The development of knowledgeable nursing assistants as creative caregivers (KNACC)

Twenty million individuals in the US require help with self-care tasks, including one million living in residential care and 1.5 million in nursing homes.1 Long term services and supports are the care provisions people need when they cannot complete self-care tasks independently. These services are provided in both community-based and institutional settings.2 The number of direct care jobs is expected to increase by 1.3 million by 2028,1 with 25% of the workforce demand in nursing homes and 25% in residential care facilities.2 Most long-term care staff are certified nursing assistants (CNAs), who provide 80% of the direct care residents receive from providers.3, 4 Certified nursing assistants are critical in enhancing resident well-being and ensuring optimal care outcomes. This requires training to use complex skills that lead to relationship building and effective communication; however, training varies greatly and needs to be more consistently implemented.1

The role of the CNA is vital to the health and wellbeing of older adults living in long term care (LTC), who may experience increased levels of isolation. Social isolation is connected to increased risk for depression, cardiovascular disease, high blood pressure, cognitive decline, and morbidity.5, 6, 7 This places an additional burden on CNAs to increase engagement with residents and provide person-centered care. Interventions that enhance engagement through meaningful activities have been found to elevate mood, increase sense of purpose, and increase longevity.8, 9, 10 Arts-based activities have been linked to reduced loneliness and social isolation while increasing socialization and communication.10

Direct care workers have the ability to implement creative care techniques to improve person-centered care and reduce social isolation. Arts-based approaches to healthcare are used in various settings to improve employee satisfaction,11 enhance patient and staff relationships,12 and reduce stress and burnout.13 Staff training, patient interactions, and caregiving practice have been targeted through CNA interventions using arts-based techniques.11 In our previous work examining CNA perceptions of creativity in relation to direct care of LTC residents, we found that CNAs recognize the value of creativity, using it to solve problems and build relationships. CNAs are well-positioned to engage residents creatively as part of their daily work, empowering CNA ownership in the process of improving patient-centered care.14

A guided systematic approach to learning skills that enhance creative engagement may strengthen the ability of CNAs to influence positive resident outcomes. It may also have the benefit of increasing personal empowerment and satisfaction while working within LTC. Kantor's structural empowerment theory explains the concept of one's perceived situational influence on one's ability to do their job well.15 Regardless of individual personality, it has been well-established that empowerment occurs only when the employment situation provides opportunity, resources, information, and both informal and formal support.15, 16 Staff feel empowered when opportunities for growth and development are readily available in the work environment.17, 18 Introducing creative engagement as a skill that CNAs use to enhance the well-being of older adults in their care has the potential of increasing perceptions of situational influence through development, resource sharing, and support.

The purpose of this study was to collaborate with CNAs to translate the National Center for Creative Aging's Creative Caregiving Guide (CCG)19 for CNA use in the everyday course of long-term care. The (CCG) is a multimedia web-based toolkit consisting of video modules and instructions for arts-based Creative Caregiving communication techniques, derived from evidence-based motivational and constructionist communication approaches.19 Each module has four training components (preparation, complete training video, individual steps in the process, and feedback and reflection) that teach specific creative interactive techniques integrating movement, music, storytelling, art making, poetry, and reflection. The CCG was originally developed, in partnership with professional teaching artists, for family caregivers of persons living with dementia for use in the home environment to support positive interaction, communication, and enhance connection.19 However, many LTC residents don't have families present to practice CCG. While nursing assistants are well-positioned to engage residents in new and innovative ways, obstacles include competing time demands and lack of systematic training.

The purpose of this manuscript is to describe the process to determine, via a participatory approach, what adaptations need to be made to the CCG techniques and materials to support usability, relevance, adoption, and integration by CNAs in a long-term care setting.

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