Exploring crucial programme characteristics and group mechanisms of an empowerment programme for certified nursing assistants-A qualitative study.

AIMS: To identify crucial programme characteristics and group mechanisms of, and lessons learned from hindrances in an empowerment programme for certified nursing assistants and contribute to the development of similar programmes in other care settings.
DESIGN: Exploratory qualitative study.
METHODS: Between May 2017 and September 2020, we used in-depth interviews and participant observations to study four groups participating in an empowerment programme for certified nursing assistants (N = 44).
RESULTS: We identified three crucial empowerment-enhancing programme characteristics: (1) inviting participants to move outside their comfort zone of caregiving; (2) stimulating the use of untapped talents, competencies and interests; (3) supporting the rediscovery of participants' occupational role and worth. Crucial group mechanisms encompassed learning from and with each other, as well as mechanisms of self-correction and self-motivation. Hindrances included a perceived lack of direction, and a lack of organizational support and facilitation.
CONCLUSION: We showed the significance of creating an inviting and stimulating environment in which participants can explore and function in ways they otherwise would not. Likewise, we identified how this can help participants learn from, critically correct and motivate one another. IMPACT: The programme under study was uniquely aimed to empower certified nursing assistants. Our insights on crucial programme characteristics and group mechanisms may benefit those who develop empowerment programmes, but also policymakers and managers in supporting certified nursing assistants and other nursing professions in empowerment endeavours. Such empowerment may enhance employee retention and make occupational members more likely to address challenges affecting their occupational group and the long-term care sector.

INTRODUCTION

Long‐term caregiving is increasingly complex—due to changes in the population and the more complex, chronic health and social needs of its recipients—requiring a high‐quality workforce in the long‐term care (LTC) sector. Depending on the LTC context, the majority of this workforce consists of either certified nursing assistants (CNAs), healthcare aides or nursing assistants (Chamberlain et al., 2019; Hewko et al., 2015; Tuinman, 2021). In many countries, the number of workers within these occupational groups falls short of the demand (Hewko et al., 2015) and organizations struggle to retain their employees. This is also the case with CNAs in the Dutch LTC sector, on whom we focus this study.

Existing research has shown that retention is enhanced when CNAs feel their work is meaningful and appreciated (Both‐Nwabuwe, 2020). While CNAs have an essential role in day‐to‐day caregiving—a role in which they are well placed to develop indispensable client knowledge and identify workflow inefficiencies (Mianda & Voce, 2018)—they often lack the skills to convey their specific knowledge and professional interests, and are underappreciated and marginalized by registered nurses and managers within their care organizations (Kroezen et al., 2018; Zysberg et al., 2019). As such, CNA empowerment is critical to CNAs' abilities to apply their indispensable knowledge. In this study, we define empowerment as ‘enabling to act’ (Chandler, 1992; see also Bradbury‐Jones, Irive & Sambrook, 2010), specifically with regard to conveying their knowledge and interests. Such empowerment may be achieved by developing leadership qualities such as self‐awareness, communication skills and knowledge‐base expansion (Cummings et al., 2020; MacPhee, Skelton‐Green, Bouthillette, & Suryaprakash, 2012). Empowerment is not only critical to CNAs' perceptions of their work as meaningful and to retention enhancement, it is also key if we want them to take on their essential role in ensuring the quality of the LTC sector.

Having studied a CNA empowerment programme in the Netherlands, our exploratory qualitative study allowed us to develop unique insights into which programme characteristics and relevant group mechanisms help generate positive outcomes for participants that existing deductive research, which uses mostly quantitative methods, has previously been unable to identify. Likewise, our approach also allowed us to identify the hindrances for participants within the programme and organizational context. Our findings contribute to the development and design of empowerment programmes for nurses generally, and CNAs in particular.

BACKGROUND

Empowerment through leadership‐development programmes

Existing literature supports the idea that strengthening leadership qualities enhances the empowerment, position and resilience of registered nurses and other medical professionals (e.g., Berghout et al., 2020; Fitzpatrick et al., 2016; Heinen et al., 2019; MacPhee, Skelton‐Green, Bouthillette, & Suryaprakash, 2012; Paterson et al., 2015; Ramseur et al., 2018). Similarly, the strengthening of leadership qualities has been found to encourage both nursing students to become agents for positive change (Hendricks et al., 2010) and nurses to tackle challenges in the healthcare system (Cummings et al., 2020; Montina et al., 2015). Moreover, existing research emphasizes the importance of leadership qualities and empowerment on all levels of nursing (Duygulu & Kublay, 2011).

Nonetheless, literature on empowerment or leadership‐development programmes for CNAs is currently non‐existent. In fact, to the best of our knowledge, the programme studied in this paper is unique in being the first to be designed for CNAs specifically. Given their training and (starting) position within their organization, tactics for empowering CNAs are likely to differ from those intended for nurses on other qualification levels (Cummings et al., 2020; Duygulu & Kublay, 2011; Fitzpatrick et al., 2013; Paterson et al., 2015; Ramseur et al., 2018). As such, our study allowed us to gain explicit insights into which programme characteristics enhance or hinder the strengthening of CNAs' leadership qualities specifically.

An empowerment programme for CNAs

Within the Dutch LTC sector, CNAs constitute the largest occupational group, providing the most care to vulnerable people in nursing homes and home care. Notably, Dutch CNAs' education level and role in care delivery differ from that of CNAs, care aides, nursing assistants or licensed practical nurses in North American (i.e., Canada and US) and UK settings. After secondary schooling, Dutch CNAs complete 3 years of practice‐oriented education at a vocational training centre compared with one year of training in most other countries (Beck, 1999; Maurits et al., 2017; Torpey, 2011). Dutch CNAs are also allowed to autonomously provide support with activities of daily living, personal care and primary nursing care such as administering medication, dressing wounds and giving injections (Kroneman et al., 2016; Maurits et al., 2017). Consequently, their role and responsibilities in care delivery are more comprehensive than that of the above‐mentioned occupational groups in other countries, while probably being most similar to the newly introduced role of ‘nursing associate’ in the UK.

Dutch CNAs currently face several challenges concerning their role and position in LTC organizations. First, many CNAs experience a lack of appreciation from, for example, registered nurses and supervisors. Second, in terms of organizational involvement, CNAs are often unrepresented in, and not invited to advisory boards and nursing councils. Moreover, adjacent occupational groups fail to recognize their professional interests and knowledge, because CNAs often lack the skills necessary to articulate these. Third, their opportunities for professional development are limited. Altogether, despite them spending the most time with clients compared with other occupations (Chamberlain et al., 2019; Hewko et al., 2015), and their intimate knowledge of clients' needs, CNAs experience a pervasive lack of professional agency and skills to exert influence, which is why their empowerment is important.

In order to empower CNAs, the Dutch Nurses Association (DNA) initiated a programme designed for members of this occupational group. Altogether, the programme aimed to enable (i.e., empower) participants to act on their insights and increase their spheres of influence (Bradbury‐Jones et al., 2010) both by (better) conveying their interests to referent audiences, and by introducing changes within their organizations, e.g., initiatives to improve their opportunities as an occupational group. To this end, the programme supported participants in strengthening their self‐awareness, improved communication styles and skills and an increased understanding of developments within their own organizations and the overall LTC sector. Additionally, participants were able to practice lobbying, networking and negotiating.

The programme consisted of eight collective, 8‐h days of instruction every 4–5 weeks, for a maximum of 10 months. In between sessions, participants were given assignments to enhance their personal reflection and experiential learning opportunities by, for example, developing and implementing an improvement project within their employing organization. Guided by two certified trainers specialized in leadership development for nurses, plus one facilitator from the DNA (henceforth: facilitator), the programme also included individual coaching sessions and a full day ‘field trip’ to the Ministry of Health, Welfare and Sports. Moreover, each participant was given a mentor within their own organization with whom they could reflect and discuss their personal development goals or struggles. The formulation of individual development plans, including specific learning goals, also helped participants take ownership of their own development. See Table 1 for a more comprehensive overview of the programme based on the Template for Intervention Description and Replication (TIDieR) (Hoffman et al., 2014).

TABLE 1

Template for intervention description and replication (TIDieR) checklist (online source)

1. Brief name	Empowerment programme for CNAs
2. Why	There was no specific theory or model that informed the programme. The main goal of the empowerment programme for CNAs is to empower participants, by developing skills (i.e., become able) to convey the interests of their occupational group in their organization and beyond, and to become more visible individually and as an occupational group. To this end, the programme was designed to offer participants experiential learning experiences to Develop their self‐awareness; Reflect on their communication style and skills and improve the latter; Develop their knowledge base regarding developments in the health care sector and organization processes; Develop their own view on their occupational role and responsibilities and convey this to others; Develop a sense of ownership and responsibility in introducing solutions and changes in their organizations; Lobby, network and negotiate on behalf of their occupational group As the programme aimed to support the learning and development of individual participants, the latter were encouraged to formulate individual learning goals and adjust them during the programme when necessary rather than (pre)defining (individual) outcome measures prior to the programme
3. What—materials	Programme materials consisted of short articles about, for example, the Dutch health care system. Also, participants were expected to read the formal occupational role description of CNAs as well as adjacent occupational groups Besides, participants were encouraged to read organizational policy documents. Yet, it was up to individual participants whether they actually did so
4. What—procedures	Prior to the programme, the trainers and convener held intake meetings with potential participants to assess their eligibility, motivation and learning goals. During the programme, participants did a DISC personality test. Based on this, participants developed a personal development plan, in which they specified individual learning goals. Also, participants were given assignments that offered experiential learning experiences. Examples of assignments are: shadowing their CEO for a day; giving presentation or pitches and a media training, to learn how to convey a (short) key message creating and working on an improvement project for their organization; convening a workshop during a conference for CNAs. During the programme, participants had a mentor within their organization that was to support them in connecting to other people in the organization and with whom participants could discuss their personal development goals or struggles as well as the development and progress of their improvement plan. As such, educational techniques included: experiential learning, shadowing, mentorship, Coaching
5. Who provided	The Dutch Nurses Association (DNA) organized the pogramme. Two certified trainers, specialized in leadership development for nurses and organizational change in health care settings, guided the programme. They were supported by a facilitator from the DNA, who was a former CAN. Besides, guest speakers from the DNA provided individual parts of the programme on specialized topics. These trainers and facilitator initially developed the programme and decided upon the course curriculum. However, as described below (see 9. Tailoring), adaptations to the course curriculum were made in response to needs and wishes of participants
6. How	The programme consisted of face‐to‐face days of instruction (contact sessions). In addition, the programme included a ‘field trip’ (see also point 7). Also, return days for programme alumni were organized. Besides, participants had individual coaching sessions with their mentor. Finally, the trainer had one meeting with each participant and their mentor. The field trip involved, first, a visit to the Dutch parliament, including an exchange with a member of one of the ruling political parties and a tour of the parliamentary building. Second, participants visited the Ministry of Health, Welfare and Sports, which included an exchange with policy makers about issues and questions that participants wanted to discuss
7. Where	Seven out of eight days of instruction took place in the building of the DNA. One day of instruction was ‘on location’: in the organization of one of the participants. Before the COVID‐19 crisis return days took place in the DNA building, during the crisis the meetings were online (using Teams)
8. When and how much	The programme consisted of eight 8‐h days of instruction, that took place every 4–weeks, and a field trip. Programme duration was 8–10 months. Return days took place about every 6 months after programme completion. The number of the individual coaching session was to the discretion of the participant and their mentor
9. Tailoring	Participants were encouraged to work on individual learning goals and adjust them during the programme when they felt like it. As such, no outcome measures, for individual participants or the programme as a whole, were defined prior to the programme. During the programme, the trainer and facilitator regularly discussed with participants what their needs were in terms of what subjects they wanted to discuss or what they wanted to develop or work on in addition to what was mentioned under two and four (above). These wishes and needs were heeded to as much as possible in subsequent course days
10. Modifications	Following the previous point, small programme adjustments were made in response to quests of the group. However, no noteworthy modifications were made that affected the content and overall aim of the programme
11. How well—planned	Not applicable
12. How well—actual	Not applicable

THE STUDY

Aims

For this study, we aimed to identify crucial programme characteristics and group mechanisms of an empowerment programme, plus which lessons could be learned from the hindrances reported by participants.

Design

For our exploratory qualitative study of four participating groups—one pilot group (May 2017–January 2018) and three subsequent groups (September 2018–May 2019)—we used ethnographic methods such as in‐depth interviews, participant observations and informal conversations. These methods allowed us to gain insight into both the mechanisms within each group, and participants' experiences and perceptions, plus to identify which programme characteristics enhanced versus hindered their empowerment (Ybema et al., 2009). We used the Standards for Reporting Qualitative Research (SRQR) in reporting our results (O'Brien et al., 2014).

Participants

All participants were CNAs (N = 44), of whom 22 worked in a nursing home and 18 in home‐care settings. For participant recruitment, the DNA distributed an informational brochure among organizations known for fostering an environment to stimulate employee development. These organizations' managers either distributed this brochure internally, asking interested CNAs to apply themselves, or directly selected CNAs who matched the desired profile, i.e., those with a known ambition to develop personally and become role models for other CNAs. Other study participants consisted of CNA mentors from within the participating organizations (N = 18, as some mentored more than one CNA). During an intake meeting with the facilitator and one of the trainers, participants were further informed about the programme. Additionally, the intake meeting served to assess the ‘why’ and ‘how’ behind potential participants' desires to participate in the programme and become role models for their peers, and to determine their developmental needs.

Data collection

First, we drew on in‐depth interviews, conducted with both programme participants and their mentors (See Figure 1). Participants from the first (pilot) group (N = 14) were interviewed twice: halfway through and 1 month after programme completion, for a total of 28 interviews. Participants from the following three groups (N = 30, 10 participants per group) were interviewed three times: once in the final month of the programme, plus once eight months and once 15 months after programme completion, for a total of another 72 interviews (some participants were not available for every interview and/or changed functions). Interviews with participants lasted between 30 and 90 min. Interviews with mentors were conducted after the programme ended and lasted between 20 and 50 min. All interviews were recorded and transcribed verbatim.

FIGURE 1

Study flow and overview of data collection (online source)

Lead interview questions—listed as an online supplementary source—were developed to invite participants to share their experiences of the programme, including which (personal) changes it had induced, what they had learned and whether and how the programme had affected their position within their organization. Moreover, participants were asked to reflect on which programme elements they considered important versus which could be improved. Mentors were asked similar questions.

Second, our data comprise some 150 h of participant observations made by the first author. These observations occurred during participant intake meetings, collective instructional sessions, return days, the field trip and throughout meetings between the trainers and the facilitator. The first author's role of ‘participant observer’ (Ybema et al., 2009) entailed her: participating in activities during collective instructional sessions, engaging in informal conversations with those present during lunch and coffee breaks, and joining the conversation during meetings between the trainers and the facilitator. Resultantly, the researcher quickly became part of the sessions and meetings, allowing attendees to act as if the researcher was not there (Ybema et al., 2009). Some notes were taken during the meetings in situ, while extensive notes were taken as soon as possible afterwards.

Ethical considerations

The Research Ethics Review Committee of ‘Vrije Universiteit Amsterdam’ approved this study. Research participants were informed about the study by the first author upon their initial meeting. Furthermore, participants also received information about the study via email, including details of the research goals, a confidentiality confirmation and instructions on how to withdraw from the study at any time if so desired. At the start of each interview, confidentiality was again confirmed (fake names are used for participant quotes in the results section) and participants were invited to ask questions and/or raise concerns. Written informed consent was also obtained from all participants.

Data analysis

In line with the exploratory nature of our study, and because there is limited available knowledge regarding the characteristics and group mechanisms of empowerment programmes for CNAs, we adopted an inductive approach to data analysis (Elo & Kyngäs, 2008). This inductive analysis was performed in three stages. First, the first and second authors familiarized themselves with the data by reading the interview transcripts and field notes several times. Second, we identified and preliminary coded programme characteristics, group mechanisms and hindering elements. Coding was done in MAXQDA, a software package designed to manage and analyse qualitative data (http://www.maxqda.com; VERBI GmbH, Berlin, Germany). Third, these codes were organized into descriptively labelled themes, e.g., ‘inviting CNAs to move outside their comfort zone of caregiving’. Throughout the process of data analysis, the first and second authors regularly discussed their initial insights. Likewise, they also discussed their interpretations of emergent findings with the other co‐authors until an agreement was reached.

Validity and trustworthiness

Data triangulation, i.e., combining data from in‐depth interviews with observational data (Ritchie, Lewis, Nicholls, & Ormston, 2013), enhanced our study's validity. For example, through observations made during instructional sessions the first author was able to detect specific group mechanisms, which also helped put participants' experiences as shared in interviews in context. Member checks, also referred to as respondent validation (Varpio et al., 2017), further enhanced our study's validity and trustworthiness. Specifically, during interviews, the first author would present interviewees with data interpretations and emerging insights, i.e., from both her observations and the previous interview rounds, and ask whether participants recognized their interpretations and/or could offer further contextual considerations (Varpio et al., 2016).

FINDINGS

We identified three crucial and strongly connected empowerment‐enhancing programme characteristics and two crucial group mechanisms, and describe these in the following paragraphs. From there, we will address two hindering elements and, in the discussion, elaborate on the lessons learned.

Inviting CNAs to move outside their comfort zone of the caregiving setting

First and foremost, we found that the programme characteristics of simply inviting, stimulating and challenging CNAs to reflect on their behaviour and engage in activities outside their comfort zone of caregiving were crucial to their empowerment. While this may seem obvious, the trainers and mentors stressed that CNAs are generally not encouraged to perform activities beyond the scope of caregiving. While participants were initially somewhat reluctant, the assignments functioned to motivate participants to become more agentic and to engage in activities other than caregiving. As one participant reflected:

During instructional meetings, and because of what they [the trainers] ask of you during assignments… You're expected to think beyond caregiving. This made me think more about my own role. Basically, they expect you to be active and contribute. So, at some point, you have to start doing that, and then you realize you are actually quite capable of doing so. (CNA33).

Mentors' accounts and our insights from observing participants during instructional sessions underscored an increase in participant enthusiasm and entrepreneurial attitudes, plus increased abilities to engage within their organizations, both individually and with peers. Likewise, observations during instructional sessions showed a rise in participants' self‐confidence following participation in activities other than caregiving. Moreover, by sharing their positive experiences, participants also inspired other participants to do the same. One participant, reflecting on the programme, articulated how she had experienced the support:

I learned a whole range of new things about myself, but also about the organization. Your view is broadened—you meet a lot of new nice people within your organization, but also outside it. We can actually do a lot more than we think. (CNA1).

Stimulating the discovery and use of untapped talents, competencies and interests

Congruent with the previous programme characteristic of inviting participants to move outside their comfort zone of the caregiving setting, another crucial programme characteristic was to facilitate participants in discovering their own unique talents, competencies and interests. This was primarily done through assignments: from giving presentations to writing projects, media training and participating in discussion sessions. Often to their own surprise, participants (re)discovered untapped talents, competencies and interests. Such discoveries often went hand in hand with the breakdown of self‐erected barriers for certain activities; feeling, instead, empowered as they did so.

Observations from instructional sessions provided us with tangible examples. For example, one participant conveyed how she had never acted on her interest to become more involved in her organization's policy processes. The reason: she was afraid of lacking the communication skills necessary to offer valuable input in the context of a formal meeting, e.g., with managers. However, after several discussion exercises, she realized—and this was repeatedly confirmed by her peers—that she was actually very capable of sharing clear and valid arguments. Feeling empowered and confident, she, eventually, adopted a role on an advisory board.

As another example, participants were often expected to give short presentations during instructional meetings. This served as an exercise in storytelling or in concisely conveying their viewpoint on a particular matter. Doing so, one participant discovered she had a unique talent for writing and sharing almost poetic stories about her work as a CNA. As she told her stories, she would often move other participants and the trainer to tears. Encouraged by these experiences, she further developed this skill of moving an audience, building confidence as she went. Towards the end of the programme, she read a story to an audience of CNAs during a conference, again moving people to tears. During an informal conversation with the first author afterwards, she emphasized how the programme had brought her there.

Not all experiences and attempts resulted in satisfactory outcomes, however, as participants generally set high standards for themselves, which sometimes led to disappointments. Whenever this (knowingly) happened, the trainer and other participants would encourage persistence, meanwhile setting more realistic expectations or goals. After subsequent attempts, the conclusion was sometimes to focus on a different, more personally fulfilling activity or skill. In general, participants were encouraged to concentrate on and strengthen skills that suited their interests and capacities.

Supporting the rediscovery of participants' occupational role and worth

Throughout the programme, participants were also stimulated to give words to why they had once chosen to become a CNA and why they currently wanted to continue their work as one. Observations during instructional sessions showed a gradual improvement in their abilities to articulate these thoughts. Moreover, programme assignments repeatedly encouraged participants to engage in discussions about the core of their occupational role. This resulted in most participants' increased or renewed commitment to and love for their work, and conveying a renewed sense of belonging and professional worth. Besides, participants became better at verbalizing how their role was both unique and complementary to the role of registered nurses, and stand up for the interests of their occupational group. As one participant put it:

The programme has really revitalized my wish to keep developing myself, both professionally as an CNA and personally. I definitely want to become more involved within the organization, to participate in platforms and additional trainings. And jump into the breach for fellow nurses to make sure our occupational role remains appealing. (CNA38).

Altogether, our findings show that the programme supported CNAs to rediscover the core and the worth of their occupational role, and enhanced their (re)discovery of neglected or untapped talents and competencies. Taken together, this enhanced the empowerment of participants: participants felt able and confident to represent their occupational group, or share their views. Importantly, participants also discovered that their role as a CNA could be broader than they thought. Rather than seeing becoming a registered nurse as the next step in their professional development, participants realized there were many interesting opportunities within their role as a CNA. As such, the programme also stimulated CNA retention.

Learning from and with each other

Learning from and with each other was the first crucial group mechanism we observed. As the various types of activities in the programme were new to all participants, they all found themselves in a similarly vulnerable position. Concurrently, a strong sense of community and companionship within each group emerged. To elaborate, because every participant put great effort into completing challenging assignments, they immediately gained each other's mutual respect and admiration. By repeatedly framing the participants as pioneers of their occupational group, emphasizing the challenges ahead, and celebrating every time an obstacle was overcome, the trainers and facilitator enhanced this sense of community and companionship. Assisted by the trainer and facilitator, instructional sessions provided a safe environment in which participants were challenged and encouraged to try new things—things participants would ‘never have done otherwise’ (CNA20).

Relatedly, participants also indicated they had learned the most from each other's experiences. For many participants, this involved realizing there were other CNAs who, like them, did not completely ‘fit in’ with their teams, e.g., because of their willingness to speak up or because of their strong or ‘alternative’ opinions about work‐related matters. Through the programme, these participants were able to connect with like‐minded peers, which felt ‘like a warm bath’. One participant recalled:

Within my team, I've always felt a bit like the odd one out, but I did not feel like that in this group. It felt like coming home every time we met, that was really great. It brought me a lot on a personal level: from always feeling a bit different to feeling recognized and that others appreciate you for who you are. (CNA26).

Moreover, participants learned from how their peers presented themselves, articulated their opinions and/or handled issues within their organizations. Similarly, participants learned from how their peers coped with challenges and setbacks, which in turn encouraged them to persevere in the face of opposition. By inviting participants to share their experiences, such mutual learning was deliberately encouraged by the trainers, and participants positively served as each other's role models, e.g.:

Jane, she's such a fighter. Lesley was really good at expressing herself. Frida, she was a bit shy at first, but also very capable at conveying a message—meanwhile, it'd take me 15 min to articulate what I wanted to say. I always thought her ability to articulate her thoughts was very special. […] Everyone brought something to the table. I learned something from everyone. (CNA19).

Seeing and learning from others had an empowering effect in the sense that it made participants realize they could do it themselves and enhanced their efforts to try and persist themselves.

Mechanisms of self‐correction and self‐motivation

The second crucial group mechanism we observed was each group's development of capacities for self‐correction and self‐motivation. This showed during instructional sessions when, e.g., a participant displayed a passive or pessimistic attitude towards their own abilities, or complained about meagre effects of their actions within their own organization. Throughout the programme, and following the example of the trainers and facilitator, participants called out when peers exhibited such an attitude. That is, participants would remind each other that such an attitude was uncharacteristic of a pioneer or undesirable as a representative of the occupational group. Moreover, they would stress that a passive wait‐and‐see or pessimistic attitude had characterized their occupational group for too long, and that it was in no way helpful.

Collectively, our findings indicate that the group mechanisms of, on the one hand, social support and companionship and, on the other hand, critical but constructive mutual feedback were crucial mechanisms. Observations during instructional sessions showed that the former was a prerequisite for the latter.

Hindrances: lacking direction, and lacking organizational support and facilitation

In addition to the crucial programme characteristics and group mechanisms, we also identified two hindering elements. First, as mentioned by participants, was a perceived lack of direction. Specifically, participants were encouraged to discover their individual talents and which skill(s) they wished to develop. Still, many participants initially struggled with this autonomous space to ‘go and explore’ (Advice from trainer, fieldnotes). Instead, they sought more direction in terms of what was expected. Somewhat paradoxically, participants experienced the freedom provided as a lack of direction. The trainers and facilitator reflected on this experience together and agreed that the CNAs lacked agency. Instead, as a result of their everyday work, they were accustomed to being told what to do. Consequently, participants expected also the trainer or their organization to give them explicit instructions. As mentioned above, participants eventually learned to critically but constructively address these passive attitudes when they appeared.

Second, we identified the hindrance of participants' perceived lack of support and facilitation within their organizations—a sentiment expressed by roughly half of those interviewed. Participants reported, for example, that their organizational‐colleague CNAs were showing a lack of interest in the programme, or were jealous of how they were developing new skills. This frustrated participants and sometimes caused a relapse into pessimism. Besides, participants often reported suboptimal (financial) facilitation within their organization. The extent to which participants received financial compensation for their participation in the programme—i.e., when hours spent on the programme were paid in full—influenced the amount of time participants spent on assignments outside instructional sessions. On the one hand, participants who received little or no compensation reported feeling reluctant to spend extra time on assignments compared with those who received full compensation. On the other hand, participants from the latter group sometimes felt that their role in care delivery, or their relationship with colleagues, was being compromised due to fewer care‐provision hours throughout the duration of the programme. Participants also indicated that, unless they had managed to secure either concrete further plans or tangible results within the organization before the programme's completion, then organizational support and facilitation generally decreased thereafter. Reflecting on the organizational environment, the trainers and facilitator later acknowledged that they had implicitly expected organizations to develop a more supportive structure.

In fact, the two hindering elements identified were arguably intertwined. A lacking sense of ownership and direction begot less organizational facilitation and vice versa.

DISCUSSION

Our main contribution is in delineating the crucial characteristics and group mechanisms of a CNA empowerment programme, and the lessons learned from hindrances. That is, we contribute by providing insights into the value of the programme's peer group, and particularly into the value of the shared learning experience for CNAs. By triangulating our interviews and observations of instructional sessions, we have been able to capture how group cohesion and shared feelings of ‘we're all in this together’ enhance the exchange of positive experiences and setbacks among participants. Participants were challenged, and felt empowered, to try new things. By observing their shared learning experience—including their critical, though constructive, mutual feedback—we were able to identify how mutual support and a shared experiential learning opportunity (c.q., Abraham, 2011) are essential characteristics of CNA empowerment programmes, enhancing the empowerment both of the group and individual participants. Subsequently, our findings complement existing quantitative research on leadership‐development programmes, which often fails to address programme characteristics and intra‐group mechanisms.

Our findings further point to the importance of challenging CNAs to engage in activities within their organization beyond their familiar caregiving setting. CNAs and comparable occupational groups may initially be reluctant to explore undelimited space and to enter into experiential learning experiences. This is hardly surprising given the marginalized position in which many CNAs find themselves (Both‐Nwabuwe, 2020). Our findings also underscore the importance of accumulating positive experiences for the enhancement of participants' self‐confidence. Due to their engagement in programme activities, participants increased their visibility, which, in turn, furthered their empowerment through subsequent experiential learning experiences (c.q., Hoeve, Jansen, & Roodbol, 2014).

This directs our attention to the importance of ensuring a safe, supportive and stimulating environment in which CNAs can experiment—a dynamic that is frequently absent in care organizations (Cummings et al., 2020; Curtis et al., 2011). Only in the context of such an environment will empowerment programme participants be able to fruitfully utilize their newly developed talents and skills following programme completion (c.q., Swearingen, 2009). A supportive organizational environment also facilitates participants. By this we mean that nurse involvement in, for example, advisory bodies should be considered normal and warrants facilitation in terms of financial compensation.

Additionally, participants' positive learning experiences and acquisition of new skills and interests not only had an empowering effect, they also fuelled participants' commitments to their occupational role and group. Specifically, some participants indicated they had been at a crossroad in their career, wondering whether to continue working as a CNA. Throughout the programme, these participants discovered ways and means for developing themselves and professionalizing within their occupational group, preventing a decision to exit the CNA field. The latter is an essential finding in light of the challenge of CNA retention (Both‐Nwabuwe, 2020; Hewko et al., 2015).

Limitations and future research

In this study, we have focused on the crucial programme characteristics and group mechanisms observed in the evaluated empowerment programme, and briefly attended to its (short‐term) outcomes. Future research could focus more on these outcomes, and on the changes implied for both participants and their employing organizations. Such research could focus on how CNAs actually implement changes within their organizations and address the challenges currently facing the LTC sector—thus assessing the longer‐term significance and impact of such empowerment programmes. Such a long‐term focus also allows for valuable insights about how the empowerment process evolved after programme completion.

Furthermore, we have not focused on the relationship between CNA empowerment and client outcomes. While we certainly underscore the relevance of doing so (cq., Wong & Cummings, 2007), we also pose that positive outcomes on the client level may only become apparent after a more extended period of time. That is, the CNAs in our study were initially focused on their own empowerment and visibility within their own organizations out of necessity: once they are able to carve out a place beyond the caregiving context, they will be better positioned to address the needs of care recipients. Future research will need to study whether this projection is correct.

CONCLUSION

Because of its focus on CNAs, the empowerment programme we evaluated was unique among care‐worker empowerment initiatives (Duygulu & Kublay, 2011). Our study contributes by identifying the programme's crucial characteristics and group mechanisms, thereby showing the significance of creating a warm, inviting and stimulating setting in which CNAs can explore and try new things. We have also identified how this encouraged participants to learn from, correct and motivate each other. When CNA empowerment programmes are developed in other caregiving settings, we believe these characteristics will remain essential. By developing CNAs' leadership qualities in a safe and supportive environment to enhance their empowerment, CNAs should be better prepared to eventually embrace their essential role in addressing challenges—both within their occupational group and in LTC sectors around the globe.

AUTHOR CONTRIBUTIONS

MW, KK, HN, RG, BB and PG were responsible for the study conception and design or acquisition of data, or analysis and interpretation of data. MW and KK performed data collection and analysis. MW, KK, HN, RG, BB and PG were involved in the interpretation of the data. MW, KK, HN, RG, BB and PG were involved in drafting the manuscript or revising it critically for important intellectual content. MW, KK, HN, RG, BB and PG have given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. MW, KK, HN, RG, BB, PG agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1111/jan.15259.

Appendix S1

Click here for additional data file.