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An Analysis of Literacy in CNAs
By Betty Chen

Introduction
By providing direct care to elderly residents, certified nursing assistants (CNAs) are an essential component of many residents’ well-beings and the nursing facility. CNA training programs greatly influence performance by establishing a literacy base for CNAs to build upon. Although it might appear as though there is no literacy involved in a job that is mostly physical work, two types of literacy frequently associated with nursing are health literacy and information literacy. Health literacy is the ability to comprehend information and services regarding one’s health (Scott 153). An example from the CNAs perspective is repositioning a bed ridden resident to prevent formation of bed sores even though the resident may not realize or understand the significance of this task. Information literacy is the ability to know when to gather information and how to use it (Forster 195). An example would be the use of iPads to chart resident activities such as how many times a resident has showered in a given period. CNAs on a different shift may utilize the iPads to gather information on their residents’ status.

Indubitably, both health and information literacy play a major role in a CNA’s care for the elderly. This affects everyone because at any given time, most individuals know of somebody under the care of a CNA. Additionally, with better modern health care practices and advanced technology, the amount of people living longer and the length they live have increased. Existing research often associate CNAs with illiteracy and poor performance. Despite health and information literacies being applicable to other health care professions, CNAs have a negative connotation when it comes to literacy and workplace performance. Though this deficit could be linked to many factors, one is specifically the CNA training program because this is where new skills are learned and habits are formed. Training programs, composed of classroom training and hands-on training, are completed prior to taking the certification test to be a CNA. Hands-on training can be in the skills lab, which has mannequins and wheelchairs for a new CNA to practice with, and the nursing home, where a new CNA is pair with a veteran CNA in daily practices.  It is here, in the training program, where literacy should be incorporated and improved because proper literacy usage leads to better relationships and cultivates growth of knowledge in the nursing home. At this time, there is a gap in research because there is not enough credible information on how literacy can be incorporated in the nursing and training program to create better CNAs.  This research is a continuation of existing claims on literacy in nursing.

The purpose of this research is to investigate literacy that can be found within nursing and the education program. This study will particularly focus on the forms of communication and abilities displayed in the CNA workplace and the training program offered at my high school. Through these techniques in the program, individuals such as myself and my former classmates have learned the literacy and language of becoming a CNA. The study will also consider further literacy usage found in the nursing home when communicating and working with residents and coworkers.

Literature Review
CNAs
Generally, academic journals on CNAs concentrate on how disreputable CNAs are in nursing homes. After administering health care knowledge exams to CNAs, Nancy Kusmaul’s study concludes from the test scores that CNAs did not have the proper knowledge on the conditions that affect the elderly (24). The CNAs scored lower than other health care professionals (i.e. social workers and nurses) even though they spent a significant amount of time with and have the most direct impact on residents. Alison M. Trinkoff et al. extend on the effects of possible inadequacy in CNA training by measuring the quality indicators (QI) such as pain, falls, or weight loss, in their study “Training Hours vs QI rates” (Trinkoff et al. 507). The researchers found that decreased training hours correlated with increased QI rates. Training is essential to the performance of a CNA because it leads them to have better confidence and provide better care based off their knowledge. Despite using different methods, both studies and many similar studies arrive to the same conclusion that CNAs are inadequate care givers.

As previously stated, an effective training experience is necessary to improve the quality of CNAs. Training is an individual’s first introduction to the CNA field, and this initial exposure establishes the basic knowledge for providing health care and creates everlasting habits. Improving such training programs is difficult because of limited resources, particularly of funding and time (Kusmual 23). Though difficult, CNA education should place efforts on modifying the way the training program is taught. A better training experience will allow CNAs to have better relationships with residents and display more passion for their careers. This is significant because there is always a need for CNAs due to the rate of turnover and growing population of elderly (Kusmual 24; Trinkoff, et al. 507). Since the growing population of elderly is inevitable, improvements to turnovers can be achieved through better training.
 
Health Literacy
The term “health literacy” first appeared in 1974 in health standards when Jane Lawless and researchers repeatedly associated it with “health related experience” (Lawless et al. 145, 152). The definition of health literacy, as stated by the US Department of Health and Human Services, is “The degree to which an individual can obtain, process, and understand the basic health information needed to make an appropriate health decision” (Scott 153). It is a skill found in nursing and has an impact on the health care provided by CNAs.

Sheryl A. Scott elaborates on health literacy by emphasizing that illiteracy develops “negative health outcomes and high health care costs” (153). In addition to the outcomes and costs, this illiteracy also leads to loss of valuable time and creates negative impressions of the environment. Health illiteracy applies not only to health care provider but also to clients. Often clients or residents in the nursing home are unaware of their health condition. Literacy is needed so they can make the right decisions for their health. A literate environment is established when both health care provider and client are knowledgeable about the health situation. According to Carolyn Speros, it is the nurse’s role to be more active and assist client knowledge by using layman terms and images (Speros 638.) It is crucial that health literacy should be included in the education program to ensure a graduate is produced that can guide clients to better understand their own health literacy.

Information Literacy
Information literacy is related to libraries and librarians—places and people where information is stored and found. Lawless notes that the concept of information literacy is based on “information need” where there must exist a “need,” and individuals who are literate have the ability to successfully fulfill this “need” (Lawless et al. 152). Therefore, information literacy is when an individual “can determine the extent of information needed, access information effectively, and critically evaluate information and its sources” (Barnard 509; Foster 195). Alan Barnard expands the definition of information literacy by stating that it is a skill that can generally be applied everywhere because all fields and workplaces need information and knowledge (509). Human interaction plays a large role in information literacy as a  a study by John Crawford and Christine Irving concludes that generally in workplaces, humans are a source of information when it comes to information literacy (35). This conveys that not only is someone literate capable of finding information, but they also have connections with other people and are able to gain and share information across their environment.

Information literacy is needed everywhere. In a study by Marc Forster, the results show that while information literacy is “essential to effective nursing practices,” it is not included in nursing programs (Forster 199). Nurses cannot learn this valuable skill if they are never introduced to it. Barnard supports this by stating information literacy is needed for “successful implementation of evidence-based approaches to clinical-practice” (Barnard 509). If literary, individuals can synthesize the information they have and apply it to clinical settings. The capability to use the information is just as important as knowing where to find it, and nurses who can do both become an expert. In fact, in Forster’s study, it becomes clear the influence information literacy can have on future success. He references six levels of information awareness ranging from “the passive minimalist” who seeks basic and background knowledge to “the leader, philosopher, and strategist” who has the highest information literacy, and it is in these higher levels were the administrator of the health care facilities usually exist (Forster 199). Literate individuals have high positions, better knowledge, and more connections with people versus those who were illiterate and have poor work performance.

Summary
Searching for articles relating to the literacy of CNAs or nursing homes was a difficult task. Many scholarly journals did not go in-depth about literacy in the training program or nursing home. Articles which did discuss training programs often stated it was a “first kind” or “first study” in its field. The topic is not frequently researched because of how easy it is to overlook CNAs and the work they perform. In the absence of scholarship on CNA training, articles on workplace conditions were used to understand the necessary real-world working conditions.

Taken together, the literature review suggests two literacies that are prevalent throughout the nursing field: health literacy and information literacy. Health literacy is being knowledgeable about the health condition and how to treat it. Information literacy is knowing where to locate information and how to apply it. Despite the prevalence of both literacies in all workplaces and CNA workplaces, they are not incorporated in education programs. The lack of literacy can cause poor health outcomes, high costs, loss of time, and negative environments. To a CNA, this leads to inadequate resident care and loss of passion in their career. As the elderly population continues to grow, the need for CNAs is growing, so education programs need to incorporate it into their courses.

To improve CNA literacy and awareness, this paper aims to answer the following research questions:

• What factors contribute to a CNA’s literacy in the nursing home and training program?
• How can literacy in the training program be improved for new CNA’s?

Methods
The data for this research was collected from textual analysis and interviews based from my high school nursing education course. The texts I analyzed include the course syllabus, four of the twenty-seven skills sheets, and four of my weekly reflections of my nursing home encounters. The course syllabus set the standards to be covered for the course. It is a general layout of the dates the class will meet at the nursing home and the material that will be covered in class. The skills sheets are step by step instructions on how to perform a task such as walking a resident to a wheelchair or taking a resident’s blood pressure. The steps are written in a clinical tone where the authors intended to protect the health and safety of the resident and CNA to conveniently perform a skill. The weekly reflections include, but are not limited to the student’s goals, thoughts, clinical observations, and patient measurements.  Students were encouraged to record the skills used and write in medical terminology to demonstrate their knowledge of class. All three texts are a different genre of writing with different patterns, but all are employed in nursing.

Moreover, I conducted interviews with two CNA program graduates, Paula and Laura, and the instructor of the course, Mrs. Turner. Paula and Laura enrolled in the CNA program a year before I did and were certified after taking the state test. Both have known me for more than 3 years and are currently pursuing pre-med degrees. Mrs. Turner is a BSN who has taught nursing education along with other health science courses at the high school for over five years. In addition, she recertifies the program bi-annually and must attend annual workshops to be recertified herself. I chose to conduct interviews because it allowed the respondents to express themselves and their personal opinions in depth based off their experience. The interviews were conducted via email where I asked questions relating to the course layout and the general literacies of being a CNA. Lastly, I conducted a coding analysis for specific words on the texts and interview responses. The results were discussed in three sections for this study: the importance of literacy to resident care, people that influenced literacy, and other resources that influenced literacy.

Results and Analysis
All of the qualitative data collect was first organized into a Coding Chart found in figure 1. Eight frequently used words with relations to nursing were coded. The total amount of words in the chart excluded words that did not have at least three characters such as I, a, it, etc. All words listed in the chart represent similar alternative forms—for example, “resident” also counts “residents” and “resident’s.” In my weekly reflections, the terms “Resident” or “CNA” were often used to refer to a certain person for reflection purposes, and this contributes to the higher percentage.

It is deduced from the figure that the terms “Resident” and “Patient” are interchangeable and only one is mainly used in each situation. The Skills Sheets always used “Resident” because they would always associate the term with Long-Term Care Facilities and “Patient” is associated with hospitals. Even though the syllabus was a broad outline of the course, it managed to use almost all eight of the selected words. Since the skills sheets were for instructive purposes, each only used the necessary word “Resident” because the person is the object receiving the physical actions for each skill. The interview responses focused more on cause and effect and relate better “kills,” “Experience,” and “Understanding” with better “Patient” “Care.” Interestingly, Mrs. Turner did not frequently used either “Resident” or “Patient” because her responses were primarily geared towards the student or CNA performance aspect due to her roles as a teacher and the requirements for the course.

Textual Analysis
To begin, the course syllabus is its own genre by setting the expectations for the new CNA class and sustaining validity throughout the whole semester. Two entities it accentuates outside normal classroom syllabi are reputation and confidentiality. It states uniform and appearance must be appropriate, and students “will be held accountable for your actions as any team member… would be” in a work-based environment. The appearance nonverbally communicates who a CNA is and their intentions. This is not only to protect the reputation of the school and allow continuation of future courses, but students within the course will be providing first-hand care to the residents within a nursing home. Confidentiality is enforced by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and exists in all health care fields. It is an example of health literacy and patient’s rights. By establishing important elements of the program, the syllabus reinforces how serious the course (and being a CNA) is.

The skills sheets are written in second person format and similar to the genre of an instruction manual. Their purpose is to introduce, guide, and eventually test new CNAs on task performance. Handwashing is the very first skill, and all CNAs must be tested on it since this practice is so essential to breaking the chain of infection. All the skills, with handwashing being the exception, start off as “Knocks on door. Identified hands should be washed. Explains procedure to resident” and end with “Maintains respectful interactions at all times.” This repetition conveys the significance of these steps. Certain steps are bolded and result in automatic failure for that skill if missed such as “locking wheelchair brakes” or “Candidate’s recorded pulsing rate is within 4 beats of Test Observers recorded rates” for the Vital Signs skills. These safety and accuracy aspects cannot be overlooked because they play such a large role in a CNA that one cannot even be certified if they are not competent. The skills sheets consider job safety, sanitation, and efficiency when executing the steps for a task.

The weekly reflections, written in first person by the students, have a journal genre. The first reflections made multiple observations of the facility. First, there is a set of codes the nursing home had set for all its staff members. For example, Code 10 would mean “tornado/severe weather” and Code Red would mean “fire”. Next, colored circles placed on the wall above the resident’s bed represented transfer status. A green circle conveys a resident can self-ambulate and a blue circle conveys two CNAs are required to lift and move the resident. Additionally, a small cartoon image of autumn leaves stuck on the door frame of the room would signify the resident inside was at fall risk, and CNAs should take extra caution. Lastly, there were multiple beeping sounds in the nursing home. A high pitch one would mean a wandering resident was attempting to wander out of the facility. A chiming sound signified there was an emergency call light in the shower room. Whether visual or auditory, these are all set examples of communication between the CNAs in the nursing home facility.

On the first visit, veteran CNAs taught students how to use iPads to electronically record charting information on a patient, such as the type of bath a resident took or any bowel movement recently made. Charting reminds the CNAs of any tasks leftover to perform and update other CNAs on the status of a resident. This is an example of information literacy because CNAs must know how to interpret the chart and extract the information they need. When it comes to language, CNAs have their own lexis. An example of this occurs in the reflections with reference to CNAs “burping” a resident’s colostomy bag, which means releasing the gas from the bag, a lexis within the CNA community that many ordinary persons may not understand or use.

Interviews
Paula was the first CNA program graduate I interviewed. She defined literacy as “the use of language, technology, and numbers to understand and gain knowledge of a certain culture.” An experience she shared was the importance of proper communication to an Alzheimer’s resident who may be illiterate. Paula mentioned the skills sheets and instructor as her resources that aided her throughout the course. Her suggestion for improving the program is to increase the work-based portion of the course so CNAs may gain more hands-on experience. She ended by stating how she was constantly learning something new every day and nursing created easy attachments to the residents.

Similarly, Laura, the second CNA program graduate, described literacy as being “able to read information and understand the logic behind different protocols.” Two resources she used while taking the course were the skills sheets and the notes she took from her instructor’s PowerPoint lectures. For improvement, she recommended teaching CNAs “the negative possible outcomes that results from” wrongdoing. A literate experience she witnessed was when a CNA used multiple towels to cover a resident while she was cleaning because the resident was not able to communicate how cold he was. She included that the most difficult part of the program for her is making sure she was doing her job correctly and that the resident was comfortable.

Mrs. Turner is the instructor of the course. In her interview, she shared many aspects of her role and her thoughts of the program. In addition to teaching, she herself must be a qualified teacher for the course and be recertified annually. She must also obtain consent from the state, the school, the students, the parents, and the nursing home to administer the course. On the topic of literacy, Mrs. Turner extended by stating its use in classroom and clinical situations. Medical math, medical terminology, and electronic documentation are all different elements of literacy. When asked about improvement, she suggested extending the classroom time requirement so students have a satisfactory knowledge for the field. Mrs. Turner gave some examples of illiteracy that could result from deficit training such as a CNA throwing contaminated linen on the floor and even issues as meticulous as not assuring bed linens are wrinkle free when making bed which can lead to development of pressure ulcers. Here, she mentions the classroom tests that ask students what to do in a scenario. Some positive modifications she has seen the nursing home make is placing new CNAs with more experienced ones. Another modification was the creation of positions such as a specific CNA in charge of showering, lessening a CNA’s work load and allowing for more focus on their patient care. She ends on a note stating CNAs “must be able to apply critical thinking skills to a multitude of situations” and a lack of classroom background limits them.

Discussion
The textual analysis and interviews reveal the importance of literacy to resident care. The syllabus stresses how appearance and confidentiality are professional healthcare concepts CNAs must follow, and the skills sheets strictly define the steps to take in executing a skill. This study encountered many positive examples where CNAs properly cared for a resident. Negative examples demonstrated that a deficiency resulted in resident abuse and neglect. We were also exposed to examples where residents were illiterate and could not even communicate their needs, but the CNA understood what the resident needed as Speros established they should (638). Additionally, it is interesting to note the communications between different CNAs contributes to resident care. CNAs share their own lexis, visual code, sound alert, and electronic charting system. These are all demonstrations of health and information literacy.

Throughout the research, many CNAs referred to the people they interacted with as a factor of literacy during the training program. This is an aspect of information literacy where an individual forms connections with other humans as a source of information (Crawford and Irving 35). One of the first people mentioned in the analysis are CNAs who introduce and teach new CNAs how to administer resident healthcare. Some CNAs demonstrated negative practices for their convenience because they are worked overtime and are understaffed; however, many were thoughtful in doing their job and understood how to take care of residents. Another person commonly referenced from the analysis was our instructor. In addition to teaching and testing us, she also personally showed us how she would perform tasks and always spent time answering questions. Our peers were also resources as we were often split into pairs at the nursing home and helped each other.

Additional important factors mentioned were the skills sheets, class handouts, lecture notes, practice tests, and videos shown in class of other CNAs performing a task which offered us visual images. One other resource that was not acknowledged in this study but brought to my attention is the skills lab room in my high school. We would often practice our skills in this room while supervised by our classmates and the instructor. This is where we would begin synthesizing our knowledge and apply it to a clinical setting which demonstrated another feature of information literacy.

There are many improvements which can be made to the training program that enhance a new CNA’s knowledge and ability of the field. The interviews suggest more focus on negative outcomes of poor CNA practices to raise awareness for new CNAs. The interviews also recommended extension of the hands-on and classroom portion of the course. The hands-on portion can be extended by allowing new CNAs unlimited access to the skills lab. This permits CNAs more time to practice and perfect their skills. Extension and in-depth teaching of the classroom portion gives new CNAs the knowledge behind why certain skills are performed that would be easily overlooked if not learned it in class. Conveniently, towards the end of the course, the instructor required all students to write out ways that the program could be improved in the weekly reflections. My weekly reflections included: implementations of stricter rules to prevent falls, establishments of activity rooms or group conversations run to preserve and encourage resident’s speech and social skills, and installation of trash bags in all rooms to discourage CNAs from throwing contaminated linen on the floor. These are a few viable suggestions for the program.

Conclusions
I acknowledge there are at least three limitations to this study. First, the study did not have access to more interviewees. Next, the respondents were strictly females and from a single high school and nursing home; therefore, the results are specific to that area. Lastly, there were not enough existing studies to compare these results. However, this study did answer the research questions, providing examples of literacy and methods to improve CNA training through these literacies. Based on this study, I recommend future replications to perform more in-depth analysis and conduct a variety of interviews. More researchers need to direct attention and contribute to this topic because CNAs are direct caregivers in nursing homes and have extensive interactions with clients. With more research, it is possible to implement improvements to the CNA program and the literacy of CNAs, resulting in better treatment.

Works Cited
Barnard, Alan, et al. “Information Literacy: Developing Lifelong Skills through Nursing Education.” Journal of Nursing Education, vol. 44, no. 11, Nov. 2005, pp. 505-510.

Crawford, John and Christine Irving. “Information Literacy in the Workplace: A QualitativeExploratory Study.” Journal of Librarianship and Information Science, vol. 41, no. 1, 01 Jan. 2009, pp. 29-38.

Forster, Marc. “Six Ways of Experiencing Information Literacy in Nursing: The Findings of a Phenomenographic Study.” Nurse Education Today, vol. 35, no. 1, Jan. 2015, pp. 195-200.

Kusmaul, Nancy. “The Content of Education for Direct Caregivers.” Educational Gerontology, vol. 42, no. 1, Jan. 2016, pp. 19-24.

Lawless, Jane, et al. “Health Literacy and Information Literacy: A Concept Comparison.” Reference Services Review, vol. 44, no. 2, Apr. 2016, pp. 144-162.
Paula, Laura, and Mrs. Turner. Personal Interview. 2018

Scott, Sheryl A. “Health Literacy Education in Baccalaureate Nursing Programs in the United States.” Nursing Education Perspectives (National League for Nursing), vol. 37, no. 3, May/Jun2 2016, pp. 153-158.

Speros, Carolyn. “Health Literacy: Concept Analysis.” Journal of Advanced Nursing, vol. 50, no. 6, 15 June 2005, pp. 633-640.

Trinkoff, Alison M., et al. “CNA Training Requirements and Resident Care Outcomes in Nursing Homes.” The Gerontologist, no. 3, 2017, p. 501.

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Betty Chen is currently a freshman enrolled at the University of Central Florida, studying health sciences. After graduating, she plans to attend medical school and pursue a career in the medical field. A member of the Burnett Honors College, she wrote this research inquiry in her Honors English Composition II course taught by Dr. Mary Tripp. Betty chose to research on literacy in the nursing homes after taking the Nursing Education class offered in her high school where she became a certified nursing assistant. She looks forward to conducting more research and writing more papers throughout her college career.

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