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6/28/14 3:13 PM Ovid: Maximizing Caring Relationships Between Nursing Assistants and Patients: Care Partners.

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[Departments: Spotlight on Caring]
JONA: The Journal of Nursing Administration
Issue: Volume 42(3), March 2012, p 144147
Copyright: 2012 Lippincott Williams & Wilkins, Inc.
Publication Type: [Departments: Spotlight on Caring]
DOI: 10.1097/NNA.0b013e3182484efd
ISSN: 0002-0443
Accession: 00005110-201203000-00006
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Maximizing Caring Relationships Between Nursing Assistants and Patients: Care Partners
Prestia, Angela MSN, RN, CNA; Dyess, Susan PhD, RN
Author Information
Author Affiliations: Chief Nursing Officer (Ms Prestia), Good Samaritan Medical Center, West Palm Beach, Florida; and Assistant Professor (Dr Dyess), Christine E. Lynn
College of Nursing, Florida Atlantic University, Boca Raton.
The authors declare no conflict of interest.
Correspondence: Ms Prestia, Good Samaritan Medical Center 1309 North Flagler Dr, West Palm Beach, FL 33401 (

Certified nursing assistants (CNAs) are an integral part of the care team in most hospitals. The chief nursing
officer at a community hospital in Florida developed a program of communication, education, and accountability to
highlight the role of the CNA as a team member. This easy-to-implement initiative resulted in increased
understanding about the CNA role in delivering high-quality patient care and increases in patient satisfaction with
responsiveness of staff to call lights.

Regulatory agencies, organizations focused on quality, and consumer groups have championed the cause and
importance of patient satisfaction in relation to healthcare quality.1-3 For patient satisfaction outcomes to be
optimal, a culture of compassionate care must exist requiring the commitment of all staff. While caring expectations
are communicated beginning with orientation and beyond with the licensed nursing staff, the certified nursing
assistants (CNAs) are often given this information as an afterthought. Certified nursing assistants, or care partners, at
some institutions, are integral members of a balanced healthcare delivery team. High-performing organizations and
chief nursing officers (CNOs) need to spend deliberate time with CNAs in recognition of the contribution they make to
both nurse and patient satisfaction.4,5

Part of the complex responsibilities of the CNO includes (1) developing a culture of care that supports patient
safety, quality, and satisfaction outcomes; (2) outlining expectations and accountabilities for roles; (3) providing
resources including education, systems, and tools for accomplishing those expectations; and (4) providing a
mechanism to evaluate the impact of the culture of caring and thus care outcomes. One medical center in southern
Florida demonstrated dramatic improvements in patient satisfaction as reported by the Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS)6 with the implementation of an initiative focused on


In 2005, The Centers for Medicare & Medicaid launched the hospital quality initiative including the HCAHPS
system of measuring and reporting patient experiences including satisfaction with care.7 This program was targeted
to improve outcomes through increased organizational accountability and public reporting of performance.
Satisfactory performance in the HCAHPS category of responsiveness of staff is dependent on the interaction of all
staff members with the patient including the CNA.

Information about the role and importance of the CNA in the care team is sparse in the literature. Engagement
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Information about the role and importance of the CNA in the care team is sparse in the literature. Engagement
and communication are stressed by some authors as a key to CNA performance.8-10 It has been suggested that nurse
leaders should consider strategies to support and encourage cooperation between and among nurses and nursing
assistants to decrease care omissions.11,12 The American Organization of Nurse Executives (AONE) developed guiding
principles for relationships among professional nurses and support services in clinical settings.13 Supportive of the
AONE principles that identify the CNO as a catalyst for change, actions that develop strategies to incorporate the
CNA as a care partner are a unique approach to patient satisfaction.

Increasing Understanding Through Education

At a 333-bed for-profit community hospital in southern Florida, an education program was developed to educate
the CNAs to the importance of their role as care partners. All CNAs were expected to participate in the program and
were paid for the hours in class. At the onset of the initiative, the HCAHPS ranking for the category of responsiveness
of staff was below the target of 75th percentile. A first step in addressing the issue of patient satisfaction began with
education. The education sessions for CNAs were designed by a team from nursing and other services. The team
wanted the information to be meaningful, fun, interactive, and practice altering. Caring theory 14-16 guided the
shared mental model education. There were 7 aspects of the day: (1) CNO expectations; (2) discussion about what
caring service was and looked like at the hospital; (3) teaching how to build caring, trusting relationships; (4)
discussions about patient experiences including the expectation for a standardized process for hourly rounds; (5)
education about HCAHPS and why it was important; (6) discussion about acceptable caring responses; and (7) clinical
caring skills stations to reinforce desired behaviors. Each CNA participant received a workbook and was informed of
the new organization title, care partner. In the following sections is a discussion about each aspect in the education

CNO Expectations

At each session, the CNO placed emphasis on the importance of the CNA role as a care partner to the healthcare
team at the hospital. The message encouraged CNAs to commit to making a caring connection with each patient and
highlighted the importance of the nursing assistant role in patient healing. The mission, vision, and values and the
care partners contribution to patient satisfaction were introduced. These messages were later reinforced by nurse
managers and staff nurses to support the organizational commitment and clarity of purpose.

Caring Services

One teaching tool that was fun and worked well to emphasis the importance of excellent customer service was
the FISH philosophy and video.17 The 4 principles of FISH are (1) play, (2) make their day, (3) be there, and (4)
choose your attitude. The CNAs laughed as they watched the employees on the video engage their customers in
routines at the fish market. Lively discussion ensued as the CNAs brainstormed ideas to work as a team, to create
opportunities to connect with patients, and discuss ways to demonstrate caring and how to maintain a positive
attitude while still having fun at work.

The AIDET Tool

Developed by Quint Studer,18 the tool and acronym AIDET represents acknowledge, introduce, duration, explain,
and thank.18
The CNO shared the elements of the AIDET tool and presented guidelines to accomplish AIDET
within patient-care partner interactions through role modeling during the educational sessions. Nurse managers and
nurses were made aware that care partners would use the AIDET tool in their workday.

Creating Caring, Trusting Relationships

One team member presented an interactive session on developing caring relationships with the patients and
coworkers. The concepts of a caring philosophy and the supporting nursing framework were introduced to the
group.14-16,19 This content was presented to shift the mind-set of CNAs from following orders in the practice
environment to responding to patients and others because it is the right thing to do. Kalischs 12 research and
recommendations regarding missed care opportunities were presented. In the study, several areas of omitted nursing
care were identified as persistent challenges for acute care organizations including ambulation, turning patients,
hygiene, delayed or missed feedings, and proper intake and output documentation. The care partners learned that
many of their responsibilities were highlighted in areas noted where care is most often missed.
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Patient Expectations During Caring Experiences

The concept of hourly rounding had been tested and was recommended by the Studer group 18,20 as a best
practice. The frequent, deliberate, purposeful contact with staff members is considered an essential tactic in
improving patient satisfaction. Hourly rounding has been shown to reduce call-light utilization after consistent
implementation.20 According to Studer, 3 expected behaviors (the 3 Ps) are necessary to ensure the success of
hourly rounding 20: potty, pain, and position. In support of the caring philosophy, the CNO integrated biomedical and
psychospiritual factors 21 and developed 3 Ps focused on caring: possessions, presence, and personal. The new set of
6 Ps was introduced to the care partners at a skills fair where behaviors were reinforced. Nurse managers
participated in these sessions. Performance evaluation including monitoring demonstration of the 6 Ps has been
maintained in the units since the introduction.

Measuring Patient Satisfaction

The goal of this section of the program was to help the care partners make connections between actions, patient
satisfaction, and safety. The HCAHPS survey and process were formally introduced.7 When hospital scores for
responsiveness of staff and call light answered were presented, there was an obvious lack of understanding and
awareness in the audience. The care partners could not believe baseline hospital scores were in the 50th percentile.
They were astounded to learn how lack of responsiveness to call lights contributed to patient falls.12 Unit statistics
were presented to the care partners to create a sense of ownership and a common platform of understanding for the
importance of addressing the patient experience outcomes as part of a culture of caring. At the conclusion of the
educational session, the CNO congratulated each care partner and awarded them a certificate of attendance and a
new stethoscope. Photographs were taken and published in the hospital newsletter, highlighting the program,
content, and participation.


The education day achieved the overall goals first envisioned by the CNO. The didactic portion highlighted
responsibilities, identified accountabilities, reinforced the value of caring behaviors, and provided content about the
importance of the CNAs as partners in care. Care partners gained an understanding about the impact their actions on
patient satisfaction and why CNAs were integral to the team.

Evaluations were excellent with requests to have additional educational days in the future. Incremental
increases in the patient satisfaction scores were noted; this was specifically seen in the item responsiveness of
staff. Incremental progress was noted within quarterly averages, with scores approaching the 75% target (Figure 1).
Score improvement trends progressed as did the initiative that promoted the CNA as care partner.

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Figure 1. Patient satisfaction scores before and after the care partner program.

Nursing administrators participate in shaping a culture that evolves from the values articulated within nursing
as caring.14
Understanding and embracing CNAs as care partners with offerings of annual targeted education
days are vital to the sustainability of excellence in patient satisfaction at a single community hospital and may be of
value to others as we strive to attain the best for our patients in all areas including patient experience scores.


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12. Kalisch BJ. Nurse and nurse assistant perceptions of missed nursing care. JONA. 2009; 39 (11): 485493. UCD-AMC
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