Unity in Diversity: Developing a Cross-Cultural Care and Communication Toolkit for Certified Nursing Assistants in Nursing Homes

With over one million Americans residing in certified nursing homes, there are more than one million American families experiencing care transitions. New residential environments often represent a unique culture change, including the ways in which care are supervised and structured. Additionally, direct care in nursing homes may be provided by professionals from a different ethnic or cultural membership from residents’ own background, each bringing their own perspectives and experiences.

Indeed, the most critical indicator of optimal care for long-term care residents stems from assistance provided by certified nursing assistants, or CNAs, who play a critical role in the long-term care health system.¹ CNAs are disproportionally likely to be women or people of color. The proportion of foreign-born CNAs has also increased over the last few years.²

As a group, CNAs are healthcare professionals who provide various types of basic care under the supervision of registered nurses. CNAs assist with activities of daily living such as bathing, dressing, or using the restroom. They also help monitor vital signs, and provide emotional support to residents given the significant amount of time spent with residents.

Despite the indispensable nature of their work, CNAs are often not recognized for their significant contributions to geriatric care. Studies have begun to explore the deep disparities faced by this essential workforce, ranging from social-based discrimination, haphazard work environment, low wages, to limited career advancement.^{3,4 5,6}

Additionally, in contrast to the fact that CNAs are likely providing care to a resident from a different ethnic or cultural background, the workforce has not been equipped with adequate cross-cultural training and education to do so.⁷ Practicing culturally sensitive communication in nursing homes is essential to effective care in increasingly racially/ethnically diverse resident and workforce populations.⁸ It is also a critical component to prevent abusive and neglectful caregiving behavior.⁹

To this end, in partnership with the Geriatric Workforce Enhancement Program (GWEP) at the University of Southern California, colleagues and I at Weill Cornell Medicine are developing a cross-cultural care and communication training tailored to CNAs. Our goal is to ensure that this toolkit aligns with the needs of both residents and CNAs from diverse ethnic and cultural backgrounds. Guided by the cultural humility framework,¹⁰ Train-the-Trainer model,¹¹ and Age Friendly principles of care,¹² we hope this toolkit will be acceptable and feasible to use for the long-term care workforce. Ultimately, providing CNAs with simple and practical strategies to mitigate cross-cultural communication barriers can likely lead to greater job morale, satisfaction for workers, reduce neglect, and improved understanding of care needs for residents as well as their family members. Despite all the challenges that may come with evolving demographics in residents and long-term care workforce, finding and delivering high-quality, culturally- sensitive, person-centered care is what unites us in this fight against abuse and neglect.

Reference List

1. Squillace MR, Remsburg RE, Harris-Kojetin LD, Bercovitz A, Rosenoff E, Han B. The national nursing assistant survey: Improving the evidence base for policy initiatives to strengthen the certified nursing assistant workforce. The Gerontologist. 2009;49(2):185-197.

2. Jun H, Grabowski DC. Nursing Home Staffing: Share Of Immigrant Certified Nursing Assistants Grew As US-Born Staff Numbers Fell, 2010–21: Study examines the numbers of immigrant certified nursing assistants and US-born nursing home staff. Health Affairs. 2024;43(1):108-117.

3. Shippee TP, Fabius CD, Fashaw-Walters S, et al. Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports. Journal of the American Medical Directors Association. 2022;23(2):214-219.

4. Travers JL, Teitelman AM, Jenkins KA, Castle NG. Exploring social-based discrimination among nursing home certified nursing assistants. Nursing Inquiry. 2020;27(1):e12315.

5. Truitt AR, Snyder CR. Racialized experiences of Black nursing professionals and certified nursing assistants in long-term care settings. Journal of Transcultural Nursing. 2020;31(3):312-318.

6. Rosen T, Lachs MS, Teresi J, Eimicke J, Van Haitsma K, Pillemer K. Staff-reported strategies for prevention and management of resident-to-resident elder mistreatment in long-term care facilities. J Elder Abuse Negl. 2016;28(1):1-13.

7. Sengupta M, Harris-Kojetin LD, Ejaz FK. A national overview of the training received by certified nursing assistants working in US nursing homes. Gerontology & geriatrics education. 2010;31(3):201-219.

8. National Academies of Science E, and Medicine;. The national imperative to improve nursing home quality: Honoring our commitment to residents, families, and staff. 2022.

9. Ramirez M, Teresi J, Holmes D. Demoralization and attitudes toward residents among certified nurse assistants in relation to job stressors and work resources: cultural diversity in long term care. J Cult Divers. 2006;13(2):119-125.

10. Chang ES, Simon M, Dong X. Integrating cultural humility into health care professional education and training. Adv Health Sci Educ Theory Pract. 2012;17(2):269-278.

11. Poitras M-E, Bélanger E, Vaillancourt VT, et al. Interventions to improve trainers' learning and behaviors for educating health care professionals using train-the-trainer method: A systematic review and meta-analysis. Journal of Continuing Education in the Health Professions. 2021;41(3):202-209.

12. Edstrom KF, Fallah BD, Morgan EA. Age-Friendly Framework in Post-Acute and Long-Term Care: Implementing the 4Ms in Long-Term Care. J Am Med Dir Assoc. 2024;25(3):408-409.