptions of quality.

Keywords

nursing home consistent assignment staffing

Consistent assignment of certified nursing assistants (CNAs) is a staff scheduling strategy used to improve care and work quality in nursing homes. A consistent assignment is one in which residents are cared for regularly by the same CNAs (Advancing Excellence in America’s Nursing Homes, 2016). It enables regular, ongoing interaction between CNAs and residents leading to close relationships that facilitate person-centered care delivery and early detection of subtle changes in resident health condition (White-Chu, Graves, Godfrey, Bonner, & Sloane, 2009). Consistent assignment has been associated with lower CNA turnover (Campbell, 1985; Castle, 2013; Patchner, 1989), increased job satisfaction (Burgio, Fisher, Fairchild, Scilley, & Hardin, 2004), increased resident satisfaction (Teresi et al., 1993), and fewer survey deficiencies (Temkin-Greener, Zheng, Cai, Zhao, & Mukamel, 2010). Furthermore, few studies have documented a lack of improvement or negative effects after implementation of consistent assignment (Roberts, Nolet, & Bowers, 2015). Staff burnout (Ramirez, Teresi, Holmes, & Fairchild, 1998), unchanged or increased turnover (Berman, 1989; Brannon, Zinn, Mor, & Davis, 2002; Burgio et al., 2004), staff disapproval of boring or high demand assignments (Kaeser, 1989; Patchner, 1989), and feelings of isolation, loneliness, and frustration when consistent assignments undermine teamwork (Anderson & Spiers, 2015) have been reported after implementation. The potential benefits and limited drawbacks resulted in its development as a central quality goal of the Advancing Excellence (AE) Campaign (Advancing Excellence in America’s Nursing Homes, 2016), adoption in Medicaid Pay for Performance programs (e.g., State of Tennessee Department of Finance and Administration, 2014), and universal endorsement by “culture change” advocates (Pioneer Network, n.d.).

Research has shown residents report a preference for, and satisfaction with, consistently assigned CNAs (Kaeser, 1989; Levy-Storms, Claver, Gutierrez, & Curry, 2011). Care by more CNAs requires repetitively expressing care preferences, which is exhausting and impersonal (Roberts, 2012) and hampers residents’ ability to receive individualized care (Caspar, O’Rourke, & Gutman, 2009; Roberts, 2012). However, the impact of documented variation in consistency of assignments (Boumans, Berkhout, & Landeweerd, 2005; Castle, 2013) on resident experiences has not been studied. The amount of time staff are assigned the same resident each time they are on duty (Castle, 2013; Temkin-Greener et al., 2010; Teresi et al., 1993) is a common measure. This demonstrates performance relative to capacity but it does not delineate the actual number of CNAs caring for residents. It may inflate consistency if a home is staffed with part-time or per diem positions or experiences high turnover or absenteeism and may disguise what residents actually experience. Research examining the number of CNAs per resident in homes using different assignment models is needed to begin to understand how variation might affect resident experiences of care.

The purpose of this study was to take the first step in understanding the quality of consistent assignments from a resident perspective by describing and comparing the number of CNAs staffed per resident in adopter and nonadopter homes. The study is the first to report on the use of raw staffing data collected from Directors of Nursing (DONs) to calculate and describe variation in consistent assignment practices.

Method

Sample

A maximum variation, purposive sample of 30 nursing homes was recruited across the United States (Table 1). Two types of culture change homes were recruited as “adopters” and traditional homes as “nonadopters,” reflecting high, intermediate, and low commitment to consistent assignment (Table 2).

Table 1.

Sample Characteristics.

	Adopters (n = 20)	Nonadopters (n = 10)
Bed size*	88.8 (52.7)	117.1 (45.1)
For profit	6 (30)	6 (60)
Chain membership*	4 (20)	7 (70)
Residents/unit*	15.4 (4.0)	18.8 (4.3)
CNA HPRD*	2.6 (0.6)	2.2 (0.3)
5 star rating	4.1 (0.6)	4.0 (0.5)

Note. Means (SD) and Frequency (%).Mann–Whitney U tests for ordinal data and Fisher’s exact tests for dichotomous data were used to determine significant differences between groups. CNA = certified nursing assistant; HPRD = hours per resident day.

Significant differences (p < .5) between adopters and nonadopters.

Table 2.

Comparison of Home Types.

Type of home	Architecture	CNA work	CNA staffing	Dominant practices
Neighborhood	Some level of remodeling or new construction has taken place to shrink units into partial-fully functional households (laundry, kitchens in every unit). Sometimes, the number of residents on the unit is much smaller to make it more homelike. Private resident bed and baths. Neighborhoods can be within a larger building or may be a smaller home (e.g., greenhouse or small house models).	CNAs often go beyond provision of direct care. CNAs sometimes become “universal workers” responsible for light housekeeping, laundry, food preparation, and direct care. Self-managed work teams. Sometimes responsible for staffing, budgeting, and purchasing for neighborhood.	Consistent assignments. CNAs care for the same residents every time they work.	Flattened leadership structure, CNA empowerment, flexibility that supports individual resident choice (e.g., wake time, bathing, activities, food).
Nonneighborhood	Varies. More homelike accents may be added, but long hallways are still common, with some centralized services. Some additional dining options may be added to offer more options to residents and staff.	Varies. CNAs may only provide direct care or may operate in universal worker status.	Consistent assignments. CNAs care for the same residents every time they work.	Flattened leadership structure, CNA empowerment, flexibility that supports individual resident choice (e.g., wake time, bathing, activities, food).
Traditional	Institutional, with centralized laundry, kitchens, dining areas, and nursing stations. Multibed resident rooms line long hallways. Shared bathrooms.	CNAs provide direct care, such as assistance with activities of daily living (bathing, grooming, eating) and delegated care from nurses.	Rotating with little to no attention to assigning CNAs to the same residents each time they work.	Focus on staff-driven, efficient routines. Hierarchical leadership approaches.

Note. CNA = certified nursing assistant.

Recruitment

Neighborhood homes (N = 13) were identified through the Pioneer Network, a leading network of culture change stakeholders. The Pioneer Network drew a random sample of homes from their database of “deep” culture change homes. Recruitment materials were sent to homes until 10 agreed to participate. To be eligible, homes were required to use consistent assignment and have independently functioning units with kitchen and laundry.

Nonneighborhood homes (n = 7) were recruited through AE. Homes enrolled in the consistent assignment goal and self-identified as nonneighborhood culture change homes were invited to participate during a regular network call with over 30 participating organizations. To be eligible, homes had to use consistent assignment and have implemented more than one culture change activity but not remodeled to develop independently functioning units.

Traditional homes (n = 10) were identified through Quality Improvement Organizations in three states who suggested homes that adhered to a “traditional” care model. To be eligible, homes had to use rotating assignments and not have implemented any major culture change efforts. Up to two invitation calls were made to DONs until 10 homes agreed to participate.

Procedures

The study was deemed exempt by the local institutional review board. DONs at each home were contacted to confirm eligibility and commitment to the study. Study materials were mailed and included an introductory letter, set of instructions, and list of incentives.¹ DONs were asked to return a partially redacted resident list and either daily assignment sheets or staff schedule for one nondementia unit including all, or mostly all, long-stay residents. DONs were instructed to make edits reflecting call-ins or other changes.

CNA assignments were abstracted from daily assignment sheets and staff schedules. Unclear assignments were reviewed with the home prior to data entry. Data were entered into the Consistent Assignment Calculator v1.0, a tracking tool developed by AE, which requires users to enter a list of resident names, classify them as short or long stay, and list the CNAs assigned to each matched by shift across each week of a month. The tool automatically calculates the average, minimum, and maximum number of CNAs/resident. The average is calculated based on staffing patterns over an entire month. The minimum and maximums are calculated based on the lowest and highest number of CNAs/resident over a weeklong period.

Analysis

The average, minimum, and maximum number of CNAs/resident/month were calculated using the AE tool. Mann–Whitney U tests (chosen due to small sample sizes) were conducted in NCSS 9 (2013) to determine whether average numbers of CNAs/resident/month varied across homes.

Results

The average number of CNAs/resident/month varied across all homes (Figure 1). The average number of CNAs/resident/month in adopters was 14.1 and nonadopters 19.5. The lowest average was achieved by an adopter (nine CNAs/resident/month) and the highest by a nonadopter (28 CNAs/resident/month). The range also varied and was considerably wide in some homes. An adopter reached the lowest minimum (six CNAs) and a nonadopter the highest maximum (34 CNAs). Six CNAs/resident is the lowest possible number in 1 week given 8 hr shifts, 40 hr work weeks, and no replacements. A level of 34 CNAs/resident is almost 6 times higher and suggests a resident was cared for by one or more CNAs every shift of every day for the entire week.

Figure 1.

Comparison of consistent assignment across homes.

Across the different home types, there was an upward trend in the number of CNAs/resident, with the lowest in nonneighborhood and highest in traditional homes. However, there was significant overlap across all three. The average number of CNAs/resident/month in half of the adopters was as high as, or higher than that in some nonadopters. Furthermore, 80% of nonadopters had averages and ranges lower than or overlapping with those of adopters.

A Mann–Whitney U test showed the difference, on average, of 5.4 CNAs/resident/month between adopters and nonadopters was significant (Z = 3.14; p = .002). Traditional homes had significantly higher average numbers of CNAs/resident/month than neighborhood by 4.9 CNAs/resident/month (Z = 2.52; p = .012) and nonneighborhood homes by 6.4 CNAs/resident/month (Z = −2.89; p = .004). The difference, on average, of 1.5 CNAs/resident/month between neighborhood and nonneighborhood homes was not significant (Z = 0.92; p = .358).

Discussion

By reporting the actual number of CNAs/resident, this study takes the first step toward understanding the quality of consistent assignments from a resident perspective. Findings suggest the length of time over which the number of CNAs remains stable, extent of overlap in staffing practices between adopters and nonadopters, and organization of teamwork may affect resident perspectives of quality.

The ability to maintain the same numbers of CNAs/resident over time varied. Some homes were fairly consistent from week to week. There was a wide range between minimum and maximum in others suggesting residents might experience wide swings in the number of CNAs, in some cases doubling from one week to another. This finding raises questions about the most important measure of the quality of assignments from a resident perspective—averages or stability over time. More research is needed to determine the association between resident perceptions of quality and sustained consistency. Furthermore, variation in assignments found in this study is consistent with prior research demonstrating varying practices across homes (Castle, 2011) and inability to achieve perfect consistency (Boumans et al., 2005; Castle, 2011; Cohen-Mansfield & Bester, 2006). By using a comparator group in this study, the significance of this variation was highlighted. At some level, variation among adopters results in practices that overlap those in nonadopters raising questions about the practical differences from a resident perspective. Future research is needed to determine a quality threshold distinguishing a level of consistency that results in positive resident experiences. In addition to counts of caregivers, research is needed that directly solicits resident perceptions and opinions about the quality of consistent assignments.

Evidence to support a recommended level of consistency in assignments is lacking. AE has developed, based on expert opinion and practical experience, the only available benchmark—residents should be cared for by no more than 12 CNAs per month (Advancing Excellence in America’s Nursing Homes, 2016). The results of this study both support and challenge this goal. Some adopters reached the goal, whereas none of the nonadopters did. The benchmark may distinguish homes that are intentional about and committed to consistent assignment. However, given the purposive sampling strategy used in this study, finding only 30% of facilities committed to consistent assignment met the goal raises questions about its achievability. More research is needed to determine achievable levels of consistent assignment that support a positive resident experience of care. While outside the scope of this study, future research is also needed that examines the factors that necessitate certain staffing patterns within a consistent assignment structure such as resident acuity or level of need, which may also affect the achievable level and quality of assignments.

The sampling and data collection approaches in this study allowed comparison of structural differences in staffing. Among adopters, nonneighborhood homes trended toward lower numbers than neighborhood homes. This seems paradoxical, given neighborhood homes are considered highly committed to consistent assignment. However, neighborhood staffing is also somewhat unusual; each is assigned a two-CNA team, meaning residents appear to be cared for by two CNAs even if only one is required. Conversely, nonneighborhood homes assigned staff to specific residents, better reflecting the actual number of CNAs. Some traditional homes assigned CNA teams to residents. However, they did this by assigning a “floater” responsible for care of all residents to each unit. “Floaters” inflated numbers and were found in homes with the highest numbers of CNAs. Teamwork has been found to provide positive benefits to CNAs (Aubry, Etheridge, & Couturier, 2013) and self-organized teams have been associated with fewer quality deficiencies (Andersen, Smith, & Havaei, 2014). While increasing the number of CNAs, teamwork may allow staff to quickly and effectively address resident needs. Balancing teamwork and minimization of CNAs should be examined in future research.

To overcome measurement and self-report data limitations in prior research (Roberts, Nolet, & Bowers, 2015), this study was the first to use raw staffing data from assignment and scheduling sheets. While we believe it resulted in an accurate portrait of consistent assignment, the process was challenging. Each home used unique tracking methods that required explanation and clarification during data entry, a process that may be burdensome for both homes and research teams in larger studies. The best methods for measuring and calculating consistent assignment are yet to be determined. Developing objective measures that combine organizational capacity for consistent assignments and the impact of assignments on residents may provide practical information about the ways consistent assignment influences outcomes and quality.

Consistent assignment has been linked to a number of positive outcomes including lower CNA turnover and higher quality (Castle, 2011, 2013). Nursing home structural characteristics (e.g., profit status; Hillmer, Wodchis, Gill, Anderson, & Rochon, 2005) and philosophical orientation (Grabowski et al., 2014; Sullivan et al., 2013) have been linked to quality. Higher quality has been linked to lower CNA turnover and absenteeism (Castle, Engberg, & Men, 2007), which could affect staffing practices. While homes in this study did not differ by profit status or five-star ratings of overall quality, they did on other structural factors. A possible explanation for lower numbers of CNAs among adopters may be better quality and more stable staffing, in turn resulting in more consistent assignments. Longitudinal research is needed to determine how quality, turnover, consistent assignments, and outcomes interrelate and covary.

Limitations

This study was based on a retrospective review of provider records that were not consistently edited to reflect staffing changes. It is not possible to say how many CNAs actually interacted with each resident, only how many were scheduled to care for each. This study used a small, purposive sample of homes. Furthermore, due to the time-intensive nature of data collection for the study and limited resources, we were unable to recruit additional traditional homes, resulting in a sample skewed with more adopter homes. Data were derived from multiple types of homes in multiple states. Future studies should be conducted with larger, more representative samples. Finally, measures of home quality or length of culture change adoption were not included.

Footnotes

Authors’ Note

The content is solely the responsibility of the authors and does not necessarily reflect the official views of the National Institutes of Health. The work was deemed exempt from review by the University of Wisconsin–Madison Institutional Review Board (IRB)—Protocol 2011-0367.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Commonwealth Fund [BB]; training support during the conduct of the study by the John A. Hartford foundation BAGNC Scholar’s program [TR]; and partial support from the Clinical and Translational Science Award (CTSA) program, through the National Institutes of Health National Center for Advancing Translational Sciences (NCATS) [UL1TR000427 BB].

Notes

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