A Nurse Practitioner–Led Heart Failure Education Program for Certified Nursing Assistants in a Long-Term Care Facility

Heart failure (HF) is one of the most expensive cardiovascular diseases to manage and treat in the United States, and it is the leading cause of hospitalization and readmission for Medicare beneficiaries.^1,2 Approximately 20% of long-term care (LTC) residents have a diagnosis of HF.^3,4 Compared with Medicare beneficiaries with HF residing in the community, LTC residents with HF have more medical comorbidities, significantly higher mortality rates, and an increased risk of hospitalization.⁵ 

Approximately one-quarter of all Medicare beneficiaries hospitalized for HF are discharged to LTC for skilled nursing care, and, of those, 25% are readmitted to the hospital within 30 days, costing Medicare an estimated $12 billion per year.^1,5-7 Hospital readmissions also place elderly individuals at an increased risk for disruption in care and for sequelae such as delirium, falls, and infections.⁸

Current evidence-based practice guidelines for HF management in LTC specifically note the importance of the certified nursing assistant (CNA) in recognizing early HF exacerbation symptoms.⁹ In their recently published scientific statement on HF management in skilled nursing facilities (SNFs), the American Heart Association (AHA) and Heart Failure Society of America (HFSA) recommended CNA education on HF management and monitoring.¹⁰ Thus far, reports on the effectiveness of CNA education and training programs have been mixed, and there is limited research available on the impact of CNA HF education and training programs, on CNA knowledge of HF, and on the morbidity and mortality of SNF residents with HF.

Kotter’s 8-Step Process for Leading Change (8-Step Process)¹¹ has been used in the past to guide facility-wide implementation of HF management protocols in the LTC setting.¹² This framework recognizes that developing relationships, buy-in, and trust from stakeholders at the various organizational levels of a business are some of the most important factors in successful implementation of any project. The 8-Step Process outlines eight essential steps that an organization should complete in order to execute and sustain change. These eight steps can be divided into three distinct phases of change: (1) creating a climate of change; (2) engaging and enabling the entire organization; and (3) implementing and sustaining change. 

Because of its successful use in similar settings, the 8-Step Process was used to guide the development, implementation, and evaluation of this clinical project. The three aims of the project were to: (1) improve CNAs’ knowledge of HF management strategies; (2) improve CNAs’ reporting of acute changes in the condition of residents with HF; and (3) reduce rehospitalizations of the facility’s skilled unit residents with HF.

Methods

Study Design

This was a 3-month pilot quality improvement project that included an educational intervention for CNAs and used pre-post and time series designs, depending on the variable that was assessed, to evaluate outcomes. Written consent to conduct the project was obtained from the facility administrator prior to implementation. The Vanderbilt University Institutional Review Board (IRB) approved the project as “Non Research” (IRB #140889) prior to its implementation. 

The site of this quality improvement project was a skilled nursing care unit at a freestanding, for-profit, 180-bed LTC facility in a southern state of the United States that serves a Medicare and Medicaid dual-eligible population. HF was the unit’s most common short-stay, skilled admission diagnosis and the most common diagnosis prompting hospital transfers and readmissions. In the 6 months prior to implementation of the project, the monthly census of skilled residents with an admission diagnosis of HF ranged from 12 to 18 residents.

Table 1 details the relationship between the 8-Step Process and our approach to this project. Project participants included all full-time and part-time CNAs employed by the facility but excluded those who did not work with residents on the skilled unit. CNAs were recruited via posters in work areas, and the facilitator, an NP, visited units to explain the project in person. Of approximately 75 eligible CNAs employed by the facility, 66 consented to participate.

Enrolled CNAs were informed that participation in the project was voluntary and that they could withdraw at any time. They were also informed that the facility’s administration would not have access to any of the project data, that all participant responses would be kept anonymous, and that results from the HF knowledge tests would be reported on the aggregate level. Participants were assigned a unique identification number at the beginning of the project. They used this number to sign-in on class attendance records; they also placed this number on the upper right-hand corner of their pre- and post- intervention HF knowledge tests. The project facilitator maintained the list of participants and their assigned numbers in a secure location.

Heart Failure Education Program

The HF educational program was delivered in three 20-minute HF educational sessions, with each session separated by 1 week (Table 2). Multiple sessions were offered during all three 8-hour shifts on Wednesdays (weekday staff) and Saturdays (weekend staff). The project facilitator, a nurse practitioner (NP), taught all education sessions. All educational content was adapted from the HFSA’s patient education materials and was based on the HFSA 2010 Comprehensive Heart Failure Practice Guidelines¹³ as well as on CNA observation measures outlined in the Heart Failure Assessment Guidelines for Long Term Care,⁹ endorsed by the University of Iowa College of Nursing, John A Hartford Foundation Center of Geriatric Nursing Excellence.  

HF knowledge was assessed through the CNAs’ score on the Atlanta Heart Failure Knowledge Test (AHFKT-2). The AHFKT-2 is a 30-item, multiple choice and forced choice (yes/no) self-administered questionnaire that measures HF knowledge. Initial psychometric testing by Reilly and colleagues was done on community-dwelling patients with HF and their family members.¹⁴ 

For the current project, five questions were omitted from the AHFKT-2 because they were not relevant to CNA practice. Three HF nurse experts independently reviewed the revised tool for content validity, rating each test item for clarity, wording, and language and for relevancy.¹⁵ All three HF nurse experts agreed that the instrument as a whole was relevant, appropriate, and succinct.

A demographic questionnaire and the modified AHKFT-2 were administered at baseline. The AHKFT-2 was then re-administered 1 month later, approximately 1 week after the third and final HF educational class had been conducted. All modified AHKFT-2 tests were hand-graded. The total number of questions answered correctly was recorded on the front page of the test.  

All collected data were analyzed on the aggregate level and were analyzed using SPSS software. Nominal data from the demographic questionnaire were summarized by calculating the total number and percentages. Categorical variables were reported in frequency and percentage distributions. All scores on the modified AHFKT-2 were analyzed on the aggregate level. Mean average test scores were reported as total number of items correct, and the project facilitator converted this to percentage total correct by dividing the total number of questions answered correctly by the total number of questions on the test (25). Paired t-tests were used to compare aggregate pre-post intervention total mean scores from CNAs who had completed both the pre- and post-intervention AHFKT-2 tests. Point totals on the pre-test and post-test were compared in three different aggregates: CNAs who attended 3 classes (n = 28), CNAs who attended 2-3 classes (n = 43), and CNAs who attended 1 class (n = 4).

Communication of HF Symptoms to Nursing Staff

The CNAs’ communication of HF symptoms to nursing staff was assessed through the number of times they used the Stop and Watch early warning communication tool on residents with HF. The Stop and Watch early warning communication tool is part of the INTERACT II QI initiative designed to improve the identification, evaluation, and communication of changes in LTC resident status to potentially reduce avoidable hospitalizations.¹⁶ The CNAs were trained on the use of a pen-and-paper form of the Stop and Watch tool approximately 1 year prior to the start of the clinical project. They were then trained on how to access the form when it was embedded into the unit’s electronic communication system, approximately 1 month prior to the start of the clinical project.

Audits of CNAs’ use of the Stop and Watch tool on residents with HF were done at six different time points throughout the project. The total number of times the Stop and Watch communication tool was completed by CNAs for residents with a primary diagnosis of HF was recorded at each audit. The total number of residents with an admission diagnosis of HF was also recorded at each audit. An audit was done 1 month prior to the start of the educational intervention (Audit #1), the Monday after each of the three educational classes (Audits #2, #3, and #4), and then one month after completion of the three educational classes (Audit #5). An additional audit (Audit #6) was performed 6 weeks after the fifth audit. 

HF Rehospitalizations

The project facilitator also conducted an audit of the number of rehospitalizations of residents with HF during the 3 months prior to the project (March–May 2014) and the 3 months during the project (June–August 2014).The rehospitalization rate was calculated as a percentage of the total number of skilled nursing care unit residents with admission diagnosis of HF that was hospital readmissions. The percentage of the unit’s residents with HF readmitted to the hospital within 30 days of admission from the 3 months prior to the project was compared with that of the 3-month project implementation period.

Verbal Feedback From Project Participants

Step 5 of the 8-Step Process advises engaging and empowering employees for action. As a component of this engagement, the project facilitator solicited continuous verbal feedback from bedside nurses and the director of nursing (DON) regarding the CNAs’ understanding of signs and symptoms of HF exacerbation as well as their ability to identify and report HF exacerbation signs and symptoms to bedside nurses. The project facilitator also requested and received verbal feedback from the participating CNAs about their perceived abilities to find and report signs and symptoms of HF exacerbation and any communication barriers. Throughout the project, the project facilitator kept a written record of all feedback obtained from CNAs, bedside nurses, and the DON.

Results

A total of 66 CNAs participated in the project. The majority of participating CNAs were young (aged 21-39 years), African American females who worked at the facility full-time, and nearly 38% of them had worked at the facility less than 1 year (Table 3). Twenty CNAs (30.3%) attended two educational sessions, and 33 CNAs (50%) attended all three sessions (Figure 1). CNAs who attended two classes had a significant increase in AHFKT-2 scores, with a mean post-implementation AHFKT-2 score of 90.4% (22.6 out of 25; standard deviation (SD) 1.9) from a pre-implementation score of 75.4% (18.9 out of 25; SD 3.27) (t, 5.137; df, 14; P < .001). 

Of the CNAs who attended all three educational classes, the average score on the post-implementation AHFKT-2 was 93% (23 out of 25; SD, 1.6). This was a significant increase from the average score of 78% (19 out of 25; SD, 2.7) on the pre-implementation AHFKT-2 (t, 6.686; df, 27; P < .001). 

No completed Stop and Watch communication tools were filled out for residents with HF on any of the six audit dates. Of note, all Stop and Watch tools reviewed during the final audit were related to facility maintenance issues. 

When providing feedback to the project facilitator, the DON and bedside nurses cited examples of the CNAs’ increased frequency of physical findings related to HF. The most frequently cited examples were CNAs’ findings of increased abdominal and peripheral edema in residents with HF. CNAs had also discovered instances in which residents with HF who did not have orders for a low sodium diet or for fluid restrictions. These CNA findings initiated care team responses to address acute resident changes and to modify resident medical orders.

The 30-day hospital readmission rate for skilled nursing care unit residents with HF dropped from 13.5% (5 of 37) in the 3 months preceding the project to 5.7% (2 of 35) during the 3-month clinical project.  

During the first educational session, the CNAs voiced concern that they were not told which residents had a diagnosis of HF. This generated CNA discussion about potential alerting methods and strategies. No formal HF alert system was used during the project. However, CNAs’ ideas were shared with the DON and administrator, who later agreed to implement an HF alert system after completion of the clinical project.

Discussion

At the end of the clinical project, the CNAs who attended 2-3 educational sessions demonstrated understanding of the signs and symptoms of HF exacerbation as well as basic HF caregiver management strategies. Yet, it was difficult to measure their clinical application of this knowledge, as they did not use the Stop and Watch tool to document their findings of acute changes in residents with HF but instead gave oral reports to supervising nurses. 

Although most staff members were supportive of the project, the project’s biggest challenge was engaging the CNAs, bedside nurses, and nursing supervisors in the use  of the Stop and Watch communication tool. Although they had received several in-service sessions on accessing and using the electronic version of the tool, the CNAs and bedside nurses had varying degrees of understanding how to find and then submit the tool within the electronic communication system. Additionally, the CNAs reported that different unit supervisors communicated varying expectations of when the Stop and Watch tool was to be filled out. It is likely that this confusion and miscommunication contributed to CNAs’ perception that the process of filling out the tool took too much time, as the most frequently cited barrier to completing Stop and Watch documentation was the lack of time to perform the task. Despite acknowledging the potential value of the tool, the CNAs and bedside nurses stated that they considered a CNA’s oral report of acute findings to a supervisory nurse to be adequate and time-efficient; thus, they preferred oral reporting of acute changes over use of the Stop and Watch tool. Finally, CNAs reported disliking the amount of documentation required for their jobs. One CNA described the Stop and Watch tool as “just another form to fill out.” These implementation barriers are similar to prior LTC research findings of staff resistance to additional work responsibilities and staff disengagement.^12,16,17

Very little has been previously reported about the feasibility of providing disease-specific, face-to-face education for CNAs. In our experience, some of the inherent challenges in the short term included scheduling and CNA engagement. This project addressed scheduling challenges by holding sessions during CNAs’ scheduled shifts. Conducting sessions during scheduled shifts required support from both the DON and the bedside nurses who covered the CNAs’ duties during the sessions. Similar to other studies conducted in LTC, the DON’s role as project champion was instrumental to this project’s success,^12,16-19 and that support was particularly important for scheduling. Conducting educational sessions during CNAs’ shifts required the project facilitator to invest time during all shift times, including night shifts and weekends. While this scheduling format was project facilitator intensive, it contributed to the high rates of CNA attendance. In addition, CNAs reported this type of scheduling as a source of satisfaction. Thus, the rate of attendance surpassed the project facilitator’s expectations.

Because reports of projects conducted with CNAs are rare, anticipated CNA engagement was unknown. The CNAs in this project, however, were highly engaged, as evidenced by their attendance rates and knowledge improvement and as supported by their verbal feedback. Use of the 8-Step Process enhanced the CNAs’ feelings of ownership and their investment in the facility’s HF care processes. This is important, as studies have shown that organizational empowerment is associated with CNA job satisfaction.²² Without input and ownership from health care workers who are responsible for implementing the desired change within a facility, the likelihood of sustaining this change significantly decreases.²³

Most CNAs expressed their gratitude for the educational content, and many also requested more educational programs on different clinical topics. The CNAs not only had improved test scores after completion of the educational program but were engaged participants in learning, expressed interest in learning, and acknowledged that they needed more education to improve their capabilities of providing high-quality care for the facility’s residents. The CNAs were also able to provide examples of how they were applying learned HF content to resident care. This was complemented by feedback from the DON and bedside nurses that the CNAs were verbally reporting signs and symptoms of HF exacerbation. These project findings are congruent with other studies demonstrating an improvement in CNAs’ knowledge after education.^20,21

One dimension of feasibility that was not addressed by this project is sustainability. The CNA turnover rate is high nationally, which can introduce additional challenges to sustainability of any educational program. Whether or not educational engagement might improve job satisfaction and reduce turnover is unknown.

The findings from this clinical project should be interpreted cautiously. The sample size was small, and the project was conducted on a single unit. Given its short duration (3 months), the sustainability of the project outcomes is unknown. The project did not include a plan for long-term monitoring and evaluation of the CNAs’ knowledge of HF. The project design did not include bedside teaching and the project facilitator did not have access to residents’ medical records. Thus, the project facilitator was unable to directly witness the CNAs’ clinical application of HF knowledge when working with residents with HF, and the fidelity of the CNAs’ reported discoveries of HF exacerbation signs and symptoms is unknown. The project did not include a rigorous qualitative analysis of CNA feedback. Finally, although the unit’s 30-day rehospitalization rate of residents with HF dropped during the implementation of this project, this finding is limited in that there was no control of variables (ie, “do not transfer” orders, disease status) that may have influenced hospital readmission rates. Therefore, other factors may have contributed to the decrease in hospital readmission rates among residents with HF other than as a result of the improved HF knowledge among CNAs.

Bedside teaching by a NP should be considered in future efforts to improve and strengthen CNAs’ observation skills, their clinical application of HF knowledge, and their development of a structured approach to reporting these symptoms to supervising nurses. A CNA could greatly benefit from an NP’s clinical expertise, and these teaching experiences could equip an NP with understanding of the ways in which CNAs learn and transfer knowledge to clinical practice. Additionally, an NP’s visible leadership and reinforcement of the importance of the work of CNAs would challenge hierarchal staff practices that often undermine improvement efforts. 

Future quality improvement efforts should include review of medical records of residents with HF to ascertain the direct impact of CNA observations on patient status. Additionally, both the Stop and Watch tool and the process of its submission should be revised and simplified so that CNAs can communicate resident changes efficiently. A CNA should be included in this development to promote CNA input and maximize buy-in.

Conclusion

Despite its limitations as a quality improvement project, the results of this project lend support to a growing body of literature suggesting that CNAs are receptive to and may benefit from clinical education.^19,20,21 Next steps may include adapting the intervention to other units in the pilot facility and other LTC facilities as well as assessing whether CNAs’ improved knowledge translates into clinically significant changes in care and/or patient outcomes. The ongoing use of a framework such as the 8-Step Process will allow for CNA engagement in devising best practices for operationalizing their new knowledge. The project highlighted a need for ongoing attention to CNA–nurse communication and the role of CNA communication of their patient assessments to the registered nurses in their facility or unit. 

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