Impact of Serious Mental Illness Online Training for Certified Nursing Assistants in Long Term Care

Abstract

Introduction:

Certified nurse assistants (CNAs) spend the most staff time with nursing home residents, yet they receive little training in addressing the mental health needs of residents with Serious Mental Illness (SMI).

Methods:

Forty CNAs from four long term care facilities took the online interactive CARES^® Serious Mental Illness^™ training consisting of two modules guided by the Recovery Movement philosophy of care.

Results:

Responses from pre-post testing, Likert-items, and open-ended questions indicated that CNAs gained information, changed their perspectives, and had more confidence in dealing with SMI. Although there were minor concerns regarding length, clarity of content, and technical issues, CNAs found the online format acceptable and easy to use, and many said they would recommend the training.

Discussion:

CARES^® Serious Mental Illness^™ online training appears to be a viable way of helping CNAs address the mental health needs of long term care residents.

Conclusion:

Additional testing on CARES^® Serious Mental Illness^™ is planned.

Analysts from the Congressional Office of the Budget (as cited in Carbine, 2008), estimate that 39%−49% of the U.S. population will need nursing home (NH) care during their lifetimes. Little attention has been paid to strengthening the knowledge and skills of certified nurse assistants (CNAs) responsible for most NH care of the frail older adults. Alecxih (1997) evaluated CNAs’ training as insufficient to fulfill their frontline caregiver duties to monitor health status, measure vital signs, assist elders with activities of daily living, and to offer companionship and comfort. Using data from the 2004 National Nursing Assistant Survey, Sengupta and colleagues (2010) found that at least one-third of the CNAs perceived their initial training to be inadequate to perform their jobs. In a recent study of CNA’s understanding of basic subject areas of aging, cognition, and mental health, Kusmaul (2016) concluded that current training of CNAs is inadequate in its delivery methods, content, and quantity, and that CNAs often do not learn information essential for their jobs. Ejaz and Noelker (2006) have warned of the shortcomings of a mere 75 hours of required CNA preparation to treat fail elders, when U.S. cosmetologists must complete 1,500 hours of training before they may treat hair.

This lack of education of the long term care frontline workforce is undoubtedly even more true regarding managing the mental health problems of those NH residents with Serious Mental Illness (SMI). As early as 2004, more than 4,000,000 (12%−15%) individuals in the United States 65 or older had Serious Mental Illnesses (SMIs: McCarthy, Blow, & Kales, 2004). SMI may be defined as persistent psychiatric problems significantly interfering with daily living, and include the psychotic spectrum diagnoses of schizophrenia and delusional disorders, as well as severe affective disorders such as bipolar and/or major depressive illness (Becker & Mehra, 2005). Individuals with SMI have a 20–25 year shorter life span than the average, and are common in NHs and assisted living facilities (ALFs) (Becker & Mehra, 2005; J.A. Hartford Annual Report, 2011; Rosenblatt et al., 2004; Molinari et al., 2008). Unfortunately, CNAs receive little or no formal education in care competencies related to older adults with SMI in NHs, either during the federal minimum 75-hour CNA training now required for U.S. certification, or during the 12 hours of annual continuing education mandatory in most states (Requirements for States and Long Term Care Facilities, 2011; Paraprofessional Healthcare Institute, 2014; Smith & Baughman, 2007). Although three-fourths of CNAs find continuing education “very useful” (Sengupta, Ejaz, and Harris-Kojetin, 2012), compromised healthcare outcomes for those older adults with SMI in NHs may be a consequence unless CNA training can address and support their specific physical, psychosocial, and cultural needs. We describe the results of an online CNA training program on participant’s knowledge about the care of people with SMI living in NHs and ALFs, and the satisfaction of the CNAs with the online learning program.

Findings Related to Problems Caused by Residents with SMI

Although dementia is the most prominent neuropsychiatric diagnosis in NHs, approximately 10% of NH residents may have SMI (Becker & Mehra, 2005), and 12% of residents in ALFs are diagnosed with a psychotic disorder (Rosenblatt et al., 2004). Residents with SMI present significant management difficulties in NHs. McCarthy, Blow and Kales (2004) combined cross-sectional assessment with administrative data to determine correlates of behavior problems in 9,618 NH residents in Veterans Affairs Hospitals. Almost two-thirds of residents with SMI exhibited behavior problems, with 29.3% exhibiting verbal disruption, over 15% engaging in physical aggression, and 57.6% manifesting other forms of behavior indicating distress (often referred to as inappropriate behavior). Residents with SMI were more verbally disruptive than residents with dementia. Other research suggests residents with SMI in NHs are more likely to exhibit aggressive behavior than those with SMI living in the community (Bartels, et al., 1997). In one study, 26.8% of NH residents with schizophrenia were verbally aggressive and over 12% were physically aggressive (Bowie, Moriarity, & Harvey, 2001). Mosher-Ashley, Turner and Oneil (1991) early-on documented long term care administrators’ uneasiness over admitting deinstitutionalized residents because of concerns over behavior disruptive to staff. The need for staff training to feel more comfortable in delivering appropriate care appears to be key (Molinari et al., 2008).

SMI Treatment in Long Term Care Settings

The prevalence and diversity of mental health problems in long term care settings have not allowed a specific research focus on interventions for residents with SMI. Harvey et al. (1998) argue that the inappropriate NH care delivered to older adults with schizophrenia often results in detrimental physical, psychiatric, and functional outcomes. Expanding rehabilitation efforts (Bartels et al., 2014; McCarthy, Mueser, & Pratt, 2008; Pratt, Mueser, Bartels, & Wolfe, 2013) and modifying strategies from Recovery Movement-oriented programs (American Psychological Association, 2013) to actively engage those with SMI to promote a more meaningful life in long term care settings should be a priority.

Findings related to Residents’ Quality of Life and CNA Training issues

As Burton, Chaneb, and Meeks (2007) note, coping with SMI can be a constant struggle throughout life, and older adults with SMI must deal with both aging and mental health issues. Quality of life and adaptive functioning in the NH setting have been consistently related to personalized care, flexible routines, optimal physical environment, and participation in meaningful activities that promote residents’ skill development, autonomy, and family involvement (Logsden, 2000; Rosen, 1997; Timko, Nguyen, Williford, & Moos, 1993). However, in one study utilizing focus groups comprised of NH staff members, it was discovered that non-psychiatry specialty NHs may employ staff with biased views of the mentally ill that interfere with optimal care (Molinari et al., 2009). Negative actions include refusing to admit residents with SMI, segregating them from the rest of the NH population, fearing them, inappropriately hospitalizing them if they experience any acute episodes, or refusing to re-admit them to the NH after hospitalization. A review of the literature yields a dearth of intervention studies specifically designed to improve frontline caregiver skills and knowledge of older adults with SMI in NH settings (Becker & Mehra, 2005; McCarthy, Blow, & Kales, 2004). Most NH research addressing disruptive behavior targets behavior problems of those with dementia. Although similarities exist in behavior patterns of residents with SMI and those with dementia, differences exist as well. NH residents with SMI often have been symptomatic throughout their lives. Yet even after acute psychotic episodes, their prognoses may be good, and they may at least return to baseline with proper treatment. Residents with dementia, however, experience steady and irreversible cognitive decline, with or without acute psychotic episodes. According to Molinari et al. (2009), CNAs caring for both sets of residents usually cannot discern or interpret differences in clinical presentations between SMI and dementia. Research shows that caregiver behavior has a strong effect upon those with SMI for good or ill, and resident relapse into psychotic episodes correlates with high emotionally expressive caregivers, and hostile care services and environments (Butzlaff & Hooley, 1998; McDonagh, 2005; Weardon, Tarrier, Barrowclough, Zastowny, & Rahill, 2000). Snowden, Sato and Roy-Byrne (2003) discussed training to improve treatment of depression and behavioral symptoms of dementia, and acknowledged that CNA turnover may account for lack of demonstrated training effectiveness. Taken together, this evidence suggests serious gaps not only in CNAs’ abilities to work effectively with NH residents with SMI, but also in current methods of program evaluation of CNA education in long term care settings and how to maintain didactic gains.

The effectiveness of internet-based training for CNAs in long term care facilities is well established (Gaugler, Hobday, & Savik, 2013; Hobday, Savik, Smith & Gaugler, 2010), but experts acknowledge that didactic sessions, workshops, continuing education formats, and distribution of educational materials do not necessarily change caregiver behavior, although interactive learning with follow-up discussions and evaluative processes may positively affect caregiver outcomes (Davis, et al., 1999; Linehan, 2007). Unfortunately, alternatives to print format training resources are scarce for those dealing with SMI. In separate studies, an online mental illness training program focusing on building behavioral skills and instilling knowledge using video modeling was well-received by NH registered nurses, CNAs, and licensed health professionals. This training increased participants’ knowledge (myths of mental illness) and sense of self efficacy at post-test (Irvine, Billow, Bourgeois, & Seeley, 2012) and at 8-week follow-up (Irvine, Billow, Bourgeois, et al., 2012). However, the modules in the two Irvine studies were not specifically focused on SMI.

To remedy gaps in the long term care training literature, we conducted an evaluation of the CARES^® Serious Mental Illness^™ (CARES SMI) online program to determine if it was effective in increasing CNA knowledge of caring for residents with SMI. The CARES^® Approach framework (Hobday et al., 2010) provides a simple, structured way to reduce and in some cases prevent behavior in people living with dementia that may be considered problematic to staff. The CARES Approach is person-centered care and does not localize the problem within the person living with dementia, but instead employs the term ‘behavior’ as opposed to stigmatized versions of the term such as ‘aggressive,’ ‘agitated,’ ‘inappropriate,’ or ‘disruptive’ behavior. This important distinction helps nurses, CNAs, and other staff recognize that all behavior is interactive and a natural reaction to cognitive decline and not necessarily intentional or the ‘fault’ of the individual with dementia. CARES is taught to CNAs and nursing personnel via the easy-to-learn and easy-to-remember acronym, CARES (C = Connect with the person; A = Assess behavior; R = Respond appropriately; E = Evaluate what works; and S = Share with others).

The CARES SMI program (described below) is a modification of the CARES^® Approach framework and consists of two modules teaching CNAs the detrimental effects of stereotypical attitudes toward residents with SMI in long term care facilities, and providing CNAs with experiential models and interactive practices to support a healthcare environment in which residents’ emotional needs are understood, highlighted, planned for, and addressed. The major didactic component of the CARES^® SMI is utilization of the person-centered approach to caregiving as the basis for the development of successful strategies to manage the behavioral difficulties and psychotic symptoms of residents with SMI.

Methods

Program Description

This study was approved by the University of South Florida’s IRB. The two CARES SMI modules (“Introduction to SMI”; “Providing Appropriate Care”) used in this study modified the CARES Approach in individuals with SMI, with inclusion of content guided by the Recovery Movement philosophy for those with SMI (APA, 2013). The CARES^® Approach to dementia care dovetails nicely with the main tenets of the Recovery Movement, i.e., to promote the attitudes that those with SMI are not defined by their illness, those with SMI should have the least restrictive care possible, services should be provided within a low emotionally expressive environment, and that decision-making in treatment planning should be shared (APA, 2013, Weardon et al., 2000). The two modules take approximately 2–3 hours to complete, depending upon how many of the special features are accessed. Two special features of these modules are video interviews and interactive video clips from both experts and consumers which personalize individuals living with SMI, presenting them holistically rather than as reflecting mere diagnostic categories. Module 1 introduces learners to characteristics of different types of SMI and how SMI affects patients and their interactions with others. Module 1 includes the topics: “Understanding mental illness”, “Living with varying forms of SMI”, “Taking care of you”, “Things I can do”, “You can make a difference”, SMI vs. dementia”, and “Living with SMI”. Module 2 deals with how to sensitively address the needs of those with SMI and introduces the CARES approach for this purpose. Module 2 includes the topics: “Managing a Serious Mental Illness and recovery”, “Recovery and the CARES^® Approach”, “CONNECT”, “Assess behavior”, “Respond appropriately”, “Evaluate what works”, and “Sharing with others.” Module 1 and Module 2 were written to be sequential and complementary but can be taken alone depending upon the CNA’s experience with SMI.

The adult learning methodologies of interactivity and participatory environments were incorporated into the CARES SMI modules (McHugh & Barlow, 2012). Although CARES program users do not necessarily interact with other learners in person, they do interact with the program in novel ways to build skills through video-based activities and integration with the general CARES Approach. Users view videos of actual people with SMI (not actors) and are then guided through the CARES (Connect, Assess, Respond, Evaluate, and Share) process. Users also view additional videos of actual care providers interacting with the person with SMI, write answers to questions after each video, and receive “correct” feedback. In another type of interactive, participatory learning activity, the CARES program user is presented with “stories” of 4 people, each one having a different SMI (schizophrenia, bipolar disorder, schizoaffective disorder, and major depression). The person “speaks” to the learner, answering questions about his or her life, the illness, and support received. Additional information and perspectives are provided by the person’s medical professionals and family members. Another interactive activity produces a “plan” for how users can handle and moderate stress and stressful situations related to caregiving. Finally, the program offers a number of built-in quizzes to check and reinforce user learning as users complete the CARES SMI program.

Participants

Based on an initial RCT proposal and per agreement with the NIMH grant program officer, two states (Georgia and South Dakota) were randomly selected for the study. Investigators downloaded the Nursing Home Compare spreadsheet of Medicare facilities (https://www.medicare.gov/nursinghomecompare/search.html), randomly ordered all facilities in the state, and began ‘cold calling’ site administrators for possible inclusion in a study to improve CNA knowledge of SMI. Sites from Georgia or South Dakota were identified in this manner. Towards the end of the study when targeted enrollment had not been achieved, we turned to a convenience sample to recruit more participants. These last participants came from a NH/ALF in North Carolina, where one of the authors had done prior CARES training (but not on SMI nor in the building where current recruitment occurred).

The final sample was comprised of CNAs (n=40) from four long term care facilities across three states. One ALF was located in South Dakota and employed seven CNAs who completed the training. Two facilities were located in Georgia, with one CNA in a NH and seven CNAs in an ALF who completed the training. The final facility was located in North Carolina with 19 CNAs in the NH component and 6 CNAs in the ALF component who completed the training. Two of the facilities had ‘above average’ staffing, one had ‘average’ staffing, and one has ‘below average’ staffing. Participants received free access to the training, and were paid $50 upon completion of the study. Sixteen CNAs consented to participate but either did not compete the pre-test (n =8), or did not compete either the pre-test or post-test (n=8).

Only those participants who completed both modules and who answered all questions were included in the analyses. There was no missing data. The sample consisted of 40 CNAs (20 employed at NHs and 20 employed at ALFs). The mean age of the CNAs was 36 (SD = 12.7), 90% (n=36) were female, 52% (n=21) were White, and 97.5% (n=39) had at least a high school degree. In relation to experience, the mean number years of CNA employment was 6.2 (SD = 6.04), and 82.5% (n=33) of the CNAs indicated they had received prior online training. The great majority of the CNAs owned a personal computer (90%; n=36) and had regular high-speed internet access (97.5%). Table 1 summarizes the descriptive characteristics and pre-post test scores of the entire sample. As a rough gauge of the generalizability of the findings, we compared our sample of CNAs with a national sample of direct care workers i.e., nursing assistants, home health aides, personal care aides (Paraprofessional Healthcare Institute, 2011). The mean age of 36 years for our sample was lower than the average age of 42 years for direct care workers; the 90% female figure was very similar to the 89% of all direct care workers who are female; the 52% of Whites in our sample was a little higher than the 47% of direct care workers who are White; the 6.2 years of average working experience of the CNAs in our sample appears comparable with 76% of direct care workers with between 1–9 years of experience. (Paraprofessional Health Institute, 2011).

Table 1.

Descriptive Statistics and Pre-Post Test Scores

Variable	M (SD)	n (%)	Minimum	Maximum	t(39)	p
Participant Demographics
Female		36 (90)
Black/African American		17 (42.5)
White		21 (52.5)
Hispanic		7 (17.5)
Age (years)	36 (12.7)		19	64
Education (≥High school)		39 (97.5)
Married		19 (47.5)
Experience
CNA (years)	6.2 (6.0)		0	24
Length of Employment (years)	2.9 (4.1)		0	17
Prior Online Training		33 (82.5)
Computer Accessibility
Owns Computer		36 (90)
Regular Internet Access		39 (97.5)
Test Scores
Module 1 Pretest	67.7 (15.9)		17	92
Module 1 Posttest	79.6 (12.2)		42	100
Module 2 Pretest	78.5 (17.0)		30	100
Module 2 Posttest	86.5 (17.8)		20	100
Module 1 Pre- Posttest					-5.52	.<.001
Module 2 Pre- Posttest					3.36	<.01

Note. N = 40. SD = standard deviation.

^*Test scores refer to percent of items answered correctly

Measures

Pre-post testing: The participants completed an online pretest and posttest for the two SMI training modules. The 22 multiple choice questions (12 for Module 1; 10 for Module 2) were study-specific. They were written by content experts and reviewed by an assistant experienced in writing test questions. The questions sampled the main points and material of the two modules including prevalence of SMI (“How common is SMI in NHs?”), its associated diagnostic categories and symptoms (“The major categories of SMI are?”), differences between dementia and SMI (“ One difference between a resident with SMI and a resident with dementia is?”), stigmatization of those with SMI (“Which is true about people with SMI ?”), the appropriate caregiver attitude towards residents with SMI (“A good way for a nurse assistant to care for residents with SMI is?”), the Recovery Movement (“Some of the main principles of the Recovery Movement are?”), and the CARES framework (“In the CARES® Approach, what does “assessment” mean ?”). See Table 2 for a list of all the questions. Average number of days between pre-test and post-test was 5.4 days, with 17/40 completing the training in one day. However, there were a few outliers with four people taking more than 10 days, and one person 46 days.

Table 2.

Test Questions for SMI Online Training

Module 1

Which of the following is most likely affected by Serious Mental Illness (SMI)?

How common is SMI in nursing homes?

A good way for a nurse assistant to care for residents with SMI is:

The major categories of SMI are:

If a resident has loss of appetite, does not want to get out of bed, and does not want to participate in activities, what would he or she most likely be suffering from?

If a resident is over-active and has severe high and low mood swings, what would he or she most likely be suffering from?

Which of the following is an SMI with both a “thought disorder” and a “mood component”?

Which is true about people with SMI?

Which of the following is true about the treatment of people with SMI?

One positive thing about SMI:

Which of the following is true about your behavior towards someone with SMI?

One difference between residents with SMI and residents with dementia is:

Module 2

The best strategy for nursing assistants to care for people with SMI behaviors in nursing homes is:

The best way of connecting with residents with SMI is:

Some of the main principles of the “Recovery Movement” are:

A meaningful role in life:

For those with SMI, acceptance by others:

Why is “hope and healing” important in the lives of nursing home residents with SMI?

In the CARES® Approach, connecting with those with SMI is:

In the CARES® Approach, what does “assessment” mean?

In the CARES® Approach, when a staff member “responds” to a resident with SMI who is showing psychotic symptoms, the staff member should understand that:

“Empowerment” allows nursing home residents with SMI to:

Likert items: Fourteen Likert scale items related to aspects of the training were rated on a five-point scale. Please see Table 3. For example, participants were asked whether they strongly agree, agree, unsure, disagree, or strongly disagree with statements such as “The internet training program was an interesting way to learn compared to learning in a classroom or by reading”, and “The information provided in the training program will help me better communicate with family members and other professional caregivers”.

Table 3.

Likert-scale Statements Related to Aspects of SMI Online Training

Statement	Strongly Agree	Agree	Unsure	Disagree	Strongly Disagree
This Internet-based training program was an interesting way to learn compared to learning in a classroom or by reading.	15 (38%)	25 (63%)
The information presented in this training program was easy to understand and follow.	16 (40%)	23 (58%)		1 (3%)
The graphics, sound, and video in this presentation made the training more interesting than other training programs I have participated in.	15 (38%)	21 (53%)	3 (8%)		1 (3%)
I am more confident about my skills in helping and caring for people with serious mental illness (SMI) after completing this training program.	16 (40%)	24 (60%)
I would recommend this program to other CNAs.	18 (45%)	21 (53%)	1 (3%)
I would recommend this program to other professional caregivers (nurses, social workers, home health aides, etc.).	17 (43%)	23 (58%)
I would recommend this program to the families of people with serious mental illness.	22 (55%)	17 (43%)	1 (3%)
The videos gave me new ideas on how to interact with someone with serious mental illness.	17 (43%)	20 (50%)	2 (5%)	1 (3%)
It was easy for me to fit the training program into my schedule.	12 (30%)	19 (48%)	6 (15%)	2 (5%)	1(3%)
As I completed this program, it was important to be able to go back and review sections of the program as often as I wanted.	18 (45%)	21 (53%)	1 (3%)
I preferred learning with this Internet-based training program as opposed to sitting in a classroom.	14 (35%)	20 (50%)	4 (10%)	2 (5%)
I have a better understanding of the behavior that is associated with serious mental illness after completing the training program.	16 (40%)	24 (60%)
I am more confident and comfortable in communicating with someone with serious mental illness after completing this training program.	15(38%)	25 (63%)
The information provided in the training program will help me better communicate with family members and other professional caregivers.	13 (33%)	27 (68%)

Open-ended questions: Participants were also asked to answer five qualitative, open-ended questions (e.g., “what suggestions do you have that would make the training program better as we move into Phase II development?).

Analyses

To determine whether the online training improved participants’ knowledge on SMI, paired sample t tests were calculated to test for statistical significance between pre- and posttests. These data were analyzed using IBM^®SPSS^® (Version 22). Qualitative data were entered into Microsoft^® Excel^® for data management and analysis. For Likert scale statements, data were sorted to determine frequency of responses. Regarding analyses of the five qualitative, open-ended questions, two investigators independently coded the open-ended questions to identify emerging themes related to participants’ experiences with the online training. Coding discrepancies were discussed and resolved using a coding by consensus method (Daaleman, Usher, Williams, Rawlings, & Hanson, 2008).

Results

Sample Comparisons

For the total sample, Module 1 pre-test scores ranged from 17% - 92% correct, M= 67.7(SD= 15.5), while posttest scores ranged from 42% - 100%, M= 79.6(SD=12.2). A paired-samples t test was calculated to compare the mean pretest score to the post test score for Module 1. A significant increase from pretest to posttest was found (t(39)=−5.52, p<.001). The effect size estimate (d) based on the pretest standard deviation was .76 indicating a gain of over three-fourths a standard deviation compared with the pretest scores. Based on the recommendations made by Cohen (1988) for evaluation of effect sizes in social and behavioral sciences, this is a large effect size.

Module 2 pretest scores ranged from 30% - 100% correct, M=78.5(SD=17.02), while posttest scores ranged from 20% - 100%, M= 86.5(SD= 17.76). A paired-samples t test was calculated to compare the mean pretest score to the post test score for Module 2. A significant increase from pretest to posttest was found (t(39)=3.36, p<.01). The effect size estimate (d) based on the pretest standard deviation was .47 indicating a gain of almost half a standard deviation compared with the pretest scores. Based on the recommendations made by Cohen (1988) this is a medium effect size.

Likert Scale statements

The majority of the participants responded positively to all 14 statements. All participants indicated they were more confident about their skills in helping and caring for people with SMI after completing the training and would recommend this program to other professional caregivers (nurses, social workers, home health aides, etc.). Likewise, almost all participants (97.5%, n=39) indicated they would recommend the training to other CNAs and families of people with SMI. All of the participants indicated that after completing the training they had a better understanding of the behavior associated with SMI and were more confident and comfortable in communicating with someone with SMI. The ease of participants being able to fit this training program into their schedule showed the greatest discordance; 7.5% of the participants (n=3) expressed disagreement and 15% of the participants (n=6) were undecided.

Open-ended questions

All 40 CNAs responded to each question. The questions and associated themes are described below, including illustrative quotes.

Positive aspects of training program

All respondents expressed what they liked best about the training program in their own words. Themes that emerged include: (1) convenience of the training; (2) delivery format; (3) real life examples; (4) increased knowledge about individuals with SMI; (5) ease of use; and (6) content. The benefits of being able to complete the training at any time, location, and at their own pace were important. One respondent stated,

“When doing the training on line, if I miss something or didn’t understand anything (sic) I could go back and recheck myself. And another thing I like about this was I (sic) worked on my time.”

The inclusion of video interviews and vignettes of real individuals with SMI and health care providers in the training videos made the training realistic and helped respondents gain a better understanding of individuals with SMI. Another respondent said,

“I enjoyed hearing the individual speakers. The videos allowed me to see and hear things from both a medical / teacher perspective as well as from an individual that has been affected by SMI. I thought that breaking down “SMI” into individual diseases such as Schizophrenia, Bipolar Disorder, Schizoaffective Disorder and Major Depression was important. It allows us to understand as caregivers that they are not the same and while some symptoms may be similar, they may have variations as well, and all of this should be considered when approaching and working with a person on a daily basis.”

Negative aspects of training program

When asked about what they liked least about the training program, approximately one-third of the respondents had nothing negative to say about the program. Of those who recorded negative comments, the following themes emerged: (1) training length; (2) technical considerations; (3) more comprehensive coverage of materials needed; (4) delivery format; (5) ease of use; and (6) content.. With the exception of one respondent stating the training was too short, the other quotes reflected that the length of the training program was too long. A small minority of respondents experienced technical problems while completing the training. One respondent said,

“Hard to navigate and understand how to navigate between web pages. Much of the text was too repetitive.”

Another respondent suggested,

“Put it all on one website.”

More in-depth coverage of certain materials was needed by some respondents. A different respondent mentioned,

“I felt as though some of the questions on the test were not covered clearly enough in the information provided in the modules.”

Ways program will be helpful to CNAs caring for someone with SMI

The CARES SMI training had a positive impact on the respondents’ beliefs about their ability to care for individuals with SMI. Themes that emerged included: (1) increased knowledge; (2) increased confidence in caring for individuals with mental illness; (3) changed perspectives about people with mental illness; (4) applicability providing daily care; (5) improve quality of care; and (6) improved performance. Almost all of the respondents noted at least one way in which the program improved their perceived ability to care for persons with mental illness. In addition to increasing knowledge about SMI, a few respondents indicated the training made them more confident and changed their perspective about individuals with SMI. One respondent said,

“The videos helped me to understand what people with mental illness go through daily. I know that building trust and therapeutic communication is the key in dealing with SMI. I feel like I would have a better approach and understanding in the future.”

Another respondent mentioned,

“I will be able to take the steps learned and apply them to my daily activities. Learn to be (sic) patient and take care of myself, leave when it gets stressful.”

Advice to improve training program

Overall, the respondents felt that the training program was good and provided positive feedback on the benefits of the program. Themes that emerged related to recommendations for improvement include: (1) technical issues; (2) length; (3) delivery format; (4) content; (5) real life examples; (6) target audience; and (7) ease of use. One respondent said,

“Better instruction on how to begin and complete.”

A different respondent stated,

“I would suggest more videos because I feel like when you see someone speaking about their individual experience you connect with the situation a little better. I would also recommend more questions throughout the module. I found those questions to be like little brain teasers while going through the modules. When I missed one of the answers I tried to go back and find it in the material I had read previously to make sure I understood it correctly. I would also recommend adding a few additional questions on the Post-Test and Pre-Test.....there is nothing wrong with challenging our minds. I enjoyed the modules and appreciate the opportunity to participate in this phase.”

A few respondents also recommended including additional training on how to deal specifically with physical aggression by residents. One respondent mentioned,

“In dealing with real life situations, I feel that a course on how to redirect violence would greatly help. Even though understanding triggers, we, as cna’s (sic) are still sometimes caught in the crossfire of a violent episode. It would be nice to have true training on how to redirect the violence.”

Recommendations to others about training program

Perceptions of the training program and how respondents convey their training experiences and perceived benefits to others is of importance in the training of administrators. An overwhelming majority of the respondents provided positive feedback about the training. Half of the respondents indicated the training increased their understanding of SMI. Other themes that emerged included: (1) applicability to providing daily care; (2) comprehensive; (3) helpful; (4) necessary; (5) informative; (6) easy to use; (7) good learning tool; and (8) could lead to improved performance. Below are statements from four different respondents:

“I would recommend the program because it is comprehensive, useful, and brief. Since it is accessible via Internet, the program is also highly accessible.”

“The program is very helpful, it gives (sic) good descriptions, examples, testimonies of what a person with SMI experiences. It also describe(s) the types of SMI.”

“It is very informative and a good learning tool for connecting, responding, becoming a friend to an SMI person (sic), not only for a care assistant, but also for family members that are struggling with it.”

“All healthcare’s employees would excel in their performance after doing the program.”

Discussion

We evaluated the effectiveness of the CARES^® Serious Mental Illness^™ training to improve CNAs knowledge and attitudes about SMI. Significant gains in CNA participant knowledge were documented from pre- to post- test for both training modules. Although a few participants were concerned regarding technical considerations, length of the training, and clarity of instructions/content, the majority responded ‘strongly agree’ or ‘agree’ regarding the acceptability, ease, and format of the training process. They said they learned more about SMI, changed their perspectives, and increased their confidence in dealing with such residents. Training in person-centered care via the CARES Approach framework appears to be a viable way for CNAs to acquire important basic understanding of how to connect, assess, respond, evaluate, and share information for those with SMI. The training focused on ‘personalizing’ people living with SMI so that symptomatic behavior is viewed as just one aspect of an SMI individual’s character, and emphasized changing attitudes about ‘psychiatric patients’ from feared, unpredictable individuals to fellow human beings struggling with mental illness.

These results are consistent with evaluations of prior mental health training modules in NHs (Irvine et al., 2012; Irvine, Billow, Bourgeois, et al., 2012), indicating that mental health training can be delivered effectively and efficiently online and that long term care personnel are able to gain relevant knowledge via an asynchronous online format allowing learners access to the material on their own schedule. It is hoped that such enhanced understanding and availability of training will reduce the number of unnecessary hospitalizations and re-admissions, a practice that has well-known deleterious effects on NH residents (Ouslander, Weinberg & Phillips, 2000). The content of mental health training for CNAs should reflect preventative as well as remedial efforts, thereby cultivating a safer environment for both staff and residents.

CNAs are not expected to conduct professional interventions or even to conduct comprehensive assessments, but the online CARES^® Serious Mental Illness^™ training may instill knowledge concerning how to connect with people living with SMI by treating them with respect and dignity rather than fear and avoidance. The program may also be useful in teaching CNAs how to detect and report basic mental status changes to their supervisor or director of nursing. Such training of CNAs is a valuable but daunting goal. CNAs are frontline staff and often the first ones to observe alterations in a resident’s thinking that may require treatment. They spend the most time with residents, are frequently the targets of behavior that may be classified as agitated or aggressive, and are untapped resources for managing such behavior and supporting good quality of life (Kramer & Smith, 2000).

This study is limited by the use of a convenience sample of CNAs in a restricted number of NHs and ALFs from three states. We do not know the number of CNA’s who refused to consent to participation in the study, nor did we conduct a reliability assessment of the pre-post test items. A simple one group pre-post study design was used with no control group, and we did not examine how the work settings (NH vs. ALF) may have differentially affected the results. The findings may not be generalizable to staff at other NHs or ALFs around the country or to CNAs without access to computers and the internet. Actual time spent on the course modules was not tracked. Although the increase in test scores appears both statistically and practically significant, an ultimate aim of this research is to translate this knowledge into improved skills and positive health-related consequences, but achievement of this aim was not evaluated in this study. Also, the qualitative evaluations may have been subject to bias given that participants received free access to the training program and were given $50 compensation to be part of the study and perhaps felt somewhat obligated to answer the questions in a positive direction. Finally, although the verbal content and video clips depicting actual care of someone with SMI were geared towards older adults with SMI in NHs, many of the video interviews of those with SMI were with volunteers with SMI who were younger (<50 years ), and higher functioning than typical NH residents. Augmentation of content and video specifically focusing on older SMI residents is planned for future development.

This is the first study that directly evaluated an online training module in long term care settings for CNAs which specifically earmarked care for those with SMI. We found that CNAs were very comfortable with the training process and content, gaining a significant amount of relevant knowledge. Future studies must determine if such acquisition of knowledge transfers to gains in CNA skills that ultimately result in better outcomes for residents with SMI. There is some evidence that medical education involving interactive participatory learning that allows physicians to apply skills may change practice behavior and possibly yield positive health effects (Davis et al., 1999). Indeed, long term care research suggests that the ingredients of a comprehensive successful CNA training program should also include administrative support, participative management involving all employees in feedback and decision-making, CNAs’ self-monitoring of new skills, supplemental training to prevent skill decay, and ongoing performance feedback and incentives (Burgio & Burgio, 1990; Burgio, et al. 2002; Stevens, et al., 1998; Stevens & Hochhalter, 2006). CNA training alone may not be able to change the way SMI is identified and managed in NHs, and additional research should determine whether NH professional staff such as social workers and nurses need to take such training to assist in its widespread implementation. Online training content might also be tailored to staff members working with SMI individuals in specific geriatric settings such as ALFs, day centers, senior citizen centers, and home-based care to assist with psychiatric rehabilitation by promoting the view that those with SMI have their own unique needs.