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BY: CAROL R.HEGEMAN

Ms. Hegeman is director of research, Foundation for Long Term Care, Albany, NY.

A CNA Mentoring Program Can Improve Staff Retention in Long-Term Care Centers

Once upon a time, legend has it, there were long-term care (LTC) administrators who could look at the turn-over rates for new certified nurse aides (CNAs) and smile contentedly. But those days, if they ever truly existed, have taken on the feel of myth. In today's world, a consistent workforce of competent, caring, dedicated nursing assistants has become the Holy Grail of long-term care, an elusive prize that most LTC professionals never attain.

And it's no wonder. The national CNA turnover rate in long-term care is 71 percent¹ — an unfortunate statistic that represents a challenge to both financial health and quality of care. It's an ominous statistic, conjuring visions of a day when our most vulnerable and elderly citizens might have to choose between spotty care and none at all.

Poor staff retention is an insidious problem because it feeds on itself. When the ratio of staff members to residents is low, CNAs leave their jobs because of frustration, exhaustion, or both. And when a CNA leaves, the ratio falls even lower, creating a downward spiral of continuing staff dissatisfaction and increased turnover.

This downward spiral erodes resident care. Quality improvement efforts — no matter how creative and effective — are undermined if aides do not stay long enough to use what they have learned. Good LTC centers claim to have a culture of caring. But how can they sustain this culture if CNAs are not around long enough to learn it? How can they sustain it if they do not have a support system that shows CNAs that they are themselves cared for?

Although there is no magic solution to the turnover problem, one promising answer can be found in a study concerning a multisite CNA peer mentoring program developed by the Foundation for Long Term Care (FLTC), Albany, NY, a not-for-profit research and education entity affiliated with the New York Association of Homes and Services for the Aging.

The FLTC's "Growing Strong Roots," a peer-mentoring program, has been tested and implemented successfully in both large and small facilities; in facilities both with and without unions; and in rural, suburban, and urban facilities. At sites that had the Growing Strong Roots program, FLTC researchers found an average 25 percent increase in the retention of new CNAs. Sites that did not have the program showed an improvement of only 10 percent (a figure that, because it may reflect only environmental factors, is statistically insignificant). All participating facilities improved their retention rates, some by as much as 41 percent.

Growing Strong Roots won a 2005 Award for Best Practices in Human Resources and Aging, sponsored by the American Society on Aging and the Brookdale Center on Aging of Hunter College, New York City. The award is given each year to an agency or organization that has developed creative solutions to workforce dilemmas in the areas of recruiting, training, management, and retention.

Growing Strong Roots
In 1999, when the FLTC first began researching the peer-mentoring concept, it surveyed the nursing home members of the New York Association of Homes and Services for the Aging, the Pennsylvania Association of Non-Profit Homes for the Aging, and the Life Services Network of Illinois, all of which are state affiliates of the American Association of Homes and Services for the Aging. The survey was intended to uncover best practices in peer support or mentoring for CNAs. The research revealed many excellent CNA peer-mentoring programs.

Armed with this information, the FLTC applied for a grant from the Fan Fox and Leslie R. Samuels Foundation, New York City, to develop a peer mentoring program based, in part, on earlier models. In 2001 the foundation approved the application, providing the FLTC with a three-year, $291,000 grant. Growing Strong Roots was unveiled in 2002.

In this program, peer mentoring is a carefully designed and managed process in which respected veteran CNAs (called "mentors") model exemplary care and help newly hired CNAs (called "mentees") learn and thrive. The idea is that mentors will transfer their knowledge, compassion, and caring ethics to mentees, thereby replicating exemplary care. Mentors also provide a warm and welcoming environment to mentees. As an added benefit, the peer-mentoring process recognizes and honors the experienced CNA.
Growing Strong Roots is intended to:

• Improve a facility's CNA retention rates
• Improve orientation processes so that they reflect the facility's values
• Reinforce critical skills and behaviors
• Teach the value of caring
• Use exemplary aides as role models for exemplary care
• Support new staff members and help them feel valued by the facility

Growing Strong Roots differs from peer mentoring that is really an informal orientation or preceptor program designed only to be sure that a new employee understands procedures. Growing Strong Roots is a five-part peer- mentoring system that involves commitment from administrators, careful preparation, tailored training and ongoing support for the mentors, and an effort to achieve "buy-in" from nurse supervisors. The five parts are:

• Training materials that tell managers how to operate the project
• A one-hour workshop for supervisors, to ensure their support
• Six hours of mentor training
• Three to nine hours of booster training for mentors
• A newsletter for mentors, to help them maintain interest in the project

Growing Strong Roots differs also from more informal programs in including workshop content that underscores to mentors the importance of their role in helping mentees fit in with their peers and develop positive friendships at work. This attention to such affective needs is based on retention research showing that CNAs who had colleagues who cared about them were more likely to remain on the job than CNAs without caring colleagues. Peer mentoring takes the common phrase "a culture of caring" and applies it to CNAs as well as residents. In fact, at the beginning of the mentor training session, new mentors are asked to consider the high degree of care they show to residents and apply it to the new CNAs.

Some Program Basics
The FLTC designed Growing Strong Roots so that:

• The person assigned to coordinate the program in the LTC center participates in three hours of orientation with several facility administrators.
• Each nursing home selects its own mentors.
• Mentoring takes place after the CNA certification is complete. It is intended to supplement, rather than replace or duplicate, the usual training of new CNAs.
• Registered nurse (RN) supervisors are oriented to the project.
• Mentors do not teach or reteach clinical skills. Formal education remains the responsibility of the in-service educator. Mentors are encouraged to notify training staff when retraining seems necessary.
• Each mentor-mentee team maintains an active relationship for four or more weeks. The intensity of the relationship is highest in the beginning and decreases as the program goes on. Mentors act as both friends of their mentees and advocates for them. Mentors model correct clinical skills, positive attitudes, and time management. They also reinforce information about formal policies and procedures, and explain informal policies and interpersonal relationships in the facility. Through watching mentors demonstrate both caring behaviors and excellent care-planning and time-management skills, new CNAs learn a critical but often untaught "trick of the trade" — management of the workload in a way that enables them to respond to the collective needs of residents rather than work around a rigid task list.²
• Mentors and mentees work the same shift and do so in the same unit. If necessary, the LTC center should rearrange work schedules so that mentors and mentees work together.
• Mentors are compensated for their mentoring. The form of compensation is, of course, determined by the employer. Options have included hourly wage increases during the mentoring, permanent salary increases, honorariums for each training session, and such benefits as extra vacation days or relief from weekend shifts.

Organizing the Program
At each LTC center, the Growing Strong Roots project coordinator is responsible for its day-to-day implementation and supervision. Selection of the project coordinator is, therefore, a critical step that can make or break the peer-mentoring experience.

The FLTC recommends that the choice of project coordinator be based on candidates' personal attributes, not their titles. These attributes should include enthusiasm for the project concept, rapport with CNAs, and sufficient status in the facility to enable him or her to work effectively with the management team and RN supervisors. Of course, the position demands basic organizational skills as well. In some LTC centers, the director of in-service education is assigned to coordinate the Growing Strong Roots program. In others, associate and assistant administrators, human resource persons, and charge nurses have assumed the role.

However, no matter how talented or dedicated the program coordinator may be, he or she will not be successful without ongoing support from administration. This is especially important if the project coordinator is not part of the traditional management team. At one LTC center, for example, no one thought to inform the controller that mentors should receive a pay raise, a mistake that resulted in a demoralizing situation for the mentors.

An LTC center should not, moreover, rely on a single program to fix systemwide problems that impair staff retention (e.g., short staffing, poor scheduling, and case-mix challenges), no matter how successful the program has been in other venues. Growing Strong Roots is a program that should be "owned" by the entire facility, and seen as one component in a mix of efforts intended to make the facility a great place for both residents and staff. The administrator who simply delegates this program, rather than infusing it with his or her interest and support, will not have a successful peer-mentoring project.

How Many Mentors?
Ideally, an LTC center should have a mentor on each unit and each shift. To determine the number of mentors needed, a facility's leaders should first determine how many new CNAs will start at one time and plan to train that many mentors and one or two more. At the very minimum, there must be a mentor on each shift.

In choosing mentors, the FLTC recommends conducting a formal interview and selection process. Facilities whose employees belong to a union need to work closely with their union representatives on this issue. However, facilities should beware of a selection option that might be suggested by unions — that mentors be chosen according to job seniority. Doing so is likely to prove to be a "kiss of death" to the program. Many long-tenured CNAs would be excellent mentors, but others will not. As in choosing the project coordinator, those selecting mentors should pay attention to their personal attributes.

Training
The Growing Strong Roots program requires training for both mentors and RN supervisors.

Training for Supervisors An orientation for supervisors is critical. Without such an orientation, supervisors are likely to resent "their" CNAs being used in a mentoring program. If supervisors are shown that mentoring is important in building a better CNA workforce, even if it sometimes takes CNAs away from their units, the project will have a far better chance of being successful.

The training content for supervisors includes a review of the rationale and goals of the project. It provides time for supervisors to make suggestions concerning implementation of the project, thereby making their support more likely.

Training for Mentors Training works best when led by an outside trainer at a place outside the facility. Such training sends a clear message to the mentors: This is not just another in-service. Without such a clear distinction, it is hard for mentors to truly appreciate the importance of the role they are being asked to assume.

Growing Strong Roots training is highly experiential in nature, with carefully designed "role plays" and case studies at its core. Through it, mentors are taught how to:

• Identify four roles of the mentor (role model, social support, tutor, and peer resource)
• Describe how a positive attitude sets the tone for social and professional integration of mentees into the facility
• Demonstrate the use of effective communication skills, including listening skills, communication "blockers" and "enablers," and conflict management*
• Describe ways to use leadership skills to recognize and manage potential conflicts and solve problems
• Recognize situations in which information or guidance is needed from other sources and be able to access those sources
• Use mentoring skills in simulated mentor-mentee sessions

* Communication "blockers" include interrupting, blaming, using such phrases as "always" and "never" when describing behavior, and refusing to respond directly to the concerns expressed by the speaker. "Enablers" include questions, statements, and body language that encourage the speaker to elaborate on his or her concerns, thereby facilitating communication.

The program also includes "booster training," which is offered at intervals determined by the LTC center. These reinforcement sessions review the skills introduced in the training program and encourage participants to share challenges and the solutions they have devised for them. In addition, new skills appropriate for the mentor are taught. As a supplement to the booster sessions, the FLTC also includes in its training package a set of newsletters that reinforce mentors' skills between initial training and booster sessions.

Mentoring on the Unit
Although facilities and their mentors will adjust the Growing Strong Roots program to fit their particular needs, the following schedule can serve as a model.

Day One The new CNA, the mentee, "shadows" the experienced CNA, the mentor, observing and asking questions. The mentee watches how the mentor interacts with residents, sees how challenges with residents are handled positively, and learns the formal and informal rules of the organization. The mentor is careful to emphasize how to deliver warm compassionate care, use good time management, and handle some of the inherent frustrations of the job. The mentor is also careful to see that the mentee meets other staff members and has company (if the mentee desires it) at mealtimes and on breaks.

Days Two through Five The mentee begins to take care of residents, with the mentor assisting and modeling good care as detailed during the first day. Direct care of residents by the mentee increases incrementally over these days.

Week Two Most new CNAs now have a full complement of residents to care for. The mentor spends about an hour a day with the mentee, providing support, troubleshooting adjustment challenges, and answering questions.

Weeks Three through Four During these weeks, the time that the mentor spends with the mentee decreases incrementally, so that by the fourth week, the time is down to an hour a week. That hour is focused on helping the mentee adjust to the demands and special nature of the work environment, search out answers to care questions, and use existing facility resources (such as an employee assistance program) to resolve personal challenges that could affect the job.

Mentoring is usually completed within four weeks, although experience has shown that the time frame should be made sufficiently flexible to meet new CNAs' needs. For example, a bright new CNA who has previously worked in an adult home and had an excellent rapport with elders is likely to need less support and mentoring time than a new CNA with no experience.

Mentors usually appreciate being trusted to make a decision about whether a mentee needs more time. Comments such as the following are common: "My mentee was very slow and often got behind with resident care, but I could see that she had a warm way with the residents. I was sure that she would be good for her unit and that if she just had some more time, she would get a routine down. She just needed extra mentoring time and support. Without this program, all of us would have simply thought she was lazy and incompetent and would have welcomed her termination. Because of the program, she became a favorite CNA on her unit."

Positive Results
As noted, Growing Strong Roots has been evaluated at multiple sites. FLTC's researchers found that nursing homes that implemented the program had a statistically significant improvement in retention, while a control group of similar nursing homes did not. These evaluations were conducted over three-month periods. "Retention" was defined as the percentage of those CNAs who, hired at the beginning of the project, still remained at the facility at the time of data collection. Among the specific findings were the following:

• Three months after implementation, the average retention rate in the Growing Strong Roots group was 84 percent. In the quarter before the program's introduction, the average rate had been 59 percent. The result was a 25 percent increase in retention.
• In the same three-month period, retention for the control group increased from 38 percent to 48 percent, a 10 percent increase in retention.

Data on longer periods was inconclusive, probably because of problems with data collection. The FLTC is currently gathering information on Growing Strong Roots implementation at 22 additional LTC centers. When this study is completed next fall, more longitudinal findings will be made available.

Is the Program Worth the Cost?
What are the costs of a peer-mentoring program like Growing Strong Roots?* The cost of hiring professional trainers (an approach the FLTC highly recommends) varies. Mentor preparation costs include a full day of paid time during mentor training and a half day of paid time for booster sessions (one to three are recommended). There are also meal costs during training. And, of course, the mentor must be compensated, through a temporary or permanent salary increase, honorariums for each mentoring experience, or some other nonfinancial incentive.

* The Foundation for Long Term Care offers a Growing Strong Roots package. For information about the package and its price, contact the foundation at 150 State Street, Albany, NY, 12207; 518-449-7873 or [email protected]. For information about outside trainers for Growing Strong Roots, contact Francis Battisti at [email protected].

However, the most significant costs are for "backfill": arranging for someone to perform a mentor's duties when he or she is in training or working with a mentee. Backfill costs during the mentoring period will depend on the time allocated for mentoring and on the LTC center's salary and benefit range. In a low-budget model, the mentor will be with the mentee for five days in the first week, one or two days in the second week, and a few hours in week three. Some mentees will need less time; some will need more.

There are additional in-kind costs, as well. Coordinators usually work on the project with no additional reimbursement, but at a possible cost to other duties they might have been performing had they not been leading the mentoring program.

On the other hand, peer mentoring is cost-effective when compared with the hidden costs of doing nothing about turnover of new CNAs. The cost to the employer of every CNA who is trained but then quickly leaves has been calculated at $4,000,³ including temporary labor expenses, advertising fees, the lower productivity of new workers, and orientation costs.⁴

Assume, for example, that a LTC center employs 80 CNAs at a full-time salary of $20,000 apiece but experiences an annual turnover CNA rate of 40 percent. The facility's annual turnover costs would be $128,000 (i.e., 32 CNAs multiplied by $4,000 in turnover costs per CNA). If the facility, through a mentoring program, were to increase new CNA retention by 15 percent, the new turnover rate would be 25 percent. Annual turnover costs would be reduced from $128,000 to $80,000. If the annual peer-mentoring costs were in that range, the program would easily pay for itself. If the costs were less, the program would provide some savings.

Peer mentoring reduces costs in another way as well. High turnover creates a demand for temporary workers from employment agencies — CNAs who not only cost more than regular employees but also are unable to provide the loving, familiar attention to residents that a permanent staff member can provide.

These numbers, of course, cannot be guaranteed. No program can promise that past results will be true in different facilities. However, the calculations provide a useful way of weighing the costs and benefits of Growing Strong Roots.

A Positive Response
Growing Strong Roots has brought positive responses from the LTC centers that have tried the program. "Our facility has seen tremendous improvement in staff retention as a result of the peer mentoring program," noted one participant.⁵ "Staff mentoring the new employees has felt increased self-worth, and the new [CNAs] have become self-confident much faster. Every resident wins." The statement sums up the powerful effect peer mentoring can have. It shows how peer mentoring and similar support programs may be used as critical tools in the fight to maintain a qualified and caring long-term care workforce well into the 21st century.

NOTES

1. American Health Care Association, Results of the 2002 AHCA Survey of Nursing Staff Vacancies and Turnover in Nursing Homes, Washington, DC, February 2003, p. ii, available at www.ahca.org/research/rpt_vts2002_final.pdf.
2. C. Hegeman, Growing Strong Roots: Peer Mentoring of CNAs to Enhance Retention and Care, Foundation for Long Term Care, Albany, NY, 2004.
3. . K. Pillemer, Solving the Frontline Crisis in Long Term Care, Frontline Publishing, Cambridge, MA, 1996.
4. J. Fitzgerald, "Nursing Home Crisis Won't Fix Itself", Boston Globe, February 26, 2002.
5. R. Reid, CEO, Mohawk Valley Nursing Home, Mohawk, NY, conversation with the author in 2003.

The following poem was written by Connie Trendel, a former certified nurse aide who is now director of publications, National Association of Geriatric Nursing Assistants, Washington, DC.

THE CARING TREE

Nursing facilities are like trees.
The residents are the leaves,
Growing, changing and falling away from the tree.
The branches are the homes,
giving the leaves a safe, nurturing environment to do their growing.
The other staff are the limbs;
they keep the branches sturdy.
The administration is the trunk of the tree,
supporting the limbs and branches.
I'm sure you are wondering where nursing assistants fit in this analogy . . .
They are the roots.
Leaves fall, branches and limbs may break in a strong wind.
You can even cut into the trunk of a tree, but if the roots are strong
growth will continue.
Have you ever seen a tree that has a root disease?
The leaves will die without the nourishment the roots provide.
The limbs, branches and trunk will remain for a while, but they too eventually die.
Nursing assistants are the roots of every facility.
In the past, they've been called the "low man." I guess they are.
After all, roots are the lowest part of the tree . . . also one of the most vital.