There are few things more challenging than seeing a certified nurse assistant (CNA) not follow the individual feeding plan you've developed. Not only is it frustrating, there is growing evidence that CNA feeding practices may increase a resident's risk of aspiration pneumonia as well. So, what can we do to improve CNA compliance with our feeding plans? Two recent studies have provided insight on this issue.
Previous studies have suggested CNAs need better training and knowledge about dysphagia to improve their feeding skills. It has been assumed that once CNAs understood the rationale and consequences of a feeding plan, they would apply their new knowledge into their feeding practices. However, most practicing SLPs know from personal experience that providing this information to CNAs does not automatically result in positive feeding skills.
In an attempt to better understand why CNAs feed residents as they do, two qualitative studies were recently conducted with 20 CNAs in four nursing homes. The research was funded by the Cornell Gerontology Research Institute. In the first study (Pelletier, in press), CNA knowledge of dysphagia and how to feed residents was assessed using three methods: 1) non-participatory structured feeding observation; 2) critique of staged feeding behaviors on a five-minute (videotape) film, and; 3) a semi-structured personal interview. The results of this study were compared to the feeding information provided to CNAs in their certification class and textbooks.
CNAs demonstrated weak feeding practices in terms of technical skill, safety, and communication across all methods. Most surprising was the lack of accurate, adequate knowledge of and information about dysphagia in CNA certification course instruction and textbooks. Only 25% of the textbooks published the signs and symptoms of dysphagiaÑand none discussed how to feed residents with challenging behaviors.
Without this information in textbooks, CNAs reported a wide range of feeding strategies they learned from one another on the job. Results from this study suggest SLPs need to do a better job of communicating with our nursing colleagues. In addition, in-service training by SLPs might be better focused on learning what feeding problems CNAs perceive rather than teaching them the mechanics of a swallow. In this manner, we can validate their feeding problems, provide accurate and pertinent answers to their questions, and collaborate in problem-solving to develop the best solutions.
A second study (Pelletier, submitted) examined the feeding beliefs of these CNAs using Q methodology, a type of statistical method that applies quantitative analysis to qualitative data (Brown, Durning, and Seldon, 1999). CNAs confirmed that there appears to be two opposing CNA feeding belief systems. These belief systems were labeled by the CNAs as "social" feeders and "technical" feeders. "Social" feeders believe in meeting both the psychosocial and nutritional needs of residents equally and will not "push" someone to eat. "Technical" feeders, on the other hand, believe their main role is to ensure residents maintain adequate nutrition. Technical feeders may view social feeders as "slacking off" while social feeders view technical feeders as "force feeding" residents. Increased awareness of one's beliefs is important when trying to change one's behaviors, and thus, sharing this information with CNAs may increase awareness of their belief system and feeding behaviors.
So much of what a CNA does when feeding depends on feeding experience, knowledge, values, institutional factors, and resident characteristics. SLPs can help CNAs improve their feeding skills by engaging CNAs in a discussion of their feeding problems and brainstorm possible solutions, training CNAs how to improve their communication skills while feeding, understanding the belief systems that influence their feeding practices, and increasing our communication with our nursing colleagues.