No AccessSIG 2 Neurogenic Communication DisordersClinical Focus31 Oct 2019

Positive Culture Change in Long-Term Care: A Procedure to Enhance Speech-Language Pathologist–Certified Nursing Assistant Collaboration


    The majority of residents in long-term care (LTC) facilities have cognitive communication impairments impacting their ability to communicate basic wants and needs to caregivers, particularly certified nursing assistants (CNAs). Speech-language pathologists (SLPs) are the most qualified individuals to educate CNAs about residents' communication behaviors; however, there is limited literature that outlines specific, evidence-based procedures for CNAs and residents in the LTC environment. The purpose of this article is to describe such a procedure, including 2 case examples, within a framework of positive culture change.


    This clinical focus article aims to describe the details and benefits of providing professional support for CNAs during a communication plan intervention. Then, the article will discuss the association between professional support and positive culture change in LTC. Professional support involves valuing the experience and time CNAs spend with residents, consistently requesting feedback regarding trained communication strategies, educating, demonstrating, and problem-solving with CNAs, as well as acknowledging CNAs' use of communication strategies during daily care with residents.


    SLPs can serve as trendsetters in establishing a positive, functional organizational culture in LTC by providing professional support to CNAs. This article outlined an evidence-based procedure designed for SLPs working in the LTC environment to contribute to such positive culture change.


    • Allen-Burge, R., Burgio, L. D., Bourgeois, M. S., Sims, R., & Nunnikhoven, J. (2001). Increasing communication among nursing home residents.Journal of Clinical Geropsychology, 7, 213–230.
    • American Speech-Language-Hearing Association. (2019). 2019 SLP health care survey: Survey summary report: Number and type of responses. Retrieved from
    • Brazil, K., Kaasalainen, S., McAiney, C., Brink, P., & Kelly, M. L. (2012). Identifying education needs in end-of-life care for staff and families of residents in care facilities.International Journal of Palliative Nursing, 18(2), 77–83.
    • Bryan, K., Axelrod, L., Maxim, J., Bell, L., & Jordan, L. (2002). Working with older people with communication difficulties: An evaluation of care worker training.Aging & Mental Health, 6(3), 248–254.
    • Burgio, L. D., Allen-Burge, R., Roth, D. L., Bourgeois, M. S., Dijkstra, K., Gerstle, J., … Bankester, L. (2001). Come talk with me: Improving communication between nursing assistants and nursing home residents during care routines.The Gerontologist, 41(4), 449–460.
    • Burgio, L. D., Stevens, A., Burgio, K. L., Roth, D. L., Paul, P., & Gerstle, J. (2002). Teaching and maintaining behavior management skills in the nursing home.Gerontologist, 42, 487–496.
    • Caris-Verhallen, W. M., Kerkstra, A., Bensing, J. M., & Grypdonck, M. H. (2000). Effects of video interaction analysis training on nurse–patient communication in the care of the elderly.Patient Education and Counseling, 39, 91–103.
    • Cassie, K. M. (2012). A multilevel analysis of aggressive behaviors among nursing home residents.Journal of Gerontological Social Work, 55(8), 708–720.
    • Castle, N. G., & Engberg, J. (2005). Staff turnover and quality of care in nursing homes.Medical Care, 43(6), 616–626.
    • Choi, J., & Johantgen, M. (2012). The importance of supervision in retention of CNAs.Research in Nursing & Health, 35, 187–199.
    • Decker, F. H., Harris-Kojetin, L. D., & Bercovitz, A. (2009). Intrinsic job satisfaction, overall satisfaction, and intention to leave the job among nursing assistants in nursing homes.The Gerontologist, 49(5), 596–610.
    • Dijkstra, K., Bourgeois, M., Burgio, L., & Allen, R. S. (2002). Effects of a communication intervention on the discourse of nursing home residents with dementia and their nursing assistants.Journal of Medical Speech-Language Pathology, 10(2), 143–157.
    • Donoghue, C. (2009). Nursing home staff turnover and retention: An analysis of national level data.Journal of Applied Gerontology, 29(1), 89–106.
    • Douglas, N. F., & Hickey, E. (2015). Creating positive environments in skilled nursing facilities to support best practice implementation: An overview and practical suggestions.Seminars in Speech and Language, 36(3), 167–178.
    • Douglas, N. F., Hinckley, J. J., Haley, W. E., Andel, R., Chisolm, T. H., & Eddins, A. C. (2014). Perceptions of speech-language pathologists linked to evidence-based practice use in skilled nursing facilities.American Journal of Speech-Language Pathology, 23, 612–624.
    • Eggenberger, E., Heimerl, K., & Bennett, M. I. (2013). Communication skills training in dementia care: A systematic review of effectiveness, training content, and didactic methods in different care settings.International Psychogeriatrics, 25(3), 345–358.
    • Eklöf, M., Törner, M., & Pousette, A. (2014). Organizational and social–psychological conditions in healthcare and their importance for patient and staff safety. A critical incident study among doctors and nurses.Safety Science, 70, 211–221.
    • Fitzpatrick, P. G. (2002). Turnover of certified nursing assistants: A major problem for long-term care facilities.HOSPITAL TOPICS: Research and Perspectives on Healthcare, 80(2), 21–25.
    • Généreux, S., Julien, M. A., Larefeuil, C., Lavoie, V., Soucy, O., & Le Dorze, G. (2004). Using communication plans to facilitate interactions with communication-impaired persons residing in long-term care institutions.Aphasiology, 18(12), 1161–1175.
    • Glisson, C., Schoenwald, S. K., Kelleher, K., Landsverk, J., Hoagwood, K. E., Mayberg, S., … Research Network on Youth Mental Health. (2008). Therapist turnover and new program sustainability in mental health clinics as a function of organizational culture, climate, and service structure.Administration and Policy in Mental Health and Mental Health Services Research, 35(1–2), 124–133.
    • Grosch, K., Medvene, L., & Wolcott, H. (2008). Person-centered caregiving instruction for geriatric nursing assistant students: Development and evaluation.Journal of Gerontological Nursing, 34(8), 23–31.
    • Hartmann, C. W., Meterko, M., Rosen, A. K., Zhao, S., Shokeen, P., Singer, S., & Gaba, D. M. (2009). Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration.Medical Care Research and Review, 66(3), 320–338.
    • Heliker, D., & Nguyen, H. T. (2010). Story sharing: Enhancing nurse aide–resident relationships in long-term care.Research in Gerontological Nursing, 3(4), 240–252.
    • Hemmelgarn, A. L., Glisson, C., & James, L. R. (2006). Organizational culture and climate: implications for services and interventions research.Clinical Psychology: Science and Practice, 13(1), 73–89.
    • Hoerster, L., Hickey, E. M., & Bourgeois, M. S. (2001). Effects of memory aids on conversations between nursing home residents with dementia and nursing assistants.Neuropsychological Rehabilitation, 11(3–4), 399–427.
    • Institute of Medicine. (2000). Improving the quality of long-term care. Retrieved from
    • Jenkins, H., & Allen, C. (1998). The relationship between staff burnout/distress and interactions with residents in two residential homes for older people.International Journal of Geriatric Psychiatry, 13, 466–472.
    • Johnson, R. W., Toohey, D., & Wiener, J. M. (2007, May). Meeting the long-term care needs of baby boomers: How changing families will affect paid helpers and institutions.The Retirement Project: Discussion Paper Series. Retrieved from
    • Kinjerski, V., & Skrypnek, B. J. (2008). The promise of spirit at work: Increasing job satisfaction and organizational commitment and reducing turnover and absenteeism in long-term care.Journal of Gerontological Nursing, 34(10), 17–25.
    • Lange, J. W., Mager, D., Greiner, P. A., & Saracino, K. (2011). The ELDER project: Educational model and three-year outcomes of a community-based geriatric education initiative.Gerontology & Geriatrics Education, 32(2), 164–181.
    • Le Dorze, G., Julien, M., Brassard, C., Durocher, J., & Boivin, G. (1994). An analysis of the communication of adult residents of a long-term care hospital as perceived by their caregivers.European Journal of Disorders of Communication, 29, 241–268.
    • Lubinski, R. (1981). Language and aging: An environmental approach to intervention.Topics in Language Disorders, 1(4), 89–98.
    • Lubinski, R. (1995). State-of-the-art perspectives on communication in nursing homes.Topics in Language Disorders, 15(2), 1–19.
    • Magai, C., Cohen, C. I., & Gomberg, D. (2002). Impact of training dementia caregivers in sensitivity to nonverbal emotion signals.International Psychogeriatrics, 14, 25–38.
    • McCallion, P., Toseland, R. W., Lacey, D., & Banks, S. (1999). Educating nursing assistants to communicate more effectively with nursing home residents with dementia.The Gerontologist, 39(5), 546–558.
    • McGilton, K. S., Rochon, E., Sidani, S., Shaw, A., Ben-David, B. M., Sargosa, M., … Pichora-Fuller, M. K. (2017). Can we help care providers communicate more effectively with persons having dementia living in long-term care homes?.American Journal of Alzheimer's Disease & Other Dementias, 32, 41–50.
    • McGilton, K. S., Sorin-Peters, R., Sidani, S., Rochon, E., Boscart, V., & Fox, M. (2011). Focus on communication: Increasing the opportunity for successful staff–patient interactions.International Journal of Older People Nursing, 6, 13–24.
    • Mebane-Sims, I., & Alzheimer's Association. (2009). 2009 Alzheimer's disease facts and figures.Alzheimer's & Dementia: The Journal of the Alzheimer's Association, 5(3), 234–270.
    • Meyer, D., Raffle, H., & Ware, L. J. (2012). The first year: Employment patterns and job perceptions of nursing assistants in a rural setting.Journal of Nursing Management.
    • Page, C., Marshall, R., Howell, D., & Rowles, G. (2018). Use of communication plans by certified nursing assistants: Little things mean a lot.Aphasiology, 32(5), 559–577.
    • Page, C., & Rowles, G. (2016). “It doesn't require much effort once you get to know them”: Certified nursing assistants' views of communication in long-term care.Journal of Gerontological Nursing, 42(4), 42–51.
    • Parsons, S. K., Simmons, W. P., Penn, K., & Furlough, M. (2003). Determinants of satisfaction and turnover among nursing assistants: The results of a statewide survey.Journal of Gerontological Nursing, 29(3), 51–58.
    • Pennington, K., Scott, J., & Magilvy, K. (2003). The role of certified nursing assistants in nursing homes.Journal of Nursing Administration, 33(11), 578–584.
    • Perry, J., Galloway, S., Bottorff, J. L., & Nixon, S. (2005). Nurse–patient communication in dementia: Improving the odds.Journal of Gerontological Nursing, 31(4), 43–52.
    • Reina, M. L., Reina, D. S., & Rushton, C. H. (2007). Trust: The foundation for team collaboration and healthy work environments.American Association of Critical-Care Nurses Advanced Critical Care, 18(2), 103–108.
    • Ripich, D. N., Wykle, M., & Niles, S. (1995). Alzheimer's disease caregivers: The FOCUSED program.Geriatric Nursing, 16(1), 15–19.
    • Ripich, D. N., Ziol, E., Fritsch, T., & Durand, E. J. (1994). Training Alzheimer's disease caregivers for successful communication.Clinical Gerontologist, 21, 37–56.
    • Ryan, E. B., Hummert, M. L., & Boich, L. H. (1995). Communication predicaments of aging: Patronizing behavior toward older adults.Journal of Language and Social Psychology, 14(1–2), 144–166.
    • Sangaleti, C., Schveitzer, M. C., Peduzzi, M., Zoboli, E. L., & Soares, C. B. (2017). Experiences and shared meaning of teamwork and interprofessional collaboration among health care professionals in primary health care settings: A systematic review.The Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, 12, 24–33.
    • Schneider, B., Ehrhart, M. G., & Macey, M. W. (2013). Organizational climate and culture.Annual Review of Psychology, 64, 361–388.
    • Sengupta, M., Harris-Kojetin, L. D., & Ejaz, F. K. (2010). A national overview of the training received by certified nursing assistants working in U.S. nursing homes.Gerontology & Geriatrics Education, 31(3), 201–219.
    • Sorin-Peters, R., McGilton, K. S., & Rochon, E. (2010). The development and evaluation of a training programme for nurses working with persons with communication disorders in a complex continuing care facility.Aphasiology, 24(12), 1511–1536.
    • Tomblin, M. G., MacKenzie, A., Rigby, J., Rockwood, K., Gough, A., Greeley, G., … Lackie, K. (2013). Service-based health human resources planning for older adults.Journal of the American Medical Directors Association, 14(8), 611–615.
    • U.S. Department of Health & Human Services. (2012). Administration on Aging/Administration for Community Living: A profile of older Americans: 2012. Retrieved from
    • U.S. Department of Health & Human Services. (2013). Nursing home data compendium. Retrieved from
    • Van Weert, J. C. M., Kerkstra, A., van Dulmen, A. M., Bensing, J. M., Peter, J. G., & Ribbe, M. W. (2004). The implementation of snoezelen in psychogeriatric care: An evaluation through the eyes of caregivers.International Journal of Nursing Studies, 41, 397–409.
    • Wiener, J. M., Squillace, M. R., Anderson, W. L., & Khatutsky, G. (2009). Why do they stay? Job tenure among certified nursing assistants in nursing homes.The Gerontologist, 49(2), 198–210.
    • Williams, K. N. (2006). Improving outcomes of nursing home interactions.Research in Nursing & Health, 29(2), 121–133.

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