Addressing Relationships Between Nurses And Nursing Assistants

Nurses and nursing assistants spend more time at the bedside than any other providers, so the relationship between them drives patient outcomes. When communication and teamwork hold, both staff and patients benefit. When they break down, both suffer. Here is what causes the breakdown, what it costs, and what nurses, CNAs, and supervisors can do about it.

What Breaks the Relationship Down

The Nursing Staff's Role

Communication makes or breaks the relationship. Research by Miller, Beynon et al., and Campbell et al. found that nurses and CNAs alike want feedback, and not only when something goes wrong. Without positive feedback, nursing assistants feel unappreciated and are more likely to leave the field.

Feedback runs both ways. Nurses in these studies valued CNAs who flagged changes in patients, offered ideas, and did their jobs well, because it made their own work easier.

CNAs also valued nurses who helped with two-person tasks like turning patients. In Miller's study and Pickering et al., nursing assistants reported injuring themselves, or knew of others who had, when no second person was available to lift or move a patient. One group in Campbell et al. scheduled nurse-and-CNA turns every two hours.

Reporting patient changes to the nurse is a core CNA responsibility. Across these studies, nursing assistants said they chose which nurses to approach based on how those nurses had responded before. Some stopped reporting changes or asking for help from nurses who had not supported them, which leaves CNAs unsupported and ultimately hurts patients.

To keep the relationship intact, nurses should:

• Help CNAs who need support with a patient or are running behind
• Communicate changes in patients' conditions or care plans
• Listen when CNAs report changes in their patients
• Recognize CNAs when they share feedback, offer insight, and work hard

Management's Role

Nurses delegate to CNAs more than anyone, but they are not the only ones who shape the relationship. Management policy matters too.

When leaders prioritize speed over safety, CNAs make do with the time and resources they have instead of following best practices, and they get reprimanded for "taking too long." Some leaders also push tasks that have to be documented daily over tasks that do not. CNAs report ignoring patients who needed the bathroom because they had to shower other patients and log it on the shower schedule.

Management should prioritize safe, high-quality care over cost and speed, supply staff with what they need, and let patient needs set priorities rather than the documentation checklist. No one should be punished for taking the time required to give complete, safe care. Per Miller, CNAs are three times more likely to be injured on the job than workers in any other profession, and the right policies prevent those injuries.

The nursing shortage compounds all of this, and CNAs often absorb the stress. Leaders should encourage cooperation, and nurses can help by protecting CNAs' break times.

What Strong Relationships Produce

When the team communicates and works within each member's scope, both staff and patients gain.

For staff: clearer communication, higher patient survey scores, less burnout and stress, work divided fairly by scope and schedule, and lower turnover.

For patients: best practices followed, better outcomes, no missed care, fewer falls and accidents, and higher satisfaction.

Solutions

Conflict drives people out of the job and out of the field. Health Affairs data put median annual turnover in nursing homes at 94%, a rate that climbed after the pandemic and that damages both patients and the team.

What Nursing Assistants Can Do

For CNAs who stay, healthier ways to handle conflict serve both patients and the team:

• Keep the focus on the patient's needs
• Stay professional
• Tell your supervisor when communication or teamwork breaks down
• Separate personality differences from job performance
• Find teammates who value the CNA role

The unhealthy responses documented in the research, which serve no one, include skipping care, not reporting incidents or changes, doing two-person tasks alone, ignoring safety procedures, and disengaging from patients' emotional needs.

What Supervisors Can Do

Nurses and nurse supervisors build the relationship by backing good communication and making sure everyone is on the same page. Concrete steps:

• Discipline or remove anyone who bullies staff, and enforce a visible zero-tolerance policy
• Listen to CNAs' observations about patients
• Encourage breaks and self-care
• Prioritize care by patient need, not by what has to be documented
• Step in when a CNA is running behind
• Meet with CNAs individually or as a group to hear concerns
• Remember CNAs work under the nurse's license, so accidents, falls, and missed care put that license at risk

CNAs feel heard when supervisors act on the concerns they raise, not just when they listen. As one CNA put it, hands-on staff see the patient across the full day and across many settings, so they catch changes the patient never reported. Per Beynon et al., nursing assistants provide 80 to 90% of direct care, which makes their observations a real source of insight into patient changes and patterns of workplace conflict.