Certified nursing assistants (CNAs) are the backbone to most long-term care organizations. In addition to national efforts to increase CNA wages and benefits and standardize CNA career pathway models currently underway, nursing homes adopting age-friendly care can embrace opportunities to empower and advance the role of CNAs.

Age-friendly health systems use a framework called the 4Ms to reliably organize care for all older adults in every interaction across settings. The 4Ms represent four evidence-based elements — What Matters, Medication, Mentation (dementia, depression and delirium), and Mobility. The two key drivers of age-friendly care are:

  1. Knowing about the 4Ms for each older adult (“assess”).
  2. Incorporating the 4Ms into care delivery and care plans (“act on”). 

CNAs spend the most time with residents among nursing home staff and can readily lead the “act on” of all 4Ms during personal care. However, an area not routinely designated to CNAs is “assess.”

While formal assessment of most 4Ms elements is performed by other disciplines (for instance, What Matters by activities staff), CNAs can routinely assess delirium (under Mentation) as a vital sign, giving CNAs lead roles to both “assess” and “act on.” 


Age Friendly Health Systems: Guide to Care of Older Adults in Nursing Homes recommends two delirium assessments: the Confusion Assessment Method (CAM) and the Ultra-Brief Confusion Assessment Method (UB-CAM). The UB-CAM is a two-step screening protocol developed in part by Donna M. Fick, RN, PhD, Director of the Center of Geriatric Nursing Excellence at Penn State, and a free app with the screen is publicly available.

Research shows that the first step of UB-CAM, which is a two-item screener called UB-2, can be administered by CNAs as accurately as RNs and physicians. UB-2 can be easily incorporated during personal care and serve as the first-line delirium screening for nursing home residents.

For instance, UB-2 is administered by CNAs to all skilled nursing residents at admission and every 72 hours at the Presbyterian SeniorCare Network in Pennsylvania, with positive screens followed up by nurses and physicians. Presbyterian became an age-friendly health system in 2022 and has approximately 100 CNAs and nine “Lead CNAs” — a new position that puts CNAs in leadership roles to ensure excellent person-centered care and services during every shift. 

Act on — Story of Ms. T

Delirium is often reversible. Once identified and acted on, it can resolve quickly, which not only improves resident outcomes but can be a gratifying experience for CNAs. Dayna, a Lead CNA at the Willows in Oakmont, Pennsylvania, shared a successful story of helping Ms. T, a resident admitted to her floor.

Dayna Rearick

Dayna was able to help resolve Ms. T’s delirium within a week and a half through non-pharmacological interventions, and described this experience as transformative. (Read more about how Dayna helped to resolve Ms. T’s delirium.)

When asked about what made this experience most rewarding, Dayna said, 

It’s kind of difficult in the beginning, but at the end, it’s like you meet a whole other person, and this is the right person, this is the real person, this is the person that has the name attached to them.” 

Regarding her tips for success, Dayna shared:

Everyone’s going to move differently, think differently, act differently, and they’re going to need to be cared for differently, so thinking out-of-the-box, thinking new, is what we need to do to better care for them individually.

Taylor McMahon

In addition to successful stories like Ms. T’s happening each day, Lead CNAs at Presbyterian have taken leadership in creating two delirium education posters, a pamphlet, and a delirium cart of non-pharmacological interventions. They have also guest-lectured for undergraduate nursing students alongside Presbyterian SeniorCare’s Director of Nursing, Taylor McMahon, RN, DP, CNDLTC.

Empowering CNAs

As more and more nursing homes are becoming age-friendly, CNAs likely will have more opportunities to lead and facilitate the implementation of the 4Ms framework. These leadership roles may help empower CNAs, enhance job satisfaction, and reduce feelings of not being a valued team member and the associated turnover, while improving the quality of care delivered to residents. 

Shih-Yin Lin, PhD, MPH, is senior research scientist and project director at Aliviado at the Hartford Institute for Geriatric Nursing, part of the NYU Rory Meyers College of Nursing.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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