Wfi“ I}. ’J Lr". 4 . i“ flaking? . ux 3‘3??ng <1 -\ z “E a??? * mfififis“ ....‘Eat- x 3; . V ‘ A ‘ 3515““ A r' abuts; .343: C‘ V 4 . ég‘E-Sifi- -. ‘~», ~‘., ".1 . $5., "{1‘ ‘ ”w , . ’94.“ ‘51.; ‘J ..v‘u ,. .:. £353“ '33. 3‘ I R’é‘.§’; Qua-‘3: .1 ‘5 n Jic-o 4 ! f‘_ \ an. .‘.O r '_.‘ u . ..n.u..‘_ .,,;.‘. 5.1%ng - yum-,9“ " 4A. :7, ' ‘.Ml4:mlo‘uwl.r..¢; W ‘k V}: J‘ if: “'3‘ ‘ vf HUI-#53" ‘4-gv-aaxg .‘.' ‘ c" “3" u 3! k . "'6' . \w "x ‘n‘uu‘ul u. u .9 L _ ("1".1?“ 7 ,’ \ 531.333'3 o“ ,. _ . b” a ‘5‘ ‘ a. . w . ’ . x 3:53,: 1%“ _ ‘3 “1.1% n a «x w:- a" ' V “*“m’ . -_1 , I 1" ‘I‘ 'l ‘ \ 1. .3 , ‘ “ .‘ - x ‘ ’ 3"}. \‘if- 9. L :7va _' - . -~ ~ - , }. A '1“; "' .. . ‘ ‘N . I ‘ . ‘\i' .V‘V‘ “L"- V551 ‘ ‘ '5, .49 '51.»... n :51 1“, .95.. , A ,. ~ “Pk-1545. , 53'; s; mm as Hm w. ~" :1. A #1:»? ~~ 3. -.'.‘.‘. . '4' HQ. > \n-lfifi" ‘ " . , is?!» ‘ y)?“ x $54 ‘3‘ . " ‘ : n 1-}; - ‘ “vii-n u ... ‘ ‘-'- - v ._ . ,. .*. ‘ Q. m u‘ ‘1‘... . “’3‘,“ " '7' "M'Lb. tifiiiii'liifll WM]Iflflifliiililliimifliflill 3 1293 01051 7815 This is to certify that the thesis entitled A Descriptive Study of the Perceived Continuing Education Needs and Interests of Nursing Assistants Employed in Nursing Homes presented by Judy Lynn Jerome has been accepted towards fulfillment of the requirements for . M degree in M W *5»; Major professor Date AQ/Q/ (73 0-7639 MS U i: an Affirmative Action/Equal Opportunity Institution LIBRARY Michigan State Unlverslty PLACE ll RETURN BOX to roman this chockom from your need. To AVOID FINES Mom on or odor. dd. duo. DATE DUE DATE DUE DATE DUE | MSU I. An Nflmctlvo Action/EM Opportunity Inflation ‘ ,fi_________.——_ mill: Am‘u‘- .. .- ...-ammo..- . ism-arr: name}: izmhfifii‘. . -...512L " mmgugi.._‘.- A DESCRIPTIVE STUDY OF THE PERGEIVED CONTINUING EDUCATION NEEDS AND INTERESTS OF NURSING ASSISTANTS EMPLOYED IN NURSING HOMES By Judy Lynn Jerome A THESIS Submitted to ‘ Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1993 ABSTRACT A DESCRIPTIVE STUDY OF THE PERCEIVED CONTINUING EDUCATION NEEDS AND INTERESTS OF NURSING ASSISTANTS EMPLOYED IN NURSING HOMES By Judy L. Jerome A descriptive study using the qualitative focus group interview technique was undertaken with nine nursing assistants at two nursing homes. The areas of concern explored were: 1) perceived job and environment, 2) perceived view of continuing education, and 3) perceived relationship of job and continuing education. The results indicated nursing assistants are keenly aware of the negative image and low status of the position but see continuing education as a possible vehicle for recognition and improvement of the role. They emphasize the need to conveniently incorporate continuing education programs that provide meaningful information readily applied in the work setting. Recommendations for additional research and implications for education are presented. ACKNOWLEDGEMENTS I would like to give heartfelt thanks to Sharon King, my committee chairperson, for her unwavering support, gentle prodding, and expert direction. In the spirit of Florence Nightingale, the 'lady of the lamp’, Sharon proved to be my guiding light. I would also like to thank my committee members: Linda Beth Tiedje and Patti Peek for their shared expertise, flexibility and encouragement. To my parents I say thank you for teaching me the value of quiet perseverance in the face of daunting tasks. To all of my family I say thank you for your unquestioning support, which I have the assurance of knowing is always available for the asking. And to my sister-in-law Jaye, thank you very much for your continued inspiration. How fortunate I am. I would like to extend my sincere gratitude to my friends and co-workers who provided the support and encouragement I needed during this work. Especially to Marcia for the technical support; to Roger, Gary and Doug for the calm, reality-based words offered during my desperate times; to Raymond for the motivating admonition, "just do it". To any one who helped me in any way, I offer my genuine thanks. Please share in my joy at the completion of this work. iv TABLE OF CONTENTS List Of TableSOOOOOOO0..O0.000....0.00.00.00.00... List of Chapter I. II. III. FigurESooooooooooo00000000900000.0000.0000 INTRODUCTION TO THE STUDY Overview................................. Introduction............................. Background of the Problem................ Relevance to Advanced Nursing Primary Care Practice......................... Purpose of Study......................... Statement of Problem..................... CONCEPTUAL FRAMEWORK ovePVieWOOOOOOOOOOOOOOOOOOOOOOOOO00...... Conceptual Definition of Variables.......... Perceived Job and Environment Description Perceived View of Continuing Education... Perceived Relationship Between Job and Continuing Education................. Use and Relevance of Malcolm Knowles Adult Education Model................. Relationship of Variables to Knowles Adult Education Model................. Conceptual Limitations................... A Descriptive Model of the Study......... Summary.................................. REVIEW OF THE LITERATURE ovePVieW0.000000000000000000000000000000000 Perceived Job and Environment Description.. Perceived View of Continuing Education... Perceived Relationship Between Job and Continuing Education.................. Learning Needs Assessment................ Summary.................................. V Page ...vii ..viii ..14 ..14 .15 ..16 0.0.17 ..20 ..21 ..21 ..24 0.0.25 0.0.30 0.0.34 Chapter IV. VI. APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX METHODOLOGY AND PROCEDURES Overview................. Methodology.............. Sampling Frame........ Recruitment of Sample. Procedure................ The Interview Guide... Conducting the Group.. C O O O O O 0 Data Management and Analysis.. Methodological Assumptions and Limitations Human Subjects............ Summary.......... DATA PRESENTATION Overview......... Preparation...... Sample Descriptio Summary of Findin Sample Recruitment... Perceived Job and Environment Descript n.. SS. i Perceived View of Continuing Education. Perceived Relationship Between Job and Continuing Education................ summaryOOOOOOO..........OOOOOOOOOOOOOOO0.0 INTERPRETATIONS AND RECOMMENDATIONS Overview.................................. Limitations............................... Discussion of Findings...................... Perceived Job and Environment Description Perceived View of Continuing Education... Perceived Relationship Between Job and Continuing Implications for Implications for Implications for ammoow> Education................ the GCNS Practice....... Research............ Education........... Summary.............................. vi FORM. INTRODUCTORY LETTER........... CONSENT FORM.................. DEMOGRAPHIC INFORMATION . INTERVIEW GUIDE............... METHODS SURVEY.............. . APPROVAL LETTER FROM UCRIHS. . FIELD NOTES................. . REFERENCES......... 0 O O n Page ..35 ..35 ..38 ..39 ..40 ..41 ..42 ..44 ..47 ..49 ..50 ..51 ..51 ..51 ..52 ..54 ..55 ..58 ..64 ..69 ..70 ..70 ..72 ..72 ..74 ..78 ..82 ..85 ..86 ..87 ..88 ..89 ..90 ..91 ..93 ..94 ..95 ..98 Table LIST OF TABLES Characteristics of Study Participants..... Teaching Methods Questionnaire Results.... Information Sources Cited By Participants. Program Topics Named By Participants...... Comparison of Sample to State-Wide Nursing Assistant Population....................... vii Page 0.53 ..62 LIST OF FIGURES Figure 1. Descriptive Model of Study.....................23 viii CHAPTER ONE OVERVIEW Aging happens. It is a natural, inevitable process, as we now know it. We attempt to influence the progression in our favor, but the direction continues. As time passes, the likelihood of requiring assistance with activities of daily living increases. One group providing this help are nursing assistants working in nursing homes who provide 80-90% of the hands-on care (Katz et al., 1991; National Citizens’ Coalition for Nursing Home Reform, 1991). The purpose of this study is to consider the perceived continuing education needs and interests of nursing assistants. In Chapter One, pertinence of the study is introduced and followed by background information. A link to an advanced primary care nursing practice is proposed. INTRODUCTION Within the past five years, an analysis of the demographics of the population in the United States has confirmed an increase in the number of elderly. The number of persons 85+ is growing six times faster than any other population group (Kane et al., 1989). Although the elderly population continues to expand as a result of an increased life expectancy and an aging baby boom generation, little evidence exists that supports the possibility that those 2 attaining old age in the future will be any less chronically ill or disabled than previous cohorts. With the number of elderly in institutional settings predicted to remain approximately 5% of the elderly population, that percentage will represent larger actual numbers of individuals as the aging population becomes a greater proportion of society. Age is an important factor in nursing home admission. Life expectancy for women is 77.6 years and men 70.1 years (US Senate, 1990). Among those 64- 74 years old, the admission rate is less than 2%. This rises to 7% for those age 75-84, and then jumps to 20% for those 85 and older. Longitudinal studies suggest that persons at age 65 have between a 25-40% chance of spending some time in a nursing home before they die. (Vicente, Wiley, and Carrington, 1979). A nursing home may be defined as a care center for the long-term treatment of stable residents who need assistance with activities of daily living (e.g., feeding, toileting, bathing, dressing, mobility) and management of health problems (Eliopoulis, 1989). Although some residents are admitted to the nursing home temporarily and then return to the community, many live the remainder of their lives in this setting. For these residents, the facility truly serves as a residence. The greatest influence on the growth of nursing home beds was the introduction of Medicare and Medicaid in 1965. Both entitlement programs gave consumers access to costly nursing home care, usually not included in traditional health care insurance policies and assured provider payment. Between 1960 and 1970 the number of nursing homes more than doubled, and the number of nursing home beds tripled (Eliopoulis, 1989). During the 1970’s, the problems of some nursing homes made the headlines and reports of inhumane care flourished. I In response to public pressure for improved Federal regulatory involvement in the nursing home sector, in 1983, the Health Care Financing Administration (HCFA) signed a contract with the Institute of Medicine (IOM) of the National Academy of Sciences for a study of nursing home quality and regulation. The conclusions and recommendations, reported in Improving the Quality g1 Car; in Nursigg flgmgg (IOM, 1986), are generally considered to be the foundation of the nursing home reforms contained in the Omnibus Budget Reconciliation Act of 1987 (OBRA). OBRA 1987 (Public Law 100-203) represents the most substantial changes in both standards and the regulatory process since the inception of federal funding and regulation of nursing homes. Regulatory criteria, the standards of performance expected of facilities, are developed and defined as foundations for improvements both in quality of care and quality of life provided to the residents. As of 1 October 1990, nursing homes are held to this new, higher standard of care that focuses on the residents’ "highest practicable physical, mental and psychosocial well-being". Nursing homes are directed to support "individual needs and preferences" to "promote maintenance or enhancement of the quality of life of each resident" (OBRA, 1987). Standards of care and the enmeshed regulatory process include consideration and criteria for the training of nursing assistants employed in nursing homes. A survey by the National Citizens’ Coalition for Nursing Home Reform found that 21 states required nurse assistant training in 1987 (National Citizens’ Coalition for Nursing Home Reform, 1991). The standards for these programs varied widely in content and quality. The IOM study noted that nurse assistants "usually are not experienced or adequately trained for their jobs, in some places many speak English poorly, and they often are new to the job as well" (Institute of Medicine, 1986). Nursing assistants provide 80-90% of the hands-on care of residents in nursing homes (Katz et al., 1991; National Citizens’ Coalition for Nursing Home Reform, 1991). To translate the spirit of the law (OBRA 1987) into quality of care and quality of life for nursing home residents, adequate training of nursing assistants is identified as essential. BACKGROUND OF THE PROBLEM The nursing assistants are a nonprofessional work force who deliver resident care under the direction of licensed nurses. There are many working conditions for nursing assistants which can affect the quality of the care delivered. These include low educational status, cultural and language barriers, low wages and a poor working environment. Nursing services represent the backbone of physical care on a 24 hour basis and nursing assistants are the primary providers of that care for residents. To get a sense of the expectations and responsibilities of the nursing assistant position, the following is an outline of the required content for training issued by HCFA in 1989: Begnineg tnaining nrion Ln nny dizect contnct with residents: * Communications and interpersonal skills Infection Control Safety/emergency measures Promoting residents’ independence Respecting residents’ rights **** Basic Nunsing Skills Taking and recording vital signs Measuring and recording height and weight Caring for residents’ environment Recognizing abnormal signs and symptoms of common diseases and conditions Caring for residents when death is imminent **** * Personal Care Skills, includin , but not limited Ln ******** Bathing Grooming, including mouth care Dressing Toileting Assisting with eating and hydration Proper feeding techniques Skin care Transfers, positioning, and turning Mental Health and Social Service Needs * * * Care Modifying aide’s behavior in response to resident’s behavior Identifying developmental tasks associated with the aging process How and when to manage behavior by reinforcing appropriate behavior and reducing and eliminating inappropriate behavior Allowing the resident to make personal choices, providing and reinforcing other behavior consistent with residents’ dignity Using the residents’ family as a source of emotional support 2: Cognitive Impaired Residents Techniques for addressing the unique needs and behaviors of individuals with dementia Communicating with and understanding the behavior of cognitive impaired residents Appropriate responses to the behavior of cognitive impaired residents Methods of reducing the effects of cognitive impairments Basic Restorative Serviceg * * **** Training the resident in self-care according to the residents’ abilities Use of assistive devices in ambulation, eating and dressing Maintenance of range of motion and mobility Preventive turning and positioning in bed and chair Bowel and bladder training Care and use of prosthetic and orthotic devices Residents’ Rights * * Providing privacy and maintenance of confidentiality Promoting the residents’ right to make personal choices to accommodate their needs * Giving assistance in resolving grievance and disputes * Providing assistance to participate in resident/family groups and other activities * Maintaining care and security of residents’ personal possessions * Providing care which maintains the resident free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate facility staff * Maintaining the resident’s environment and care to avoid the need for restraints Family members of nursing home residents and elder care advocacy groups were instrumental in demanding inclusion of nursing assistant training and competency regulations in the reform law. Trained and competent nursing assistants are clearly seen as essential to high quality of care and quality of life for the nursing home residents. The ambitious Training and Competency regulations promulgated in OBRA 1987 represent a beginning in the direction of assuring this occurs. The intent of the Nurse Aide Training and Competency Evaluation section of OBRA 1987 is to assure that each nurse assistant who works in a Medicaid or Medicare certified facility is competent to provide services to residents. Provisions of the law mandate that nursing assistants participate in a state approved training course as outlined above and delivered over a minimum of 75 hours within 4 months of date of hire. Competency evaluation programs are developed by each state government and must include an evaluation of skills. Implementation of the Training and Competence regulations in the proposed time frames has been difficult for many states. Among the OBRA reforms, the Training and Competence regulations illustrate the problem of inadequacy in the design of the reform and may limit effectiveness (Katz et al., 1991). Issues include: 1) the need for regulations to address the quality of the training program, 2) mechanisms for financial support of facilities providing training and, 3) a need to supplement the 75 hours of training, which most experts consider an absolute minimum, with pertinent, high-quality inservice training programs in the nursing homes. By the February, 1991 deadline mandated in OBRA 1987, nursing homes must annually provide a minimum of twelve hours of in-service education and include a program in the care of the cognitive impaired. In designing continuing education programs to complement the basic training provided, the thoughts of the nursing assistants becomes critical information. According to adult educator Malcolm Knowles (1980), the starting point in program planning is always the adult learner’s interests. The intent of focus group research in this study is to reach the nursing assistants’ felt continuing education needs and interests. RELEVANCE TO ADVANCED NURSING PRIMARY CARE PRACTICE For the Gerontological Clinical Nurse Specialist (GCNS), the nursing home is a site for delivery of primary care to a frail, elderly population. The first contact and ongoing care has the advantage of being like a 'house call’. The GCNS has an opportunity to develop a working framework in this setting to operationalize the characteristics of an advanced nursing, primary care practice. By nature of the complexity of problems found among nursing home residents, a multidisciplinary team is viewed by experts as essential in provision of care. The team approach begs for coordination in problem-solving/care management. With a wholistically framed primary care philosophy, the GCNS is well-suited for the role of coordinator. The GCNS foundation in nursing is beneficial as nursing service provides the 24 hour care, translating and coordinating the plans of other disciplines. The nursing assistants are primary providers of the planned care. The GCNS can clearly orchestrate these efforts at the point of delivery. Though the nursing home setting is considered a ‘home’ for residents, it remains a formal institution under governmental regulation and scrutiny. Since nursing homes are primarily Medicare/Medicaid funded, the intent of governmental oversight is to insure effective use of taxpayer’s money and fulfill the social obligation to assure 10 quality of care for nursing home residents. Within this generalized and cumbersome system, the individual resident, though receiving overall benefit, may also become lost. The GCNS becomes advocate for the individual resident in application and interpretation of the formal system mandates. Within the constraints of the facility and working with the physicians, other interdisciplinary team members, nursing staff, nursing assistants and family members, the GCNS helps develop a reality-based, individually-driven plan of care for the resident. Provision of primary medical care in nursing homes is hampered by logistical and economic factors. The physician must often juggle an office schedule with nursing home visits frequently resulting in once or twice a month facility rounds. Reimbursement for the routine visit is hardly adequate for the time that is required to provide good medical care, including travel to and from the facility, assessment and treatment planning for residents with multiple problems, communication with members of the interdisciplinary team and the resident’s family and proper documentation in the medical record (Kane, et al., 1989). The GCNS can augment and assure access to primary medical care in the nursing home by collaboratively working with the physician and facility staff to manage acute and chronic health care problems. A variety of medical and functional problems occur commonly in nursing homes, such as 11 incontinence, weight loss, skin breakdown and behavioral manifestations of dementia. The GCNS facilitates effective medical care by contributing to the team care needed to address these problems. The significance lies in enhancement of the resident’s sense of being cared for at a time of physical vulnerability thus allowing an opportunity to support individual growth potential throughout the life span. In primary practice in the nursing home setting, the GCNS is able to be ngcountgble for all the framing characteristics described above.The accountability is to the resident and their families; to the facility, the nursing staff and members of the interdisciplinary team; to the medical staff; to the community; and to themselves. The newness of the GCNS role provides an opportunity to promote and be accountable to advanced practice nursing in an unique primary care setting. The technology of primary care is described as soft tech. The interventions of touch, listening, presencing and counseling are some of the tools. In the nursing home, this 'gentling’ approach is well-suited. This is when effective caregiving measures go beyond 'state of the art’ to ’state of the heart’. ’ As a GCNS practicing primary care in this setting, it is critical to recognize that beyond the time spent directly delivering interventions, the clinical management plan is 12 enacted by the nursing assistants during day-to-day caregiving. The effectiveness of the treatment plan hinges on the understanding and, more importantly, the acceptance of the plan by the nursing assistants who deliver direct care. Reliance on the nursing assistants for a measure of the success or failure of a designated treatment plan requires the GCNS to have an awareness of the training background and educative interests of these employees. In the role of educator, the GCNS knows a learning needs analysis of the target audience is helpful in designing a pertinent continuing education program. PURPOSE OF STUDY The purpose of this study is to begin eliciting information about the learning needs and interests of the nursing assistants from their own perspective. To this end, a qualitative research approach will be used. This information, enmeshed with the wholistic goals of the GCNS’s clinical management plans can provide direction for future educational efforts. STATEMENT OF THE PROBLEM What are the perceived continuing educational needs and interests of the nursing assistant employed in a nursing home? As has been stated, a significant portion of resident 13 care in nursing homes is delivered by the nursing assistants. This justifies the training and competence verification of nursing assistants as one focus of the nursing home reform law (OBRA 1987). Though implementation of this law is current and plagued with lack of clarity and consistency in interpretation, a timely next step is to initiate program planning for the required twelve hours of continuing education. With this in mind, this study attempts to explore what the nursing assistant considers to be his/her continuing educational needs and interests. 14 CHAPTER TWO OVERVIEW In this chapter, the variables will be conceptually described as developed in a qualitative research methodology. The framework for the study will be explained using Knowles (1980) theory of adult education. The variables will be described in terms of the framework and conceptual limitations considered. A model will be given and discussed depicting the relationship between the concepts within the context of the study problem. CONCEPTUAL DEFINITION OF VARIABLES The purpose of this study is to explore the perceived continuing education needs and interests of nursing assistants employed in nursing homes. The qualitative process of discovery generates a dynamic accumulation of information. The questions are used as a guide for data collection and are the variables. A list of questions to address the purpose of the study is prepared and then organized into areas of concern. In exploring the perceived continuing education needs and interests of nursing assistants employed in nursing homes, the questions will be directed toward three areas of concern: l5 1) Perceived job and environment description 2) Perceived view of continuing education 3) Perceived relationship between job and continuing education 1) PERCEIVED JOB AND ENVIRONMENT DESCRIPTION The role expectations and work environment of the nursing assistant employed in nursing homes are changing as rapidly as the health care system itself. Admissions to nursing homes represent a complex population with increasingly diverse needs and unpredictable responses. With the prospective payment reimbursement system in place and the concomitant movement to discharging patients "sicker and ' nursing homes are becoming increasingly like acute quicker,’ care hospitals and also are being used for short-term rehabilitative purposes, as well as for long-term residential care (Liu and Manton, 1984). The nursing assistant represents minimally prepared personnel that do the hardest work, direct care (Johnson- Pawlson and Goodwin, 1986) in generally inadequate surroundings for deficient compensation. People do not perform in a vacuum (Rummler and Brache, 1988) but are influenced by the expectations of their job and the work setting. The work environment is important in motivating individuals to use what they learn (Hinckley, 1990). Therefore, in assessing continuing education needs and interests, it also is important to get an idea from the 16 nursing assistants of the context, their work environment, in which the programs will occur. 2) PERCEIVED VIEW OF CONTINUING EDUCATION Although the work role expectations of nursing assistants in nursing homes are extensive, initial and ongoing educational preparation is not commensurate (Johnson-Pawlson and Goodwin, 1986). Changes occurring as a result of nursing assistants being prepared under the OBRA mandated training and competence regulations have not been evaluated. An additional question is the benefit to long term care of the elderly derived from a training program based on a medical-nursing model (OBRA, 1987) rather than an "instinctive home-care orientation" (Barney, 1983), or a psychosocial approach to nursing assistant practice (Weber, 1990). The case for continuing education is well supported in the literature, "The most effective, efficient program in the world will be of little lasting value if there is no ' (del Bueno and subsequent development and reinforcement,’ Altano, 1984). In addition, previous educational experiences will influence the nursing assistants’ view of continuing education programs. Several related questions include: Do nursing assistants feel there is a place for continuing education? Are educational programs a source of stress? Why would they choose to attend or not attend? What makes it 17 easy to attend? 3) PERCEIVED RELATIONSHIP BETWEEN JOB AND CONTINUING EDUCATION Training does not guarantee improved performance and quality (Hinckley, 1990). Training does need to address the whole workday environment and the wholeness of persons confined to and working in that environment. Jackson (1972) describes "... wholeness is a goal for every resident in their effort to reach full potential for living and to sustain good mental health. But it is a goal for those serving as well as for those served." The nursing assistant’s job is directly linked to the nursing home residents care and welfare. Performance requires technical knowledge and skills as well as diligence, hard work, and humanitarian commitment to the personal care of the residents (Weber, 1990). Questions related to job and continuing education include: Where do nursing assistants get information to perform their jobs? What problems encountered in their work would be ' ameliorated with education? Is there a place for continuing education in the busy workday world? What would it look like? 18 USE AND RELEVANCE OF MALCOLM KNOWLES ADULT EDUCATION MODEL In order to achieve maximum learning, continuing education programs need to be built upon the principles of adult education (Knowles, 1980). Since over three quarters (78%) of nursing assistants are between the ages of 21 and 40, adult education principles are especially relevant (Jackson and Schafer, 1993). Malcolm Knowles (1980), a leader in the field of adult education, gives some valuable insight into the adult as a learner. His assumptions of andragogy (the science of teaching an adult) provide general characteristics of the adult learner and therefore directly influence the plan for teaching a continuing education program. A summary of these four assumptions follows. First, the adult’s "self concept moves from one of being a dependent personality toward one of being a self directed human being" (Knowles, 1980, p.45). Adults see themselves as motivated and in control of their lives. Their chief sources of self-fulfillment are now their performances of roles such as that of employee. Incorporating the learner in planning educational programs provides some autonomy and control. Second, the adult "accumulates a growing reservoir of experience that becomes an increasing resource for learning" (Knowles, 1980, p.44). Knowles (1980) expands this by adding that "adults have a richer foundation of experiences to which they relate new experiences,...adults have acquired a 19 larger number of fixed habits and patterns of thought and therefore tend to be less open minded" (p.50). Consideration of learner experience may increase meaningfulness of the program, prevent boredom secondary to repetition of material or explain learner difficulties. Third, the adult’s "readiness to learn becomes oriented increasingly to the developmental tasks of his social roles" (Knowles, 1980, p.51), such as that of employee. The adult’s motivation to learn is strong when learning the new information will meet a pressing need. It is more conducive to teach what the learner wants to knowbefore teaching what the teacher wants the learner to know. Fourth, the adult’s "time perspective changes from one of postponed application of knowledge to immediacy of application" (Knowles, 1980, p.53). The teaching process is enhanced if the adult learner knows what is taught in the program will soon be used on the job. Based on these assumptions, emphasis is placed on involvement of the adult learners to diagnose their own learning needs within the assessment phase of the teaching- learning process. The study purpose is to explore the perceived continuing educational needs and interests of nursing assistants employed in nursing homes, obtaining learning needs information from the adult learner involved. 20 RELATIONSHIP OF VARIABLES TO KNOWLES ADULT EDUCATION MODEL According to Knowles (1980), the purpose of adult education is to produce competent people - people who are able to apply knowledge in changing conditions. In this qualitative study, the competent people are working nursing assistants. The questions developed for the interview guide ask about three variables: the nursing assistant’s perceptions of 1) job/work environment, 2) continuing education needs and interests, and 3) the relationship or interaction of job and education. The questions for the focus group were adapted from a study assessing beliefs about nutrition education done by Crockett, et. al. (1990) and based on Knowle’s model and assumptions. In considering self-direction, questions were used to get a sense of the perceived motivation and control the nursing assistants in their work setting. Where do they obtain information to do the job and how do they learn best are probed. The influence of gnngninnng is sought through questions about past educational experiences to include preferred methods of learning and development of current work habits. Knowle’s assumption of neadiness Ln lgnnn, or what represents a pressing need, is explored through questions that ask about problems nursing assistants face and topics of interest. The inherent relationship of continuing education and the job are manifest in the 21 potential for immediacy nf nnpligntion. Questions that probe the nursing assistant’s process of change and role of education are used. CONCEPTUAL LIMITATIONS In this study, the application of Knowles adult education model and assumptions occurs within the context of a work setting, the nursing home. The idea of continuing education being something you do for yourself as opposed to something done to you is influenced by the context of an organizational setting’s educational requirements, i.e. attending an elective cooking class versus a mandatory fire safety program. As a limitation, educational program goals in the job setting are work-related and may be driven by regulations and requirements. The nursing assistants as adult learners are often mandated participants rather than self-selected. Motivation to attend may include other employment-related factors such as job status or advancement. The addition of education-related activities to a full day’s work is also a consideration in how the potential adult learner views the role of continuing education programs. A DESCRIPTIVE MODEL OF THE STUDY Figure 1 depicts a model of this study. The purpose of the study is to explore the perceived continuing education 22 needs and interests of nursing assistants employed in nursing homes. Within the intended learner, the perceived needs and interests, are indicated by a dotted line figure. Exploration of these needs and interests are directed by the assumptions of Knowles adult education theory (indicated by *). As the intended learner, the nursing assistant brings to the continuing education program the influence of past *experience, both educational and work-related. The assumed tendency toward inglf direction may influence the nursing assistant to set individual performance expectations to fulfill the employee role as a developmental step. The arrows indicate the two-way flow of job/environment influencing the needs and interests of the nursing assistants/learners. The continuing education learning experience in this study occurs within the job environment, the nursing home. The job environment impacts the nursing assistant’s *peadiness p_ learn through existing educational policies and requirements and the institutional role expectations. The learning experience is enhanced by the potential for *inmediacx pf application within the work setting. The dotted lines reflect this interaction between the job environment and the learning experience. 23 mZOFnEDmm< m.m.._>>OZv_. 93.2:— pcm £332 cosmos—cm 9:35:50 85.3.. \ EEEmm< 9:952 t Eco—232$- ._ x33- moszwnxm. «co—.2085 3:223..- omhommfiimmm. 1 _. 225m ho. .285. $238on . 92:9". I Cocoouooogoooozcioo ".0 >0 named with code words, and 4) designated segments are extracted and written to an output file to allow comparisons (Seidel & Clark, 1984). With this help from THE ETHNOGRAPH program, the interpretive tasks of making sense of the data can be attended to more closely. A second coder, experienced in qualitative research analysis, reviewed data and categories. To implement THE ETHNOGRAPH program and guide analysis 46 of the data, initial coding categories were derived from the described conceptual framework and the questions/probes of the interview guide. THE ETHNOGRAPH program accommodated the changes in coding decisions that emerged in the analysis of the data from the groups. Having reduced the raw data to categories and descriptive statements (Krueger, 1988), the next step was to extract meaning and draw conclusions from the data which j’r‘l I 2 .... . is data analysis (Knafl and Webster, 1988). Keeping in mind the research intent of generating a follow-up survey, data analysis was guided by the need for developing meaningful content and language for questions. The perceived needs and interests for continuing education of nursing assistants unfolded as topical categories with potential to identify a range of importance for tabulation by how frequently topics were mentioned. Another area of information involved the type of information nursing assistants perceive as being needed, such as review/reinforcement of previously learned topics, additional explanation of frequently performed duties or new information. These thoughts were possibilities for data analysis within the purpose of this study. However, the final work of analysis was not done until data is collected, sorted and reviewed. Qualitative research, by nature, results in several potential pathways to investigate, some revealed at the time of analysis. The guiding principle for selection of 47 categories was the purpose of the study. METHODOLOGICAL ASSUMPTIONS AND LIMITATIONS The research concerns of reliability and validity have been described and debated in the literature for application and necessity in qualitative studies. The work of Chenitz and Swanson (1986) describe the development among "rough qualitative researchers of what could be called analogs" to quantitative measures of reliability and validity, usually referred to as establishing adequacy of evidence and credibility. Using this categorization, establishing adequacy of evidence (reliability) is akin to considering the extent to which the study can be replicated. Because no two researchers are alike, replicability is problematic in qualitative work. A careful description of context, sample, and methods can improve the potential of replicability. In this study, the context is in the natural setting, which increases certainty about the accuracy of the participant responses (Morgan, 1988) and eases efforts to repeat the study. The convenience sample is purposive and clearly defined but selection of additional groups will yield differences because of the individuality of potential participants. Though the methods are outlined, the nondirective nature of discussion if facilitated by different moderators may influence results of the focus 48 group interaction. The interview guide and use of the same moderator helps minimize this limitation for this study. Having two researchers analyze and interpret the data will improve reliability by increasing the likelihood of generating less biased summaries and conclusions. The researcher for this study functions as the moderator and does the data analysis which enhances the continuous evaluation of the research process but also potentiates the possible prominence of researcher-driven goals. The second coder will negate this effect. Multiple sites and a large number of groups would improve adequacy of evidence but are not within the time frame of this study effort. The categorization of validity as credibility has a clearer translation in qualitative research by relying on participant perception and experience. One concern is whether the interaction reflects actual behavior or the influences of the group and the act of making public statements. The extent to which results are applicable across groups is a possible concern (LeCompte and Goetz, 1982) but can be addressed by varying the settings. For this exploratory study, comparability is not as critical as the diversity of information obtained using focus groups. In Chenitz and Swanson (1986), factors that threaten validity during data collection in qualitative research are described. An attempt to address the effects of history in this study is made by selecting participants who are 49 certified by passing State competency exams. It is recognized that previous training received by the participants will vary. The ’snap-shot’, one-time data collection nullifies maturation effects. Sample bias will be problematic if dominant members of the group monopolize the interaction. It will be the role of the moderator to prevent this from occurring. Another bias issue is related to true representation of the nursing assistants in nursing home population. In this study, the demographic data indicate the nursing assistants sampled were comparable to nursing assistants state-wide. The reactive or observer effect is critical in this study of perceptions. It will be important to demonstrate with supportive data that categories are meaningful to participants and reflect their reality (LeCompte and Goetz, 1982). The debriefing period will include a review of the projected categories and an opportunity for participants to agree/disagree or comment. HUMAN SUBJECTS When discussing the research project with the administration of potential nursing home sites, presence of any formal organization structure to approve on-site research was ascertained. Procedures for approval as designated by the institutional policy was followed. The following procedures were enmeshed with field 50 procedures to assure confidentiality and anonymity of the facilities and participants in the study: 1) All materials generated during the study were kept in a locked file cabinet by the researcher. 2) Access to tapes was limited to the transcriber and researcher only. 3) Tapes, once transcribed, were destroyed. 4) Access to transcripts were limited to the researcher and second coder as designated. 5) All names and identifiers were omitted in transcribing. 6) Direct quotes used in analysis were not linked to any participant. 7) Participant names were not revealed to the employing facility by the researcher. 8) The facilities and participants were not identified by name in any report of the research findings. An application for review of this project involving human subjects was submitted to the UCRIHS of Michigan State University as directed (Appendix F) and approved. SUMMARY A qualitative research study utilizing a focus group interview approach to study the perceived continuing education needs and interests of nursing assistants employed in nursing homes has been described. Considerations in developing a sampling frame were discussed and the plan to recruit subjects was given. The framework for conducting the focus groups was portrayed and system of data management and analysis outlined. Projected assumptions and limitations of the study were considered. 51 CHAPTER FIVE OVERVIEW The purpose of this study is to describe the perceived continuing education needs and interests of nursing assistants employed in a nursing home. This chapter will contain the results of the study. Preparation of the Interview Guide questions is described. A discussion of the sample recruitment efforts will be given followed by a description of the sample population used in the study. Study results are then summarized. PREPARATION A pilot test of the questions used as the Interview Guide was done with a group of three certified nursing assistants employed at a 22-bed, hospital-based, long term care unit. As a result, some changes were made in the sequence of the questions to improve clarity, flow and answerability. SAMPLE RECRUITMENT An 120-bed extended care facility in a rural county was selected as a site #1. A date for the focus group interview was set with the help of the facility contact person and a sign-up sheet placed near the time clock. The sign-up sheet 52 was lost and a second date was set and sign-up sheet placed. The date selected coincided with an unforeseen union contract negotiation for nursing assistants. None of the six potential participants, who had signed the sign-up sheet, attended the focus group session. This interview was abandoned. Site #2 was a 76-bed, hospital-based extended care facility in a rural county. On the day of the planned focus group interview, one participant attended, two participants had been called in to work, and two did not show up. This interview was abandoned. A 75-bed extended care facility in a different rural county was site #3. Of the nine eligible participants, seven did attend and participate in the focus group interview. Site #4 was an 120-bed extended care facility located in the sole urban center of a rural region. Five potential participants signed up with only two attending and participating in the interview. SAMPLE DESCRIPTION The study sample consisted of participants from two focus groups and two different sites. One group had seven participants and the other two for a sample size of nine (n=9). Table 1 summarizes the demographic characteristics of study participants. 53 Table 1 Characteristics of Study Participants (n=9) Characteristic Gender male female Ag; 18-25 26-35 36-45 46-55 The mean age was 33 Marital Status married single divorced 1 pi Children Living n; flpng none 1-2 3 Household Income (n=7) SID-15,999 $16-20,999 $21-25,999 $26-30,999 $31-35,999 Number 54 (Table 1 cont.) Employnent Status 40 hours/week 6 24-28 hours/week 3 Shift Worked dayshift 3 afternoons 5 midnights 1 Length pf Employment 1-2 years 6 3-7 years 1 8-14 years 2 Education Completed (n=8) high school 7 college degree 1 SUMMARY OF FINDINGS In analysis of the interview transcripts, three themes were identified in each of the three areas of concern. First, for the nursing assistant’s perceived job and environment description, the themes were: (1) Job Benefits, (2) Job Hassles, and (3) Work Strategies. For the second area of concern, the nursing assistant’s perceived view of continuing education, the themes were: (1) Motivators, (2) Negative Reactions, and (3) Preferred Methods. In the third area of concern, the nursing assistant’s perceived relationship between job and continuing education, the 55 themes were: (1) Information Sources, (2) Needed Programs, and (3) Ways To Do. PERCEIVED JOB AND ENVIRONMENT DESCRIPTION JOB BENEFITS Responses coded in this category included statements which revealed elements or factors in the work role and environment that are reported as positive aspects. Four participants made statements describing job pluses. One participant referred to being a nursing assistant in long term care as the "job of the future" because of the current demographic trends of an increased elderly population. A second participant agreed with reservation, "you’re definite you have job security, for now, anyway, I don’t know what will happen in the future". In addition, two participants noted a sense of family- like involvement with residents as a valuable component of the job which resulted in a sense of personal gratification. On an individual level, one participant describes a resident, "He’s a quadriplegic so you know he doesn’t go anywhere. He’s like a buddy more so than a patient. He’s like a part of the family". A broader mention of this feeling is stated by one participant, "We love our jobs here and we get so attached to the people, they are like family". This final comment was supplemented by affirmative nods by the other six participants in that focus group. 56 JOB HASSLES Responses coded in this category included statements made by participants that describe elements or factors in the work role and environment that are reported as negative aspects. This constituted by far the most active theme, each of the nine participants made at least one specific comment with frequent nonverbal agreement by the group members to each other’s statements. Participants felt the image of the nursing assistant employed in nursing homes was predominantly negative in media portrayal and in society at large. Five participants made such references with one participant noting, ”Out to a social place, people ask what do you do? I’m a nursing assistant in a nursing home. 'Oh, you do that? And you’re in one of those terrible places that smells like urine?’ That’s what they see. And it’s the whole society". Along with a negative image, several participants noted a sense of low status within the nursing home setting, as one participant remarked, "you’re just a nurse aide". Seven participants made similar references with an over-riding sense of not being included in decision-making that influences their work role. One participant comments, "They institute policies and procedures that will help us do our jobs and so that we comply with the regulations. Our input doesn’t mean nothing. Somebody else makes the decisions". This is coupled with another participant’s belief that the 57 nursing assistant’s thoughts as the provider of direct care would be valuable, "They never ask our opinion of things that are important for residents. And we’re the primary caregivers." The nursing assistant role is in a state of evolution as new rules and regulations are implemented. This is noted by four participants as a pressure to do more within the same timeframe and with the same amount of help. One participant states, "Every time they turn around, we’ve got something else added to the list", with a second participant appending,"And we don’t get any more help to do it with". Augmenting the pressure of increased job expectations of the nursing assistant role, one participant made a strong case for the need for environmental support in terms of improved adequacy and management of supplies. The participant states, "Having things readily accessible to you and always in the same place so you can get them when you need them is important. It always seems like you’re running back and forth. You make fifteen trips to do one simple job. You waste a lot of time." Three other participants gave specific examples of such equipment-related problems. WORK STRATEGIES Responses coded in this category included reports of methods or work practices used by nursing assistants to facilitate job performance. Four participants made 58 statements in this category. Several participants noted the length of time spent in this type of work determined the strategies or "routine" of your performance. Experience influenced the nursing assistant’s level of comfort with the work as well as the approach taken. As one participant noted, "If you have been here long enough, you know how to cut corners without cutting patient care. Like if you do Vitals one day, you can do some the next day if you don’t have time. In developing the work strategies, the methodology cited by four participants was trial-and-error events, using new admits, residents with a change in condition and combative residents as examples. One participant notes, "If you’re talking about if they’ve had a stroke or anything, you just do what they used to do and then you find out what the prognosis is. You find out how bad the stroke was, was it on the right side, the left side, and you work from that. You try to do, I mean you just go with what they do. You change the routine a little bit". PERCEIVED VIEW _£ CONTINUING EDUCATION MOTIVATORS Responses in this category included statements that expressed nursing assistant’s reasons for attending continuing education programs, expected benefits and positive reactions to past educational experiences. Five 59 participants made statements in this category. Three participants noted that continuing education requirements existed for maintenance of the nursing assistant certification. Beyond the mandatory reason for attending continuing education programs, four participants reported a belief that such efforts would enhance the position and image of nursing assistants. One participant expressed a desire to see, "some sort of education program whereby nursing assistants would be elevated to at least a semiprofessional level as opposed to manual labor, which is where we find ourselves now." At a more personal level, one participant felt continuing education "would help our self-esteem in what we do and make us feel better about what we do and consequently we would be better with our patients". Nursing assistants are highly involved in activities beyond basic nursing care because of the direct care they provide and the evolving nature of the nursing home population. The ongoing Change in regulations and focus of care have caused much upheaval to routines. Three 1 participants strongly expressed a desire for explanation of change, with one participant noting, "I’m going to be more likely to do it if you can tell me why". In resident care, three participants related stories of a change in health status and their desire as a bedside caregiver to understand and learn from the situation. One participant stated, "it 60 helps to know why the patient is the way they are". NEGATIVE REACTIONS Responses coded in this category were comments describing difficulties or rationale for not attending continuing education programs. Eight participants made statements in this category. Three participants commented on the unrealistic nature of some programs, citing movies and videotapes as chief offenders. Examples cited made it difficult to apply the information in the work setting. As one participant discussed a program on oral care, "Really, you have one (resident) that doesn’t open his mouth, or that refuses or you give them a toothbrush and they throw it across the room. They don’t show those (in the films)". Attendance at continuing education programs is often an expectation that is added to the nursing assistant’s workday. Attendance on off day is usually compensated by a standard amount, "we get six dollars no matter how long we’re here". One participant acknowledged efforts of facility education personnel to make some accommodations in scheduling, "but I just don’t have time to take away from my patients. Your day is ruined." Besides the infringement on the nursing assistant routine, a second participant noted, "When you get up on the floor, the residents are mad at you, 'where have you been? Nobody would take me to the pot’, and 9 you know it’s going to be one of those nights.’ Similar 61 comments were made by three more participants. Under the OBRA regulations, there are mandated topics to be covered annually such as oral care and working with the demented resident plus state and institutional requirements for programs such as safety and universal precautions. Three participants noted the repetition as problematic with one commenting, "I’m hearing the same thing over and over and over again. And it makes it very hard to go to the twelve hours that we’re required to get in, in a year." Another participant adds, "It’s a terrible waste of time". PREFERRED METHODS Responses in this category reflect a critique of various teaching strategies. Eight teaching methods were reviewed by the participants using both a written questionnaire (see Appendix E) and focus group discussion. On the questionnaire (n=9), preference for teaching strategies clustered on a Likert scale ranging from Strongly Like to Strongly Dislike. Two methods were most often endorsed as Strongly Liked: Lecture/Discussion and Guest Speakers. Table 2 depicts the results from the questionnaire including the mean. 62 Table 2 Teaching Methods Questionnaire Results (n=9) Strongly Like Dislike Strongly Like Dislike (1-3) (4-5) (6-7) (8-10) Method Videotnpe/Movies 5 - 2 2 Mean = 4.0 SlideZTapes 2 4 2 , 1 Mean = 4.6 Lecture/Discussion 6 1 - 2 Mean = 3.0 Computer-Assisted 2 3 3 1 Programs Mean = 4.8 Guest Speakers 6 1 - 2 Mean = 3.0 Take-Home Packets 1 4 1 3 Mean = 5.5 Skills Labs 4 2 1 2 Mean = 3.9 Ecstep Displays 1 3 3 2 Mean = 5.3 Additional statements about the various teaching strategies were made during the focus group sessions. Six participants made statements about VideotapeZMovies. Three nursing assistants noted the lack of realism in productions with one commenting, "you can tell it’s a trumped up situation... give me some real footage." Viewing time was mentioned by one participant as, "Sort of depends on the time of the day. I tend to sleep through video programs." A 63 second participant notes, "If they put a VCR in the break room, I might tend to sit down there and watch it", though another participant later states, "The break time should be your own time." A tongue-in-Cheek solution offered by another participant was, "I think they should put a VCR in the bathroom". The SlideZTape teaching strategy received no comments during the focus group discussions though all partiCipants indicated an understanding of the technique. Two participants made positive comments about the teaching method, Lecture/Discusgion noting, "I enjoy the lectures. There is a lot of information". In terms of Computer- Assisted Pro rams, one participant reported experience with this teaching strategy through a college course, describing the method, "they are wonderful". At both sites, a computer- assisted program was used for basic training but number of participants familiar with method was not ascertained. Five participants commented on use of Guest Speakers. Two described specific, memorable topics and speakers, noting the experience was "really enjoyable" and "very helpful". A caveat is made by one participant who states, "guest speakers are things that are worthwhile listening to," but noting the time taken from the workday, the participant questions, "is it worth having a bad day because I went to hear this person talk?" One participant reports receiving "highlights" of the speaker’s presentation from a 64 co-worker attending, while a second participant states, "I would be waiting to see the video". Take-Home Packets received comment from four participants. Three participants doubted the success of this teaching strategy with one commenting, "That would go over like a lead balloon". At issue was use of personal time with one participant stating, "I’d never get to the take home thing" and a second noting "I don’t like anything that I have to take home and figure into my schedule at home too". Only one participant commented that Skills Labs were, " though all participants indicated experience with "okay, this teaching strategy. Poster Displays were cited by two participants who noted their extensive presence in the work setting, but questioned the value in terms of, "you don’t get inservice credit for having looked at them". PERCEIVED RELATIONSHIP BETWEEN J_B AND CONTINUING EDUCATION INFORMATION SOURCES Responses in this category referred to methods or resources used to obtain knowledge and skills that impact job performance. Table 3 summarizes the information sources and number of participants making citation. 65 Table 3 Information Sources Cited by Participants (n=9) Source f of Participants RN/LPN 6 Other Nursing Assistants 5 On-the-Job Experience 5 Charts/Documentation 2 Residents 1 Responses during the focus group sessions acknowledged using the RNZLPN as a source of information in light of their position within the nursing home. One participant notes, "If I have a question about work, I go to the supervisor". Participants requested information from pnnpp nursing assistants recognizing their experience as one participant states, "I always ask somebody (nursing assistant) who has had them (resident) before". On-the-job experience was cited as an information source for developing work habits and delivering care to specific residents. For example, to master organizational skills, one participant states doing so by, "I guess mostly being on the floor a lot. You pick out a pattern for yourself". In terms of using a transfer belt when assisting residents to or from a chair, one participant comments, "if you feel comfortable with them, use them. But if you feel comfortable with the resident and you know them well 66 enough, you know how to transfer them (without a belt)". Resident charts/documentgtion were cited as information sources by a one participant who had been on the job for 14 years and a second participant who was completing an Associate Degree nursing program. Documentation done by nursing assistants consists of graphics and flow sheets. A final source of information noted by one participant as, "Sometimes we even talk to the patient," was met with affirmative nods by other group members. NEEDED PROGRAMS Responses coded in this category involved topics reported as potentially being helpful/useful in enhancing job performance. Seven participants offered suggestions for specific topics or categories of topics. The most frequently mentioned topic was dealing with difficult residents. The descriptors used by participants for residents in this category included "combative,' those 9 "who think they are the only resident,’ and residents who "really have their minds together". The need as expressed by one participant was, "help in how to handle them". The effects of disease and the aging process on the residents was a prevalent topic. Participants cited experiences with residents who suffered a stroke or evidenced bleeding as a change in condition as instances when additional information would have been helpful in their 67 ongoing provision of direct care. As one participant states, "I don’t want to know what the disease processes will ultimately do in minute detail. I want to know enough about it so that I can deal with this resident intelligently". Citations of the topic of communication skills were directed to staff interaction with one participant clarifying, "between the nursing assistants and the nurses". In noting the topic of organizational skills, one participant acknowledges, "Organization is kind of a hard thing to teach somebody," while three other participants describe the importance of this skill as how to, "prioritize "survive your care," "get through your shift," and Table 4 lists specific topics and categories, noting the frequency of mention. Table 4 Program Topics Named by Participants 0 ic Frequency of Mention Dealing with Difficult Residents 5 Organizational Skills 4 Disease Processes and Aging 3 Communication Skills 2 Stress Relief/Relaxation 2 Effects of Medications 2 Death and dying 1 68 WAYS TO DO Responses coded in this category include comments pertaining to suggested approaches to successful facilitation of continuing education programs for nursing assistants in the nursing home. Participants offered recommendations of specific programs, approach and direction of content, and methods of integration in the work setting with seven participants contributing ideas. One participant felt a role-reversal program would benefit all staff in appreciating what a workday is like, "every nurse should be a nursing assistant for a day". A second participant expanded the program to "a nurse aide should take a turn as a patient for one day, sit in a chair for eight hours in a restraint". As a solution to repetition of required programs, one participant suggested, "a pre-test...if I can pass the test, I must have the knowledge, then let me go back to work". Program content geared to the specific populations of the nursing home were cited as desirable by participants. One notes, "I want to know enough...so that I can deal with the resident intelligently and have some idea of what I can expect them to do". Beyond the expected benefits of increased knowledge and skills, the participants stated the desire for inclusion of additional rewards for nursing assistants as a result of participation in educational programs. One participant 69 commented, "you need a carrot, you need some recognition ... to keep you motivated". A second participant suggested, "some steps and hey, you’ve attended ’X’amounts of inservices in relationship to this, maybe we have a different class of nurse aides that are allowed to do more things". SUMMARY In this chapter, the data is reported within the framework of the three areas of concern for the study. Examples from the text of the focus group interviews are given as thematic, supportive statements. Discussion of the results and implications for advanced practice nursing will be in Chapter Six. 70 CHAPTER SIX OVERVIEW In this chapter, acknowledgement of additional limitations of the study is made, followed by a discussion of the findings. Recommendations for further research are included. Implications for advanced practice nursing by the Gerontological Clinical Nurse Specialist with primary care emphasis are discussed, followed by implications for research and education. LIMITATIONS With the completion of data collection, additional considerations that influence the representativeness and generalizability of the findings of the study are noted. One, the difficulty in recruiting participants yielded one focus group with seven members and a second group with two participants. The responses from the two member group were essentially the same as the seven member group though the potential diversity was likely effected. Second, the seven member focus group took place in a small, rural facility and the two member group was held at a large, urban setting. The influence of location and size of institution was not considered in this study but may be a factor for consideration in future research. A third limitation of this study is the total number of 71 participants (n=9). Table 5 compares the sample to the state-wide nursing assistant population (Dept. of Public Health, 1993). Table 5 Comparison of Sample to State-Wide Nursing Assistant Population Characteristic State (%) Study Sample (%) r1 ' n = 50,219 n=9 E Gender 1 r i male 9% 11% i female 91% 88% L. ASE 18-25 31% 11% 26-35 30% 44% 36-45 7% 22% 46-55 11% 22% In Table 5, the gender of the sample population closely reflects the state-wide population. The sample population does have a higher percentage of participants in the older age groups than in the state-wide population. This may influence study results in terms of length of employment effects, subsequent impact of experience, and view of nursing assistant position as a career starting point or end point. As an early work in researching this understudied population, the qualitative methodology revealed an approach that provided pertinent information that can be used to develop learning needs assessment tool. An additional benefit may have been reflected in the moderator’s sense 72 that the interview sessions provided a nonthreatening forum for the nursing assistants to verbalize their perceptions and concerns about their role and their work in the nursing home to an unknown researcher with a potential for impact. As noted by one participant, "I hope this stuff gets to the people in charge who need to hear it". DISCUSSION OF FINDINGS A guiding framework for this study of the perceived continuing education needs and interests of the nursing assistant employed in a nursing home has been the three areas of concern: 1) perceived job and environment description, 2) perceived view of continuing education, and 3) perceived relationship between job and continuing education. Continuing this framework, findings are discussed with consideration of the literature and the assumptions of Knowles (1980) in describing the adult learner. PERCEIVED JOB AND ENVIRONMENT DESCRIPTION The interview guide used to conduct the focus group sessions did not include questions that addressed perceived benefits of the nursing assistant position. The two findings, a sense of job security and personal gratification from direct care, surfaced independently, perhaps reflecting their level of importance and an area for further research. The current mode of learning the job expectations and 73 work role is described in terms of on-the-job training utilizing a trial-and-error methodology. Participants refer to experience and years of service as the source of their expertise and comfort in the position. The content of the learning experience is driven by the performance expectations and requirements of the nursing home and as one participant states, "surviving the job". This experiential learning of the work role, which is supported by the environment of the nursing home, needs to be recognized in Knowles’ assumption that "adults have acquired a larger number of fixed habits and patterns of thought and therefore tend to be less open-minded." The wealth of accumulated experience can thereby make anticipated behavioral changes more difficult. To support the behavioral changes sought through continuing education, Campbell et al. (1991) recommend "a sociocultural environment to foster these skills as a job expectation and an integral part of the care of nursing home residents." The work environment is described by the participants of the study as fraught with reminders of the negative image and low status of the nursing assistant role. The sense of lack of support extends to the physical working environment in terms of inadequate equipment and inefficient supply systems. This portrayal of the job and work environment by the participants brings to question the amount of autonomy and 74 control felt by nursing assistants. As adult learners, Knowles (1980) assumes, "self concept moves from one of being a dependent personality toward one of being a self directed human being". Within the nursing home environment and nursing assistant role, the findings suggest some inhibition or lack of recognition of this developmental task. PERCEIVED VIEW OF CONTINUING EDUCATION The assumed natural developmental movement of adults toward self-direction described by Knowles (1980) may be evidenced in the participants notation of using successful work strategies as a method of learning. The nursing assistants seem able to fulfill the implementation of this developmental task within the confines of their current roles. In addition, the participants clearly propose a role for continuing education in promoting this development. The nursing assistants in this study described continuing education as a means to improve their image and position, and hence their self-esteem. The general sentiment of participants defined a strongly felt awareness of the lack of status or placement of the nursing assistant position in the health care professions. Yet participants emphasized the key role they perform as the primary providers of direct care to the nursing home residents. Participation in continuing education is viewed as a 75 potential vehicle for recognition of the importance of the work performed and 'professionalization’ of the role. From the results of this study, the nursingassistants indicate the current continuing education programs do not fulfill this need. Continuing education is also viewed by the nursing assistants as a means to provide the 'why’ or explanation for expected and required changes in their routines or work behaviors and for the observed changes in the residents they work with daily. This kind of information augments the expertise of basic nursing care developed from the mandatory classes and from experience to enhance work performance. Tellis-Nayak’s (1989) observation that despite mandated educational programs in nursing homes, there is little expectation for change to occur, may be refuted by focusing continuing education efforts to respond to nursing assistants’ expressed need and interest for meaningful explanation. As Knowles (1980) acknowledges in discussing "readiness to learn", it is more conducive to teach what the learner wants to know before teaching what the teacher wants the learner to know. Having described what they see as the role of continuing education in the work setting, the nursing assistants go on to emphasize the importance of provision of programs in a manner that is not "a waste of time". The majority of past participation in workplace education 76 programs has been attendance at mandatory sessions, often required on an annual basis. The nursing assistants relate the repetitive nature of the familiar content as an example of an unproductive learning experience. Alternative methods, such as 'testing out’ options for familiar topics, are suggested as time-saving ways to meet the requirements with efforts spent in providing innovative programs for dissemination of new information. At this time, continuing education programs are an addition to the workday expectations of the nursing assistant with minimal compensation for attendance on off time. Participants indicated an appreciation of the logistical difficulties in scheduling class times but also strongly indicated a reluctance to interrupt and complicate an already full workday or to give up break time and days off to attend. A separation of work and continuing education activities in terms of off-duty time and reasonable reimbursement is suggested. A final implication by nursing assistants in terms of efforts to provide meaningful and useful continuing education programs is to make presentations as realistic as possible. This relates to Knowles (1980) "immediacy of application". Generating programs as close to the actual day-to-day work experience will help the nursing assistants implement the acquired knowledge and skills. Effective programs will have little lasting value, as del Bueno 77 explains, "if there is no subsequent development and reinforcement". A setting-specific, realistic presentation may be a critical connection in meeting the continuing education needs of the nursing assistant, assuring immediate application, and facilitating subsequent retention of the learned knowledge or skill. Follow-up and reinforcement are also indicated, rather than reliance on one time only programs. Considering the previous discussion that reflects some clear expectations of continuing education programs, a surprising result from the study is the strong preference by the nursing assistants for the teaching methodologies of lecture/discussion and guest speakers. This finding may be derived from participants past educational experiences in a pedagogical school model and limited experience in an adult learning framework. The passive nature of the methods in terms of participation by the learner may be attractive as nonthreatening, undemanding events in the full workday world of the nursing assistant. The finding may also reflect a lack of experience with other methods, i.e. computer- assisted programs or small group discussions. Additional research on the nursing assistants as adult learners would be helpful and application of adult learning models in the work setting would be of interest. 78 PERCEIVED RELATIONSHIP OF JOB AND CONTINUING EDUCATION In the workday world of the nursing assistant, how does continuing education fit in? When asked about current resources for information, the participants cited most frequently the R.N. or L.P.N. "in charge". Though this source proved useful for situations of immediate need, a caveat was noted of difference of opinion among the professional nursing staff leading to lack of clarity and continuity in caregiving methods. The nursing assistant felt caught between needing information, receiving conflicting information but having to perform as directed, even when contradictory. An additional source of information was other nursing assistants who had the experience of caring for a particular resident in the past or had faced a similar situation. The other source cited was the residents themselves either in response to direct questioning or through a trial-and-error approach. From these findings, it is clear that work-related information is generated primarily for immediate use and from experience. Previously it was noted that the nursing assistants were interested in explanation of changes in procedures or resident’s condition, the "why". This depth of information goes beyond the immediate task at hand. In Canar and Johnson’s (1986) work, a learning needs assessment tool was developed but demonstrated few if any perceived needs by the 79 direct care staff, including nursing assistants. It may be that the needs identified were task oriented and the provider staff indicated possession of the skills and knowledge. The participants of the current study implied having a foundation of the 'what’ to do and were interested in the 'why’, as it might impact the 'what’. All of the topics cited during the interviews are part of the basic, mandated program. The topics most frequently mentioned by the nursing assistants fall in two categories: 1) resident care-related and 2) work process-related. In terms of resident care, working with "difficult" residents was the most cited. The difficult residents were described as being combative, demented, demanding and cognitively intact. Further research on the nursing assistants’ perceptions what defines the 'difficult’ resident would be enlightening. In addition, the nursing assistants expressed interest in understanding changes brought on by the aging process, the effects of advancing chronic diseases, the prognosis of disease-related or disease-caused functional disabilities and the expected and unexpected effects of medications on residents. From this listing, it is clear that the nursing assistant is looking for an explanation for observed changes in residents and perhaps some anticipatory planning capabilities for care provision. One of the work-process related topics noted by 80 participants was the need for good organizational skills as a matter of "survival" in the hectic workday of the nursing home. It may be that more staff is needed and that getting more organized will help only to a limited extent. Further research may be helpful. A second topic was communication skills. This was expressed as an institution-wide need and may reflect the perceived low status of the nursing assistant. Coupled with this sentiment was the ’ participant’s belief that the nursing assistant is the primary care provider and should be included in any decision-making process that directly effects their work with the residents. The final topic cited was a self-care issue of stress management. The nursing assistants expressed concern over the daily pressure felt on the job to perform more duties in a specified, regulated manner, without a reasonable explanation of 'why’ and without any request for their input. The prevailing sense of powerlessness is compounded by the sense of lack of recognition for the work performed. Without recourse or avenues to vent the reported stress, a participant concern was the carry-over into their personal lives and a need to displace stress and "kick the dog". With these topics in mind, developing and presenting continuing education programs for nursing assistants, must include consideration of convenience in logistics issues and realistic application potential. In addition, beyond the 81 dissemination of new knowledge and new skills, the nursing assistants would like a system of recognition built into the active participation in continuing education programs. A clinical ladder program for nursing assistants that would provide rewards and a vehicle for advancement was suggested. Future research into the development and outcomes of such programs would be useful. A final component necessary for continuing education programming in nursing homes is an awareness of the system within which the expectations are to be realized. In the education based, intervention toileting program developed by Schnelle, Newman and Fogarty (1990) the lack of continuation by nursing assistants may have been due to not considering the setting and consulting the nursing assistants’ responsible for ongoing implementation. Additional studies of successful applications of research findings in the actual work setting are needed. In summary, the position of the nursing assistant is poorly defined in health care and specifically, in the step- child, nursing home industry. The direct care responsibilities of nursing assistants for a growing population of nursing home residents perhaps warrants additional consideration of their status and preparation for the role. The newly mandated education program is a start but without evaluation and reinforcement may not be sufficient. Evaluation of dollars saved by enhanced nursing 82 assistants skills would be especially useful in the current cost containment environment of health care. And without defining direction for the role of the nursing assistant and recognition of their work, the foundation for continuing education program development is weak. IMPLICATIONS FOR THE GCNS PRACTICE The target population for the advanced nursing practice of the GCNS remains the elderly across settings. Within the nursing homes is a growing population that could benefit from the knowledge and skills of the GCNS. In spite of the need to be a presence in this setting, there is not recognition of the potential benefits in the rules, regulations or reimbursement mechanisms of the nursing home industry. A GCNS may have a position as an administrator, educator, clinician, or combinatiOn of all of these. As an administrator, the GCNS does not deliver direct care but directs and is responsible for the care provided by staff, including the nursing assistants. From this study, the GCNS can acknowledge an awareness of the felt negative image and low status of nursing assistants and take steps to remedy the situation by instituting employee recognition programs with clear criteria for nomination and rewards such as awarding Certified Nursing Assistant pins as State certification is accomplished, and providing a choice parking place to the Nursing Assistant of the month. 83 The importance of education in the nursing home system can be supported with results from small-scale, outcome- oriented studies done after educational programs are provided that evidence time and cost savings realized by investing in development of the nursing assistant role. Such findings can enhance efforts to secure financial commitment for staff development programs from the Board of Directors of the facility. Another method of supporting and providing continuing education programs for nursing assistants would be to sponsor special meetings or conferences. This could be done by seeking financial sponsorship from involved health care companies or local health care institutions. In the role of educator, the GCNS may be responsible for provision of continuing education programs for nursing assistants to meet regulatory requirements or site specific needs. One way to preclude the repetitive nature of mandatory programs would be to offer a paid, one-day event quarterly that fulfilled the requirements and utilized various teaching methods and updated materials. From the results of this study, other continuing education programs are indicated. One approach might be to use case study presentations of particular residents that have evidenced a change in condition or are considered 'difficult’. A peer review program would involve the nursing assistants as presenters and as consultants, 84 building communication skills, self-esteem, professional identity and team cohesiveness. There may be a method to consider a 'problem of the week’ with group problem-solving techniques to seek solutions. Application of adult learning theory will need to 1% include the challenge of fostering adult learning i methodology within the constraints of a business operation. ‘ Realistic, site-specific, useful and logistically convenient programs driven by the needs of the facility and the nursing i assistant/learner should be offered using situations and examples specific to the setting. The GCNS educator should know the dominant medical conditions of residents, the incidence of incontinence, restraint use, falls and other nursing home problems effecting the work of nursing assistants and current research that could enhance the care delivery system of the facility. As identified by the nursing assistants in the study, a system of recognition and reward for continuing education efforts is warranted. The GCNS functioning as a clinician in a nursing home is providing direct care and guiding indirect care. This may be a part of a primary care practice. In considering the results of this study, the GCNS can acknowledge the expertise of the nursing assistant by seeking information about resident status from them and consulting these direct caregivers when considering changes in the plan of care. As a role model, the GCNS in the facility may find ample 85 opportunities to offer impromptu continuing education experiences one to one with potentially immediate impact for staff enhancement and resident care. IMPLICATIONS FOR RESEARCH In this descriptive study, the focus group technique was used to explore ideas and opinions of nursing assistants without the constraints of a written questionnaire. A group size of four to five participants would probably be ideal. To assure an adequate breadth of findings, conducting more groups would be helpful, until data gathered was repetitive of earlier groups (Morgan, 1988). Replication of the study with more ethnically diverse groups is indicated, as is strong consideration of the setting in terms of location and facility size. A survey to document nursing assistant’s continuing. education needs could be developed from the focus group results to include questions about content and methodology with plans for repetitive administration. This could be correlated with evaluations of programs offered and accomplishment of projected outcomes. Quantifying a cost savings of "empowered" nursing assistants who work cooperatively with GCNS’s may be another direction for research. Studies to evaluate efforts in continuing education that involve follow-up and reinforcement versus one time 86 only programs would be helpful. IMPLICATIONS FOR EDUCATION The poorly-defined, poorly-developed relationship between the professional nurse and the nursing assistant tends to be supervisory in nature. From the results of this study, that relationship is best described as strained. Nursing assistants report lack of continuity in direction, lack of appreciation of work load or work performance and exclusion in decision-making as sources of the strain. Professional nurses, who are responsible for direct and indirect care provision need to recognize the pivotal role of the nursing assistant. The nursing home industry is significantly effected by cost constraints felt by all health care providers. Their product, care delivery, is predicated on the poorly paid, poorly benefitted, overworked and poorly trained nursing assistants. The research suggested may prove the cost- saving benefits of a commitment to the recognize and develop of nursing assistants as the valuable resource. An additional outcome of such research to be considered would be the cost-savings of staff retention. On a broader scope, the results from this study indicate a need for decision-makers who impact policies and regulations effecting the nursing home industry, to be made aware of the effects of their decisions at the level of 87 implementation. This may be facilitated through the advocacy work of the GCNS in supporting the nursing assistants in developing and promoting a professional identity by communicating their needs at local, state and national levels. At the community level, the image of the nursing assistant is colored by sensational news reports of abuse and a negative, historical view of nursing homes. There is an underappreciation for the time consuming, sometimes physically difficult and often emotionally taxing care work provided by the majority of nursing assistants. Community support could be promoted by special recognition programs such as, "Nursing Assistant of the Month", and involvement in Nursing Assistant day with features in the local papers. SUMMARY In this chapter, the results of the study of the continuing education needs and interests of nursing assistants employed in nursing homes is presented from their perceptions. Implications for the GCNS in practice are discussed, as are implications for research and education. Additional proposed research directions are recommended. APPENDIX A 88 APPENDIX A Date: Dear : Would you be interested in volunteering to participate in a research study to be done at your workplace? If you decide to be a participant, you will be expected to take part in a discussion with a small group of other nursing assistants that will take two hours. We will be talking about the kinds of education programs you would be interested in attending that might help you in your work as a nursing assistant in a nursing home. The discussion will be tape-recorded, typed up without names and then the tapes are destroyed. The purpose of this study is to gather this information from the people who know the most about it. Your shared opinions, thoughts and feelings are a very important contribution. Refreshments will be served and participants will receive a $10.00 payment. The group discussion will take place on: DATE: TIME: LOCATION: If you would like to participate in the study, please: 1) read and sign the Agreement to Participate form 2) fill out the Demographic Information form 3) return both in the stamped, addressed envelope by If you have additional questions about the study or your involvement, please contact Judy Jerome at 935-6520 or 889- 5763. - Thank you again, for your time and consideration of this project. Sincerely, APPENDIX B 89 APPENDIX B AGREEMENT TO PARTICIPATE I have been asked to participate in a research study that is looking at the educational program needs and interests of nursing assistants who work in a nursing home. My participation involves taking part in a small group discussion with co-workers that will last about 2 hours. The discussion for the study will take place where I work, but not during my scheduled work time. The group discussion will be tape-recorded with only the research team having access to the tape. The typed copy of the discussion will have all names and identifying remarks left out. All results will be treated with strict confidence and as a participant, my name will not appear in any report of the research findings. On request, a report, within these restrictions, will be available to me. I understand that my participation is voluntary and I may Choose to end my involvement at any time. I further understand that participation or nonparticipation will not affect my work in terms of promotion, raises or conditions of employment in any way. At the end of the group discussion, I will receive a $10.00 payment for participation. I am satisfied with the explanation of my role in the research study and agree to participate in the group discussion. NAME: DATE: 89 APPENDIX C 90 APPENDIX C DEMOGRAPHIC INFORMATION NAME: DATE OF BIRTH: SEX: (Circle one) Female Male MARITAL STATUS: (Circle one) Married Single Divorced Separated Widowed NUMBER OF CHILDREN LIVING WITH YOU: YEARLY FAMILY INCOME: DATE OF MICHIGAN NURSING ASSISTANT CERTIFICATION: DATE OF EMPLOYMENT AT THIS FACILITY: USUAL SHIFT WORKED: HOURS CURRENTLY WORKED IN A WEEK: EDHQAIIQN GRADE COMPLETED: OTHER TRAINING OR FORMAL EDUCATION: PREVIOUS EMPLOYMENT: (List any jobs in health-related field) APPENDIX D CATEGORY: PERCEIVED JOB AND ENVIRONMENT DESCRIPTION 1 O 2. 91 APPENDIX D INTERVIEW GUIDE Whose opinion do you value in providing care to the residents? What changes have you made in how you give care to the residents in the last few months? What led to these changes? Where do you get information to make changes in how you give care? What work habits contribute to good resident care? What are the two or three greatest caregiving problems facing nursing assistants? Can they be solved? CATEGORY: PERCEIVED VIEW OF CONTINUING EDUCATION 1. Do you believe education programs help? What two or three kinds of education programs have the most potential for helping? What does continuing education mean to you? Are continuing education programs of interest? I am going to give you a list of methods that are used to provide continuing education and explain what they are. Then I will ask you to score each method on a scale of one to ten, with one meaning you Strongly Like the method and ten meaning you Strongly Dislike the method. After collecting the lists, I will ask for any additional comments about each method. APPENDIX D (cont.) 92 INTERVIEW GUIDE (cont.) CATEGORY: PERCEIVED RELATIONSHIP BETWEEN JOB AND CONTINUING EDUCATION 1. What would be the most fun or interesting to learn about residents and caregiving? 2. What are some of the best ways to learn about these topics? 3. What would help you to make changes in how you care for residents? Why is it hard to change? What are the reasons why you might choose to change? What makes it hard to change? APPENDIX E 7‘"__3 93 APPENDIX E Following is a list of methods used for continuing education programs. Please CIRCLE the number which best describes how you feel about each method. STRONGLY STRONGLY LIKE DISLIKE VIDEOTAPED PROGRAMS 1 2 3 4 5 6 7 8 9 10 SLIDE/TAPE PRESENTATIONS 1 2 3 4 5 6 7 8 9 10 LECTURE AND DISCUSSION 1 2 3 4 5 6 7 8 9 10 COMPUTER-ASSISTED PROGRAMS l 2 3 4 5 6 7 8 9 10 GUEST SPEAKERS 1 2 3 4 5 6 7 8 9 10 TAKE-HOME LEARNING PACKETS 1 2 3 4 5 6 7 8 9 10 SKILLS LABS 1 2 3 4 5 6 7 8 9 10 POSTER PRESENTATIONS 1 2 3 4 5 6 7 8 9 10 APPENDIX F 94 MICHIGAN STATE UNIVERSITY OFFICE Of VICE PRESIDENT POI RESEARCH EAST LANSING 0 MICHIGAN 0 «flu-I.“ AND DEAN Of THE GRADUATE SCHOOL September 10, 1992 Judy L. Jerome P.o. Box 1770 Frankfort, MI 49635 RE: ”PERCEIVED CONTINUING EDUCATION NEEDS AND INTERESTS OF NURSING ASSISTANTS EMPLOYED IN NURSING HOMES", IRB #92-445 Dear Ms. Jerome: The above project is exempt from full UCRIHS review. The proposed research protocol has been reviewed by a member of the UCRIHS committee. The rights and welfare of human subjects appear to be protected and you have approval to conduct the research. You are reminded that UCRIHS approval is valid for one calendar year. If you plan to continue this project beyond one year, please make provisions for obtaining appropriate UCRIHS approval one month prior to September 10,1993. Any changes in procedures involving human subjects must be reviewed by UCRIHS prior to initiation of the change. UCRIHS must also be notified promptly of any problems (unexpected side effects, complaints, etc.) involving human subjects during the course of the work. Thank you for bringing this project to my attention. If I can be of any future help, please do not hesitate to let me know. Sincerely, ! 4&3 David E. Wright, , Chair University Committee on Research Involving Human Subjects (UCRIHS) DEW/pjm cc: Dr. Sharon King "515 u on All-meme Anna/Equal Gym-unn- lawnmo- APPENDIX G 95 APPENDIX G FOCUS GROUP INTERVIEW FIELD NOTE GROUP ONE NOVEMBER 5, 1992 Conducting the group: take more time setting up ground rules, i.e. plans to go round robin to get all participating, okay to pass * more time for warm-up and introductions > * seating with moderator in centered position Themes and comments: * reference to looking in the chart for information * sentiments about resident’s having all the ’rights’ and the staff having none * expression of stress reaction, openness in terms of wanting to react * remarks about having to put on a false front for residents * strong feelings about being inferior, unrecognized at all levels (work setting, in community, in country) * role of licensed personnel, interaction and impact on nurse assistant’s work * sense of pressure to do more without adequate resources "why don’t they ever ask us?" hard to apply educational programs because not realistic * insulted by State certification exam and administration of test at sites ** Moderator reaction: The group was initially shy, with two participants dominating the interaction. Gradually more participated and were candid in remarks. Though they commented about the room being 'bugged’, it was interesting that at the end, some said they hoped the information would get back to the facility. Though comments were made about "caring" about the residents in terms of their feelings/persons, more dominant- were task and work setting concerns, especially involving the role of the nursing assistant. APPENDIX G (cont.) 96 Participant who commented she did not want to work at a nursing home had been fairly quiet until the end when she indicated a desire to know about med reactions/side effects and diagnostic information about residents that would help her care for and understand what was happening to them. Her previous comment was in regard to having supplies to do the job. Resident behaviors (combative) seemed the significant topic of interest. Mandatory programs were "enough" but tended to get repetitive. It was interesting that specific topics did not really come up. Education seemed to be seen as a possible way to elevate the nursing assistant in status. But it was strongly stated that it could be used to help others in the nursing home understand the work of the nursing assistant also. APPENDIX G (cont.) 97 FOCUS GROUP INTERVIEW FIELD NOTE GROUP TWO MARCH 25, 1993 Conducting the group: * difficulty with only two because at times comments were more a matter of 'your turn’ then perhaps spontaneous * more warm up necessary in small group to achieve comfort level Themes and comments: * lack of "team" in work setting, more a sense of being out there on your own. Hard to tell if this was viewed as being preferred * what is npp said is as telling as what is, nonverbals * rules/regs - after tape off comment "I’d like to go to L ------- and meet those people and tell them how they’ve made my life hell" * lack of references to residents as individuals or sense of their role ... driven by research focus? or site? * we - they - them view, lack of control/autonomy sense * end comment: "I’m surprised more people didn’t sign up to do this, what with the food and money * powerless to influence job * nursing assistant a dead-end position * re: continuing education comment at end - "they’ve done surveys and asked us this tons of times. Maybe if they just gave us a list and we checked off what we’d like." Moderator reaction: The group consisted of a female who was completing the ADN program at the local community college and a Black male, a minority in the local population. The female was very articulate and had been in the position a long time. The gentleman had held this position a short time but had previous experience at other facilities. Both participants were highly involved in the discussion and thoughtful before answering. The student nurse seemed to feel it necessary to "answer" each question and try to do so "correctly", perhaps due to student role. The strong overiding sense was of the 'out on your own’ to get the work done but with no say in decisions passed down from 'them’. This facility was the largest and this may have played into that. There also was no sense of a relationship with the residents beyond 'work to be done’ but the caring was there. It generally was overwhelmed by the workload/expectations. LI ST OF REFERENCES 98 LIST OF REFERENCES Almquist, E., Stein, 8., Weiner, A. & Linn, M. (1981). Evaluation of continuing education for long-term personnel: Impact upon attitudes and knowledge. Journal of American Geristrics Society, 29(3), 117-122. Barney, J.L. (1983). A new perspective on nurse’s aide training. Geriatric Nursin , 1, 44-48. Bockmon, D.F. & Riemen, D.J., (1987), Qualitative versus quantitative nursing research. Holistic Nursing Practice, 2(1), 71-71. Burgio, L.D., Engel, B.T., McCormick, K., Hawkins, A. & Scheve, A. (1988). Behavioral treatment for urinary incontinence in elderly inpatients: Initial attempts to modify prompting and toileting procedures. Behavior Therapy, 19, 345-357. Burgio, L.D., Engel, B.T., Hawkins, A. McMormick, K. & Scheve, A. (1990). A descriptive analysis of nursing staff behaviors in a teaching nursing home: Differences among NAs, LPNs, and RNs. The Gerontolo ist, 30(1), 107-112. Campbell, E.B., Knight, M., Benson, M., & Colling, J. (1991). Effect of an incontinence training program on nursing home staff’s knowledge, attitudes and behavior. The Gerontolo ist, 31(6), 788-794. 99 Canar, M.J. and Johnson, J.C. (1986). An employee learning needs assessment concerning mental health needs of residents in a long-term care setting. The Journsl of Continuing Educstion in Nursin , 17(1), 5-11. Chandler, J.T., Rachal, J.R. & Kazelskis, R. (1986). Attitudes of long-term care personnel toward the elderly. The Gerontologist, 26(3), 551-555. Chenitz, W.C. & Swanson, J.M., (1986). From practice to grounded theory. Menlo Park: Addison-Wesley Publishing Company Cobb, A.K. & Hagemaster, J.N. (1987). Ten criteria for evaluating qualitative research proposals. Journsl of Nursing,Educstion, 26(4), 138-143. Cohen-Mansfield, J. (1989). Sources of satisfaction and stress in nursing home caregivers: Preliminary results. Journsl of Advsnced Nursin , 14, 383-388. Creason, N.S., Grybowski, J.A., Burgener, S., Whippo, C., Yeo, S.A. & Richardson, B. (1989). Prompted voiding therapy for urinary incontinence in aged female nursing home residents. Journsl of Advanced Nu sin , 14, 120-126. Crockett, S.J., Heller, K.E. & Peterson, J.M. (1990). Assessing beliefs of older rural Americans about nutrition education: Use of the focus group approach. Perspectives in Prsctice, 90(4), 563-567. 100 delBueno, D.J. and Altano, R. (1984). Competency-based education: No magic feather. Nursin mana er, 15, 48-53. Eliopoulos, C. (1989). Caring for the nursing_npne pntient: Clinicsl snd managerial chsllenges for nurses. Rockville, Maryland: Aspen Publishing Inc. Fisk, V.R. (1984). When nurses’ aides care. Journal of Gerontological Nursing, 10(3), 119-127. Headricks, M.M. (1982). Determining the learning needs of personnel in nursing homes. The Journsl of Continuing Education in Nursing, 13 (2), 18-22. Hinckley, N.E. (1990). What we need is a new attitude. Provider, 2, 15-18. Hu, T. Igou, J.F., Kaltreider, L., Yu, L.C., Rohner, T.J., Dennis, P.J., Craighead, W.E., Hadley, E.C. & Ory, M.G. (1989). A clinical trial of a behavioral therapy to reduce urinary incontinence in nursing homes. Journal of the Anericsn Association, 261(18), 2656-2662. Institute of Medicine. (1986). Inprovingvthe quality of csps in nursing honss. Washington, D.C.: National Academy Press. Jackson, H. (1972). The concept of wholeness in long-term care facilities. In Mental health: Principlss and training in nursingnhgne csre. (DHEW Pub. 73-9046). Washington, D.C.: United States Government Printing Office. 101 Jackson, M.M., & Schafer, K. (1993). Identifying clues to infections in nursing home resident: The role of the nurses’ aide. Journsl of Gerontological Nursin , 19 (7), 33-42. Johnson-Paulson, N.J. and Goodwin, M. (1986). Total approach to nurse aide training. Provider, 8, 14-18. Kane, R.L., Ouslander, J.G. & Abrass, I.B. (1989). Essentials of clinical geristrics. New York: McGraw- Hill Information Services Company Katz, P.R., Kane, R.L. & Meezey, M.D. (Eds.). (1991). Advances in Long Tern_gsne: Volune I. New York: Springer Publishing, Inc. Kingry, M.J., Tiedje, L.B. & Friedman, L.L., (1990). Focus groups: A research technique for nursing. Nursing Research, 39(2), 124-5. Knafl, K.A. & Webster, D.C., (1988). Managing and analyzing qualitative data: A description of tasks, techniques and materials. Epstern Journsl of Nursing Research, 10(2), 195-218. Knowles, M.S., (1980). The modern practice of adult educstion: Fronnpedagpgy tonsndrggpgy. New York: Cambridge, The Adult Education Company. Krueger, K., (1988). Focus groups: A practical guide for gpplied resssrch. Newbury Park, California: Sage Publications. 102 LeCompte, M.D. & Goetz, J.P. (1982). Problems of reliability and validity in ethnographic research. In N.S. Glasman & J.W. Pelligino (Eds.), Review of Educatignsl_ Research, 52(1), 31-60. Liu, K. & Manton, K.G. (1984). The characteristics and utilization pattern of an admission cohort of nursing home patients. The Gerontologist, 24, 70-6. Lofland, J. & Lofland, L.H., (1984). Analyzing social settings: A guide to qualitstive observation and analysis (2nd Ed.). Belmont, California: Wadsworth. Marshall, C. & Rossman, G.B., (1989). Dessgning Qualitative research. Newbury Park, California: Sage Publications, Inc. Morgan, D.L., (1988). Focus groups ssgguslitstive research. Beverly Hills, California: Sage Publications National Citizens’ Coalition for Nursing Home Reform. (1991). Nursing hone reform law: The basics A guide prepared by the NCCHHR, Washington, D.C. Newman, M.A., (1979). Theory development for nursing. New York: F.A. Davis Co. Rummler, G.A. and Brache, A.P. (1988). The systems view of human performance. Trainin , 9, 45-53. Schnelle, J.F., Newman, D.R. & Fogarty, T. (1990). Management of patient incontinence in long-term care nursing facilities. The Gerontolo ist, 30(3), 373-376. 103 Schnelle, J.F., Traughber, 8., Morgan, D.B., Embry, J.D., Binnion, A.F. & Collman, A. (1983). Management of geriatric incontinence in nursing homes. Journsl of Applied Behsvior Analysis, 16, 235-41. Seidel, J.V. & Clark, J.A., (1984). The ethnograph: A computer program for the analysis of qualitative data. Qnslitative Sociology, 7(1/2), 110-125. 1 Stewart, D.W. & Shamdasani, P.N., (1990). Focus groups: Theoryssnd prsctice. Newbury Park, California: Sage Publications. Tellis-Nayak, V. & Tellis-Nayak, M. (1989). Quality of care and the burden of two cultures: When the world of the nurse’s aide enters the world of the nursing home. Ins_ Gerontologisn, 29(3), 307-313. United States Senate. (1990). Aging America: Trends and projections (DHHS Publication no. serial 101-J). Washington, DC: U.S. Government Printing Office. Vincente, L., Wiley, J.A. & Carrington, R.A. (1979). The risk of institutionalization before death. Ins_ ’ Gerontolo ist, 19, 361-366. Weber, G.H. (1990). Geriatpic assistants: An annotated bibliography withsnodels to enhance practice. New York: Greenwood Press. 104 Woolfork, C.H. (1988). An in-service program that worked. Geriatric Nursing, 3, 94-97. Wright, L.K. (1988) A reconceptualization of the "Negative staff attitudes and poor care in nursing homes" assumption, The Gerontologist, 28(6), 813-820.