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Prepared for: Capital Workforce Partners By: Connecticut Women’s Education and Legal Fund
July 2011
CNA Advancement InitiativeProject Report
Table of contents
Background
Participant snapshot: A profile in numbers
Individual change
Facility change
Partnership change
Sustaining: building on a foundation of practice
knowledge
Stories
2
3
9
19
27
31
33
In 2003, the Board of Directors for Capital Workforce Partners (CWP)
identified the health care cluster as a “strategic priority,” for North
Central Connecticut and a primary workforce development objective
for this organization.1 Home to a large number of general and com-
munity hospitals, long-term care and rehabilitation facilities and over
650 doctors’ offices, this area of the state has significant workforce
needs in health care fields. In response, CWP convened the Health-
care Workforce Advancement Committee to collect, analyze and
act upon data and employer recommendations describing projected
workforce needs. The data indicated that Certified Nursing Assistants
(CNAs), comprising roughly half of total employment in nursing and
long-term care facilities, could play an important role in talent devel-
opment in the field.2 The first project developed in response to: a) the
available data, and b) an assessment of the academic needs of under-
prepared yet interested frontline workers in healthcare facilities wish-
ing to advance their knowledge and credentials, was the Bridges to
Health Care Careers program in 2005. A CNA Advancement Initiative
was developed using selected Bridges to Health Care Careers program
components informed by the practice knowledge also gained by the
Commonwealth of Massachusetts in its implementation of their Ex-
tended Care Career Ladder Initiative.
As proposed and implemented, the Certified Nursing Assistant (CNA)
Advancement Initiative has become a model to provide education
to frontline staff and promote culture change within the partner-
ships developed with long-term care and homecare organizations.
Yet, the impact of the activities implemented by Capital Workforce
Partners and its partners grew well beyond the CNAs for whom it
was designed.
Created and administered by CWP, the model includes:
• contextualized basic skills instruction, and educational and ca-
reer supports designed to meet the literacy and numeracy reme-
diation needs of the frontline healthcare workforce;
• seven clinical specialty courses including Issues of Aging, Demen-
tia and Alzheimer’s, Mental Health, Substance Abuse, Rehabili-
tation, Medical Terminology, and Hospice and Palliative Care
delivered onsite at facilities and in both workplace and work-
based iterations;
• a customized leadership course to enhance self-confidence and
self-efficacy, and to support the collaborative model of health
care delivery;
• awareness of healthcare career advancement opportunities; and,
• culture change activities to enhance the leadership skills of su-
pervisory staff in healthcare facilities, enabling organizations to
benefit from the results of having created a collaborative model
of health care delivery.
The final outcomes of these activities have been the talent develop-
ment of frontline workers and supervisors, the enhancement of col-
laborative working relationships among adult education, community
college and workforce development providers, and improvements in
the quality of care in long-term and home health care facilities.
This report will provide a reflection on the changes that occurred as
a result of the participation of employees, employers and program
partners. Some of these changes are easily quantifiable – the number
of participants, score changes in reading and math abilities, cours-
es created and implemented – and that information is captured in
this report. Yet many changes are less concrete, although equally
as important. The changes in individuals – the largely diverse and
female workforce – and the wide ripple effect created in the long-
term care facilities are profound. We will attempt to describe those
changes through the stories of some of those workers. These stories
were gathered in conversations held over two years of the project
and, though abbreviated, will communicate the human outcomes
of participation.
Background
2
1 CWP, CNA Advancement Initiative Technical Proposal, p.12 Ibid., p.3 (citing Department of Labor, Office of Research data)
Participant snapshot: a profile in numbers
In total, 368 individuals participated
39%
37%
17%
4%
2%
White
Black or African American
Hispanic or Latino
More than one race
Asian
3
In total, 368 individuals participated
93%Female
44 yrsMean age
0Identified as having a disability
90% High school graduates or have achieved a GED
+
60% Employed full-time
$14.54 Mean wage for participants
35hrs Average hours worked per week
67% Received health benefits*
33% Did not receive health benefits*
$10-$18 Wage range for most participants
8% Have a foreign degree
in the project over the course of the three years. The program participants are a fairly diverse group, racially and ethnically.
*not all participants gave this information
4
Alexandria Manor
Bidwell Care Center
Chelsea Place Care Center
Hebrew Home & Hospital
Jerome Home
Manchester Hospital (ECHN)
Riverside Health and Rehabilitation Center
Southington Care Center
The Orchards at Southington
Trinity Hill Care Center
VNA Healthcare
Wintonbury Care Center
Woodlake of Tolland
Total
15
10
15
41
40
35
6
75
24
25
41
11
29
368
4.1
2.7
4.1
11.1
10.9
9.5
1.6
20.4
6.5
6.8
11.1
3.0
7.9
100.0
Participants from employer partners took part in the program; number of participants per partner and percentages follow.
Employer Partner # Participants Percentage
13
Southington Care
Hebrew Home
Jerome Home
The Orchards
200
190
78
60
37.5
21.6
51.3
40
Employer Partner Number of eligible staff/site 3
Number of participants
Percentage engaged in the
Initiative3
200
190
78
60
5
3 Eligible staff numbers are approximations received from facility administrators.
32086% CNAs
154% Dietary Staff
113% Licensed Practical Nurses (LPNs) or Registered Nurses (RNs)
4 1% Social/Behavioral health care workers
3<1% Housekeeping Staff
113% Adminstrative Staff
3<1% Personal Care Assistants
1Participant each reported the following occupations: Emergency Department Technician; Exercise Physiologist; Recreational Director; and Security.
6
324 frontline workers were enrolled in 556 clinical courses in total:
Dementia & Alzheimer’s Medical Terminology Issues of Aging
36.7% 27.2% 29.6%
Hospice & Palliative Care Leadership Mental Health
Rehabilitation
36.7%
Substance Abuse
18.5% 20.7%12%
10.8% 8.6%
7
It was exciting for the instructors and for the administrators.
It strengthened their belief that students could learn and it
raised the level of expectation of care for their clients. For
students, the stigma that existed was taken away because
it was an integrated course, a cohesive way of teaching and
learning.- Dr. Marie Spivey, Administrator of Allied Health and Nursing Initiatives and Programs, CWP
“
“65%enrolled in one course
17.2%enrolled in two courses
8.9%enrolled in three courses
3.1%enrolled in four courses
2.8%enrolled in five courses
1.2%enrolled in six courses
2.8%enrolled in seven courses
1studentenrolled in nine courses
8
The CNA Advancement Initiative had, at its core, a number of important goals for the direct care
staff participants. These included the development of academic and clinical skills that would bet-
ter prepare them for continued study in the allied health and nursing fields; the mastery of clinical
Individual change
72.7%completed their first course and were granted certificates
84.5%completed their second course and were granted certificates
82.1%completed their third course and were granted certificates
88.9% completed their fifth course and were granted certificates
88.9% completed their sixth course and were granted certificates
88.9% completed their fourth course and were granted certificates
(224 of 308) (93 of 100)
(46 of 56) (24 of 27)
Learning Gains
Data collected by CWP in Hartford Connects, an Efforts to Outcomes, a software program used by Capital Workforce and many other governmental and non-profit institutions to collect and analyze program data, reveal the following learning gains.
(16 of 18) (8 of 9)
9
80% completed their seventh course and were granted certificates
1completed their eighth and ninth courses and was granted certifi-cates for each
information; and, the development of greater self-confidence and self-efficacy in using newfound
knowledge to enhance their own practice and contribute to the quality of care.
(4 of 5) (Participant)
Gains related to CASAS (Comprehensive Adult Student Assessment Systems) scores
The mean increase in CASAS score (pre- and post-testing) for participants enrolled in Basic Skills Education is:
Math (for 71 students): 5.58;
Listening (for 8 students): 4.63 points; and,
Reading (for 100 students): 4.67 points.
To put these score gains into some context, adult education administrators at Capital Regional Education Council (CREC) have suggested that they anticipate an average gain of three (3) points in CASAS scores after 75 hours of instruction.
10
In designing and producing an intervention plan, project developers
and administrators anticipated staff participation would yield the fol-
lowing impacts – immediate improvement in staff self-esteem, en-
hancement of task performance and communication with clients and
other staff, and higher earnings. A survey conducted near the end
of the first project year revealed that instructors detected changes in
students’ attitudes and work patterns as a result of their participation
in classes. Approximately two-thirds of instructors observed personal
growth (e.g., more confidence) in the students they taught; 4 in 5 in-
structors observed both educational growth and greater collaboration
among students. Instructors also suggested that students had a better
sense of their own needs and abilities, showed an eagerness to learn
new things and relearn past knowledge at more in-depth levels, exhib-
ited pride in their efforts and had increased confidence to understand
and approach new techniques of learning new material and academic
subjects (e.g., algebra).
In interviews since, administrators point to students’ increased self-
confidence and care delivery, and to vastly improved documentation
skills. While the program had transition into community college as
one goal, the importance of these other goals was not lost on admin-
istrators or students.
At VNA Health Care, Personal Care Assistants (PCAs) and CNAs work in
the field with indirect supervision and a great deal of autonomy. Their
knowledge of disease systems and syndromes that affect their popula-
tion increased with their participation in classes. Aldine Fray, Homecare
Aide Supervisor at VNA Healthcare, observed “a noticeable increase in
their self-confidence in making clinical decisions about their patients.”
Fred Lauria, Vice President of Human Resources at VNA, articulately
synopsized program goals as three-fold, “jump-starting participants
with a long-term goal of matriculating, building confidence in clinical
skills and advancing the workforce up the medical career ladder.”
Lauria indicated that, for VNA participants, the second goal was most
applicable. Fray added that their core group of participants is a ma-
ture workforce who are satisfied with their current job situation, and
that many of them consider the classes as an opportunity for self-
development. Lauria concurred, saying, “Although most of the VNA
participants will not elect to matriculate into higher education in a col-
lege/university setting, classes provided a confidence boost to those
with some fear about academics.”
Audrey Vinci, Director at the Orchards, an assisted living facility that
is a subsidiary of Southington Care, shares a similar story. Vinci made
the decision to participate when her annual survey of staff indicated
that they wanted more educational opportunities. The Orchards has
fewer than 100 people in residence and a relatively small (60) staff;
Vinci opened the program to all staff at the facility. CNAs, dietary and
housekeeping staff all expressed interest. “Staff feels better about
themselves; and the classes have made their career choices more
meaningful to them. It’s made them more positive – especially the
leadership course. When the CNAs who took the class get new CNAs
on board, they know how to mentor them. They feel good about
themselves and what they can share.”
Kate Gilman, Staff Development Director at Southington Care, sug-
gests that enhancing self-confidence and self-efficacy has also had
an impact on CNAs’ problem-solving skills. “We’ve seen that, instead
of going straight to the nursing staff, CNAs will often try to figure the
situation out and to intervene appropriately.”
Frangie Cruz is an Education Coach with CWP; her role is to assist
the CNAs in identifying learning and education needs and support
them in their progress. Cruz, trained as a case manager and pursuing
an advanced degree in school counseling, is responsible for program
intake and provides encouragement and follow-up to students whose
life circumstances become barriers to their education journey. “I see
a sense of empowerment developing in these CNAs – both conscious
and subconscious. ‘I am doing something for me; it’s a challenge, but
a nice feeling of achievement.’ For these CNAs, age, time constraints,
family, their own perceptions of their academic abilities have held
them back. They thought they might not do so well. And then here
they are. And for some, taking these classes has sparked an interest in
going back to college.”
Joan Jakiela, curriculum developer and instructor of many of the cours-
es offered, recalls the first debrief at Jerome Home facilitated by B&F
Consulting. “We were all sitting around the table, and one of the stu-
dents said, ‘I’m just different. I look at things different. I see patients as
possibly being my mom, my dad. I pay more attention to my personal
health now.’” And, she suggests, the growth in students who had pre-
vious unsuccessful experiences in educational settings was even more
profound. Some of her students who were not native English speakers
were able to speak about their previous experiences and dissolve the
fear and anxiety that their previous non-completion evoked.
Self-confidence and self-efficacy
11
“It also motivates you,” shared Hebrew Home’s Irina, who went on to
complete her GED and receive her high school diploma. “When I tried
to get my GED before, someone made me feel like an idiot. I appreci-
ated the support I got from Terri (Ciocci, Staff Development Director),
my teacher, and the women in my classes, including Liz (Elizabeth Beg-
ley, Allied Health Project Director), who was high-spirited and guided
us. My kids are proud; it makes me want to do more. You’re never too
old to learn.” Terri Ciocci cites Irina’s success as an outcome of her
participation and adds that Gwendolyn, another participant, went on
to college.
Students were not alone in their skill development. Nurses had the
opportunity to participate in leadership workshops. Linda Quirici,
Nursing Education Manager at Eastern Connecticut Health Network
(ECHN), also took part in B&F Consulting’s workshop for mentors.
Subsequent to attending the workshop, Quirici shared the leadership
knowledge she gained with her staff – the nursing education and clini-
cal nurse specialists throughout Manchester Memorial Hospital and
Rockville General Hospital – and plans to train the management team
at both facilities, extending the impact of the programming. She be-
lieves that the train-the-trainer model will allow her to reach super-
visors at ECHN’s two hospital facilities with the resources and skills
necessary to mentor line staff and colleagues.
“ I see a sense of empowerment developing in these CNAs – both conscious and subconscious. ‘I am doing something for me; it’s a challenge, but a nice feeling of achievement.’
“
- Frangie Cruz Education Coach, CWP
12
The contextualization of ABE was developed as a solution to the challenges that arose to enrollment in the
initial CNA Advancement Initiative ABE course offering. Enrollment was low and attrition high; as a result,
employers’ needs for a frontline workforce better equipped to identify resident needs and to understand
and complete documentation were unmet. Enrollment was negatively affected by students’ misreading of
their own numeracy and literacy needs and by the stigma attached to the need for enrolling in ABE. Educa-
tors and employment partners saw the need for and importance of embedding skill development into a
clinical context.
Elizabeth Begley, Allied Health Project Director, sheds light on the powerful effects of stigma. “They may not
want to say to their peers, ‘Well, I’m going off to math class or English’ because they’re admitting they have
deficiencies. It was pretty consistent. In some facilities, a number of people in ABE were unofficial leaders in
the CNA group, but in other facilities…the stigma was strong.”
Contextualized ABE was needed, suggests Mary Ann Pascone, the Program Manager of the Transition to
Employment Services Program at Capital Region Education Council (CREC), and instrumental to the devel-
opment process because “we needed to customize our work to meet the needs of the individual work-
Contextualized Adult Basic
Education (ABE)Addressing basic education and clinical learning while diminishing stigma
13
place and depended upon the employers to share authentic materials
which we could use to teach basic skills in the classroom.”
Students were assessed using the Comprehensive Adult Student As-
sessment System (CASAS), and scores and local employer needs in-
formed instructors’ choices of materials and methods. Some of these
methods included using logic puzzles and mind maps, and develop-
ing interviewing and writing skills by gathering resident life stories.
Instructors, informed by individual student learning needs, could dif-
ferentiate instruction to meet those needs.
“A lot of work was done in the areas of vocabulary and nursing home
forms. Methods used were cooperative learning, hands-on activities
and lots of practice on new materials,” suggests instructor Dave
Wolansky.4
And a student adds, “When I started the class, I wasn’t sure I did the
right thing, but I was so happy I decided to stay. I really liked the way
the teacher taught math. Math was so hard for me to learn and still
is, but I learned a lot in this class that I didn’t know months ago.”5
For three quarters of implementation in 2008 and 2009, retention
increased, and instructors and employer partners reported that stu-
dents requested more math instruction.
Across eight employer partners where instruction was contextualized, students CASAS scores in reading
increased an average of 5 points; in the five employers where math was contextualized, the scores increased
an average of 6 points. More specifically, scores in reading increased 7.2 points at Hebrew Home and 7
points at Southington Care; in math, scores increased 14.5 points at Hebrew Home and 8 points at South-
ington Care.
Once you feel like you’ve accomplished something by helping and seeing the difference you make… it makes your day, it makes you feel good. I love every bit of it.“ “
- Anna,CNA participant
14
4 CREC, U.S. Department of Labor ETA Presentation, Capital Workforce Partners Innovative Practices, CNA Advancement Initiative, PowerPoint presentation, June 20095 Ibid.
Ralph Braithwaite is an experienced curriculum developer and teacher. A principal with The Limitless
Consulting Group, an organizational consulting and training firm, Braithwaite has been an Adjunct Faculty
Member at the University of Hartford for over 20 years and teaches graduate and undergraduate level
courses. He has an MBA in Organizational Behavior from the University of Hartford, and an MS and BA from
Central Connecticut State University. Braithwaite taught four cohorts of students at three facilities for the
CNA Advancement Initiative – Southington Care (2 cohorts), Hebrew Home and ECHN-Manchester.
Braithwaite developed the leadership course curriculum at the behest of Ruth Krems who directs Nurse Aide
& Allied Health in Continuing Education at Capital Community College.
“Ralph has so much to draw upon; he had the materials and so much experience. I ran the curriculum by
Eileen Cleary at Saint Mary’s Home who has a wealth of experience with CNAs – a long experience with staff
development and relations - and had previously run a nursing home earlier in her career. She made some
minor refinements. This was truly one of the smoothest development processes.”
Using content he had previously authored and used in other settings, Braithwaite enhanced his curriculum
by adding content related to team leadership skill building for frontline workers. The curriculum is com-
prised of 12 modules taught over 12 weeks; each weekly class was two hours long. The modules include:
Managing for Success; Success Insights; Making the Transition; Communication; Time Management; Lead-
ership and Delegation; Team Building; Motivations; Customer Service; Conflict Management and Difficult
Employees; Problem Solving and Decision-making; Ethics and Coaching.
Braithwaite’s course materials provide instructors with a comprehensive curriculum guide. Within the guide,
instructors are given a broad array of supplemental information and context. Braithwaite described his
creating a curriculum as “making a stew” – “If I find something that is relevant and engaging I add it; I use
different methods to keep students engaged and interested.”
One module, Success Insights,6 introduces students to the DISC (dominance, influence, steadiness and
compliance) model used by many organizations to understand and develop productive workplace relation-
ships. A model of observable behavior, it relies on a self-assessment of behavior as indicated by preferences
in word associations and classifies behavior within quadrants represented by the letters in the acronym
DISC. In the module materials, Braithwaite provides an explanation of the model, descriptions of each ‘type’
and its value to the workplace, and an action worksheet related to the activity.
The Communication module offers 26 pages of guidance covering topics such as communicating with team
members, non-verbal communication, providing feedback and handling criticism with honesty and grace.
Leadership training
Providing frontline workers and their supervisors with professional development training that contributes to their self-development and workplace skills
15
6 Success Insights is protected by copyright and a product of Success Insights, Inc. the international distribution company of Target Training International.
The module contains definitions, anecdotes that illustrate the concepts, a skills assessment and discussion
prompts. It is written in accessible language and grounded in real-life experience to which students can relate.
In addition to the leadership course offered to frontline workers, Cathie Brady and Barbara Frank of B&F
Consulting developed quarterly leadership development seminars to assist frontline supervisors in creat-
ing a healthier and more positive workplace environment in which CNAs and other staff feel valued and
respected. These seminars comprise the ‘culture change’ component of the Initiative, and were essential to
changing attitudes and behaviors of supervisors employed in long-term care facilities.
Using personal reflection and small group activities, supervisors were invited to help discuss the importance
of talent development in their staff and of building and maintaining worker morale. In doing so, they began
to define and refine their definitions of leadership. Exploring the stages of development and the alignment
of developmental tasks at each age, Frank and Brady sensitively probed attitudes related to age diversity
and shared concrete supervisory practices participants could use in their practice. They delineated the impor-
tance of ‘managing by walking around,’ of using a team orientation, intra- and inter-shift communications
and modeling, and suggested that the buy-in at the highest administrative levels needed to be aligned with
supervisory goals and strategies.
As important was the discussion of changes supervisors might see in the frontline workers now engaged in
basic education and clinical courses. Frontline workers were building new skills and developing an enhanced
sense of self-confidence. One of the clinical instructors, Sonia Gaztambide, spoke about the kinds of ques-
tions students were asking during her Issues of Aging class – questions generated by the instructional model
which relied on the case study format and built problem-solving skills. She spoke of how she encouraged
students to ask hard questions and then challenged instructors to think ahead to the more challenging
queries frontline workers would be posing. Gaztambide invited supervisors to consider the challenges of
defining and redefining responsibilities and relationships of frontline workers. Two questions were of great
importance to the group and elicited thoughtful conversation: Will skill and self-confidence building change
how nurses see frontline staff? And, will nurses allow CNAs to exercise new skills?
16
Hybrid course
Aligning basic skill development with clinical course content
Sally Imfeld, a certified adult basic education teacher, was invited by Capital Workforce Partners (CWP) and
Capital Region Education Council (CREC) to observe an Issues of Aging class being taught at Southington Care
Center. The goal of her observation was to identify how to best integrate ABE with workplace classes planned
as part of the learning initiative. Imfeld noted that students struggled with organizing their work and seemed
to be unclear about their assignments. Students also had difficulty with the case studies assignment as well as
with other reading and writing tasks.
Ellen Williams had developed and taught the Hospice curriculum as part of the workplace learning initiative.
A nursing educator, Williams worked with Imfeld to imbue the adult basic education learning with clinical
content – contextualizing reading, writing and math instruction with representational graphs and medical
terminology and using clinically relevant situations.
Courses were aligned so that ABE learning would begin before and run concurrently with the Hospice work-
based learning component. ABE was offered from September through early January; the Hospice class ran
for six weeks, beginning in mid-October. Marian Eichner, Projects Support Manager at CWP, calls the course a
model of “wraparound education supports to ensure success.”
The curriculum for the Hospice course was predicated on a case study format, a format for which most
students had little preparation. Students with learning needs were enrolled in basic skill development (ABE)
with Imfeld; this component of the hybrid began six (6) weeks before the hospice course. This would allow
them to focus on learning objectives as outlined by Imfeld, and deconstruct and address the case study model
before they needed to master its use.
Imfeld wrote an ABE curriculum that placed emphasis on vocabulary and comprehension strategies (reading);
sentence structure, punctuation, mechanics and editing (writing); and, mastering basic operations and prob-
lem-solving (mathematics). Williams wrote the Hospice curriculum and used experiential learning to enhance
students’ learning in the field.
Imfeld introduced the case study model over four class periods by having students use information about a
resident with whom they were already familiar. During the fifth class, they wrote a complete case study on a
second resident with guidance from the instructor. Imfeld offered students suggestions on paragraph struc-
ture and word choice, and used student work to guide instruction for the next class, addressing grammar,
spelling and mechanics.
Sitting in on the first Hospice class, Imfield observed that students had difficulty with taking notes while listen-
ing to William’s instruction. Subsequently, Imfeld decided to sit in on each class, take notes for the students,
copy and distribute them. The strategy allowed students to concentrate on the content-laden instruction
without struggling with spelling and sentence structure. According to Imfeld and Williams, while the main
17
rationale was expedience, the outcome of the strategy for students was their increased engagement in class
discussion. Later, students who were enrolled in the hospice component but not the ABE class asked Imfeld
for copies of her notes to help them with the case study preparation.
Having an outline in front of them, as they listened to Williams, allowed students to organize their thoughts.
Additionally, class discussion became more thoughtful and productive – students did not have to split their
attention between listening and learning, and writing. The self-confidence students were developing about
themselves as learners would allow them to come back, as stronger writers, to master note-taking.
Williams used discussion to spur students to share their own and others’ rituals with respect to death and the
protocols and policies related to post-mortem care. These discussions expanded CNAs’ clinical knowledge and
also enhanced their sense of self-efficacy and improved their writing skills, as students translated conversations
to thoughtful writings. As time went on, sharing experiences continued to have a positive impact on students’
clinical assignments.
All students who enrolled in the basic skills course completed the class; additionally, students enrolled in the
clinical course (but not enrolled in ABE) also began attending the basic skills class and (as stated earlier) request-
ing the class notes. The average CASAS score change in reading was 9.8 points, and for math, 5.3 points. This
compares to score changes of 3.0 and 2.6 points, for reading and math respectively, in a selected employer
location that did not employ the hybrid model.
Marie Spivey, Administrator of Allied Health and Nursing Initiatives and Programs at CWP, suggests, “It was
exciting for the instructors and for the administrators. It strengthened their belief that students could learn and
it raised the level of expectation of care for their clients. For students, the stigma that existed was taken away
because it was an integrated course, a cohesive way of teaching and learning.”
From this successful pilot, Capital Region Education Council has created a Hybrid Course Model toolkit. The
toolkit allows for replication of this practice as a teaching model that can fully integrate basic skills enhance-
ment with a specific vocationally-focused specialty course. The importance of this effort lies in its applicability
to other vocational settings; students in areas beyond health care will benefit from the hybrid model.
Spivey adds that the broad applicability of the model is important. “The toolkit can be a foundation. As we
move into stronger relationships with the community colleges and adult basic education programs, we can use
it to extend and integrate learning in many settings.”
Steve Bender, Executive Director for 1199 Training and Upgrading Fund, suggests that the hybrid model can be
used with his students who are engaged in basic skills education outside of the workplace setting. “The hybrid
is applicable to workers in health care jobs in and outside of the workplace setting; I would be very interested
in considering the adaptations we might make so that it could be useful to our students.”
18
Facility Change
CWP, at the conception of the Initiative, acknowledged that changes
in CNAs’ skills and confidence would necessitate changes in the work-
place culture. Strategies to support CNA career advancement were
implemented in concert with strategies to assist frontline supervisors
to foster positive workplace environments. While the goal was to re-
duce absenteeism and improve retention of frontline staff, the culture
change activities catalyzed new ways of interacting. The most pro-
found change in the facilities involved in the work-based and work-
place education programs has been seen in the working relationships
among frontline, mid-level and supervisory staff at long-term care fa-
cilities. The quality of care has benefitted from having a care team that
sees itself as collaboratively contributing to patient outcomes.
Communication and relationships
Hebrew Home’s administrators suggest that communication, and
therefore, the relationships between and among CNAs and nurses,
have improved with participation in the program. Citing the interactive
leadership training for nurses facilitated by B&F Consulting, Terri Ci-
occi from Hebrew Home suggested that members of the nursing staff
found the information to be useful in their daily supervisory duties –
nurses “better understood the cultural norms expressed in workplace
and education attitudes such as time orientation.” Framing the day as
a leadership development workshop encouraged positive skill building
(with discussion about needs rather than problems). After the train-
ing, participants recommended to administrators that other nurses at
the facility attend these trainings.
Ciocci also suggests, “CNAs now understand that they’re listened to,
that is a powerful thing. Their sense of self-value has increased. And
the nurses value their input.” This is a sentiment echoed in syntheses
of debriefings – synopses written by Elizabeth Begley of each debrief-
ing meeting. Mentors reinforced learning objectives and contributed
to CNAs’ growing self-confidence, and in turn, CNAs felt more com-
fortable approaching mentors and other staff with questions about
their class assignments and work duties. This created a more collegial
environment, one in which all viewpoints were valued, and where
good ideas came from many sources.
Rosa, a CNA at Hebrew Home, suggests that her exposure to other
ways of thinking about things has changed her outlook. “When some-
one who has a different view is in your class or you work with them,
you can see things differently. It’s better for the patients. We get a
better understanding by considering what other people have to say.
Because you only know the way you know. That changed for me.”
Students interviewed during year one of the project also indicated that
skill gains had spilled over into their communication with staff and
supervisors and with residents and residents’ families. They became
more confident in their understanding of job-related written materials
and carried themselves with new-found poise. An especially moving
account of personal growth was related to evaluators by a student at
Alexandria Manor. A long-time employee at Alexandria Manor, she
had been previously unable to successfully approach the facility ad-
ministrator about workplace concerns. As a result of her taking the
class, she said, she was able to approach him and ask him questions.
“He listened,” she said, “and got back to me with answers. Even our
supervisors look at us differently.” She added later, to the evaluators
in the room, “I couldn’t look you in the eyes before this class.”
On Manchester Memorial Hospital’s (MMH – part of ECHN) campus,
administrative staff learned side-by-side with technicians and social
workers, as classes were open to the entire facility. While a commu-
nity hospital, MMH is a complex workplace with distinct functional
spaces, and staff who did not previously know each other became a
cohort with common needs. This led to increased knowledge of each
other’s roles and responsibilities and greater ease in cross-department
communications.
Participating as mentors helped nursing staff to better understand
and appreciate the capabilities of their CNA staff. Mentors engaged in
CNAs’ learning experiences observed the small and large changes tak-
ing place in self-esteem and skills. A new working dynamic emerged
and mentors and their colleagues began to see the CNAs as part of a
team in caretaking rather than as implementers of their written or oral
orders. And frontline staff developed a new appreciation for the roles
and responsibilities of their nurse supervisors by developing a greater
understanding of the many dimensions of care for which nurses are
tasked, and a greater understanding of how their work fit into the
whole care plan.
We taught something more profound. You’re a person caring for a person. The hand that touches the hand; you are that link. That to me was central. It’s about the human relationship and learning about how to do better with respect to the human relationship. . “ “
- Elizabeth Begley, Allied Health Project Director, CWP
19
20
VNA HealthCare is an outlier among the facilities involved in the initia-
tive. The agency’s CNAs and PCAs have few opportunities to talk with
peers about patient and work issues because their jobs place them in
individual’s homes and under indirect supervision. Classes provided
participants with a place and a context to share insights and chal-
lenges from the field. According to Aldine Fray, classes gave “the two
parts of VNA (PCAs and CNAs) a way to get to know and appreciate
each other and each other’s roles in home health care. Those who at-
tended classes participate more freely at in-services and ask more and
better questions.”
Fred Lauria of VNA HealthCare sees a “marked difference in interac-
tions between frontline workers and the rest of the care team.” He
adds, “In home care, there are various direct service staff, social work-
ers, therapists, nurses and aides involved in care. Typically, the hierarchy
places the CNA at the bottom of the spectrum, especially with respect
to how confidently they interact. Now, they appear more equipped to
discuss cases with the nursing and other members of the professional
staff. They are more assured in expressing their thoughts. ”
When frontline workers were given access to information in patient
charts, dynamics changed. According to Marian Eichner, “the frontline
workers felt more empowered, more excited about what they were
doing. They could ask people who weren’t their mentors for assis-
tance. Giving people the ability to say, ‘I don’t know, but I want to
know’ is just so empowering.”
It wasn’t about tasks anymoreSo Mrs. Jones wasn’t a Hoyer lift anymore. Mrs. Jones had cancer or dementia, but she was no longer just a lift. And that started to resonate pret-ty early – we humanized the residents. For me, it was interesting to know that the CNAs did not know their residents – know them in terms of what their diagnoses were, their psycho-social histories, their medical histories. They weren’t simply Hoyer lifts, feeds, checks and changes. Whatever they were, they weren’t simply a task. They had to start talking about the resident as a resident. That’s why I think the quality of care improved – because we humanized the process.
Marie Spivey concurs. “The important part of that is that it shows a
level of respect they had not had before. When the information is
shared between people, there is a certain level of respect that emerg-
es. And that’s what we’re trying to do. With the diverse nature of
our partners and the workforce, we have to bring that practice to the
forefront and that’s to respect everyone.”
Quality of care: a paradigm change
While workplace learning certainly added to frontline worker’s body
of knowledge, self-efficacy and self-confidence, more importantly it
focused everyone’s attention on residents.
As Elizabeth Begley indicates, “it wasn’t about the tasks anymore.”
“So Mrs. Jones wasn’t a Hoyer lift anymore. Mrs. Jones had can-
cer or dementia, but she was no longer just a lift. And that start-
ed to resonate pretty early – we humanized the residents. For
me, it was interesting to know that the CNAs did not know their
residents – know them in terms of what their diagnoses were,
their psycho-social histories, their medical histories. They weren’t
simply Hoyer lifts, feeds, checks and changes. Whatever they
were, they weren’t simply a task. They had to start talking about
the resident as a resident. That’s why I think the quality of care
improved – because we humanized the process.”
- Elizabeth Begley, Allied Health Project Director, CWP
“
“
21
And as a result of courses offered by employers, CNAs had a greater
awareness of the many dimensions of residents’ lives and wanted
more information that could lead them to better understand, and
also better care for, their residents. David Santoro, administrator at
Southington Care, was the first to allow CNAs access to medical charts
under the supervision of a mentor; Jerome Home and Hebrew Home
followed shortly thereafter. The kinds of information now available
to CNAs allowed them to know more about the emotional, psycho-
social and medical histories of their residents, information which
would allow them to make good decisions about both routine and
non-routine tasks.
Kate Gilman, Director of Staff Development at Southington Care,
suggests that CNAs are spending more time with residents. “I see them
taking the time to sit with residents and be more involved with their
daily activities, spending time to talk to them, to interact personally.”
Marian Eichner relates the story of the course debriefing in which the
subject of access to resident information was raised.
I keep going back to what was an a-ha moment for me – sit-
ting at the Southington Care debriefing with Cathie and Barbara
leading it and the CNAs saying ‘We don’t have access to the care
plan. We’d like to have access. We’d like to have input, see the
charts of the people we’re caring for.’ And I’m thinking, of course
you should have that and David Santoro is saying to his Director
of Nursing Services (DNS) – ‘We’ve got to make that happen.’ So,
not only did it give frontline workers the opportunity to know
more about the person they were caring for, but it also opened
up those lines of communication with the nursing staff and pro-
vided a way for the frontline workers to have valuable input into
how people were cared for and it had a positive impact on the
quality of care.
Begley posits that the information allowed frontline staff to truly
understand the behaviors they might see. “As a CNA, I could get you
up at 9am or 10am, I didn’t know that when you were working, you
worked nights and so that’s why you might be sleepy at breakfast. It
was an incredible epiphany to me, even as a former DNS.”
She continues, “We taught something more profound. You’re a person
caring for a person. The hand that touches the hand; you are that link.
That to me was central. It’s about the human relationship and learning
about how to do better with respect to the human relationship.”
Terri Ciocci suggests that the changes in her staff are observable, in
their questions and their actions. “It has become about what, and
more importantly, how do I know.” During the workday, Ciocci heard
conversations that didn’t occur prior to the program. She heard stu-
dents solving math problems in the elevators and CNAs and nurses
discussing patients’ needs which indicated to her that learning growth
and changes in relationships were authentic. And Ciocci indicates
that when the unit began “implementing improved documentation
tools, it wasn’t just about what do I do. There was a discussion of
why the tools would be effective, and how the CNAs would assist in
their implementation.”
Karen Wantek, a clinical assistant and mentor at Hebrew Home, sug-
gests that she saw an enduring effect when mentoring was added to
CNA education. “The program with mentoring worked much better
than those who just took classes. CNAs and nurses stepped up. Yet,
personality is also a factor. The results for the CNAs who are lead-
ers, especially if there is more than one on the unit, are more likely
to persist. If your personality is to be a follower, some slid back to
old practices. Maybe the followers are just less verbal though and we
can’t really know what lasts.”
Synthesis documents suggest that, after taking only a few classes,
CNAs felt empowered and experienced their relationships with resi-
dents and nursing staff differently. “Students pointed out that even
after only two classes they already understood their residents differ-
ently. They pointed out an understanding of behaviors that would
have caused frustration in the past, and a deeper understanding of
their patients’ families.”7
Terri Ciocci has no difficulty in identifying specific examples of changes
in care. Ciocci is a member of a committee that monitors resident falls
at Hebrew Home, and points to a correlation between the decrease in
resident falls and skin breakdowns on the second floor and the num-
ber of CNAs from that unit enrolled in work-based learning classes.
There is also an increase in initiative and agency.
“We were concerned about a patient complaint,” Ciocci shares. “The
patient had low mobility and there was some discussion, started by
the CNAs who now saw this issue as ‘not their – nursing – problem,
but our problem’. As a team, they discussed the use of a lap belt, of
care with hot beverages, so the resident could have a higher quality of
life. This doesn’t happen by telling people what to do.”
7 Elizabeth Begley, Synthesis of Information: Hospice WBL, Southington Care Center.
22
Translating the classroom to the facility
One of the strategies designed to help students to solidify classroom learning was the use of the DO-IT
model. DO-IT helps students to translate classroom learning into solutions for the real life issues occurring
on the facility floor. The DO-IT model – based on clinical competencies needed by CNAs – provided a way
to “facilitate a critical shift in thinking in the CNAs.”8 DO-IT cards were made to be convenient for frontline
workers to carry around in their pockets. Cards posed a hypothetical or a question that students would try
to answer using resident care as a point of reference.
The model and acronym were created by Elizabeth Begley, Allied Health Project Director at CWP, and before
that, Director of Nursing Services at Southington Care. Sonya Gaztambide was the first instructor to use the
model. Begley recalls sitting in Gaztambide’s class.
I wanted them (students) to take it (their learning) to their feet, wanted them to actually apply what they
were learning. I thought maybe we could talk about the kinds of things you’re learning and the kinds of
things they were seeing with patients. First, you’re going to describe your patient, then you’re going to
watch your patient carefully – observe – and so on. So right there in the classroom, I thought, that’s our
acronym- DO-IT. We’ve even integrated it into these online courses that we’ve written. In trying to help
students to write on the discussion board and to journal in that format. It’s really helped them to figure
out how to write a case study. We encouraged students to carry them around and use them- to spark
their memory as well as to write on. The thought was that they could have their whole curriculum in a
box and could refer back to it if needed.
Begley suggested that Joan Jakiela’s teaching style made the model real to students. Jakiela found the DO-
IT model an effective way to both organize the course and encourage students to assume responsibility for
their own learning.
“I believe that people need to become actively engaged to learn. The model gave them an assignment in
which they needed to make a connection with supervisors, mentors and other students. It gave them a
taste of what learning really is,” she indicated.
Students needed time to adjust to a new learning modality. Students like Marta, a CNA at Southington Care,
suggest that they “had to take the time to get used to the cards.” The cards required that students not
only interpret the clinical challenge, but also work with their mentors and write down possible responses.
The writing abilities of those enrolled varied – some of the CNAs had previously been enrolled in English as
a Second Language classes. Some CNAs indicated that finding an example of the posed clinical challenge
in the field, understanding the possible course of action, and then writing down notes or an answer, was
difficult to accomplish in the course of the week.
DO-IT (Describing, Observing,
Intervening and Trying) Model
8 Elizabeth Begley, Synthesis of Information: Issues of Aging WBL, Jerome Home.
23
The DO-IT model created new opportunities for relationships among clinical staff and expanded CNAs’ ac-
cess to patient information. Marta suggests that the DO-IT model was the catalyst for CNAs being allowed
to review information contained in resident charts, previously unavailable to CNA staff.
“It was a taboo,” she suggests, “we didn’t even touch them, but now, we can read the chart and find out
more information; the nurses will be more likely to explain what’s going on medically with the patient.”
This has contributed to CNAs feeling more connected to their residents and an enhanced understanding of
how different diseases impact residents behavior, the care plan and their clinical duties.
And Kate Gilman at Southington Care concurs. “Students became more interested in residents’ medical re-
cords. Prior to taking the class and their use of the card method, they didn’t know they could have access,”
Kate suggests. “They (CNAs) began initiating conversations with nurses, asking questions about different
medications and care plans,” she indicates. “I saw a difference in how they were out on the unit; they re-
sponded differently to patients.”
CNA students from Hebrew Home suggest that the DO-IT model worked well for the facility as well as the
students. The cards created a catalyst for general discussion on the floor about the clinical challenges and
also about the residents’ general health and wellness concerns. CNA students became the vanguard of a
more holistic perspective of resident health and the core of a larger group of staff that was interperson-
ally connected to each other. And at Hebrew Home, the cards and the use of patient charts is helpful to a
facility moving towards electronic documentation. Terri Ciocci suggests that the DO-IT model is a “perfect
segue to the new model (e-charts). CNA and nurse mentor conversations around both paper care plans and
e-charting have created a vehicle to make the transition smoother.”
Mary DaMotta, a clinical assistant and mentor at Hebrew Home, also suggests that the cards, beyond being
an effective learning tool, became a great reference for CNAs. The format made them more portable than
a text and more reliable than recall.
Donna Chasse used the cards a little differently in her teaching. When she started teaching the
Rehabilitation class, mentors had not been identified. In response, she revised her plan for using the DO-IT
cards so that student learning objectives could still be achieved. Chasse used the cards’ clinical challenges
at the beginning of each class as a way to spur group discussion and so that students could support each
others’ learning.
CWP formalized and integrated the model into their overall workforce development work. Begley adds, “I
wrote an aging course for Capital Community College and integrated DO-IT. I think it helps students bring to
life what they’re learning in a step-by-step way. It has been very helpful in formalizing just what work-based
learning is.”
24
Creating relationships for learning and growthMentoring
A key component in the success of work-based learning was the facilitation of mentoring relationships designed to
support communication among, and learning for, frontline and supervisory staff. A cadre of mentors catalyzed changes
in the long-term care culture to reflect a more team-based, client-centered approach. Mentors have included frontline
charge nurses and staff development and nursing administrators.
B&F Consulting, led by Cathie Brady and Barbara Frank, developed the curriculum used to train supervisory and mid-
level staff about strategies to nurture growth in the frontline staff. The curriculum was approved for professional devel-
opment credits for the nurse mentors, and is reflective of a relationship-based supervisory model.
Student-mentor pairs were introduced at a ‘meet and greet,’ where B&F Consulting and Elizabeth Begley were on
board to facilitate interactions between nurse-CNA dyads, describe learning objectives and activities and foster the
mentoring component. The group activities, according to CNAs at Hebrew Home, created an environment of trust.
“We got to know each other in a different way; we did exercises to increase the comfort level,” shared Alita, a CNA
participant at Hebrew Home.
And the new relationships with mentors enhanced CNAs’ ability to ask insightful clinical questions, not only of their
mentors, but also of other supervisors and staff. Students expressed “an increased level of comfort in approaching su-
pervisors, a decreased anxiety about asking questions, and a feeling that this improved communication would continue
even with the class having ended.”9
CNAs expressed feeling “cared about” – that their mentors cared about them not only as workers and students, but
also valued them as people. They believe that the changes provoked by these key relationships allowed them to see
themselves as agents in their work - not just workers, but good critical thinkers able to make good clinical judgments.
Nurses began to see themselves as partners with CNAs as they worked to integrate what they learned in the classroom
and on the floor.
There were challenges in some facilities with making the mentoring relationships work. And even within a facility,
CNAs had different experiences. Marta, at Southington Care, spoke about “chasing her mentor down,” while other
CNAs at Southington indicated that their mentors would seek them out, maintaining close contact with their students
and creating opportunities beyond assigned work for discussion and learning.
Hebrew Home lost many of their assigned mentors after the completion of the first class. CNA students and the re-
maining mentors were often assigned to different units or different floors, making it difficult to make use of informal
and formal mentoring opportunities.
Karen Wantek, a mentor at Hebrew Home whose mentee worked on another floor, suggested that it was difficult to
meet because of the variability of both the nurse’s and CNA’s workday. Yet, at Hebrew Home, CNA students were
also mentored by the second floor nurses, not assigned formally, but still ready to jump in to answer student questions
9 Elizabeth Begley, Synthesis of Information: Issues of Aging WBL, Jerome Home.
25
and assist with answering DO-IT clinical questions. Terri Ciocci also had her offices on the second floor and became a
mentor to all of the participants. Nurses who were informed of the program but not assigned to a CNA would show
an interest in CNAs’ learning and ask about classes. The spill-over effect had a more wide-ranging impact as nurses
would tell participants more information about their residents and their clinical issues.
According to the nurse mentors at Southington Care, the nursing staff “really cared about the learning gains of their
CNAs, and when an individual mentor was not available to help out, someone else would step in. The program helped
nurses to see aides in a different light as they took on difficult clinical questions and discussed patient needs with
nurses, often advocating for their (patient) needs.”
Some nurse mentors were very invested in CNA learning, spending time off finding supports for students. The debrief
synthesis for the Hospice class offered at Southington Care indicates,
One mentor in particular tries to do a daily check which is recognized as a best practice in this class. All the
mentors had offered time to the students on ‘off time’ either through phone or email communication. Another
mentor went online and obtained additional information for her mentees to further enhance their learning and
provided them with case studies and other skill-based materials that related to their learning each week. A key
point was a mentor who reviewed the cards and assignments so that she could anticipate questions from her
mentee.`0
In Donna Chasse’s Rehabilitation class at Hebrew Home, students did not have the benefit of a formal mentor; yet,
along the way they learned to mentor each other. Chasse used both journaling and reviews of DO-IT card assign-
ments to reinforce student learning. At the beginning of each class, the CNAs would review the question(s) posed by
the week’s DO-IT card and Chasse would engage students in a discussion of the challenge – relating the challenge to
their clinical and life experiences. Students were able to connect the issues of body mechanics and movement to their
own and their residents’ lives. They were supportive of each other as a core group of learners and developed a cohort
identity that allowed them to mentor each other.
The benefits also extended to nurse mentors who had the opportunity to work on DO-IT challenges with CNAs with
whom they may not previously have had a relationship. This enhanced collegiality throughout the facility. Additionally,
Terri Ciocci offers, the mentoring process opened up possibilities for interpersonal skill development. “We had a CNA
and a nurse that just did not get along. They were matched as mentor and mentee and as they worked together on
competencies, they got to know each other a little more. Task completion was not the sole benefit of the relationship.”
Students found the relationships enjoyable and helpful to their learning. Having a nurse mentor available to break
down the terminology in digestible bites was important to student learning, and quelled students’ anxiety related to
translating class content to their duties on the floor. And having a human sounding board was equally as valuable.
10 Elizabeth Begley, Synthesis of Information: Hospice WBL, Southington Care Center.
26
This Initiative was the first time that all of the partners involved had
worked together on one project. Therefore, it was important to the
project that someone was devoted to both expected outcomes and to
the process of the partnership. To that end, the project included B&F
Consulting, experts in culture change activities in the health care en-
vironment, who brought extensive experience in and sensitivity to the
personal and systemic effects of change to the project. B&F’s Brady
and Frank created important opportunities for team building among
partners and assisted partners in sharing strengths and challenges
through a well-facilitated debriefing process. Through a number of
effective process-oriented sessions, they created an environment in
which continuous improvement could thrive. People felt safe to have
difficult conversations and identify and address challenges.
Cathie Brady of B&F Consulting indicates that CWP had an orientation
to planning and implementation that valued continuous improvement.
The earliest culture change and project implementation meetings
were designed so that educators and employers could identify student
needs and early program successes and challenges. The large num-
ber of collaborators and the intersecting interests of the community
college system, the workforce development system and the vari-
ous long-term care facilities necessitated a regularly scheduled open
forum so that, as Barbara Frank said, “things got said.”
Elizabeth Begley’s expertise was vital to the project. Begley convened
and managed the iterative process and was a consistent presence at
partner facilities and an effective problem-solver. Her deft guidance
and deep understanding of the long-term care world was essential to
the project success. A clinician and an administrator, Begley had been
active in culture change and educational activities in her previous posi-
tion at Southington Care.
“One of the key things that helped the partnership to grow and got
employer partners engaged in implementation was that we were able
to attract Liz who spoke the language and could make the business
case as well as the people case,” suggests Marian Eichner, “Going
forward, an organization has to commit to having an expert leading
things – whether it’s an effort in allied health or advanced manufac-
turing – you have to be able to speak the same language as the em-
ployers you are working with.”
Barbara Frank and Cathie Brady indicated that Begley’s knowledge and
experience as a nursing administrator in a long-term care facility gave
her a vantage point from which she could understand both participant
and facility needs, and anticipate and address program challenges.
And employer and education partners concurred. “She provided the
right degree of support; she could walk us through the particulars
of implementation, like the financial forms, when we did not under-
stand what was being asked for. We needed some hand-holding as
we worked our way through the first classes, the first reports, and
when things were not going smoothly.”
Building collaborations and trust: Project Implementation Team
(PIT) meetings
In the first two years of the CNA Advancement Initiative, PIT meetings
were held regularly to build strong working relationships between
the educational practitioners and long-term care facility administra-
tors responsible for the project (staff development and other nursing
administrators). Attendance of all partners was strongly suggested
and partners were given the option of attending in person or by
conference call. The availability of the conference call option made it
possible for facility administrators to attend consistently. The regularity
of the meetings allowed for trust to build as partners shared informa-
tion about their programs, heard details about new developments or
reporting changes, and were kept abreast of progress made on identi-
fied challenges. For example, a PIT meeting was used to discuss the
unevenness of the instructor quality and helped partners to successfully
resolve the issues related to teaching style and student-teacher fit.
Meetings were of sufficient length to allow all views to be present-
ed and substantive discussions held. This created an environment in
which the iterative process was valued; continuous improvements
were reflective of the often differing perspectives of the partners.
Program partners identified the willingness to make adaptations to
the program as being essential to student success. One partner called
it “working as we’re going.” An example of the importance of itera-
tion is the development of the hybrid adult basic education/clinical
course offered at Hebrew Home (described earlier in the report). The
project leadership welcomed continual feedback on both general and
specific matters, and the project evolved to meet real student and
implementation challenges.
Steve Bender, Executive Director of the 1199 Training and Upgrading
Fund in Hartford suggests, “At the peak of the project, the collabora-
tion of CWP, 1199, Capital Region Education Council and the commu-
Partnership Change
27
nity colleges was very exciting; it was an impressive sectoral initiative
successful at bringing a lot of players around the table.”
Granting credit for course mastery
The CNA Advancement Initiative brought together community
college faculty and staff (largely from Continuing Education), adult
education practitioners and administrators, and workforce develop-
ment professionals to develop and implement courses that would en-
hance student content knowledge and improved resident care. Yet
another objective was to translate course mastery to college credit.
This was a long and negotiated process among many partners, with
many challenges, but with ultimate success.
Marian Eichner recalls the early discussions. “We went into the process
with all of our partners at the table understanding that we wanted the
clinical courses to be associated with college credit. Once the courses
were developed by the community colleges, they went to Charter Oak
State College (COSC) in order to evaluate them for credit. The assump-
tion was that this was something community colleges did on a regu-
lar basis. What we found was that the clinical course work that we
developed needed to be enhanced greatly before any college cred-
it could be assigned to it. It was a challenging process. There was
some miscommunication, but we did get that credit assigned and the
students were all very excited that they are getting college credits.”
Adds Marie Spivey, “The review team worked really hard to review
every word, every statement of every course before they would make
a recommendation about awarding any credit. It wasn’t as much
negotiation as it was work! These were brand new specialty courses
and they weren’t anything they had lined up in their (community col-
lege) course catalog.“
“And to be sure,” offers Elizabeth Begley, “the first courses were not
strong. Community colleges were somewhat stuck in traditional peda-
gogy with texts, but that wasn’t what the grant was about. And they
had somewhat low expectations of CNAs being able to do credit-wor-
thy work, so the original curricula may have been only foundational.”
Under the aegis of the Board for State Academic Awards, COSC
“provides diverse and alternative opportunities for adults to earn
academic credentials,” and “is committed to the premise that college-
level learning occurs in many settings.”12 COSC is committed to a sys-
tematic and thorough review process, from program selection through
on-site visits and final evaluations, to ensure that courses meet criteria
for college credit. COSC has reviewed training offered to State Mar-
shalls as well as many other allied health and technology courses.
Shirley Adams, Provost at COSC, elucidates the process. “We use our
Connecticut Credit Assessment Program (CCAP) to review the non-
credit courses to determine whether they are worthy of credit. COSC
puts together a team of faculty to evaluate the curriculum, and to
review outcomes and assessment tools. Because these courses came
out of the non-credit side (of the community colleges), staff may not
be used to preparing formal syllabi or preparing assessments of learn-
ing objectives. So there was a good deal of negotiation needed to get
the material in a format to be evaluated.”
The process was iterative; Elizabeth Begley worked with individual
curricula developers to add rigor and relevance through supplemen-
tary materials and enhanced assessment. “As a former DNS, I pushed
back to say that the courses needed certain specific things, and as
Project Director, I also pushed for more rigor.”
Originally, seven clinical courses were evaluated for credit. Six
clinical courses received one-half credit each. They include Demen-
tia and Alzheimer’s; Issues of Aging; Hospice and Palliative Care;
Mental Health; Rehabilitation; and Substance Abuse. Students who
successfully complete all six are awarded three college credits. Only
one course, Medical Terminology, which is more foundational, was
not awarded credit.
Creating Synergies
The CNA Advancement Initiative has greatly benefitted from the
synergies created by CWP’s concurrent projects. While the original
funding for the workplace learning and culture change strategies
came through a grant from the federal Department of Labor, the Rob-
ert Wood Johnson Foundation and the Hitachi Foundation in collabo-
ration with the United States Department of Labor, through the Jobs
to Careers program, funded work-based learning.
The goals of both workplace and work-based programs were to
strengthen clinical and critical thinking skills among frontline work-
ers, expand opportunities for leadership and team building among the
direct care and supervisory staff and enhance the quality of care for
patients. The programs benefitted from having strong educational and
technical assistance partners, which included Connecticut’s Commu-
nity Colleges, Charter Oak College, Capital Region Educational Council
and B&F Consulting.
12 COSC, Policies and Procedures for CCAP Reviews
28
The CNA Advancement Initiative brought
together community college faculty and
staff (largely from Continuing Education),
adult education practitioners and admin-
istrators, and workforce development
professionals to develop and implement
courses that would enhance student
content knowledge and improved resi-
dent care. Yet another objective was to
translate course mastery to college credit.
This was a long and negotiated process
among many partners, with many chal-
lenges, but with ultimate success.
29
Work-based learning, therefore, complemented and extend-
ed courses delivered onsite to frontline workers; its design
and intent was to “capture, document, formalize, and re-
ward learning that occurs on the job. Work-based learning
establishes structured expectations and competencies, and
results in academic credit or industry-recognized credentials
for achievement. It shares features with (and builds upon)
other forms of learning associated with the workplace, in-
cluding on-site classes, internships, clinical rounds or resi-
dencies, and apprenticeships. Yet it is distinguished by being
continuous with the job itself, which is structured to achieve
learning objectives. These objectives, in turn, are derived
from the skill requirements of the job.”13
According to Elizabeth Begley, work-based learning “kicks
it up a notch,” by transforming the teachers and mentors
into coaches and facilitators of student learning and making
students responsible for their own education.
Begley adds, “Students brought real life situations to the
classroom so the learning was deeper, more profound. You
never knew what scenario (from the floor) was going to
be presented, what new thing was going to pop up from
practice that you would have to teach about. It (work-based
learning) forces the instructor to say to herself, ‘Did what I
taught you stick? Are you applying what you’re learning?’
In some ways, work-based built upon the foundation of the
workplace classes.”
Terri Ciocci from Hebrew Home suggests that students who
succeeded in the workplace education courses were more
confident in moving into work-based learning. “There was
a sense of empowerment that came about from taking the
workplace classes. Students could move forward more easily
and interact better with their peers and teachers, especially
after taking lots of classes. Taking those first courses led to
stronger and stronger students.”
And the synergy created by the overlap of workplace and
work-based options engaged more than the direct care pro-
viders. Dietary and housekeeping staff who were engaged
in the classes also began to observe attitude and behavior
changes in residents and share their insights, and direct care
and supervisory staff began to take notice.
“The dietary and housekeeping staff has no real clinical interface and
yet, they were applying their new-found knowledge,” suggests Beg-
ley. “It’s kind of crazy because some would say, ‘You’re just passing a
tray,’ but I knew that Susie Smith is short of breath and I knew that
her head should be up or I know she should have a fan on her face,
that is important. Even dietary and housekeeping staff began to have
input into care for residents. The work-based learning really solidified
that we have to have a lot of opportunities for education for everyone
in the long-term care workplace.”
While the synergy created by the concurrent implementation of
workplace and work-based education was significant, smaller op-
portunities also emerged for leveraging programmatic initiatives and
creating change.
A significant component of work-based learning was mentor training;
it was open to nurses and other supervisory staff. As described ear-
lier, Linda Quirici, Nursing Education Manager at Eastern Connecticut
Health Network (ECHN), shared her experiences and knowledge from
the mentor training with her staff in a more formalized way. Cathie
Brady and Barbara Frank of B&F Consulting offered Quirici and others
the leadership curriculum and class materials so that nurses could then
train their own facility staff to mentor line staff and colleagues. The
train-the-trainer structure allows facilities to create ripples of impact as
cohorts of leaders and mentors are trained.
Marie Spivey of CWP suggests that the benefits from the synergies
created by workplace and work-based education came to fruition be-
cause of the climate created by continuous assessment. “How do you
contextualize skill building? How do you apply learning to peoples’
lives? These became questions related not only to the participants,
but also to the planners. How do we support people in their learning
process? The level of culture change was profound for the facilities
and equally as important for the educators and the implementers.”
She indicates that the guidance provided by Begley, the process-driven
PIT meetings, and funder and partner flexibility allowed the synergies
to blossom.
13 http://www.jobs2careers.org/workbased.php
30
Many of the program components designed and implemented for the
CNA Advancement Initiative exist in subsequent CWP projects. The
project was informed by previous and successful educational efforts in
allied health, such as the Bridges to Health Care project. The Initiative
also continues to inform projects both in progress and planning stages.
In specific, CREC’s Toolkit for hybrid development, prepared following
the successful hybrid course, shows promise in its potential applica-
tions in many fields of education and worker training, allied health
among them. Its concurrent structure of adult basic education and
clinical specific content has been associated with positive changes in
student CASAS scores in math and English language skills. Its use with
entry-level workers and English learners who need English and Math
remediation or reinforcement can add to practice knowledge about
its use with various audiences and may someday add to the research
base on contextualization.
Leadership courses have led both frontline and supervisory staff to
gain self-confidence and self-efficacy in addressing interpersonal and
clinical challenges. The train-the-trainer model that resulted from its
use with nursing staff can allow facilities to extend learning and en-
hance the quality of communication and care.
The clinical specialty courses, in both iterations (workplace and work-
based), have added tools to the expanding toolbox of education and
training and will stand as credit-worthy complements to other facility-
based interventions such as professional development, enabling long-
term care facilities to further develop talent within their walls and af-
fect resident care and resident lives.
According to Marian Eichner, “The CNA Advancement Initiative helped
us (CWP) to move forward with our allied health mission. The sus-
tainability was a given from the beginning of the project – the fund-
ing was available to help us to do what we had already planned to
do – strengthen relationships, enhance partnerships, respond to the
needs of employers and provide opportunities for frontline workers to
enhance their skills, provide better care to patients and position them
to move across career lattices and up career ladders.”
The Long-term Care Certificate program is the next generation of
workplace/work-based learning for frontline workers. The certificate
program, offered online through Charter Oak State College, consists
of more rigorous versions of six of the courses developed for the
Advancement Initiative (Issues of Aging, Dementia and Alzheimer’s,
Mental Health, Substance Abuse, Rehabilitation, and Hospice and
Palliative Care). Each of the six courses is worth three college credits;
upon successful completion of the certificate, students are awarded
18 college credits. These credits can enhance clinical care giving and/
or serve as an important foundation for community college study.
Currently, Eichner indicates, “eight very committed students are en-
rolled in the program.”
The clinical courses have also been used to enhance four of the nine
courses in the Gerontology Certificate program currently offered at
Capital Community College. The revised courses are being piloted
with front-line workers at VNA Healthcare in Hartford; at this time,
students are currently enrolled in the second of the four classes (Prin-
ciples of Sociology). While these courses are largely offered online,
there is a teacher/mentor available in the classroom at VNA to mediate
the students’ technology-rich experiences and assist them in content-
related learning.
Sustaining: Building on a foundation of practice knowledge
31
Eichner discusses the new delivery model.
Overall, the goals are very similar. Both certificate programs share
a mechanism by which clinical courses would continue to be of-
fered and help provide a pathway from onsite to other college
opportunities whether in allied health or another area. The model
was a response to the needs and challenges of employers and
front-line workers related to release time and floor coverage. Em-
ployees are given greater flexibility in taking courses. It’s a way
of adding to the menu of opportunities to address the needs of
front-line workers and their employers.
CWP also continues to offer the services of their Education Coach,
Frangie Cruz, to students enrolled in both Long-term Care and Ger-
ontology Certificate programs. Available for guidance and support,
Cruz will continue to help ensure student success by assisting them
in identifying any barriers to completion which arise and connecting
them with needed resources.
CWP continues to collaborate with area employers to identify work-
place needs and assist in sustaining onsite worker training using in-
cumbent worker training funds.
Writ large, the Initiative is a foundation for the present Metro-Hartford
Alliance for Careers in Health Care (MACH), a partnership which pulls
together educators and employers to address the needs of the allied
health workforce, including PCAs, long-term care workers and medi-
cal coders and billers.
Yet, the relationships forged through the Initiative cast the longest
arcs of illumination and promise. From the individual changes seen
among the CNAs, as evidenced by their stories, to the facility changes
in communication and quality of care, to the changes in the working
relationships of all the partners consciously built and forged in the
iterative process, the Initiative has joined employers, policy and pro-
gram staff, supervisors and frontline staff in efforts to develop human
potential for growth.
It is at this very personal level that the Initiative has most succeeded.
Elizabeth Begley encapsulated work-based learning as, “Looking at
the person, knowing the person, figuring out what they need, and
figuring out what we need to do to meet that need.” This may also
best reflect the process and product of the Initiative’s many efforts.
CNAs will go out of their way to make sure that a patient’s clothes match. This is seemingly a small detail – but for residents in a long-term care facility, an impor-tant one that allows them to feel presentable and cared for.
“- Rita, CNA participant
“
32
When Rita moved to Connecticut she didn’t have a high school diploma. She decided to
become a CNA, because, at the time, it seemed like it would be the easiest training for
her to complete. Rita has worked at Hebrew Home for the last 19 years – until recently,
on the second shift.
Rita feels like she is part of a care team and has the support from her peers and the
nurses. She is comfortable giving her opinion on the job, and is often asked for her
input. Rita feels that her supervisor treats her like an equal member of the team, listens
carefully to her observations, gives her credit for her contributions, respects her ability
to perform well, and helps when help is needed.
Rita believes that her patients are treated with great respect and dignity. She suggests
that what clients want most is attention – and she makes every effort to give them all
they need. Rita cited patient clothing as an example of how CNAs care for their pa-
tients – CNAs will go out of their way to make sure that a patient’s clothes match. This
is seemingly a small detail – but for residents in a long-term care facility, an important
one that allows them to feel presentable and cared for.
Rita understands that her patients usually arrive at the facility with a routine from
home, so she tries to accommodate them as much as she can. When a request is made
by a patient – for example, to have a shower at a specific time, she definitely accom-
modates it, trying to make the patient’s transition to the facility a little easier.
Rita was initially interested in the CNA Advancement Initiative courses because, she
says, “you can never be too educated.” Rita’s primary goal was to achieve her GED, and
with her career coach’s guidance and support, she was able to accomplish that goal.
She had made several previous attempts, but all were unsuccessful because she didn’t
feel comfortable in the classroom.
Achieving her GED has been Rita’s biggest accomplishment; she cannot recall anything
that has brought her more joy. Achieving her GED, a long-held dream, has filled her
with the confidence to continue her education. Rita has now inspired two other people
to complete their GED – being a role model makes her very proud. Rita appreciated the
outpouring of support she received from the program staff, including congratulation
letters she received and friends and staff showing up at her graduation. Rita feels they
really supported her in achieving her goals.
Rita has been deeply involved in workplace and work-based learning, and has taken
courses such as Issues of Aging, Hospice and Rehabilitation as well as the Math and
English skills courses needed to pass her GED. Hospice was a favorite because she
learned how to care for patients in the process of dying and how to help their families.
“When you think you know certain things, and then you go into depths of it, it’s really
eye-opening, I like the excitement of learning,” she recounts, “keeping my memory
fresh and stimulating my brain.”
Rita*, CNA participant
Rita was born and raised in Jamaica. She has lived in New York City, where she worked in the fashion district with fashion designer Willi Smith, and in Canada, where she owned a neigh-borhood market. She married and decided to move back to the U.S. – this time, to Connecticut.
* Names of all CNA participants in these profiles have been changed to protect their identities
33
Anna started working at the Hebrew Home right after she became a CNA and has been
there for the past 28 years, still working on the same floor on which she started. Anna
reports that “once you feel like you’ve accomplished something by helping and seeing
the difference you make… it makes your day, it makes you feel good. I love every bit
of it.”
Anna believes her patients are treated with respect and dignity. Her co-workers have
patience with their patients and give them the privacy and respect they deserve. Anna’s
work environment is one where she and her co-workers get along well, help each other,
care for the patients as if they were family members, and strive to complete their assign-
ments as well as possible. She feels like she is a part of a group and has the support of
her co-workers.
Anna feels that her input is valued at work. She feels that her job is important, and that
she is needed, enough that she feels comfortable giving her input whenever she feels
it is necessary.
“You’re the one that’s doing the job; you’re the one that sees the patients every day, so
they need your input”.
Anna also believes that the decisions she makes at work require a lot of thought since
there are many and various things to consider, including the wants and needs of the
patient. Anna feels her supervisor values and respects her as a member of the team.
She jumps in to assist Anna whenever help is needed and listens carefully to Anna’s
observations and opinions.
Anna believes her work is much appreciated by her patients and their families. She has
kept in touch with many family members even after the passing of their loved ones.
Anna develops and maintains relationships with these families, and feels their warm
appreciation for her skill in caring for their family member.
Anna decided to sign up for the first class, and subsequently, for every class offered.
Anna took classes such as Leadership, Issues of Aging, Rehabilitation, Hospice, and the
English and Math skills classes. She most enjoyed Hospice, because it allowed for her
to put herself in her patients’ shoes, see things from their perspective, and feel more
connected with her patients.
Anna enjoyed every aspect of the CNA Advancement Initiative program. She believes
her teachers were interesting and challenging and the material that was taught was
very valuable. There were things that Anna was used to doing in her everyday routine
that she later realized could be done differently, more effectively.
Anna has a great attitude about learning new things, and believes that, “no one is ever
too old to learn, even someone like me who has been at the same job for 28 years.”
She cannot wait until the next class is posted, because she surely is going to enroll.
Anna is pleased with the way CWP program staff has kept in touch with her, to check on
her progress and to keep motivating her to continue her education. She mentions: “It’s
really nice the support I got from them, so if they offer anything else – I’m taking it!”
Anna, CNA partcipant
Anna graduated from high school and moved from Puerto Rico to the U.S. mainland at the age of 19 after her first year of college. An injury ended her dream of continuing her educa-tion and becoming a physical educa-tion teacher and Anna became a CNA at the age of 19.
34
Nilda characterizes her residents as family.
“I tried to apply for work in child care, Monday through Friday, no weekends, no holi-
days. But…I couldn’t leave my residents.”
Being a CNA aligns with Nilda’s regard for the needs of family and the importance of
care and nurturing. Her care and concern for residents has led to her being asked to do
special duty for a dying resident whose family felt better with her by their loved one’s
side for the last three days of his life.
Nilda has worked at Southington Care for the last eleven years, and has spent the last
year caring for residents who require a higher level of care on the second floor of the
building. She has earned her certification in Hospice and is sometimes called upon to
assist her colleagues in different units with terminally ill patients and their families.
Nilda believes that the entire staff at Southington works to provide the best care pos-
sible for their residents. “CNAs, supervisors, nurses – everyone works hard to make it a
good place – they care about the people we take care of,” she adds.
Southington Care has many education and quality improvement initiatives underway
and culture change is ongoing. But with changes in patient care and workplace culture,
and shared decision making, come changes in workplace dynamics. Nilda believes that
her ability to not take workplace slights and hurts personally has served her well. “I’m
different. They say I was always laughing.”
Yet, as a team leader, Nilda takes her patient care and advocacy role seriously, and feels
that her honesty can sometimes get her in trouble. “My husband told me my mouth is
gonna get me in trouble,” she says laughingly, “But I say things that I mean.” She sug-
gests that asking too many questions of the nursing supervisors has gotten her notice,
and that some nurses “assume CNAs don’t know because they are not nurses.” These
are the growing pains of a new paradigm of care and Nilda is feeling them.
Southington Care Center is a multicultural workplace, with staff from many places in
the world – Asia, Eastern Europe and Latin America, to name a few. The diversity has
been both a strength and a challenge to staff and administrators. Nilda posited that the
presence of varied language groups helps newcomers to acclimate to the workplace
and also allows Spanish-speaking (or Albanian, or Polish) residents and their families a
degree of comfort in having staff available to translate.
Nilda has taken a wide array of classes offered as part of the CWP CNA Advancement
Initiative -- Hospice, Alzheimer’s and Dementia, Leadership and Rehabilitation among
them. She was also enrolled in the English as a Second Language course.
Nilda, CNA participant
In 2000, Nilda saw an advertisement describing the certification course for CNAs that was being offered at Southington Care. She enrolled in and passed the class and began working at Southington Care, and as she re-counts, “I haven’t left yet!”
35
Nilda originally saw the posting for the English as a Second Language
class (offered as a workplace learning option) and was encouraged
by a former administrator at a meeting called to promote CNA par-
ticipation in the new program. Nilda enjoyed the teacher and found
her English getting stronger. Students did a lot of writing, some of it
reflective, and she felt more comfortable with her writing in her work
at Southington Care. Nilda still finds verb placement counterintuitive
and tenses somewhat confusing, but believes that she has grown in
her language use, and that her growth has been both professional
and personal.
Nilda next took Medical Terminology. She suggests that taking the
class helped her in working with nurses on her floor. “The nurses will
speak in medical terminology that I could now understand, and some-
times they need our help in figuring out what’s best for the patient.”
Knowing precise medical terms could help Nilda to understand diag-
noses and diseases that affect her residents; this information directly
impacts the kind of care she gives.
Nilda found the other clinical courses as important to her practice.
“In Dementia,” she offered, “it helped me to work better with my
residents. I learned not to get them upset; and when they get upset,
how to calm them down.”
Hospice offered other lessons. “How to deal with patients in the last
days of their lives – what to say, how to treat their family, especially
when the family is in denial or struggling to understand. When you’re
willing to learn, you’ll be amazed…”
Skill building also awakened Nilda’s proclivity for advocacy. “Maybe it
was partly because I took care of people so young, or my early mar-
riage, but I always spoke up for my family.” Armed with new clinical
knowledge, she feels more confident providing patient advocacy. As a
frontline worker, Nilda believes she knows the needs and preferences
of her residents and can often anticipate their needs. In taking the
Dementia class, she saw her resident’s behaviors with new eyes. “I
know people get confused, but they still know how they want to be
treated. Sometimes someone has to stand up for the resident and for
the family. It’s not always the dementia.” And although her advocacy
has at least once gotten her challenged by her superiors about her
comments, she still feels the responsibility to articulate patient needs.
Nilda enjoyed working with her mentor, the Assistant Director of Nurs-
ing, in the Issues of Aging class. They found time to meet at the end of
Nilda’s shift. “She was really helpful in me understanding the things I
was learning in class,” she added. The class, Nilda suggested, was not
an easy one – the DO-IT model being used required CNA students to
attain competencies through clinical questions posed and answered
on cards – but by the end of the class, she said, “we all got it.” She
especially enjoyed the instructor of the Issues of Aging class, and
thought she brought a new energy and enthusiasm to the classroom
through her use of engaging techniques.
Nilda plans to go back to school sometime within the next few years.
“I don’t want to be a nurse,” she offered, “but I am interested in occu-
pational therapy.” Nilda enjoyed taking the Rehab class and believes
that it may have awakened her interest in a new career path. “I’d like
to be helping people to be as independent as they can be,” she says.
And perhaps, this course also reaffirmed experiences based in her role
in her family.
During her first marriage, she and her husband welcomed his niece,
who had a disability into their home for a year. Nilda taught her niece
to be responsible for her personal hygiene and taught her to do laun-
dry and to cook, so that she could be as independent as possible. “You
can do it, I would say. You have two good hands…” Nilda added,
“And she learned.”
Nilda’s encounter with her niece’s social worker at Children’s Hospital,
a woman who used her toes to type her notes and her breath to work
her wheelchair stayed with her. It helped inform her work with her
niece, who she says still cooks for herself, and informs her work with
patients who she helps to stay as independent as possible despite their
cognitive or physical challenges.
“Some of my coworkers, they have different excuses,” Nilda indicated.
“I’m too old, I don’t have time. I encourage them. One hour isn’t
going to kill you. Sometimes you have to sacrifice in life. You know
English, you work in this place. But sometimes when people are slow
in learning, they feel ashamed.”
Nilda also appreciates the very real barriers that stop people from par-
ticipating or completing; she adds, “I don’t have kids; I don’t need to
run home.”
But for her, Nilda says, “I have a lot of goals even though I am almost
40. I always have to look for a new challenge. Some people take their
work like a routine. But, you learn from the family, from the residents,
from the nurses. I go to everyone.”
36
Jakiela has taught Aging in America at MCC, and in developing the two courses, con-
sidered that the target audience for the work-based learning classes would be similar
to her MCC students. She worked with Charter Oak State College (COSC) to create
a course that would be authentic college-level work, and used Universal Design for
Instruction (UDI) precepts (adopted by MCC and other institutions) to guide her work.
As COSC was ultimately charged with determining the credit-worthiness of the course,
Jakiela included COSC administrators at the earliest stages.
Using UDI as a framework allowed Jakiela to create courses and strategies that would
“benefit a broad range of learners, including students with disabilities.”15 Some of the
hallmarks of UDI, as described by the various academic institutions that use it, include
flexibility, simplicity, use of multiple strategies of engagement and a problem-solving,
rather than didactic, orientation.
Jakiela indicates that she “truly designed it (the courses) as college-level; I didn’t dumb
it down.” She described the curriculum development process as walking the fine line
between rigor and accessibility – “I wanted them to have an experience they would
remember, that they could relate to their clinical duties, but also to their own lives.” She
spent a “good deal of time with the ideas I would be trying to relate – conceptually.
I wanted to make sure that it was clear and I wanted to find new strategies to reach
the students.”
Jakiela, herself a life-long learner, also translated some of what she had learned at a
film course at Yale University to add the use of film as a learning tool to her courses.“I
used Iris (a film about the story of Irish novelist Iris Murdoch and her relationship with
her partner John Bayley) to give students a different way of thinking about the effects
of Alzheimer’s on a relationship.” The film looks longitudinally at the relationship of
Murdoch and Bailey and illustrates the changes to both the patient and her family.
“A couple of them didn’t want to see it,” she adds, “But I think it broke barriers for
them, not only the content, but also they may not have seen an ‘indie’ film before. I
made it fun, brought popcorn. Many of them were visibly moved by the story.” Jakiela
believes her CNA students experienced the cognitive and emotional changes brought
about by Alzheimer’s in a way that reading a case study or caretaking on the unit could
not evoke.
Jakiela believes that creating a non-threatening learning environment must be paired
with relevant and rigorous content. As both creator and instructor, she had maximum
flexibility in revising how she taught certain modules when she felt the class was un-
clear on learning objectives or becoming disengaged. For example, students at South-
ington Care were required to take the last Dementia class she taught (Southington used
Joan Jakiela, Instructor, curriculum developer
Joan Jakiela, a gerontologist, instruc-tor, and coordinator of the Geron-tology and Therapeutic Recreation certification programs at Manchester Community College (MCC), wrote the Alzheimer’s and Dementia and Issues of Aging courses for the Initiative.
37
15 http://www.mcc.commnet.edu/faculty/UDI/faculty_qa.php
the class as a facility-wide training for CNAs), and were visibly resistant during the first few classes. But, by
the end of the six week module, she suggests, “everyone got into it. I made it personal and proposed it
as a conversation so that students wouldn’t feel frightened. We sat around the conference table and had
conversations. Giving students some space and allowing them to warm up gave them the opportunity to
begin to add to the dialogue when they felt comfortable.”
She incorporated validation exercises; the CNAs used them personally outside of class, but also began to use
them on the floor, sharing the exercises with their residents. Jakiela also used an exercise called “the DASH”
in which students shared how they would fill the dash between their dates of birth and death. The exercise
reinforced a cohort identity as students who may have worked on the same clinical unit, floor or time shift
were encouraged to share personal experiences and goals. The debriefing held at Jerome Home confirms
this. It adds, “by writing their eulogy or about the “DASH” (time between birth and death) they were more
aware of what was important in their lives which made them more sensitive to what was important to the
residents (sic) lives.”
Jakiela also used journaling as a way of helping students to be reflective and to integrate their growing
content knowledge. A debriefing synthesis suggests that students journaled often; the process helped them
to transition from their duties and the pace of the floor and fully engage in the classroom experience. Jour-
naling at the end of class also helped them to summarize what they learned and addressed any confusion
about class content.
Liz Begley summarizes what makes Jakiela an effective teacher and facilitator. “She is an incredible, incred-
ible teacher. She has taught me how to be a better teacher. She understands how to bring things to life
and she has no inhibitions about just reaching out in any way that she can to grab a student. She is really
very inspiring.”
There was a sense of empowerment that came about from taking the workplace classes. Students could move forward more easily and interact better with their peers and teachers, especially after taking lots of classes. Taking those first courses led to stronger and stronger students.
“ “
- Terri Ciocci, Hebrew Home
38
Sheri took all seven classes offered at VNA HealthCare – including Alzheimer’s,
Substance Abuse, Rehabilitation, Hospice, Aging and Medical Terminology. She en-
joyed all the classes, and that all the knowledge she learned could be applied on the job
with patients. She found the Alzheimer’s course the most interesting, informative and
useful to her everyday work and thought that the hospice training was a good refresher
as the provision of hospice care is a regular part of her job.
Sheri elaborated on how one class specifically has helped her on the job. “A lot of
times, the Nurse will be talking to you and saying a lot of medical terminology. You
sometimes feel stupid so the medical terminology class was a big help learning about
different diseases. Each of us had to pick a different disease and research it and that
was very helpful.”
The gains in knowledge and self-confidence have somewhat altered the power
dynamic in some workplaces, as CNAs (as well as PCAs) have recently acquired access
to patient information. until relatively recently, Home Health Aides were not informed
of patients’ medical conditions. Her current supervisor changed that.
Sheri said, “There are things I don’t know medically when I meet a new patient. Our
new supervisor did something about it, and now when we get our schedules we will
know something medical about the person. This was a complaint CNAs had because
we are taking care of them and we don’t know. It’s always better to know so you can
look out for more things.” This allows for a partnership among the entire care team.
At VNA HealthCare, Aldine Fray knows the capabilities and challenges of CNAs, having
practiced as one. For some nurses trained through traditional academic paths, CNA
knowledge and self-confidence may be seen as both a strength and a challenge.
Sherri, CNA participant
Sheri has an Associate’s degree in Liberal Arts from Capital Community College. She suggested that at her age (66 years old), she is not interest-ed in pursuing another certification, degree or promotion.
39
Gaztambide has taught many of the clinical courses offered as a part of the CNA Ad-
vancement Initiative, first as the instructor for Issues of Aging course taught at South-
ington Care (for Capital Community College).
She has also taught the Mental Health course, which she suggested was more of
a framework of linked concepts than a real curriculum. Her revisions to the Mental
Health course included more fully developing the conceptual framework and expand-
ing the breadth of content to make it more relevant to the CNAs engaged in the class.
To that framework, Gaztambide was able to add elements from a curriculum she de-
veloped in her work at the Alzheimer’s Association. She melded the two into a cogent,
informative and relevant whole.
Gaztambide suggests that small classes are essential to the Initiative’s success, because
they create an environment where frank and important discussions can flourish. “We
had fabulous discussions. And those things like class size make such a difference. In a
setting with fewer than 12 students, in small classes, people can talk about their beliefs
and how they affect their practice.”
Gaztambide suggests that teachers need to understand the strengths and challenges
that frontline workers bring to the classroom and have a well-honed sense of cultural
sensitivity. Additionally, frontline workers within a single facility come from various cul-
tural backgrounds, are at various stages of acculturation and have various levels of
educational attainment.
“This is a challenging population. The work they (CNAs) do, CNAs are pulled in all dif-
ferent directions, and each facility is different in its norms and relationships. Most of
the CNAs that I instructed were from a different cultural background, English was not
their primary language. This is germane because you reflect your cultural values in the
care you give to people.”
Gaztambide offers an example. Within the group of participating facilities, there are
some in which the predominant culture among the direct care staff is West Indian. For
West Indians, beliefs about physical boundaries and the meaning of personal space
may be different than for residents (or even caretakers) who may be Eastern European.
These aspects of culture created some dissonance in the relationships between West
Indian caretakers and Russian or Slavic residents, and in the approaches of culturally
different co-workers. The creation of a space to dissect and address these differences
enhanced the comfort and understanding of direct care staff in meeting the needs of
their residents.
Sonia GaztambideInstructor, curriculum developer
Sonia Gaztambide is a gerontologist, a past Director of Program Education and Services at the Alzheimer’s As-sociation of Connecticut; and a Se-nior Scientist at the Institute of Living in Hartford where she developed a teaching tool to help families to sup-port depressed elders.
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Elaine, CNA Partcipant
For as long as Elaine could remember, she had always wanted to be a nurse. After graduating from high school in 1966, her goal was to go to nurs-ing school. She had moved to Con-necticut and found that the academic curriculum here was a little more advanced than that of the southern state she called home.
Elaine had not completed the math courses required for enrollment in nursing school
and so, instead, enrolled in business courses because, as she remembers – that is what
she was told to do. She enrolled in the local community college even though her heart
was not entirely in it. During this time, she got married and had the first of four chil-
dren. “Life got in the way,” she shared. Elaine never finished her studies; she was one
credit shy of an Associate’s degree.
After getting married and buying a house, Elaine had three children and decided to stay
at home with them. Her fourth child, a son, was born with severe medical birth defects.
Elaine suggests that her son’s medical problems led to an important juncture where she
needed to reconsider how she was going to live the rest of her life. Elaine described
herself as quiet and shy growing up; but this event changed her.
Elaine never lost her early interest in the medical field and it grew while she took care of
her son. Elaine taught herself about her son’s medical conditions, including the proce-
dures, surgery, medical terminology and medications; she sharpened her advocacy skills.
Throughout the years, Elaine tried to go back to school to become a nurse, but her lack
of math skills stood in her way. Elaine said that when she finally accepted that she never
would become a nurse, she decided on another medical career. In her mid-thirties,
Elaine borrowed money, half from a friend and half from her oldest son, to pay for her
CNA training. Elaine was subsequently hired as a part-time CNA at Southington Care
Center.
Elaine became a full-time CNA at Southington Care Center after leaving her food ser-
vice job and has worked there ever since. Elaine realized soon after working at South-
ington Care that she loved being a CNA. She enrolled in every in-service training that
has been offered. Elaine took the state exam for palliative care and was qualified to
assist with hospice care.
About two years ago, Elaine completed the training to become a Restorative Certified
Nursing Assistant; her new certification has expanded her regular duties. Restorative
care, as Elaine describes it, involves helping and motivating patients after they have
been discharged from physical therapy, but still reside at the long-term care facility.
Elaine works with residents to do simple exercises to maximize their ranges of motion
and maintain their current levels of functioning and mobility. In addition, she also has
been trained to do aromatherapy and therapeutic touch with patients.
Elaine discussed the role and importance of mealtime in patients’ all-around well-being.
From her perspective, the routine surrounding mealtime is one thing over which pa-
tients still have some control. When Elaine is assigned as a Restorative CNA, one of her
duties is to encourage patients to take their meals in the dining area. Prior to her ef-
forts, only six patients would come down for breakfast but currently, due to her encour-
agement, up to twenty residents at a time come to the dining room to eat together.
41
The facility has also started to do theme nights, such as football night
or Italian night, in the dining hall. Elaine suggests that increased din-
ing room usage gets people out of their rooms and socializing and
also frees up CNAs from having to pass out trays in their rooms. This
gives CNAs more time to assist patients.
In Elaine’s opinion the patients at her facility are treated well. She
feels patients are, and should be, catered to by staff and also feels
that patients receive excellent care from the staff.
“We know the patients, they become like family. When working with
people this closely we can’t just shut them off because staff see them
at their most personal and most vulnerable.”
Elaine took pride in showing the interviewer some of the public rooms
that have been made possible by, and dedicated to, patients and their
families. These families have sent the agency generous donations as
an appreciation for taking good care of their loved ones and the facili-
ty puts the donations back into the physical environment. Elaine quite
often pointed out and commented upon photographs on the walls
marking events and holiday parties that the agency has had for their
patients over the years. She also led a brief tour out to the garden
created with the generosity of private contributions. The garden has
a manmade pond with a waterfall, and the bricks that constitute the
walkways are dedicated to patients that have passed. It is a pictur-
esque area with benches and flowers and the soft trickling of water,
and truly does provide a place of tranquility for patients and families
who spend time out there.
Elaine has mentored many new CNAs, commenting, “If you can man-
age your time and know why you are here and you have a good men-
tor to begin with, you can do pretty good. They mentor for about
three weeks now. I wrote a little thing for new CNAs. I gave advice
and used humor. Treat the patient as your relative. Manage your
time. If you don’t, you might as well go home. As a CNA you have
a lot to do. You have a lot of responsibility. You are responsible for
the people you are assigned to.” In her opinion, the most important
qualities that a CNA must possess to efficiently do the job are time
management skills, attention to detail, the ability to take the initiative
and to work in a team. As important are compassion for the residents
and the ability to show them respect and dignity.
Elaine feels validated by her supervisors and described it in the fol-
lowing way. “I feel rewarded when the charge nurse asks me to do
things, they are going to ask someone who can take on the extra
responsibility. It’s a form of recognition. They have confidence that
you know what you are doing. They approached me to do this in-
terview and I thought it was because they think I’m responsible, I’d
show up for the interviews, and I am opinionated,” she added with a
laugh.
Elaine enrolled in the courses to gain knowledge and a better under-
standing of patient issues. She thought every course was enriching
and the material could be used for some aspect of her job.
Elaine has seen evidence that other CNAs are using what they learned
in that class when they are working with patients. And for her, the
Alzheimer’s course stood out in its immediate applicability.
“If someone thinks it’s Christmas, you step into their dementia, not
try to orient them to the real world. Ask them about it and see what
they might remember. It the patient sees a rat, ask them about it.
Don’t tell them it is not there. The patient might get agitated. It was
my favorite class.”
Elaine noticed a big change in how she felt after she took the Math
course. When she first entered college in the late 1960’s and was
taking business courses, Elaine did not have the necessary math skills
to pursue nursing. She recalls being devastated then; and how her
perception of her abilities has changed.
“Math was always my weakness and I really brushed up on things and
it was for my own personal knowledge. I am not as afraid of math.
Math was stressful. It was a basic course but I always had a hang up.
Now, I can do this. I’m not stupid. Why did I think I couldn’t do this?
I would like for them to continue and provide an Algebra course. I
would take that.”
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