What to Look For in Staff Training Part 3: The Training Differential

trainingWhy is poor training such an important issue?   Is there any evidence that effective training would improve quality of care for the residents?  A recent study reported a 70% reduction in pressure ulcers when staff were properly trained and given incentives to perform better. (1,2)  Other studies have shown a direct effect on resident care or safety as a result of education on reduction of restraints without increasing injuries. (3,4) In addition, researchers also found reduced resident aggression through staff behavioral training as well as the ability to use behavioral interventions with aggressive residents. (5)

In her book Dancing with Rose, journalist Lauren Kessler goes “under cover” as a CNA in a nursing home for one year. She describes her first day as follows: “After a sobering mini-lecture about all the reasons we could get fired, we are led to the meeting room [...] where two inch thick packets of material await us. [The administrator] told us that we will start with the first document in the packet, the Employee Orientation Manual [...] each of us reading a page”. (6)  This training session lasted for almost 6 hours and the next day was her “on-the-job training”. Ms. Kessler and other trainees were tasked with waking, changing diapers, toileting, shaving, showering and transporting 11 Alzheimer’s patients to breakfast. All of this in fewer than two hours makes for a near super-human task. But they got the job done, without the deserved praise, because it was what they were expected to do. (7)

Although Kessler’s story provides merely anecdotal evidence as to the daily lives of CNAs, her experience has been retold by countless CNAs. At the University of Pittsburgh, the Center for Health and Care Work convened a series of focus groups of CNAs with the goal to determine what factors lead to staff turnover and staff retention. (8)   The focus groups were stratified to consist of either CNAs who had established relatively long tenure in their workplace of at least three years, or CNAs who switched jobs at least twice in the last three years.   Ironically, neither the low pay nor long hours were cited as the most important factors in determining whether or not to stay.  The dominant theme of the “leavers” focus group was the lack of respect.  Specifically, “leavers” described the supervisors’ expectations of unrealistic workloads and the lack of rewards or recognition for good work as the frustrating components of their job.  Inadequate training, work related injuries, and physical or verbal assault by the residents were also cited as reasons for leaving. (9)

There is no question as to why the staff turnover rate is so high. A better question to ask is; why do some CNAs end up staying? After all, these individuals could find work at a fast food restaurant for similar pay. What separated the “stayers” from the “leavers” was a feeling of being needed by the residents. Those who felt they were being “called” to service were much more likely to stay. Many felt they became patient advocates and developed good rapport with the elderly.

It is important to understand the different motivations for the “stayers” and the “leavers”.  A work climate that recognizes the dedication and special care the staff provide will reinforce retention.   Assuring an atmosphere of respect is more difficult to achieve.  This would include assuring proper staffing and adequate training and supervision.

About the Author: Debra Fox is the CEO of Fox Learning Systems and a long-time veteran of elder care staff training.  A former television anchor, Debra pioneered the use of interactive documentary techniques to improve training and elder care quality.


  1. Rosen, J., Mittal, V., Degenholtz, H. B., Castle, N. G., Mulsant, B. H., Nace, D. et al. (2006a). Pressure Ulcer Prevention in Black and White Nursing Home Residents:: A QI Initiative of Enhanced Ability, Incentives, and Management Feedback. Adv.Skin Wound.Care, 19, 262-269.
  2. Rosen, J., Mittal, V., Degenholtz, H., Castle, N., Mulsant, B. H., Hulland, S. et al. (2006b). Ability, Incentives, and Management Feedback: Organizational Change to Reduce Pressure Ulcers in a Nursing Home. Journal of the American Medical Directors Association, 7, 141-146.
  3. Capezuti, E., Evan, L., Strumpf, N., & Maislin, G. (1996). Physical Restraint Use and Falls in Nursing Home Residents. Journal of American Geriatric Society, 44(6), 627-633.
  4. Capezuti, E., Stumpf, N. E., Evans, L. K., Grisso, J. A., & Maislin, G. (1998). The relationship between physical restraint removal and falls and injuries among nursing home residents. Journals of Gerontology.Series A, Biological Sciences & Medical Sciences., 53(1), 47-52.
  5. Oh, H., Hur, M. H., & Eom, M. (2005). Development and analysis of the effects of caregiver training program on aggressive behavior in elders with cognitive impairment. Taehan Kanho.Hakhoe.Chi, 35, 745-753.
  6. Kessler, L. (2007). Dancing With Rose; Finding Life in the Land of Alzheimers . New York : Viking.
  7. Ibid.
  8. Rosen, J. (2008, December 2). Getting to the Bottom of CNA Turnover. Retrieved from McKnight Long Term Care: http://www.mcknights.com/Getting-to-the-bottom-of-CNA-turnover/article/121691/
  9. Ibid.