A mixed-methods exploration of death exposure in certified nursing assistants: moderating factors and implications

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Certified Nursing Assistants (CNAs) are responsible for 80-90% of direct-to-resident care in skilled nursing home facilities (SNFs), and often develop close, family-like relationships with their residents. With SNFs becoming an increasingly common place of death for older adults, CNAs now find themselves engaging in end-of-life caregiving without proper training, or institutional support for the emotional outcomes. Moreover, little is known about the impact of frequent death exposure on CNAs. The present project examined these issues in a set of three interrelated studies, employing mixed-methods analyses. The first study found support for a new measure of attitudes toward advance care planning (ACP) in two samples, while finding that personal exposure to death is significantly related to more developed ACP attitudes. The second, qualitative study revealed CNAs’ varying attitudes toward death, the importance of their relationships with residents, and the ways in which exposure to the dying process has influenced their ACP attitudes. Finally, while study 3 failed to find support for behavioral inhibition and experiential avoidance as moderators of the impact of death exposure on negative death attitudes, results supported the relationship between these variables and their impact on compassion fatigue. Moreover, positive death attitudes, and death exposure, were found to be more influential to ACP attitudes than negative death attitudes. Implications highlight researcher’s imperative to develop interventions focusing on education and support of CNAs in their role as end-of-life caregivers to decrease high job turnover, and increase quality-of-care outcomes for residents.

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