Shift Wars

SHIFT WARS: Turmoil in the halls of the LTC facility

In my years as a CNA I have seen many a good aide leave a job because of issues between shifts. I have also seen aides become bitter and negative because of bad feelings between other shifts. This is so silly and unnecessary- really. There are ways to manage the transition between shifts. It all starts with an attitude change.

Attitude change? Why, one might ask? Think about it for a moment. If you come to work “ready” for a bad day, you’re going to get what you ask for. If you come to work in a bad mood, chances are pretty good the day will get worse.

If you assume the folks on another shift are lazy, then in your eyes nothing they do is good enough or right. No amount of “excuses” will convince you that they had reasons for not getting everything done. Of course your excuses are paramount and real when you can’t get
YOUR work done, so you have a right to expect other shifts to understand your issues, right?

Hmm. Lets look at this mindset.

Stuff happens. To everyone, on every shift, every day. Residents get sick; they have major accidents, they die. Staff work short, new admissions show up at inopportune times, room changes happen during every shift. Equipment breaks down, water turns off or gets too cold for baths. Toilets clog up, power goes out, families complain.

Each shift has it’s own set of unique problems, staffing patterns, nursing issues, demands, expectations. Residents also have their own demands and needs that are different for each shift. One of the first things to keep in mind is this. If you have worked another shift don’t think you know it all. LTC is notorious for changes happening all the time- what used to be common may not be anymore.

Managing the transition from one shift to another is a process and it involves nurses and aides from both shifts. Communication is SO important- as well as having empathy and understanding. A process should be in place to make sure each shift’s staff has clear expectations. Leaving a unit in good shape for the next shift is the goal, and here are some ways to get to the goal:

1) Identify problem areas. First and paramount should be the residents safety, comfort and well being (not staff’s comfort and convenience).

2) Once problems are identified, list ways to prevent/fix the problems. For example, one complaint that is common between shifts is the condition of bed bound residents. Mrs. Smith is always soaked. Her bed linens have brown rings! Her clothing is wet all the way up to her neck! What can we do to prevent the oncoming shift from having to deal with this? (perhaps knowing the Mrs. Smith is a heavy wetter would indicate she has a need for toileting program geared more to her individual needs. Also, look at the products being used to manage her incontinence- maybe she needs better briefs and hourly changes.)

3) Make a form called “UNIT ROUNDS”- here list everything that should be in place for the next shift. List every area of concern; place a check box or two next to each subject.

4) Implement a UNIT ROUNDS procedure. Staff from each shift assigned to do this duty- together they make rounds and check the areas. If Mrs. Smith is found wet, staff from outgoing shift need to change her, or staff from oncoming shift except Mrs. Smith’s condition and change her themselves. This procedure will take time at first- allow at least 15minutes at the beginning stages of this. Staff who makes rounds should “sign off” they have done rounds and excepted the unit as it or fixed the problems.

Another area I frequently hear about is specific to 3rd shift and 1st shift. Getting up residents. This is more than just an issue for staff- this effects the residents, the way your day can turn out, and families. Priority MUST be given to resident rights and family concerns. Never should such an issue be talked about without input from the Resident Council, families, the DON and Administrator. Residents who get up too early will not thrive, they are apt to be tired, grouchy, not able to eat well, drink well and behavior problems can result. Getting residents up before 5am should not be allowed. Many residents are from a generation where they did awake and rise early, this should be considered when developing a plan. I think the reasons for early get ups should be resident based- not based upon making 1st shift’s job easier or less hectic. DON’s should really look into the feasibility of these types of practices and decide if morally they are right. Also, think about safety. 3rd shift has way less staff than days, and having several residents up can create a safety issue. Who is keeping an eye on the residents who are up and about?

When residents do get up early, when are they toileted? A resident who gets up at 5:30am should be toileted at 7:30 am- does the staffing pattern allow for this? Is someone from day shift available to do this, or are they all getting other residents up? Quality of life must be taken into consideration.

The culture of shift wars and charge nurses responsibility
Do the charge nurses inadvertently create more of an issue with these shift wars? Tough questions that should be looked into. When the CNA’s complain, charge nurses may not respond to the issues, or think they are petty. This creates a HUGE morale problem for the units.
Nurses need to find time to listen to the CNA’s complaints and help them identify what is important and what isn’t. Help may be needed with skills of communication with each other and members of other shifts. Implementing the Unit Rounds procedure will help but not eliminate shift wars. The nurses must set and example by getting along with the next shift.

A Call For Action

CNA’s work in a world full of intrigue and deceit. There are good points to the work: The joy of helping others who need us; the joy of being there and giving good care. Of watching our charges enjoy their limited lives. But there is another side to our work- the inner dealings between staff. Hopefully you have read the article called “Horizontal Violence”- if not please do so now. This page is furthering the message that HV started out with.

Too often we see new CNA’s come into work with high ideals and goals that seem unrealistic. And too often we go out of our way to stamp these ideals out the door. Those of us who aspire to do our jobs in the best manner possible are often left feeling disillusioned and depressed. It is my hope that CNA’s everywhere can get over this foolish mindset and get back to nursing care. CNA’s are their own worst enemies and until we all stand together, we will always be at odds with one another, and hence not respected.

Not all of this is the fault of the CNA’s. The way nursing homes are set up- the actual systems that run the facilities are also to blame. Staffing ratios do not support good care; infact the standard ratios we work with each day are the very cause of most of our problems. Management of the average nursing home supports the “Superaide Syndrome”: These are the aides that can handle killer assignments with no complaints and with no issues time wise. They can have 25-30 residents on their lists and get it all done in a few hours. No one questions the care these residents received; no one even stops to think about the fact that it is impossible to do good, or even poor care, in this time. Nurses don’t question anything because they have come to rely on Superaide to get work done- and this makes the nurses in charge of the units look good. Another thing that condones this mindset are people who have worked in a facility for years and who have always done things a certain way. Change is hard for them; new ideas and new ways of doing things don’t sit well. Of particular interest here are the newer and tougher OBRA regualtions relating to care. What was once an “easy” resident suddenly has become one with ROM needs, ambulation needs, among others. Superaide knows she cannot get all the care done, but she can’t admit to this because it might make her look bad. So what does she do? She says she does the care but in reality the care is not done. Because she is so used to being the “best”, being the one who can handle the large groups, she feels compelled to keep her reputation up. She resists asking for help, for the same reasons. Others notice that the care isn’t getting done, but no one speaks up – for various reasons. Perhaps they are in the same boat; perhaps they are afraid of the aide-especially if she has worked at the facilty for a long time. Often superaides are in mentor-like positions. Because they have worked for so many years, they are trusted to train the new aides. This is a serious problem.

Directors Of Nursing should always be aware of this. They should be out on the floors watching the staff work; watching them interact with the residents; checking out the paperwork and even timing the aides. If the DON sees a problem, she should act to correct it. Instead of an aide getting into trouble, why not hold a meeting to brainstorm ways to prevent this lack of caring-behind the scenes deceit.

What can a CNA do if she walks into a facility that has this mentality? This is a hard question. There are several options. All are not good, and depending upon the individual situations a decision will have to made that best fits the circumstance.

A scenario to ponder:
A CNA starts a new job at a facility- as a PRN staff. After about three weeks, new CNA notices she is getting out of work later than her peers, and later as in overtime. During the afternoon rounds, each CNA is assigned to get the VS of half the residents on a given unit. This is time consuming for all, but it should take about the same time for each aide. New CNA is told by Superaide to “Write in VS but don’t really do them; just look at the VS from previous days and add/subtract a number to make it look good”.

What to do???
Option A: Tell Superaide no way, thanks for the tip but it’s not how I work. And leave it at that….
Option B: Report Superaide’s advice to the charge nurse. And face repercussions real fast.
Option C: Go along with Superaide: She can’t be wrong, after all she has worked here for years…
If New CNA chooses Option A- all would be ok except for the overtime issue. And she would live with the knowledge that residents are not having their VS checked; what if something was missed (fever)? If New CNA chooses Option B, New CNA will have quite a time at work. Superaide will deny this and go out of her way to ruin New CNA’s chances of looking good; New CNA will be made to look bad and be placed on a list of people to watch out for….If New CNA chooses Option C- New CNA will live with the fact that she is falsifying records, not doing what is best for the residents, and could face serious problems if caught.

WHAT WOULD YOU DO?? Think about it.

The next section here deals with us- why we choose to skimp on care and why we choose to treat our peers poorly. One of single biggest reasons for high turnover is pay rates and lack of benefits. Right after these comes working environment: Included in environment is our relationships with peers. No one wants to work at a place where they are not respected. No one likes to be out casted or back stabbed. Yet in nursing this happens ALL the time. We do it to each other every single day. Why? To make ourselves feel better about who we are. To make ourselves look better. To take the pressure off of us and any of our own misgivings. When we choose to treat our peers in this manner, we are choosing to make our own work life harder. How is this so? Think about it: Staff leave when they are not happy with the way they are treated; they leave when they know working elsewhere is easier. Staff will say- “The hell with you!” and leave you high and dry. And if you treated them poorly than you deserve to be left.

TO SUPERAIDE:
So what can you do? You can change the way you work with other’s by simply being nice to them.You can say “please” and “thank you” more often; you can make sure you’re work is up to par and not cheat with any care. If you see that you can’t get it all done, ask others if they too are having the same difficulties. Together you could all brainstorm with management to solve the issues. Instead of infighting among each other and making the work place intolerable. Don’t sabbatage the new CNA’s/High Ideal CNA’s; instead watch them and see if you can incorporate some of their habits into your work. See if you feel better when you do it right.

TO HIGH IDEAL AIDE:
And what can you do? To start with, realize that this is one of the most difficult jobs in the world. You are responsible for human beings, and because the system doesn’t always support your idea of good care, you may need to relax a little with your expectations. You may need to be supportive of the superaides who feel compelled to rush through their work; you could set an example to them by showing them that slower may be better. If they see that you take pride in doing a good job, that you go home happier than they do,they may change their thinking. Don’t skimp on your work just to follow the crowd; move as fast as you can without sacrificing your sanity; don’t expect miracles and don’t cheat. Never faslfy records. If you can’t get it done, say so and ask for help.

TO CHARGE NURSES:
Set the tone for your units. Make it clear what is very important to you- what can be skipped and what cannot. If the unit is short of staff, meet quickly with the CNA’s and go over what HAS to be done. Help the CNA’s set priorities and goals. Offer help if you can; be there when they need you; keep an eye on the unit and the care that is being given. Don’t allow any infighting or backstabbing. A good nurse I worked with had her own way of dealing with this stuff: As soon as an aide came to her with a complaint about another aide, nurse pulled them off unit for a little meeting. Often the brunt of an issue is comminication related. This nurse had the wisdom to know that if she condoned backstabbing, she herself would eventually become a victim of it! She realized that this was not condusive to good care so she had a ZERO tolerance policy. The unit was staffed with aides who worked well together, who problem solved on their own a lot of the time.

TO DON’S:
OK the buck stops with you. You are responsible for the smooth running of the nursing dept. You are it- in the eyes of your nurses and aides. You command their respect, and you set the tone for entire nursing staff. Make sure you are not enabling the infighting and backstabbing behaviors so often seen in nursing homes. Make sure your door is truly open, as well as your mind and conscience. If staff come to you with issues, listen to them. And don’t go back behind their backs with negative “takes” on what you heard. Like the charge nurse, you should set a zero tolerance policy for the behaviors that will keep your turnover high. You can save your facilty a lot of money by retaining good, loyal CNA’s and nurses. Make sure you realize the workloads of the CNA’s- take a group once in awhile yourself to keep a reality check in place. It’s very enlightening.

WHAT NEXT??
We ask ourselves. What can we all do to make it better? Why are ratios so high, with so many expectations placed upon us? How can we get it all done? Maybe we can’t. Maybe the systems really need to change. This could take years! In the meantime we must do the best we can. No one can knock us for this. If the work proves to be too much, if we go home daily feeling bad about all the things we didn’t get done- than maybe we need to leave nursing for now. It isn’t worth our mental health. Nothing should make us so miserable. Especially work.

Working as a CNA is very rewarding, yet very discouraging at the same time. Finding a balance between what is right, what is OK and what is wrong- isn’t written in black and white. In nursing there are many gray areas for us to ponder. There are some things we know are WRONG- abuse, willful neglect, causing pain and ignoring calls for help. But there are other things that at first may seem ok- but after thinking we see they are not ok. Just because another aide does something one way doesn’t mean it’s the right way….

Follow your instincts. Most of us get a “gut” feeling when we are doing something of questionable ethic. Most of us know better. Many of the new CNA’s don’t know better and it is up to us to make sure they don’t follow that path to superaidedom….Instilling a good work ethic in another person is not that hard. Setting an example works wonders. Don’t get discouraged if you don’t feel you can “Stand up for what is right- even when it may mean you stand alone.” This is my motto, but I am a strong person who knows my own convictions and level of courage. Not everyone is in a position to do this; many of us need our jobs and need the money. If we work in a place that isn’t supportive of good care then we risk losing our jobs. Only you can decide what is important. No one else can make this choice for you. Like the poem says- “The road less traveled…” isn’t always the best road.