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of Gerontological Nursing
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Nursing
Journal of Gerontological Nursing
October 2013 - Volume 39 ! Issue 10: 34-43
DOI: 10.3928/00989134-20130612-02
FEATURE ARTICLE
Effects of an Advanced Nursing Job Satisfaction,
Turnover Rate, Assistant Education Program on and
Clinical Outcomes
Megan Brown, MPH; Roberta E. Redfern, PhD; Katrina Bressler, RN, CDP; Tamara May
Swicegood, RN; Marianne Molnar, RN, BSN, MBA
Abstract
Certified nursing assistants (CNAs) have become an integral part of the health care
system, spend the most amount of time with residents, and yet have the least amount of
training. Recent reports demonstrate that CNAs believe their salary is not commensurate
with their workload, and turnover rates in this field have indicated low job satisfaction. In
light of these issues, we developed an advanced training program for CNAs in our
institution to determine whether investing in our employees would increase job
satisfaction and therefore impact turnover rates and clinical outcomes. Although overall
job satisfaction improved slightly during the study period, satisfaction with training offered
was the only area significantly affected by the intervention; however, significant
decreases in turnover rates were observed between the pre- and postintervention
periods. Clinical indicators were slightly improved, and the number of resident urinary
tract infections decreased significantly. Offering an advanced training program for CNAs
may be an effective way to improve morale, turnover rates, and clinical outcomes.
[Journal of Gerontological Nursing, 39(10), 3443.]
Ms. Brown is Statistical Specialist and Dr. Redfern is Medical Science Writer, The Toledo
Hospital, Sponsored Research, Toledo; Ms. Bressler is Director of Nursing, ProMedica
Health System, The Goerlich Center; Ms. Swicegood is RN Case Manager, ProMedica
Caring Home Health Services; and Ms. Molnar is Director of Nursing, ProMedica Health
System, Sylvania, Ohio.
The authors have disclosed no potential conflicts of interest, financial or otherwise. The
authors thank all of the staff who assisted in implementing the training course and data
collection process.
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Address correspondence to Marianne Molnar, RN, BSN, MBA, Director of Nursing,
ProMedica Health System, Lake Park, 5100 Harroun Road, Sylvania, OH 43560; e-mail:
Marianne.molnar@promedica.org.
Received: September 17, 2012
Accepted: February 08, 2013
Posted Online: June 21, 2013
Certified nursing assistants (CNAs) have becomedue in part to economic strainsthe
employees in nursing homes who provide the greatest portion of care to residents, yet
they receive the least amount of education and training (Pennington, Scott, & Magilvy,
2003; Radcliffe, 1995; Russo & Lancaster, 1995). Mandatory CNA requirements have not
changed since being established more than 20 years ago and do not reflect the needs of
todays older and frailer residents (Sengupta, Harris-Kojetin, & Ejaz, 2010). CNAs in most
states must complete less than 2 weeks of training and then manage the daily lives of
medically complex, frail older adults, often with little guidance or support. Due to this shift
in caregiver roles and responsibilities, advanced educational programs have begun to be
developed and evaluated (Gursky & Ryser, 2007; Hancock & Campbell, 2006; Lerner,
Resnick, Galik, & Russ, 2010; Spencer, 2001), focusing on the educational process and
measuring the retention of knowledge and increases in competencies (Barczak & Spunt,
1999; Field & Smith, 2003). Although few studies have reported the effect of an
advanced educational program on clinical outcomes within their facilities, initial reports
are promising (Bonner, Castle, Men, & Handler, 2009; Bonner, MacCulloch, Gardner, &
Chase, 2007; Howe, 2008) and indicate that CNAs are enthusiastic about receiving more
training (Barczak & Spunt, 1999; Sengupta et al., 2010). Additionally, studies report that
CNAs express the desire for further education on a number of topics after completion of
an advanced educational program (Barczak & Spunt, 1999).
In comparison, relatively little research has been performed to assess the level of job
satisfaction of these CNAs. The high turnover rate of CNAs in nursing homes is
unsettling, especially considering that a recurrent theme in some interview research is
promising: I love what I do (Pennington et al., 2003). Various sources have cited annual
turnover rates of 45% to 400% and an estimated $4.1 billion in related costs (Harris-
Kojetin, Lipson, Fielding, Kiefer, & Stone, 2004; Pennington et al., 2003). Turnover of
CNAs is costly due to training of new personnel, but also disrupts the continuity and
quality of care (Harris-Kojetin et al., 2004). Reported job satisfaction has been linked to
this surprisingly high turnover rate and may be more dependent on the employees
environment and the facility than the work to be done (Arnetz & Hasson, 2007; Lapane &
Hughes, 2007; Pennington et al., 2003). Moreover, undesirable job behaviors and quality
of care have been found to be directly associated with job satisfaction (Arnetz & Hasson,
2007; Eaton, 2000; Irvine & Evans, 1995), making this an important area of focus for
administration.
Previous reports have suggested that CNAs enjoy the content of their work, but rate their
satisfaction with the rate of pay as poor (Castle, 2007). Additionally, because CNAs have
reported that their opportunity for advancement is low, the use of non-monetary rewards
has been suggested to improve this aspect of CNAs jobs. The creation of job ladders
and use of nurse mentors to foster communication have been advocated to improve job
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satisfaction (Castle, 2007). It is also believed that investing in employees by offering
further education for CNAs may help improve job satisfaction and reduce turnover rates.
Such an educational program may provide a venue for communication to occur between
CNAs and administration, while improving CNAs knowledge and skills, which may be of
use in future efforts for job advancement.
Method
Institutional Review Board approval was obtained for this longitudinal cohort study, which
utilized pre- and postintervention surveys to assess the effects of an advanced training
program on CNAs job satisfaction. The study setting is a 203-bed facility located in
Sylvania, Ohio serving the long-term and post-acute skilled care needs of adults with an
average daily census of 197 patients. With five floors, care is provided for residents of
various acuity levels, including those who need specialty care services (e.g., hospice,
dementia care). The ground floor provides extensive rehabilitation services. Staffing
includes approximately 30 RNs, 55 licensed practical nurses (LPNs), and 150 CNAs, and
has been dedicated to serving the health care needs of the community for approximately
50 years.
Administration and staff development instructors designed an educational program for
the CNAs within our facility, based on Wolgins (2004) book, Being a Nursing Assistant.
The 3-day program was designed to provide advanced training to CNAs in a range of
topics, including basic content on anatomy and physiology, infection control, and aseptic
technique principles to enhance performance and compliance with competency and
quality standards. The course also aimed to discuss the CNAs role in the health care
environment, how each CNA may contribute to efficient team function, and foster
communication skills with other health care professionals. Staff were compensated for
attending the 3-day course, which included 2 classroom days in which teaching was
accomplished via interactive lectures, visual aids, and multimedia presentations.
Students attended five individual skills laboratories on Day 3 and were required to
demonstrate competency in each. CNAs completed a clinical competence assessment
pre-test prior to participation in the course; all employees took this examination again
upon completion and were required to achieve 80% to pass the course. This educational
program was designed and implemented as a mandatory requirement for all CNAs.
Those already employed at our facility were required to attend the course and all newly
hired CNAs were also required to complete the course, such that every CNA employed
by our facility has completed this advanced training. Training all employees took
approximately 16 weeks; the course continues to be a mandatory requirement of all
newly hired CNAs. CNA staff who demonstrated clinical and academic excellence during
the course received additional training to serve as mentors. The mentor program was
implemented to provide ongoing monitoring and preceptorship of the CNA staff.
The first class was offered in March 2011, at which point the Nursing Home Nurse Aide
Job Satisfaction Questionnaire (NHNA-JSQ, Castle, 2007) and Reciprocal Empowerment
Scale (RES, Klakovich, 1995), validated instruments developed specifically to measure
job satisfaction in CNAs, were distributed to all employees attending the course.
Employees were informed that a research study was being conducted, but were not told
that researchers planned to measure the effects of the advanced training course on their
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reported levels of job satisfaction or any clinical indicators. Confidential envelopes were
provided to CNAs to collect surveys and return them to researchers anonymously. The
NHNA-JSQ was also distributed to all CNAs 6 months following the initial administration
of the instrument.
For this project, we retrospectively collected clinical data, which are continuously
maintained and reviewed by the facilitys leadership for quality purposes; this approach
was used for both the pre- and pos-tintervention periods. We compared the number of
patient falls, patient urinary tract infections (UTIs), patient decubitus ulcers, and
employee injuries for 6 months prior to the training program and for 6 months following
the last class to determine whether advanced training had an impact on clinical
outcomes. Additionally, employee turnover rates were recorded and compared to
determine the effect of this course on employee separation. We recorded the number of
CNA separations in the 6 months immediately prior to the course (September 2010
through February 2011, Period 1), as well as the year following the intervention (July
2011 until June 2012, Periods 2 and 3) to determine whether the course could have an
effect on turnover rates and how quickly that effect might be appreciated.
Statistical Analysis
Descriptive statistics were generated for demographic data. CNAs were asked to
complete the NHNA-JSQ and RES prior to participation in the educational/training
program and then again following the course. The individual scores, as well as domain
scores for each survey, were compared only for those individuals who completed both
surveys (N = 47) using t tests and Pearson correlation tests. Surveys of participants who
completed only the pre- or postintervention questionnaires were excluded for these
comparisons. Clinical outcome rates including those for acquired UTIs, skin
tears/bruises, pressure ulcers, and patient falls were compared using t tests. Employee
injury rates were also compared using t tests, whereas pair-wise comparisons of turnover
rates between pre- and postintervention periods were made using analysis of variance
(ANOVA) tests.
Results
Survey Results
During the study, 210 employees were eligible to participate; 132 CNAs completed the
preintervention survey. Of these, only 83 completed and returned the postintervention
survey; however, 36 were excluded due to incompleteness, such that 47 complete
surveys could be used for analysis. The overall response rate was 22.4%. CNAs at our
institution were primarily women (89.4%) (Table 1) and were mostly African American
(42.6%) or Caucasian (40.4%). Our sample was well distributed with respect to age
(Table 1); most had some college education, and the average amount of time employed
as a CNA was 10.7 years.
Table 1:
Study Population Demographics
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Responses to the NHNA-JSQ were scored to report overall mean scores, mean scores
for each subscale, and mean scores for each response item for both the pre- and
postintervention surveys (Table 2). Each question is scored on a scale of 1 to 10, with
higher scores indicating a higher level of satisfaction. The results indicate that the CNAs
were least satisfied with the rewards associated with their position. The mean subscale
score for rewards was 6.37, whereas the mean score for rate how fairly you are paid
was 5.28 (SD = 2.68). No significant difference was noted in this subscale or either of its
items between the pre- and postintervention surveys (Table 2, p = 0.62).
Table 2:
NHNA-JSQ Responses
CNAs rated the quality of care the highest of all subscales, with a mean preintervention
score of 9.35. Neither this subscale nor its items scores changed significantly with the
intervention (p = 0.89) (Table 2). Furthermore, CNAs scored their work content highly;
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this subscale was comprised of items such as Rate how much you enjoy working with
residents and Rate your closeness to residents and families. The mean score for this
subscale was 8.99 preintervention and did not change significantly after the educational
course (p = 0.83) (Table 2). Other subscales of the instrument, such as work demands,
workload, and coworkers, did not change significantly between the pre- and
postintervention administration of the survey (Table 2). However, the training subscale
changed significantly with the intervention (p = 0.003), as did two of the items within the
subscale: Rate whether your skills are adequate for the job (p = 0.05) and Rate the
training you have had to perform your job (p = 0.001) (Table 2). CNAs global rating of
their satisfaction with their job increased slightly between the pre- and postintervention
surveys, but was not significant (p = 0.80) (Table 2). Furthermore, the average score of
the entire survey increased slightly after the intervention, but was not significant.
Responses to the RES indicated slight increases in mean scores for all items (The RES
is scored on a scale of 1 to 5. All reported scores are means of the entire group.);
however, only the responses to My leader communicates clear, consistent expectations
were significantly different from initial responses following the intervention (p = 0.01)
(Table 3).
Table 3:
Reciprocal Empowerment Scale
Pre- and postintervention NHNA-JSQ and RES scores were compared among the CNAs
who responded to both surveys to determine whether age or number of years working as
a CNA affected satisfaction with any aspect of their job. CNAs who identified themselves
as being 41 or older reported significantly higher satisfaction than CNAs between ages
18 and 40 in four of the eight subscales of the pre-intervention NHNA-JSQ (Table 4);
older CNAs mean scores were significantly higher on 7 of the 22 items of the
questionnaire. Furthermore, older CNAs reported significantly higher global ratings of
their job satisfaction when compared to those in the 18-to-40 age group (Table 4). When
comparing the mean scores of the RES, older CNAs also tended to be significantly more
satisfied with their supervisor and indicated a greater level of pride from the work they
perform. Additionally, Pearson correlation tests of each item and subscale indicate that
the majority of the mean scores were positively correlated with age and number of years
working as a CNA, further suggesting that older CNAs are more satisfied with their jobs
(data not shown). The only subscales in which no differences were detected with respect
to age were the training, workload, and rewards subscales.
Table 4:
NHNA-JSQ Survey Results by CNA Age
The postintervention scores of CNAs were also compared as a function of age; although
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the mean reported scores of the RES remained significantly different after the course, the
only significant difference in NHNA-JSQ scores that remained was in the work demand
subscale (Table 4).
Additionally, we compared the pre- and postintervention responses of each age group
separately; the only significant difference detected after completing the course in the
older group of CNAs was with regard to training. Alternately, the mean scores of the
CNAs who identified themselves as being age 18 to 40 improved in several areas,
including training, coworkers, and work demands. Younger CNAs agreed significantly
more that their leader communicates clear, concise expectations and uses their
recommendations after participating in the advanced training program after the
intervention (data not shown). Additionally, this group of CNAs reported an improved
global rating of their satisfaction; however, this improvement did not reach significance.
Overall, our results indicate that the younger CNAs job satisfaction was more strongly
affected by the advanced training program than was the satisfaction reported by CNAs
who were 41 and older. The satisfaction of older CNAs in our facility improved after the
training; however, this group reported a higher baseline satisfaction prior to the
intervention and continued to report higher levels of satisfaction than their younger
counterparts after the training. The intervention bridged many of the existing gaps
between the two groups and significantly improved CNAs rating of the training they
received to perform their jobs.
Turnover Rates
We observed the turnover rate of our CNAs in the 6-month period leading up to the
intervention to establish a baseline turnover rate. In the 6 months prior to the intervention,
the mean monthly turnover rate was 9.03% (SD = 1.38). Our educational program began
in March 2011, such that all existing employees would complete the course in June 2011.
We observed two consecutive time periods following the intervention to allow us to
compare and determine the programs effect on turnover rates. The first time period we
observed was the 6 months immediately following the intervention, in which the turnover
rate increased slightly, but not significantly, to 9.19% (SD = 4.18) (p = 0.99) (Table 5).
However, we continued to examine mean monthly turnover rates through May 2012,
allowing approximately 1 year to have elapsed since the last employee completed the
course. During the final time period, the mean monthly turnover rate decreased to 3.94%
(SD = 2.32), a significant decrease when compared to the preintervention period and 6-
month period immediately following the intervention (p = 0.03 for both time periods). The
overall change in turnover rate was also significant (p = 0.017) (Table 5).
Table 5:
ANOVA with Pair-Wise Comparisons
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Clinical Outcomes
Clinical indicators of quality of care provided by our CNAs were chosen prior to initiation
of the research project, and CNAs were not made aware that these outcomes would be
tracked over time for research purposes. The number of patient acquired UTIs, skin tears
or bruises, falls, and acquired pressure ulcers were recorded during the 6-month periods
before and after the intervention. The average census for these periods was used to
estimate the proportions of residents affected, as the number of residents in the facility is
a dynamic variable. Chi-square analyses revealed that although the number of acquired
pressure ulcers and skin tears or bruises decreased after the intervention, neither was
significant (p = 0.62 and p = 0.33, respectively) (Table 6). However, the number of UTIs
occurring during the postintervention period was significantly lower than the rate of
acquired UTIs during the preintervention period (p < 0.001) (Table 6).
Table 6:
Chi-Square Analyses of the Effect of Advanced Nursing Assistant Training on
Relevant Clinical Outcomes
Discussion
CNA turnover rates continue to be a challenge for nursing home administration. The cost
effects of hiring and training new personnel are measurable, but more importantly, the
result is a disruption of continuity of care and subsequent decreased quality of care.
Moreover, as the aging population of our country continues to increase, the need for
caregivers in nursing homes will also continue to rise. The turnover rate of CNAs
becomes particularly troubling when one realizes that many CNAs who are leaving their
positions in nursing homes are leaving the health care work force entirely. Clearly,
without an improvement, there will soon be too few CNAs to care for nursing home
residents.
Our results echo those reported in previous studies; CNAs surveyed at our institution
indicated that their level of satisfaction with rewards for their efforts is lower than their
satisfaction with all other aspects of the job (Castle, 2007). Additionally, the highest level
of satisfaction reported by CNAs in our institution was in the quality of care they provide
to residents and the content of their work, a recurring theme in the literature. Of interest,
the results of our survey indicate that CNAs are well satisfied with nearly every domain.
Even the lowest scoring domain, rewards, received a neutral rating from employees.
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Moreover, the scores for the other domains are higher than those reported previously in
the literature. Although this might indicate a higher level of satisfaction among CNAs in
our institution, it could also be a result of our small sample, due to low response rates.
Previous reports have included national surveys of large numbers of CNAs, who reported
much lower satisfaction globally and across all domains. Other studies including small
populations also reflected higher scores in job satisfaction (Lapane & Hughes, 2007;
Moyle, Skinner, Rowe, & Gork, 2003; Lerner, Resnick, Galik, & Flynn, 2011; Thompson,
Horne, & Huerta, 2011). Therefore, the level of satisfaction that our CNAs reported may
not reflect all CNAs job satisfaction.
Although our response rate was low, preventing generalization to all CNAs, it is important
to note that the scores of most subscales of the NHNA-JSQ either stayed nearly the
same or improved somewhat. The greatest improvement observed was in the training
subscale, in which the increase in mean score reached significance. This increase in
reported satisfaction with training indicates that our program was successful in helping
our CNAs to be more prepared and confident in their abilities to perform their job.
Additionally, the improvement in the mean scores in the RES indicate that the course
was an effective forum in which administration could communicate with CNAs, as their
rating of their leaders communication of expectations improved significantly. Whereas
other items rated did not reach significance, nearly all improved to some extent. Of
particular interest is the fact that older CNAs reported higher baseline job satisfaction
than their younger counterparts. However, many of the deficits appreciated prior to the
intervention were affected by the training, such that the global ratings of satisfaction were
no longer significant between age groups following the intervention. This suggests that
advanced training may be more effective in improving the job satisfaction of younger,
less experienced CNAs, while still beneficial to the group as a whole.
Moreover, the job turnover rate of CNAs in our facility improved significantly after the
educational intervention. We examined the 6-month period prior to the intervention to
establish a baseline turnover rate and began monitoring job turnover immediately
following the conclusion of the intervention to determine the amount of time necessary to
observe the interventions effect, if any. We did not observe an immediate effect of the
intervention on job turnover rate, as turnover rates peaked in the 3 months following the
completion of the course by all employees. However, rates began to fall 3 months
following the intervention and remained low at the time of writing. Additionally, it should
be noted that implementation of the advanced training course was mandatory for CNAs
facility-wide, such that every CNA was exposed to the intervention, regardless of whether
they decided to participate in the survey portion of the research project. Although it is not
possible to assert that the intervention and creation of a mentorship program are the
direct causes of the improved turnover rates, administration carefully controlled other
factors that might impact job satisfaction and turnover rates, such as incentives and
rewards commonly offered in our facilities (e.g., pizza parties) to better measure only the
effects of the educational program. Our results suggest that offering advanced training
and a CNA mentorship program positively affected job turnover rates.
Perhaps the most important result of this study is the impact of education on select
clinical outcomes. The number of skin tears or bruises decreased slightly in the 6-month
period following the intervention, as did the number of patient falls. The number of
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acquired UTIs decreased significantly when comparing the 6-month periods before and
after the intervention, falling to less than half the rate of infection prior to the educational
course. This result suggests that the information provided regarding prevention of UTIs
was indeed successful. However, the rate of pressure ulcers increased slightly during the
study period. Although unexpected, this result allows administration to reexamine the
content of the material presented to the CNAs so that it may be adjusted to better
address this issue.
Several limitations of this study exist, most importantly, the low response rate. The
overall satisfaction scores as well as the subscale scores reported by the CNAs were all
high. When compared with national studies, which report much lower job satisfaction
rated by CNAs, it becomes a possibility that our study may suffer from bias due to
nonresponse. It is possible that only those CNAs who were satisfied with their position
overall were those who actually responded to the survey. Another limitation of our study
is the amount of time that passed between the administration of the educational course
and the time period in which clinical outcomes were observed. Although the course has
been ongoing since its introduction, only 2 months passed between the last existing
employee completing the course and the beginning of our clinical outcomes observation
period. It is possible that after longer observation periods, the effects of the
implementation of such an educational requirement may become more apparent in the
areas of job satisfaction, job turnover, and clinical outcomes.
Nursing Implications
The implications of our findings affect nurses, particularly those in administrative and staff
development roles. We have shown that development and implementation of a
homegrown training program for CNAs can improve their job satisfaction and affect
turnover rates of this staff. Furthermore, with advanced training, CNAs can positively
affect select clinical outcomes. Importantly, our research highlights the differences in
employee satisfaction as a function of age. We suggest that other institutions could
introduce a similar program to address specific clinical indicators while also improving
employee satisfaction and turnover rates. Finally, in-house development of a program of
this type allows for assessment of the effect on choice indicators, allowing administrators
and educators to target areas of weakness and adjust the program to suit their individual
needs.
Conclusion
Job satisfaction of CNAs may be linked to a number of variables of interest to health care
administrators, including quality of care and clinical outcomes. Satisfied employees are
less likely to leave an institution, thus investing in employees job satisfaction may help
retain existing employees and attract new ones, lowering costs and improving the
continuity and quality of care. Our results indicate that our CNAs are fairly satisfied with
their positions, but are least satisfied with the pay they receive. Furthermore,
respondents indicated a lower level of satisfaction with the amount of time they have to
perform their jobs, cooperation between coworkers, the amount of support they receive to
perform their jobs, and their chances to talk about concerns, suggesting other areas of
focus for leadership to improve employees job satisfaction. By offering a 3-day
educational course, we improved our CNAs satisfaction with the amount of training they
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received and improved their confidence in their ability to care for residents. Responses to
the RES suggest that the course also served as a forum for communication between
leadership and CNAs. Furthermore, observed turnover rates decreased significantly after
the implementation of the educational course and the creation of a mentorship program
for CNAs. It is our belief that although CNAs are generally not satisfied with their
compensation, increased job satisfaction can be achieved by nonmonetary means.
Improved training and satisfaction may lead to employee retention and improved clinical
outcomes.
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KEYPOINTS
Brown, M., Redfern, R.E., Bressler, K., Swicegood, T.M. & Molnar, M. (2013). Effects of
an Advanced Nursing Assistant Education Program on Job Satisfaction, Turnover Rate,
and Clinical Outcomes. Journal of Gerontological Nursing, 39(10), 3443.
Certified nursing assistants (CNAs) report a high degree of satisfaction with the work
they perform; however, those who were older or working as a CNA longer reported
significantly higher satisfaction.
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10.3928/00989134-20130612-02
A homegrown advanced training program significantly improved CNA-reported job
satisfaction and select clinical outcomes, as well as turnover rates.
The advanced training program had the greatest effect on the satisfaction scores of
the CNAs who were younger and reported fewer years of working as a CNA.
CNAs reported lowest overall satisfaction with their rate of pay; however, satisfaction
can be improved by nonmonetary means (e.g., advanced training and mentorship
programs).