Running head: STRATEGIES TO RETAIN CNAs IN LONG-TERM CARE

Strategies to Retain Certified Nursing Assistants in Long-Term Care

Natalie Williams
University of Saint Mary

Strategies to Retain Certified Nursing Assistants in Long-Term Care

In the long-term care setting arena, it seems apparent there are positive outcomes that
comes with caring and stable staffing. When a person needs care, they are at a point in their lives
where they depend on others. In long-term care, not only do the residents need care in many
cases they are vulnerable to neglect, abuse, or being taken advantage of by immoral individuals.
The responsibility of a CNA is to care for the residents. CNAs provide assistance with bathing,
dressing and other personal cares, nutrition and hydration, ROM (range of motion), oral hygiene,
maintaining a clean and safe living environment, assisting with infection control and prevention
plans to avoid spreading undue illnesses or infections to the residents, and provide psychosocial
care. CNAs are also responsible for staying alert to changes with the residents and notifying the
nurse of changes and concerns. In many cases, the CNAs are the eyes and ears of the nurse and
are relied upon to notice subtle changes and alert the nurse for follow-up. There are certain
physical and/or mental requirements for the CNA that must be met. Essential job functions are
outlined on the CNA job description to make clear the expectations of the employer. The job
descriptions are given to employees in general orientation which is done day one before any
patient care or training. Job descriptions are also updated as needed then reviewed and signed by
the CNA annually with their evaluation if their essential job requirements change.
Recruiting the type of individuals who have the passion, the heart-felt connection,
compassion, and the desire to work with the geriatric population is not always easy. Finding
strategies to recruit and maintain the type of individuals who really want to work in this area is
imperative in guaranteeing the safety of those who may or may not be able to speak for
themselves. Finding approaches to recruit the millennial workforce by providing attractive
incentives may lead to longevity and staff retention.
There is not much information that directly relates to retaining certified nurses aides
(CNAs). The literature applies more specifically to nurses rather than CNAs but the information

may be reasonably applied to CNAs as well in many cases. Poduska, (2003) frame a program
called nurse camp and explore strategies and incentives to encourage prospective medical
workers while still in high school. Exposing high school students to the nursing field can either
confirm or cause them realize this isnt the field for them. Figuring out that being a CNA or nurse
is not what you thought it is before spending time and money on pursuing this career path is
ideal. Also, literature regarding recruiting millennials by Miles (2016), offer suggestions on how
to get millennials engaged in the current job market. Determining recruitment strategies that may
result in staff retention is very much welcome in the long-term care specialty.
Issues addressed by informal study include: 1) determining incentives that work to attract
quality CNAs is an important factor in maintaining CNAs, 2) continuity of CNAs is needed to
promote a caring environment for the residents, 3) networking among nurse supervisors to
collaborate and address benefits of CNA retention.
It appears, from personal experience and info from other nurses, that CNAs who are
familiar with a resident, their families, their habits, their likes, dislikes, moods, behaviors, as well
as personalities can pick up on changes quickly and alert the nurse. Even a minimal change can
turn into a serious illness if not picked up on in a timely manner. A CNA who regularly works
with a particular group of residents can usually see changes quickly and it can be addressed in a
timelier manner. Reducing hospitalization, re-hospitalizations, falls, and fractures come with
familiar and proper staffing levels of CNAs.
The outcomes of this informal study will be determined within a ninety day period.
Effective strategies or incentives that encourage longevity among CNAs in long-term care has
been evaluated to obtain results that encourage or discourage longevity. As with any activity, the
end goal is to address quality outcomes for residents, but for the purpose of this project it is to
determine if there is a pattern or any overwhelming reasons CNAs do not continue working (not
including moving, furthering education etc.) The Motivation-Hygiene Theory will be applied in
an attempt to determine what factors tend to motivate people. Determining what common factors
influence employees to stay in their current job and be productive is an asset to the employer as
well as to the people in need of care.
Current Evidence
There is research regarding recruitment and retention strategies of nurses but not very
much regarding CNAs. Using appropriate research articles that can apply to CNAs as well as
nurses will be the evidenced based research that provides possible insight on how to address
recruitment as well as retention strategies to encourage longevity among CNAs.
Poduska, (2003) explored the thoughts behind the Nurse Camp program. It was found
that the program is good in that it gives people insight in the field and can shed new light on
myths though true by non-medical individuals. On the other hand, the camp can deter others
before they spend the time and money on a CNA class if it isnt for them. This class appears to
weed out those individuals who may not have the desire, passion, or patience to be a CNA.

STRATEGIES TO RETAIN CNA'S IN LONG-TERM CARE

The camp provides expectations for young individuals and the opportunity to ask questions and
learn about the geriatric population through following nurses and observing first-hand what is
expected. Having this foundation can have an impact on a young mind and encourage a person
that had not previously considered being a CNA to follow this path. Laying the groundwork
through these types of programs for high school aged individuals may blossom into a strong
work ethic, a passion for the geriatric population, as well as promote longevity in a long-term
care facility.
Chenoweth, Jeon, Merlyn, & Brodaty, (2010) provided insight regarding staff working
with the elderly. What are the challenges and what are some of the incentives that encourages
employees to stay. It was determined that when staff feel satisfied with their job they are more
likely to remain in their position. Also, when staff have a sense of autonomy and feel supported
by their supervisors they are more likely to be retained by their employer.
Levoy, (2013) offers material based on exit interviews that can help employers keep the
employees they have which can helps retain good employees. It is also concluded that when staff
members state reasons for leaving such as more money, flexible hours, or desired commute, if
the interviewer asks more questions other reasons can come to light. (Levoy, 2013) Finding
reasons why employees are leaving can shed light on possible needed adjustments to processes in
order to keep other valuable employees.
Mizuhira, Soler, & de Oliveira, (2015) looks in to the reasons and results of nursing staff
absenteeism. Absenteeism of staff plays a role in continuity of care and causes staff burn-out
which again affects staffing and morale. Also, Freeman & Hughes, (2010) discuss the role and
importance of continuity of care and the patients perspective of this kind of care. It stands to
reason that continuity of care can only be provided if there is proper staffing. Management
dealing with issues need to be involved in speaking to employees and seeing that concerns and
issues are addressed to avoid burnout and turnover.
Toles, Young, & Ouslander, (2013) discusses the importance of getting to know the needs
and wants of the new resident and gain information from their family to aid in providing care. A
CNA that is committed to their job and the residents under their care relate in a personal way.
When a staff member feels connected to their residents and their families they are more likely to
remain working in the capacity of a valued part of the team. Willis, (2015) discusses the
importance of praising and valuing CNAs as vital important parts of the healthcare team. The
notion of saying please, thank-you, and letting the CNA know they are very much appreciated
has been voiced during the evaluation process again and again. It is much appreciated by the
CNA when they hear they are cherished as stated by many CNAs over the years.
Miles, (2016) takes a look in to what can attract millennials to the workforce. Attracting
millennials includes portraying an organized set of values and beliefs that are important within
the long-term care facility. Describing the importance of the facility mission and express the
importance of collaboration among the interdisciplinary team to the millennial can create an

STRATEGIES TO RETAIN CNA'S IN LONG-TERM CARE

attractive environment that inspires longevity among staff. When staff feel they are an important
part of the team they become invested in seeing plans and interventions through.
Clausen, Tufte, & Borg, (2014) investigate reasons for turnover and adjustments that can
be made to prevent turnover. Lack of leadership was noted to be a reason for turnover in the
healthcare filed. Also, hours not flexible was also stated as a reason for turnover in the healthcare
filed. This is why implementing flexible hours and working with individuals around school
schedules, second job hours, or child care issues has been a positive change toward promoting an
understanding and compassionate working environment.
Outcomes include staff stating they are happy or satisfied with conditions, how they are
being treated, do they feel appreciated, do they feel they have a support system among nursing
supervisors as well as change nurses, and do they plan on staying employed in current position is
how it will be measured. Outcomes noted will rely on information obtained in recent interviews
during annual evaluations with CNAs. The questions on evaluation includes (devised by
Recruitment and Retention team); Do you have the tools you need to do your job?; What can we
do to help improve attitudes or morale of staff?; How can I as your supervisor help you to be
more successful in your job, is there any more support I can provide you to help you more?; How
can I help to reduce the stress in your job? The time frame will be decreased due to the
timeframe of the project completion time, but will rely on long term staff and those who have not
met the two-year mark but are close to it to gain info as to why they have stayed and do they
have plans to stay employed.
The annual evaluation process for CNAs is completed by the assistant director of
nursing. Evaluations are completed on an annual basis and determined by their date of hire. The
process of completing an evaluation receiving the names and hire dates of employees the month
prior to being due. Then, peer/supervisor reviews are handed out to three employees with various
questions to provide input for the evaluation whether the employee has met/not met expectations
or exceeded expectations. After receiving the peer reviews, the assistant director of nursing
(ADN) reviews the peer/supervisor reviews and completes the evaluation that correlates with the
position of the employee. After the evaluation is given by the ADN to the CNA is when the four
questions are asked of the employee to answer. Questions asked are 1) do you have the tools you
need to do your job? The answer is almost always yes, on the rare instance was no then the item
or request will be ordered or obtained to make ensure the employee has the tools needed to do
their job effectively. When employees have the resources to do their job well they tend be
pleased with their job and will invested in staying. 2) What do you think our center could do to
help improve attitudes or morale (satisfaction, enjoyment at work) of staff? This question helps
in obtaining feedback from employees of adjustments that management can explore and make to
improve the working environment for CNAs. In the past year, there have been multiple
suggestions from CNAs when asked this question and their answer was provide more staff. In an
effort to grant this request, multiple flex shifts were added and new positions were added to
provide more support for the CNAs. Positive feedback from CNAs as well as nurses have been

STRATEGIES TO RETAIN CNA'S IN LONG-TERM CARE

as a result of this change and reports of burnout has decreased resulting in retaining employees.
3) How can I, as your supervisor, help you to be more successful in your job? This question
reinforces to CNAs that supervisors are there to provide guidance and support in any way
possible. Staff feel valued and heard when this question is asked and have expressed a feeling of
team, love, and support. The last question asked is; 4) how can I help reduce the stress in your
job? This question generally ties with question two in the minds of many CNAs. They report
when staffing is stable they are less stressed. They feel better about the time they can spend with
residents by not feeling rushed due to short staffing. The majority of CNAs report they know
there is a certain amount of stress that goes with the job and can handle but it gets difficult to
handle when there are staffing challenges which pulls them in multiple directions causing stress,
anxiety, and burnout which can decrease staff retention.
Project Methods
This was an evidence-generating Project due to the lack of truly relevant literature,
besides information related to nurse. Upon web searches and literature review, the information
obtained has widely applied to nurses regarding recruitment and retention and not CNAs.
Interventions used to obtain information included; reviewing exit interviews, reviewing
interview notes, reviewing literature, interview CNAs in the facility, recruitment and retention
notes from facility, and feedback from Director of Nursing and Human Resource director.
Information has been obtained, goal is to complete project within the next 30 days.
Intervention activities include: verbal exchanges with CNAs to ask what incentives keep
them in current position, review (anonymous) exit interviews for reasons why CNAs quit,
review past thirty-day interview answers that apply to research, evaluate if past ninety-day of
Recruitment & Retention notes are of value to project, information to be kept on locked
computer or in locked home although no names will be identified only initials for reference.
Information will be analyzed to determine if there are recruitment strategies or incentives
that attracted employees who have been employed at facility for two years or longer. Data will be
analyzed to determine if past employees (per exit interviews) left for reasons that need addressed
ie; poor communication or poor teamwork. Find ways to make the recruitment process better to
attract a quality CNA workforce who are looking for longevity.
Results
The achievements of this project identified reasons interviewed CNAs stated they stayed
at facility. This project also shed light for nurse manager as to why some CNAs chose to leave
the facility. First quarter 2016 exit interview information did not specifically identify position of
person answering questions. In reviewing the information it appears those employees who
answered questions agreed or strongly agreed that they were satisfied with their
accomplishments each day, and also were satisfied with their supervisor. Based on this
information, supervisors were providing the employees with support and guidance and did not
appear to suggest they left due to being unhappy with their employment.

STRATEGIES TO RETAIN CNA'S IN LONG-TERM CARE

The turnover rate from 4-1-15 to 3-31-16 of CNAs was 52%. Included in this report, 23
CNAs were no longer employed and there are 44 active CNAs resulting in the 52% turnover
rate.
In speaking with nine CNAs and inquiring what keeps them at facility answers included;
like being a cna, the facility is more family oriented and is Christian based; good nurses and
good staff, love the residents; flexibility and working with other CNAs who have been at facility
for a while, love the residents, the commute is close; love the residents and co-workers; good
place and good supervisors; love the residents and co-workers, great place to work; have fun
working here, love the residents, love the perks; feels like a family, love the residents and being a
CNA; great place to work.
When asked after evaluation about how to improve attitudes or morale of staff employees
generally states improved staffing would help with morale although most stated that recently this
has greatly improved due to more flexible hours. When asked how supervisor can help them be
more successful in their job it was stated that supervisors are supportive and helpful. When
questioned about how supervisors could help reduce the stress in their job, being fully staffed
was the overwhelming response again stating staffing is better. The majority of respondents also
stated they knew this was out of managements control due to being fully staffed initially but
other staff members call-in resulting in being down a staff member. They all stated they do have
the tools they need to do their job.
Recently there has been an addition of several flexible shifts in an effort to reach out to
more people and provide some flexibility to current staff. This recent addition of flexible hours
has provided additional help in critical hours of the day and evening and has offered employees
additional hours providing additional convenient hours and a monetary perk as well. The flexible
hours has been well received and greatly appreciated as stated by many CNAs.
Discussion and Evaluation
Strategies to retain CNAs in long-term care was investigated. It appears staff who stay
generally like being a CNA, like their co-workers, like the facility and the Christian family like
environment, and most importantly the love for the residents. The CNAs expressed contentment
with their supervisors and their fulfillment from the care they provide to the residents every day.
Providing staff members with incentives, perks, and showing appreciation goes a long
way in keeping quality employees happy and engaged. Heatherfield (n.d.), notes ways to say
thank you to employees. Simply saying thank you to employees has been suggested in the past
by CNAs. The perks offered has also provided incentives for CNAs to remain at the facility.
Perks include; pizza party, pancakes cooked and served by employee relations, Christmas
bonuses, chocolate, and other meals and fun activities throughout the year for staff.
Continue incentives, supervisors continuing to communicating with CNAs regarding
their suggestions and requests will be important based on exit interviews and speaking to current
employees. CNAs want to be heard and want to feel like they are a contributing important part
of the interdisciplinary team in an effort to provide the best care to the residents. The new

STRATEGIES TO RETAIN CNA'S IN LONG-TERM CARE

flexible hours will also be continued as it has been a positive addition for staff. Staff also state
the appreciation for the compensation when another staff member calls-in. How this works is
when a staff member calls-in, their pay is divided among the CNAs that were assigned to work
with them. This extra incentive has been well received and appreciated by the staff that are
working hard to ensure the residents are receiving continuity of care even when not all staff are
present. Shift differentials are also a perk that CNAs enjoy. There is a fifty cent shift differential
for evening shift CNAs and seventy-five cent shift differential for night shift CNAs. Also
offered is a three dollar shift differential for every weekend shift worked which is generally
every-other weekend.
This project provided needed information for nurse manager to focus on more from this
point forward. The importance of continuing and saying more thank you just because to staff
members is important in showing appreciation for the work they do. Also, it is important to listen
to CNAs and ensure they feel they are being heard and know they are supported by mangers.
Lend a hand whenever possible and continue to be a presence to CNAs in an effort to be
available and approachable for concerns and questions. Making sure CNAs feel valued and
respected for the hard work they do is vital in preserving good CNAs in the long-term setting.

Abstract
Recruitment strategies to retain certified nursing assistants (CNAs) in long-term care is
important for continuity of care for the residents. In past experience, it appears that stable
staffing can result in positive outcomes for residents. Questions put to CNAs: 1) do you have the
tools you need to do your job? 2) What can we do to help improve attitudes and moral for staff?
3) How can I as your supervisor help you to be more successful in your job? 4) How can I help
to reduce the stress in your job? The methods used were reviewing exit interviews, reviewing
interview notes, interviewing CNAs in current facility, and reviewing recruitment and retention
notes from facility meetings. The information gathered seems to support when staffing is
adequate and staff members are consistent, residents and families are more pleased with the

STRATEGIES TO RETAIN CNA'S IN LONG-TERM CARE

quality of care. When residents and their families are happy, staff tend to be satisfied as well
leading to longevity in the long-term care setting. Having stability among staff members to care
for residents appears to decrease burnout among CNAs and promotes CNA retention.

References
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retain nurses in aged and dementia care. Journal of Clinical Nursing, Vol. 10 (1/2).
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Freeman & Hughes, (2010). Continuity of care and the patient experience. Retrieved from
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Miles, B. (2016). Purpose above Profit: how to Attract and Engage a Millennial Workforce.
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