Immigrant Certified Nursing Assistants in Institutional Long-term Care Facilities: Language Proficiency, Communication Patterns and Quality Care
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Date
2013-11-07
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Johns Hopkins University
Abstract
Background
The population of the U.S. is rapidly aging and the number of elderly (65+) requiring some form of long-term care (LTC) is expected to sky rocket. While most LTC is provided in the home by paid or unpaid caregivers, the frailest and neediest elderly are cared for in LTC facilities such as nursing homes. In nursing homes, Certified Nursing Assistants (CNAs) provide the majority of hands-on care to elderly residents. Due to increased demand for direct care workers, direct care positions are increasingly being filled by immigrants. Immigrant status can impact provision of care in a variety of ways most notably due to factors that affect communication.
Research Objectives
This study focuses on immigrant CNA communication patterns and quality of care. The objectives are: a) to describe immigrant CNA patterns of communication; b) to explore the relationship of background characteristics to communication; c) to examine the relationship of communication to quality; d) to describe the relationship between immigrant CNAs’ language proficiency, communication patterns and quality; and e) to examine the correlation between immigrant CNAs’ self-ratings and expert ratings.
Methods
This study utilized an exploratory description design employing videos of a simulated nursing home resident in a “talk to the camera” design. A convenience sample of 35 immigrant CNAs provided brief responses to 9 care challenge videos that depicted a 78 year old nursing home resident in scenarios typical of nursing home settings. CNAs responses to the 9 care challenges were videotaped. After responding to the 9 care challenges, subjects viewed the care challenge videos again and provided “think aloud” responses to open ended questions about their care choices and provision of care for each care challenge. Quantitative ratings and qualitative assessments of quality were assigned to the CNA responses by CNA experts. Linguistic experts provided ratings of spoken English proficiency. CNAs provided self-ratings of quality and language proficiency. CNAs’ responses to the care challenges were coded using the Roter Interaction Analysis System (RIAS). Descriptive statistics and associations were calculated for variables relevant to the study objectives. Qualitative analyses were conducted on the CNA experts’ quality assessments and CNAs’ “think aloud” responses
Results
Analysis of RIAS composite categories indicate that participants attended almost equally to instrumental and socio-emotional communication. Instrumental communication comprised slightly more than half of all CNA talk (54.4%) while socio-emotional communication comprised 45.5% of all CNA talk. The relationship between quality and type of communication differed across the nine care challenges. Similarly, communication behaviors associated with language proficiency differed for the nine care challenges. There was a significant correlation between quality and spoken English proficiency. Immigrant CNA quality was related to age and years on the job. CNAs with the highest quality ratings were least likely to plan to continue working as CNAs. Qualitative analysis identified eight themes relating to factors that impacted quality of care: language use, orientation, giving choice, seeking help, assessing the situation, meeting psychosocial needs, lying/giving false reassurance and building relationships.
Conclusion
These findings highlight the importance of pre-certification training, certification standards and post-certification training and supervision. In provision of CNA care, quality is context dependent. The appropriateness of the CNA’s response depends on the particular care challenge. Training should prepare immigrant CNAs to respond appropriately to a variety of care challenges. Results also highlight the importance of spoken English proficiency. That CNA spoken English proficiency is related to quality, suggests the need for a minimum standard of spoken English proficiency prior to certification. Results of the qualitative analyses offer insight into factors associated with immigrant CNA care quality and confirm the need for ongoing CNA training opportunities for immigrant CNAs and suggest specific areas to target in post-certification training.
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Keywords
Long-term care, Certified Nursing Assistants, Direct Care workers, Language proficiency, quality