Over at the Network54 Message Board, several weeks back a reader asked this:

Is there anyone familar (sic) with a “blended role” such as a C.N.A./activity Asst.? If indeed we are moving in the direction of “culture change”. I feel this could be a new job description in which to explore!

Well yes…several years ago I worked two jobs; the weekend job was at an assisted living facility that served people with dementia. The facility was divided into four neighborhoods, with 20 beds in each section. Two neighborhoods were for higher functioning relatively independent residents; another unit was for mid to late stage residents and the fourth neighborhood was for all late stage residents.

I worked in the fourth neighborhood. Most assisted living facilities don’t employ many CNA’s; they are not required to employ CNA’s and instead hire and train people to work as Resident Assistants. This is fine for less medically needy residents; the RA is more than qualified to assist people with few needs. For those with late stage dementia though, trained nursing staff should be expected.

When they hired me, I was told part of my responsibilities would include delivering activities for my assigned residents. At first I almost declined the position because I couldn’t see how it could all be done: Cares, supervision AND activities. I’d worked the nursing home beat and knew the drill: 10 to 15 people on my list, crazy expectations that were almost impossible to meet; dealing with families and overstressed charge nurses, and of course the always understanding management team…

The DON of this assisted living home must have been reading my mind: She reassured me the facility supports the blended role of CNA/Activity Assistant. To prove it, she took me on a tour to the neighborhood I would be working..and sure enough, the aides were quietly providing activities, in many different ways:

One aide had a group of four ladies sitting at a table in a small alcove like area, serving them coffee and cookies as she read from an old magazine (which wasn’t really OLD but a reproduction book);

Another aide had some men in the dining room painting little wooden plaques for some craft project they were working on;

In the main sitting room two aides had a lively group of residents doing exercises and ball tossing.

Way down in the end of this neighborhood another couple aides were doing some sensory stimulation activities with three obviously very frail, wheelchair bound residents: Scented lotion hand massages, neck massages, a CD player playing quiet Celtic tunes in the background; and to my surprise, a resident was in a recliner with a special massager pad under him- thoroughly enjoying himself.

Everyone appeared to be having a good time. The aides were not rushing and running around as I expected them to be; the residents were being tended to in very personal and productive ways. And it was ONLY 10AM.

HOW DO THEY DO THIS? I asked the DON:
The place had one Activity Director, and she was best suited working with the higher functioning residents, this left the lower functioning people with little to do. Management came up with the idea of a blended role for the aides working within the lower function unit: All the CNA’s would be responsible for resident activities as well.

The ratio for the CNA/Activity Assistant is 5:1 in this neighborhood for day shift; 7:1 for evening shift. When a resident is admitted, an aide is assigned to him or her, on a permanent basis. The facility follows the principals of consistent staffing/assignments. The aide is expected to partake in the admission process and a big part of this includes gathering information about hobbies, likes, dislikes- and plan activities for the resident. Aides from both shifts are included in this expectation.

The aides are given lots of Dementia Care Training, including the value and importance of activities…so much that activities are considered JUST AS IMPORTANT as nursing care. And at some times, MORE IMPORTANT.

The aides develop the Activity Calendar each month, based upon each resident’s likes and needs. Actually they do this two months in advance; preparation is KEY to a successful program. Many outings are planned, on both day and evening shifts- coordination is vital to make sure the trips happen. Activities are provided on both shifts as well, not just during the hours of 7 to 3…typical evening shift activities included personal care and pampering activities: Nail care with nail polish; foot soaks with a massage; Ladies Night that might introduce the women to the new face masks and latest hair care products…for the guys it often meant watching a war movie and then having a discussion after; another night it was going out to the local bowling alley…

The facility was brimming with activities…and much laughter, enlightenment and good cheer. The residents, even in their declining stages of dementia, seemed very content. There was little wandering; little exit seeking. Change of shift wasn’t at a set hour for all the aides; some came in at 6:15am and worked until 2:15pm; another couple worked 6:45am to 2:45pm- solely for the purpose of keeping this hour as distraction free as possible. They staggered the shifts and I have never seen another facility do this. This helps keep the residents from noticing an entire group of staff leaving (via hanging out at a nurses station) and the lapse of attention waiting for the next shift to arrive, get report and tend to them. There is no shift report per say- aide to aide reports are given and later if nurses need to share info, it is passed along.

This works great for assisted living facilities. I’m not sure how it work, though, for SNF- which have stringent regulation regarding activities and who can provide them. Some of these rules really go against the best interest of residents, when we think about it. Does it really matter who is tossing the ball- an activity professional or an aide? Do all games of bingo have to regulated by the government? With more and more nursing homes going through real and true culture change, these issues are being dealt with successfully. The OBRA regs are being tweaked to best suit the changes so needed in long term care. One way to do this total change is to have as few staff as possible delivering as much care and programing as possible. So, the CNA/Activity Assistant is a great role to consider.