Retention Efforts Focus on the Engagement and Support of Nursing Assistants

In Cleveland Clinic’s hospitals, patient care nursing assistants (PCNAs) lay the groundwork for basic clinical care. They combine clinical tasks with personal care responsibilities to ensure patients are comfortable, supported and safe. Bridging care and communication between nurse and patient, their role on the healthcare team is dynamic and essential.

“Nursing assistants add so much to the patient and caregiver experience, and their work contributes significantly to patient outcomes,” says Barb Zinner, DNP, RN, NE-BC, CENP, Vice President, Chief Nursing Officer at Cleveland Clinic Marymount Hospital. “Retaining this indispensable group of caregivers is a top priority of Cleveland Clinic’s executive nurses.”

According to a report by Bucketlist, nursing assistant roles consistently face some of the highest turnover rates among healthcare positions, at times exceeding 30% annually.

Zinner spearheads Cleveland Clinic’s PCNA retention efforts, which aim to ensure that these caregivers have the tools needed to perform at their highest level, that they are engaged, and that they are personally and professionally satisfied.

Keeping the pros in place

It’s common for the nursing assistant position to be used as a stepping stone for other caregiving opportunities. At Cleveland Clinic, many PCNAs are pursuing, or have plans to pursue, a nursing or other medical degree while working in the hospital, yet others find the role itself to be a rewarding career. Zinner calls these caregivers the “pros in place” and explains that they are committed PCNAs with no desire to change careers — now or later.

“Some PCNAs have no desire to attend nursing school; their goal is to be the best nursing assistant they can be, period,” says Zinner. “We want those caregivers to make Cleveland Clinic their professional home for their entire career.”

To encourage organizational commitment, Zinner and her colleague Mary Beth Modic, DNP, APRN-CNS, CDE, Clinical Nurse Specialist, Diabetes, initiated a new program that would further empower and engage these dedicated professionals.

Zinner and Modic began by redesigning a curriculum from the medical center’s highly impactful MAGNUS empowerment program for clinical nurses. Together with MAGNUS Facilitator Jane Hartman, MSN, APRN, CPNP-PC, the team created a career enrichment program designed to meet the unique needs of PCNAs.

With four cohorts now complete, the program encompasses education and training to help pros in place grow and excel in their roles. Participants, who are selected by their nurse manager or clinical director based on their job performance, attend a series of guided, interactive discussions on the dignity of career, finding purpose in your work, bringing joy to your job and expressing gratitude.

“I never expected that this program would be something that would build me up personally and professionally,” explains Michelle Hinton, a PCNA at Marymount Hospital who participated in the first cohort. “The program gave me the tools I need to fulfill my responsibilities, taught me how to multitask and showed me how to build better relationships with my co-workers.”

Hinton says the insight she garnered on approaching difficult situations, being a better communicator and listener, and encouraging and supporting her teammates has positively affected her daily work and overall career satisfaction.

“The experience gave me a sense of belonging and instilled pride in my position,” she shares.

Hinton’s testament is reflective of program results to date.

Modic explains, “The transformation of many participants is notable in observable behaviors like increased self-confidence, enhanced communication skills, and heightened sense of contribution and value to the organization.”

Support for every career phase

To further harness the valuable insight offered by the pros in place, alumni of the MAGNUS program are invited to join a systemwide PCNA task force. Among its many responsibilities, the group aims to help identify retention-related gaps and devises solutions with the chief goal of reducing PCNA turnover across the enterprise.

“These caregivers have profound ideas and innovations for retaining nursing assistants,” says Zinner, who leads the task force with Modic; Amy Graves, MSN, RN, NE-BC, CCRN, Nursing Director at Cleveland Clinic Hillcrest Hospital; Cindy Willis, DNP, MBA, CMSRN, Senior Director of Nursing Education; Anna VanHal, MSN, RN, NPD-BC, Nursing Education Manager; and Krissy Cochrane, MSN, RN, Continuous Improvement Specialist.

For the past year, the work has focused on enhancing job clarity and creating support resources for potential, new and current PNCAs. Materials are housed in a new PCNA Toolkit, which is available to Cleveland Clinic’s inpatient nursing teams. Key objectives have been to:

1. Establish clear job expectations for potential candidates.
2. Provide enhanced orientation and training for new hires.
3. Create standardized shift responsibilities and expectations for
all nursing assistants.

Potential candidates

“We knew we needed to help people better understand the job before they were hired,” notes Hinton. “Some weren’t aware of everything that was expected of them — a factor that would lead to disappointment and attrition.”

To address this potential pitfall, the task force proposed a PCNA shadowing experience. Prior to shadowing, candidates complete an interview summary that asks questions such as “What is it about working as a PCNA that you find exciting?” It also helps hiring managers evaluate an individual’s comfort level with specific job-related tasks.

The completed form, along with feedback from the caregiver leading the shadowing, helps inform nurse managers whether the potential employee is a good fit. The process provides candidates with a clear understanding of the job description and requirements.

“The process allows candidates to see firsthand what the job entails,” explains Zinner. “They are able to make a more informed decision to determine if it’s a job they can see themselves doing.”

New hires

For those who are hired into the organization, the task force has also refined its PCNA clinical orientation practices to include a precepting experience. Thanks to the enhanced training they receive, MAGNUS alumni have been well equipped to serve as preceptors along with other tenured nursing assistants.

“There are specific requirements for becoming a preceptor,” explains Zinner. “They must have commendable or above-average annual performance reviews, attend preceptor courses and quarterly PCNA Council meetings, and more.”

Upon hiring a new PCNA caregiver, nurse managers assign a preceptor by sending a detailed letter about the individual, including their work schedule, previous work experience and length of orientation. A welcome flyer is posted in the unit break room with their name, role and preceptor information.

“The new precepting is incredibly structured,” says Hinton, who often mentors new hires. “You are prepared with in-depth information about the person you are training, so you know where to start with them.”

The task force also created an orientation guideline with a detailed timeline that spans the first day of orientation to the last. It lists specific skill expectations for each day in the orientation period, which is typically about four weeks.

Preceptors provide daily feedback on caregiver performance. They prompt new hires about their goals when a shift starts, and when it ends, they ask the PCNA to share their thoughts on strengths and opportunities.

“Many people who become PCNAs have no previous medical or clinical experience,” says Hinton. “It’s a fast-paced role that can be overwhelming. Without adequate training and preparation, some new hires leave. The task force agreed that a comprehensive orientation guideline would give these caregivers the best experience possible during their training.”

Collaborative weekly meetings with the caregiver, their preceptor and the nurse manager offer further guidance and support throughout the transition. Meetings also lay the groundwork for development of the caregiver’s personal action plan.

“The weekly check-ins highlight strengths and opportunities with concrete examples,” adds Zinner. “New PCNAs are becoming more quickly engaged in their work, which boosts their confidence. They recognize that their leaders support them and want them to succeed.”

Current PCNAs

For all Cleveland Clinic PCNAs, the task force has outlined role-related care standards. These include specific tasks nursing assistants may be expected to perform during a shift. Tasks are organized in checklist format by categories that include changing/bathing, oral care, environment, and mobility, as examples.

“Last November, we began discussing the relationship between PCNAs and RNs and identified ways to enhance both roles,” says Zinner. “Delegation was one area in need of improvement. Some PCNAs didn’t realize that when they were delegated a task, they needed to go back to the nurse to tell them it was completed. Having standardized care forms helps improve communication
between all parties.”

Delegation is also a topic that is covered through educational sessions offered by task force leaders. Other topics include collaboration and teamwork (what it should look like and how caregivers can recognize and reward each other).

Additional nursing assistant support tactics include coaching and mentoring, a Nursing Support Caregiver Career Path, a job development training program to help overcome work-readiness barriers, professional development, and enhancement options to ensure individuals are working at the highest level that their training allows.

Distinctive benefits

Modic emphasizes that the role of the PCNA on Cleveland Clinic’s care teams is invaluable. “They provide the highest standard of compassionate care — often with more frequent patient interactions than any other caregiver,” she says. “PCNAs establish trusting relationships with patients and their families and provide comfort and support. They also gain valuable insight about patients that the entire team can use to inform future care decisions.”

Beyond that, the specialized skills PCNAs possess can help close staffing gaps and reduce nurse burnout, says Modic, noting that the U.S. Department of Health and Human Services anticipates the national shortage of full-time registered nurses to continue, with projections of 10% in 2027, 8% in 2032 and 6% in 2037.

Leaning on PCNAs for clinical support allows Cleveland Clinic’s nurses to spend more time focusing on complex treatments, medication administration and the critical assessments necessary for the delivery of high-quality care, notes Modic.

“The nursing shortage isn’t going away anytime soon,” Zinner says. “Care teams need to be stronger than ever right now, and PCNAs are a vital piece of the puzzle.”

Zinner adds, “Nursing assistants are incredibly important to our Cleveland Clinic family, and we want all PCNAs to flourish here for many years to come.”