State Tested Nursing Aides’Provision of End-of-LifeCare in.docx

State Tested Nursing Aides’
Provision of End-of-Life
Care in Nursing Homes
Implications for Quality Improvement
Emma Nochomovitz, MPH
Maryjo Prince-Paul, PhD, APRN, AHPCN, FPCN
Mary Dolansky, PhD, RN
Mendel E. Singer, PhD
Peter DeGolia, MD, CMD
Scott H. Frank, MD, MS
v An increasing prevalence in deaths occurring
within nursing homes has led to a growing
concern surrounding quality issues in end-of-life
(EOL) nursing home care. In addition, prior
research has failed to emphasize the importance
of state tested nursing aides (STNAs) in
providing this type of care. The purpose of this
study was to examine quality issues in EOL
nursing home care within the context of STNAs’
comfort in providing this care. A convenience
sample of 108 STNAs from four nursing homes
in the Cleveland, Ohio area used PDAs to
provide answers to an audio questionnaire.
Questions included emergent themes from the
literature pertaining to EOL care in nursing
homes, as well as materials from a national
education initiative to improve palliative care.
Findings demonstrated lack of comfort in
discussing death with nursing home residents

and their families and insufficient knowledge
surrounding EOL decisions and certain types
of EOL care. Overall, the level of comfort
providing EOL care was found to be associated
with STNAs’ perceived importance of EOL
care, understanding of hospice, and spiritual
well-being.
JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol.
12, No. 4, July/August 2010 255
Author Affiliations: Emma Nochomovitz, MPH, is
Research Analyst, National Quality Forum,
Washington, DC and Case Western Reserve
University, Cleveland, OH.
Maryjo Prince-Paul, PhD, APRN, AHPCN, FPCN,
is Assistant Professor, Frances Payne Bolton School of
Nursing, Case Western Reserve University, Cleveland, OH.
Mary Dolansky, PhD, RN, is Assistant Professor,
Frances Payne Bolton School of Nursing, Case
Western Reserve University, Cleveland, OH.
Mendel E. Singer, PhD, is Associate Professor,
Department of Epidemiology and Biostatistics, Case
Western Reserve University, Cleveland, OH.
Peter DeGolia, MD, CMD, is Director, Center for
Geriatric Medicine, University Hospitals Case
Medical Center and Associate Professor, Family
Medicine, Case Western Reserve University School of
Medicine, Cleveland, OH.
Scott H. Frank, MD, MS, is Director, Master of
Public Health Program, Department of Epidemiology

and Biostatistics, Department of Family Medicine,
Case Western Reserve University, Cleveland, OH.
Address correspondence to Emma Nochomovitz,
MPH, National Quality Forum, 601 13th St
NW, Suite 500 North Washington, DC 20005
([email protected]).
K E Y W O R D S
end-of-life care
hospice
nursing aides
nursing home
I
n recent years, the growth of the older segment of
the population and the prevalence of chronic illness
have led to increased institutionalization of the frail
and elderly prior to their deaths. In particular, nursing
homes have been identified as a place in which end-of-
life (EOL) care is occurring with increasing prevalence,
as 20% to 25% of deaths now occur in the nursing
home setting.1
Given the increasing significance of EOL care within
the nursing home setting, nursing homes are under
increased scrutiny to provide quality care. This has led
to the creation of nursing home specific measures of
quality and outcomes. As a result, a growing body of

literature highlights several concerns surrounding qual-
ity issues in EOL nursing home care. The purpose of
this study was to examine quality issues in EOL care as
they relate to the role of state tested nursing aides
(STNAs), with a particular focus on the degree to
which STNAs feel comfortable providing EOL care.
v BACKGROUND
Despite the significance of EOL care in nursing homes
in the context of the growing elderly population likely
to utilize EOL health services, there is evidence to sug-
gest that it is not a topic that is widely understood or
addressed by nursing home staff. According to Hanson
et al,2 a focus group approach may have important
implications for understanding the beliefs and practices
among nursing home staff caring for dying residents.
The study by Hanson and colleagues2 was conducted
in two nursing home facilities. Participants included all
nursing aides, nurses, or physicians working in either of
these facilities, who were willing to volunteer their time
to participate in 90-minute focus group sessions that
focused on the care of dying nursing home residents.2
Focus group participants’ resulting recommendations for
improved quality care at the end of life included four
main categories, including changes in delivery of care,
improved staff education and skills, addition of new ser-
vices, and improved support of staff.2 These findings
suggest that open discussion about death and dying can
improve the quality of care at the end of life and offer
several specific contributions to future efforts to im-
prove quality of care in EOL nursing home care.
Ersek et al3 echo the findings of Hanson and

colleagues2 in their analysis of focus group interviews
among licensed nursing staff and certified nursing aides
(CNAs) at two nursing homes in the Pacific Northwest.
This study addressed participants’ concerns and educa-
tional needs surrounding nursing home care at the end
of life. Interviews were administered by three different
investigators to a group of 15 licensed staff and 39
CNAs.3 Participants revealed major concerns surround-
ing symptom management, communication and inter-
action with patients, uncertainty and stress related to
their role as a provider, discrepancies between different
involved parties’ goals of care, time constraints, attach-
ment to residents, and self-care needs as the most
significant challenges to providing care to dying nursing
home residents. Similarly, focus group participants
from Wilson and Daley’s4 study of 155 members of
nursing home staff and administrators and their per-
spectives on dying in long-term-care facilities also
highlight improvement goals related to the individual
role of providers (ie, communication), internal aspects
of the nursing home environment (ie, private space),
and factors external to the nursing home, such as reg-
ulatory requirements and reimbursement.4
A recurrent theme throughout the literature on EOL
care in nursing homes identifies nursing assistant job
stress as an inevitable characteristic of EOL care. Both
Hanson et al2 and Wilson and Daley4 utilized focus
groups to assess quality of care within nursing homes at
the end of life, while simultaneously unveiling some of
the emotional burdens placed on those caring for
nursing home residents near the end of life. Hanson
et al discovered that there were several factors unique to
the type of care they provide that increased their ex-
perience of stress at work. For instance, lack of com-
munication and coordination with hospitals, pressure to

minimize staffing while maximizing profit, and the fact
that they are caring for an increasingly frail and impov-
erished population were identified as particular barriers
to providing the ideal setting for dying residents.2
Included in the body of knowledge pertaining to
EOL nursing home care is the potential for research
surrounding the use of hospice services to improve
quality of care and reduce healthcare expenditures. Ac-
cording to the National Quality Forum, hospice care is
defined as ‘‘a service delivery system that provides
256 JOURNAL OF HOSPICE AND PALLIATIVE NURSING v
Vol. 12, No. 4, July/August 2010
palliative care for patients who have a limited life
expectancy and require comprehensive biomedical, psy-
chosocial, and spiritual support as they enter the ter-
minal stage of an illness or condition.’’5 Miller et al
6
reported on hospice care within nursing homes in five
different states. The study compared the experience of
hospice and nonhospice nursing home patients based on
Minimum Data Set data, drug prescriptions, and Medicare
claims.6 The authors cite several advantages experienced
by hospice versus nonhospice nursing home residents.
For instance, hospice patients were found to be signifi-
cantly less likely to be hospitalized in the last 30 or 90
days of life, as well as within the last 6 months of life.6
Miller et al6 also conclude that more frequent pain
detection among hospice patients was an indication of

more thorough pain assessment among hospice patients
compared with their nonhospice counterparts. Miller
et al7 found further support for the benefits of hospice in
their comparison of analgesic pain management among
hospice and nonhospice nursing home patients. In this
retrospective cohort study of more than 800 nursing
homes in five different states, hospice residents were
found to be twice as likely as nonhospice residents to
receive regular treatment for daily pain.7
Findings surrounding the potential benefits of hos-
pice utilization highlight the need to integrate EOL
principles, such as those promoted in hospice, into the
nursing home setting. Given the degree to which STNAs
interact at a personal level with nursing home residents
and their families, it follows that awareness among
STNAs surrounding the principles of hospice and the
mechanisms by which hospice may be accessed have the
potential to benefit patients’ experience of nursing home
care.
v PROBLEM AND PURPOSE OF STUDY
Research demonstrates that there is a need for increased
attention to STNAs, as they play an integral role in EOL
care in a nursing home setting and provide up to 90% of
direct care to nursing home residents.8,9 Current re-
search fails to provide quantitative data on the needs of
STNAs responsible for EOL care, as well as their per-
ceptions surrounding quality issues in EOL nursing home
care. Thus, the purpose of this study was to describe the
experience of STNAs in providing EOL nursing home
care through a survey-based quantitative study. More
specifically, this study addresses a gap in the relevant
literature on EOL nursing home care focused on STNAs’

perceived level of comfort with providing EOL care. The
primary aim of this study was to examine the degree to
which STNAs perceive themselves to possess the neces-
sary training, skills, and knowledge to feel comfortable
providing quality care at the end of life. A secondary aim
was to examine STNAs’ comfort with the provision of
EOL care in nursing homes as it relates to job satis-
faction, spiritual well-being, and the degree to which
STNAs feel supported by their working environment.
v METHODS
The present study included a convenience sample of
STNAs from four nursing homes in Cleveland, Ohio.
The STNAs who worked for a hospice were excluded
from participation. Institutional review board approval
was obtained from Case Western Reserve University. A
sample of 380 STNAs from four nursing homes was
approached to participate. Following informed consent
and face-to-face enrollment, 108 participants (28%) com-
pleted the investigator-developed questionnaire consisting
of 62 questions.
Data were collected pertaining to demographic in-
formation, personal characteristics, and several varia-
bles pertaining to STNAs’ overall experience with and
perceived understanding of EOL care. Demographic in-
formation included age, education, and work-related
information, including how many years STNAs had been
working with older adults in a nursing home and the
number of classes they had taken related specifically to
EOL care. The collection of more detailed demographic
information was limited in an effort to preserve the
anonymity of survey respondents. Information pertain-
ing to personal characteristics was collected surrounding
individuals’ job satisfaction, spiritual well-being, and

the degree to which STNAs felt they were supported by
their coworkers. Job satisfaction was measured using a
4-component scale created by the author, after review of
existing job satisfaction literature. The internal reliability
for this instrument was adequate (Cronbach’s ! = .84).
Spiritual well-being was evaluated with the Brief
Assessment of Spiritual Insight and Commitment ques-
tionnaire.10 This instrument included 14 items measur-
ing the domains of faith, community, control, meaning,
peace, and love and has demonstrated a high degree of
internal reliability (Cronbach’s ! = .83) when utilized to
evaluate spirituality and religiosity within the primary
care setting.10 Support from coworkers was measured
by a single question asking STNAs whether they felt
❖ ❖ ❖ ❖ ❖
12, No. 4, July/August 2010 257
they worked in an atmosphere where they were sup-
ported by their coworkers.
The STNAs’ experience with EOL care was mea-
sured primarily by an investigator-developed instrument,
which included several components of EOL care, as iden-
tified by the geriatric End-of-Life Nursing Education
Consortium (ELNEC) curriculum.9 The geriatric ELNEC
curriculum is focused on long-term-care settings with
detailed sections pertaining to the role of STNAs in EOL
care.9 In conjunction with material from the ELNEC cur-
riculum, the investigator conducted a review of scientific
literature pertaining to EOL nursing home care from

the perspective of STNAs and other nursing home pro-
viders. As a result, the investigator developed the ‘‘Com-
fort Scale’’ in which STNAs were asked to respond to
whether they felt comfortable with their role in pro-
viding 12 specific types of care. The STNAs’ perspectives
on the importance of EOL care were measured accord-
ing to how important they felt each of the 12 compo-
nents of the Comfort Scale was in their provision of care.
Reliability for these investigator-developed scales ranged
from 0.88 to 0.89. The STNAs’ experience with EOL care
was also measured using a dichotomous variable that
assessed STNAs’ perceived understanding of hospice and
palliative care as different models of EOL care delivery.
Statistical Analyses
SPSS, version 15.0 (SPSS Inc, Chicago, IL), was used to
analyze the data. Descriptive statistics were analyzed
as either dichotomous variables or as part of individual
scales. In addition to the descriptive statistics, potential
associations with the outcome variable, comfort pro-
viding EOL care, were explored. It was hypothesized
that the following study variables might be associated:
perceived importance of EOL care skills, understanding
of hospice, understanding of palliative care, job satisfac-
tion, spiritual well-being, and support from coworkers.
These associations were tested using a multivariable
linear regression model. The model was adjusted for age,
education, experience with older adults, EOL education,
and EOL care experience as potential confounders. A
significant statistical test was considered if P G .05.
Participants and Data Collection Process
Audio technology was used to create a spoken version
of the questionnaire that could be administered using a

PDA. The process of transforming the original question-
naire into a version that was accessible to PDAs involved
pairing the audio recording of each question from the
investigator-developed questionnaire with its appropri-
ate answer using SEDCA software (Don’t Pa..Panic
Software, Lyndhurst, OH). PDAs served to overcome
several limitations of paper-based questionnaires, such
as reliance on respondents’ reading comprehension and
understanding of the English language.11 In addition,
PDAs have been demonstrated to increase respondents’
perception of privacy in their answers, which was use-
ful in addressing potentially sensitive information re-
garding STNAs’ perceptions of EOL care.11,12
T a b l e 1
Demographic and Job Characteristics
Variable Percentage n
Age, y
18-25 21.6 22
26-35 24.5 25
36-45 24.5 25
46-55 20.6 21
56+ 8.8 9
Education
Less than high school 2.8 3
Graduated high school or GED 43.9 47
Some college or technical school 46.7 50
Graduated college 6.5 7
Years working with older adults in
nursing home
G1 10.2 11

1-3 20.4 22
4-7 24.1 26
8-11 11.1 12
12+ 34.3 37
Times worked with dying residents
within last 3 y
0 9.3 10
1-4 31.5 34
5-8 19.4 21
9+ 39.8 43
EOL care continuing education
classes within last 3 y
0 16.8 18
1 13.1 14
2 15.0 16
3 15.9 17
4+ 39.3 42
Abbreviations: EOL, end-of-life; GED, general equivalency
diploma.
v RESULTS
Demographics
Demographic information is reported in Table 1. The
sample’s age range was 18 to 25 years, and 46% of
respondents reported some college or technical school
training. More than one-third of the sample (34.3%)

has at least 12 years of job experience in nursing
homes; 39.8% of STNAs expressed having cared for a
dying resident during recent work experience at least
nine times. Similarly, nearly 40% of participants noted
having attended at least four continuing education
classes related to EOL care in recent years.
STNA Comfort With EOL Care
Table 2 displays each item from the Comfort Scale. Each
item lists the degree to which STNAs agreed that they felt
comfortable with their role in terms of a particular skill
or aspect of care. Each individual component of this
scale was examined based on two groups of responses, in-
cluding ‘‘strongly agree’’ and ‘‘did not strongly agree.’’
This analysis strategy was based on the assumption that
respondents who did not strongly agree still had some
doubt about their understanding of the service in question.
The items in which fewer respondents strongly agreed
represent aspects of care in which STNAs expressed less
comfort or confidence. In particular, only 14% strongly
agreed that they felt comfortable talking about death.
While the majority of STNAs did express strong
agreement with their comfort in providing assistance
with activities of daily living, observing symptoms that
may occur near the end of life, and providing care at the
time of death, less than half of STNAs expressed as
much comfort with the nine other aspects of care about
which they were questioned. Only a third of STNAs
strongly agreed that they felt comfortable in their knowl-
edge of EOL decisions about care, working with a the
body of a deceased resident, or supporting a resident
experiencing nausea or vomiting.
In a further effort to describe STNAs’ level of com-

fort with the provision of EOL care, the Comfort Scale
was used as the dependent variable in a multivariable
linear regression model (Table 3). The model showed
that several of the study variables were significantly
associated with comfort giving EOL care.
Greater perceived importance of EOL care skills (B =
.161, P = .015), understanding of hospice (B = .365,
P = .006), and spiritual well-being (B = .359, P = .005)
were all associated with increased comfort providing
EOL care. Understanding of palliative care, job satis-
faction, and support from coworkers were not associ-
ated with comfort providing EOL care. These analyses
were adjusted for age, education, experience working
T a b l e 2
Comfort Scale Components: ‘‘I Am
Comfortable With My Role inI’’
Variable Percentage n
Talking about death
Do not SA 86.1 93
SA 13.9 15
Being present at time of death
Do not SA 62 67
SA 38 41
Working with body of deceased
Do not SA 65.7 71
SA 34.3 37
Supporting resident with delirium
Do not SA 54.6 59

SA 45.4 49
Supporting resident with noisy respirations
Do not SA 59.3 64
SA 40.7 44
Supporting resident with nausea/vomiting
Do not SA 69.4 75
SA 30.6 33
Supporting resident with emotional discomfort
Do not SA 61.1 66
SA 38.9 42
Providing assistance at EOL
Do not SA 39.8 43
SA 60.2 65
Observing EOL symptoms
Do not SA 46.3 50
SA 53.7 58
Observing EOL treatment response
Do not SA 57.4 62
SA 42.6 46
Providing care at time of death
Do not SA 45.4 49
SA 54.6 59
Being aware of treatment decisions at EOL
Do not SA 68.5 74
SA 31.5 34
Abbreviations: ADLs, activities of daily living; EOL, end-of-
life; SA,

strongly agree.
❖ ❖ ❖ ❖ ❖
12, No. 4, July/August 2010 259
with older adults, EOL education, and EOL care expe-
rience. These findings are strengthened by R2 = 0.471,
which suggests that nearly 50% of total variance in
STNAs’ comfort with EOL care was explained by this
model.
Additional Findings
The findings pertaining to each of the variables in-
cluded in the linear regression model shown in Table 3
are outlined in this section. The STNAs’ overall job sat-
isfaction, spiritual well-being, and perceived importance
of EOL care were analyzed according to three categorical
responses, including low, moderate, and high. The
boundaries for the low and high response categories
were established using the following formula: mean T
[(1/2)] SD. Based on these categories, approximately 19%
of STNAs rated themselves having low job satisfaction,
whereas 42% identified themselves as highly satisfied
with their job. Less than half of STNAs rated themselves
as having high spiritual wellness (41.3%). Forty-two
percent of STNAs demonstrated a high level of agree-
ment with the importance of specific aspects of EOL care
as identified by the ELNEC curriculum. Among the most
important were the abilities to observe and report EOL
symptoms, provide care at the time of death, and provide

support for residents with emotional discomfort. Under-
standing of hospice and palliative care was analyzed as
dichotomous variables, in which 66 respondents (61.1%)
strongly agreed that they understood the meaning of
hospice and when hospice may be needed, while only
26 respondents (24.3%) strongly agreed that they un-
derstand the meaning of palliative care and when it
may be needed. Similarly, support from coworkers was
analyzed as a dichotomous variable and demonstrated
that 88% of STNAs strongly agreed that they worked
in an atmosphere in which they were well supported
by their peers.
v DISCUSSION
The STNAs’ comfort with providing EOL care varied
widely. In terms of the skills and knowledge outlined by
the ELNEC curriculum as important to the role of nurs-
ing aides in the provision of EOL care, 40% of STNAs
rate themselves as having a high level of comfort,
and approximately 30% rate themselves as experienc-
ing a low level of comfort with these aspects of EOL
care. The results indicate that there is opportunity for
improvement in STNAs’ overall level of comfort with
EOL care.
There is evidence to suggest that STNAs’ comfort
providing certain aspects of EOL care may translate
into the quality of care provided. For instance, the fact
that less than 14% of STNAs strongly agreed that they
feel comfortable talking about death has important
implications based on findings from existing literature
that difficulty talking about death hinders the ability
of nursing home providers, residents, and families to
communicate openly and honestly about death.13 This

finding and others pertaining to areas in which STNAs
are less comfortable providing EOL care are important
for targeting areas in which improved nursing assistant
training or education is necessary. In addition to talk-
ing about death, the fact that only 42.6% respondents
feel particularly comfortable observing and reporting
symptoms that may occur at the end of life suggests
that this is another area of care requiring more careful
consideration in efforts to improve the quality of EOL
nursing home care. Moreover, this study provides evi-
dence to suggest that efforts to improve STNA comfort
with EOL care may find success in independently tar-
geting STNA understanding of hospice care or spiritual
well-being.
There are both strengths and limitations within this
study that may serve as lessons for future research.
The strengths of this study include its attention to a
relevant and timely topic, as well as an underrecog-
nized member of the interdisciplinary care team: the
T a b l e 3
Linear Regression Model for Comfort
Providing EOL Carea
Study Variable Coefficient (B) P
Comfort providing EOL care
(dependent variable)
1.564
.000
Perceived importance of EOL
care skills

.161 .015
Understanding of hospice .365 .006
Understanding of palliative care .187 .162
Job satisfaction j.078 .734
Spiritual well-being .359 .005
Support from coworkers .082 .687
aControlled for age, education, experience working with older
adults,
EOL education and EOL care experience.
Abbreviation: EOL, end-of-life.
STNA. This research also provides a promising foun-
dation for future research about EOL nursing home
care and nursing aides. In particular, it serves as a
potential resource for building targeted educational cur-
ricula to improve STNA education about specific aspects
of EOL care. Another strength of the study is the use of
audio PDA for data collection as this segment of the
workforce population has potential difficulty with read-
ing comprehension. The reading comprehension issue
may be why current literature on STNAs tends to focus
on qualitative methods. The investigator reported that
the PDA mode of data collection was well received by
STNAs, which suggests that this method may be useful
in future research.
This study is limited by the representativeness of

its sample. The study participants’ level of education
and job experience were not consistent with national
data. Data from the 2006 Annual Social and Economic
Supplement to the Current Population Survey, which
indicate that 65% of nursing aides working in nursing
homes have less than a high-school degree, provide evi-
dence of the level of education within this representative
of STNAs at the national level.14 Furthermore, the four
nursing homes chosen for this study included adminis-
tration that embraced the hospice philosophy and were
more likely to educate their STNAs about comprehen-
sive EOL care.
Despite these limitations, the study has important clini-
cal implications as there is a dearth of quantitative anal-
ysis of the experience of STNAs in providing EOL care.
This study demonstrated the need for more education
directed toward increasing STNAs knowledge and skill in
providing EOL care. Nursing homes can use the instru-
ments from the current study to assess STNAs’ knowl-
edge, comfort, skill, spiritual well-being, understanding of
models of EOL care, and perceived importance of EOL
care to measure the needs of their current staff. Nurs-
ing homes can then individualize education and support
of their STNA staff in this important area. The study also
indicated a need for emotional support. Hospice pro-
grams can collaborate with nursing home staff and pro-
vide support group sessions for STNAs who provide
90% of the direct care. Interdisciplinary teams need to
include STNAs in the planning of care for patients at the
end of life.
More research pertaining to this subject is necessary.
Research that includes larger samples from different states
will help define the needs of STNAs to empower them
to provide quality EOL care. The National Nursing

Assistant Survey, the first study of STNAs at the national
level, represents an example of a large-scale resource
that may have the potential to provide insight to the
experience of STNAs working in nursing homes.15 In its
current form, this survey does not aim to collect infor-
mation about nursing aides’ experience providing care
for dying nursing home residents, yet it serves as a foun-
dation for doing so.16 Additional areas for future re-
search include the relationship between nursing assistant
education and nursing home resident and/or family-rated
quality of care, as well as the role of nursing assistant
education and training in providing nursing aides with
the necessary coping strategies to improve job satisfaction
and spiritual well-being and decrease job turnover. Vary-
ing beliefs about EOL care based on nursing aides’ race,
ethnicity, or religion may also provide insight into this
area of research.
v CONCLUSION
As the result of an aging population in which people are
living longer with chronic illness and dying more fre-
quently in nursing homes, quality issues in EOL nursing
home care are inevitably integral to the future of health-
care delivery. Increased attention to this area of research
has the potential to save healthcare dollars and allow
individuals to die comfortably and with dignity. End-of-
life nursing home care cannot be examined in detail with-
out taking into consideration the most frontline providers
of this type of care: the STNAs. The STNAs are a grow-
ing segment of the nursing home care team, and this study
has identified that there is a need for consideration of
their educational resources, as well as the support systems
that are available to them in terms of spiritual well-being
and work environment.

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