Increasing Knowledge and Agency of CNAs: Serious Mental Illness in Long Term Care

The following article was written for ETE by Sara J. English, LMSW MSW of the University of South Carolina.

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The majority of persons admitting to Long Term Care (LTC) nursing facilities enter with a diagnosis of mental illness, and the vast majority of these persons receive psychotropic medication to control symptoms and behaviors related to mental illness.  Recent studies recommend alternative therapies as a response to mental illness and reports to the World Health Organization (WHO) and the American Psychological Association (APA) promote alternative therapies, such as music therapy, art therapy, stress-reduction techniques, validation therapy and redirection as preferred responses to behaviors associated with Severe Mental Illness (SMI).  Despite these recommendations, pro re nada (PRN) psychotropic medication is often chosen as a first response to residents experiencing symptoms and behaviors related to SMI.  Certified Nurse Assistants (CNAs) have the greatest direct contact and opportunity to employ alternative responses; however, they often lack the training to actively respond to SMI.  In addition, the rigid hierarchical culture of LTC facilities creates a learned passivity of response among CNAs, leading to a lack of motivation and the agency to, actively, respond to residents exhibiting acute symptoms related to SMI.  This study explores whether specific training for CNAs regarding alternative therapies for use with residents who are living with SMI increases agency among CNAs and motivates active response which, in turn, leads to decreased use of PRN medication as a first response to SMI.

Keywords: severe mental illness, long term care, certified nurse assistants, agency, staff training, alternative therapy, motivation


Currently over 86% of nursing facilities in the United States provide mental health services (Centers for Disease Control and Prevention, 2013); however, neither federal nor state regulations require Certified Nurse Assistant (CNA) training for mental illness, unrelated to dementia (Street, Molinari, & Cohen, 2012).  Morawska et al. (2013) found this absence of training as associated with lack of confidence in, and knowledge of, interventions for behaviors related to severe mental illness (SMI).  Additionally, Molinari et al., (2011) reported over 50% of nursing home residents had non-pharmacological interventions on record; yet, the use of pro re nada (PRN) medication was a common first response to behavioral issues.  This concern is long-standing.  A report to the American Psychological Association noted the importance of SMI training for nursing home staff, providers and first responders (Clay, 2000); however, federal and state guidelines continually fail to specify training, regarding SMI in LTC settings (Molinari et al, 2011).

CNAs are often the first in-line responders to residents experiencing acute symptoms and behaviors.  CNAs, aware of symptoms and behaviors associated with SMI, have potential to increase the quality of life for these persons.  Training provides information, and gives instruction, regarding alternative therapies, such as: expressive therapy, validation therapy, empathetic response, de-escalation and other non-pharmacological interventions. Training also increases self-reported agency and motivation of CNAs to actively respond to concerns related to SMI, thereby, decreasing pharmacological use.

Literature Review

Since the 1980s, deinstitutionalization of mental health facilities has impacted the provision of care (Grabowski, Aschbrenner, Rome, & Bartels, 2010).  Many persons experiencing SMI are unable to live independently.  The 2014 census reported that 1,292,583 persons identified as mentally ill were living in nursing homes (Centers for Medicare and Medicaid Services, 2014).  Additionally, residents who have received a diagnosis of SMI require screening through a Preadmission Screening and Resident Review. However, a 2014 review found screenings often conducted post-admission (Centers for Medicare and Medicaid Services, 2014), resulted in staff being unaware of, and unprepared for, the mental health needs of admitting residents.

Grabowski, Aschbrenner, Rome, and Bartels (2010) reported a greater number of persons admitted to nursing homes with a diagnosis of severe mental illness than with a diagnosis of dementia. In addition, Mechanic and McAlpine (2000) concluded that LTC facilities have become de facto providers for mental illness.

The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) established guidelines for resident care, including a provision for “the right to accommodation of medical, physical, psychological, and social needs” (para. 2), determining that residents should not be subjected to physical, psychological or chemical restraint (Klauber & Wright, 2001; United States House of Representatives, 1987).  Furthermore, Bharucha, Dew, Miller, Borson, and Reynolds (2006) concluded that non-pharmaceutical interventions were important for persons living with SMI, with alternative therapies more beneficial to the mental wellness of residents than pharmaceutical use alone.  Despite these findings, non-pharmaceutical interventions are not commonly used (Molinari et al., 2011) and the use of PRN medication was a common first-response to behavior concerns (Molinari et al., 2011).

Additionally, neither federal nor state regulations currently require CNA training specifically for mental illness, unrelated to dementia.  Street, Molinari, and Cohen (2013) found that although “routine staff training about SMI” (p.394) was seen as a cost-effective means to address residents with SMI-related issues, only six states mandated staff training for SMI.

The Framework and Environment

CNAs generally carry out instructions and react to direction by others.  Active response and choice is discouraged.  This marginalization creates and maintains the learned passivity of direct care workers.  Liu, Liu, & Wang (2011) found “institutional-level factors” (para. 4) exist which discourage agency of CNAs and as a result, CNAs learn to report, rather than respond, to concerns.  This pattern of action (or rather, inaction) can be described as “vicarious learning,” where people fail to act for fear of social reprisal from both peers and authority figures (Bandura, 1986).

Engagement in one’s work is viewed as a result of increased agency (Lorente, Salanova, Martinez, & Vera, 2014).  Teodorescu & Erev (2014) argued that reward encourages agency.  Increasing individual agency helps link intention to action (Chen, 2006).  Self-efficacy is related to agency and also to feelings of socially constructed accomplishment and well-being (Bandura, 1986).

If people do not feel rewarded for their efforts, they learn passivity; however, the same vicarious learning which encourages passivity can encourage action if supported and esteemed by peers and authorities.  Greater learning leads to greater independent action (agency) because increased self-esteem and well-being, promoted through reward, serves as a mediating factor motivating persons toward action (Bandura, 1986).


Consequently, staff training leads to better resident care (South Carolina Department of Mental Health, 2009; Grabowski, Aschbrenner, Rome, & Bartels, 2010).  The American Geriatrics Society and the American Association for Geriatric Psychiatry (2003) suggested increased direct staff training for SMI improves overall well-being for residents.  Additionally, Grabowski, Aschbrenner, Rome, and Bartels (2010) noted training “front line workers” (para. 55) as essential for effective response to needs of LTC residents living with SMI.

CNAs commonly learn to react to such behaviors by informing nursing staff of a resident’s behavior, which is often leads to PRN use (South Carolina Department of Mental Health, 2010; Grabowski, Aschbrenner, Rome, & Bartels, 2010).  Training, which focuses on various aspects of SMI, can positively impact the lives of the aging and aged mentally ill and promote non-pharmaceutical interventions as a response to symptoms of mental illness.

The provision and acknowledgement of successful training provides CNAs with rewards of elevated status, increased knowledge and self-perceived competency.  Most importantly, agency has the potential to reduce PRN use.  Pajares (2002) noted that self-efficacy is not solely based upon “how capable one is, but of how capable one believes oneself to be” (para. 35).  Inclusion of CNAs in this additional training will increase the self-worth of workers, enhance social status within the nursing home hierarchy and create a more positive and responsive environment in which people work and live.



American Geriatrics Society, & American Association for Geriatric Psychiatry (2003).  The American Geriatrics Society and American Association for Geriatric Psychiatry recommendations for policies in support of quality mental health care in U.S. nursing homes.  Journal for the American Geriatrics Society, 51(912), 99-304.

Bandura, A.  (1986).  Social foundations of thought and action:  A social cognitive theory. Englewood Cliffs, NJ:  Prentice Hall.

Bandura, A. (2001).  Social Cognitive Theory: An agentic perspective.  Annual Review of Psychology, 52(1), 1-26.  Retrieved from

Bharucha, A. J., Dew, M. A., Miller, M. D., Borson, S., & Reynolds, C., III (2006). Psychotherapy in long-term care: A review.  Journal of the American Medical Directors Association, 7(9), 568-580.

Centers for Disease Control and Prevention.  (2013).  Long term care services in the United          States:  2013 overview.  (DHHS Publication No. 2014-1040).  Washington, DC: U.S.                  Government Printing Office.

Centers for Medicare and Medicaid Services.  (2014).  2014 PASRR national report:  A review preadmission screening and resident review (PASRR) programs.  Retrieved from

Chen, C.P. (2006).  Strengthening career human agency.  Journal of Counseling & Development, 84(2), 131-138.

Clay, R. (2000).  Advocating for older people’s mental health.  Retrieved from   

Grabowski, D.C., Aschbrenner, K. A., Rome, V. F., & Bartels, S. J. (2010).  Quality of mental health care for nursing home residents:  A literature review.  Medical Care Research and Review, 67(6), 627-656. doi:10.1177/1077558710362538

Klauber,M., & Wright, B. (2001).  The 1987 nursing home reform act.  Retrieved from   

Liu, L. F., Liu, W. P., & Wang, J. Y. (2011). Work autonomy of certified nursing assistants in long-term care facilities: Discrepant perceptions between nursing supervisors and certified nursing assistants. Journal of the American Medical Directors Association, 12(7), 524–534.

Lorente, L., Salanova, M., Martinez, I. M., and Vera, M. (2014).  How personal resources predict work engagement and self-rated performance among construction workers: A social cognitive perspective.  Internal Journal of Psychology, 49(3), 200-207.  doi:10.1002/ijop.12049

Mechanic, D., & McAlpine, D. D. (2000).  Use of nursing homes in the care of persons with   mental illness:  1985 to 1995. Psychiatric Services, 51(3), 354-358.

Molinari, V. A., Chiriboga, D. A., Branch, L. G., Schinka, J., Schonfeld, L., Kos, L., &… Hyer, K. (2011).  Reasons for psychiatric medication prescription for new nursing home                   residents.  Aging and Mental Health, 15(7), 904-912. doi:10.1080/13607863.2011.569490

Morawska, A., Fletcher, R., Pope, S., Heathwood, E., Anderson, E., & McAuliffe, C. (2013).     Evaluation of mental health first aid training in a diverse community setting. International Journal of Mental Health Nursing, 22(1), 85-92. doi:10.1111/j.1447-0349.2012.00844.x

Pajares, F. (2002).  Overview of social cognitive theory and of self-efficacy.  Retrieved from

South Carolina Department of Mental Health.  (2009).  Medical model versus recovery model:  An analysis of the SC Department of Mental Health’s approach to treatment.  Retrieved from

Street, D., Molinari, V., & Cohen, D. (2012).  State regulations for nursing home residents with  serious mental illness.  Community Mental Health Journal, 49(4), 389-395. doi:10.1007/s10597-012-9527-9

Teodorescu, K., & Erev, I. (2014). Learned helplessness and learned prevalence:  Exploring the causal relations among perceived controllability, reward prevalence, and exploration. Psychological Science, 25(10), 1861–1869.

United States Department of Health and Human Services (2010).  National Action Plan to Improve Health Literacy.  Retrieved from

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Sara English is a Licensed Master Social Worker and serves as the National Association of Social Workers’ representative to the Alzheimer’s Advisory Board for the South Carolina (USA) Lieutenant Governor’s Office on Aging.  She is a recipient of the AGE SW (Association for Gerontology Education in Social Work) and has worked in the fields of mental health and aging.  She is a PhD Fellow at the University of South Carolina in Columbia, South Carolina, USA, where she is researching the intersection of relationships, reciprocity and resiliency.  Sara has recently presented at the International Psychosocial Disaster Conference in Vancouver, British Columbia, Canada and the CDAS Survival Conference at the University of Bath.

Sara may be contacted at:

Sara J. English, LMSW MSW

Hamilton College – College of Social Work

1512 Pendleton Street

University of South Carolina

Columbia SC USA   29208




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