Question Of the Week: They Won't Let Us Call Out

Question:
At my facility we're not allowed to call out! Lately there's been a lot of call outs and even more aides quitting. So we work short all the time. A couple aides have hurt their backs too cause we're short all the time. Anyway I got the "bug" last week and had a fever, vomiting, and diarrhea. I felt horrible. I couldn't eat anything; I couldn't keep anything down. I called work to let them know I would be out for my shift and they put me through to the DON. who told me to come in for work, to report to her prior to clocking in so she could assess whether I was too sick to work. If I didn't follow this directive, I would be terminated. SO I went to work and the DON took my temp (101.2)- she gave me Tylenol and a couple spoonfuls of Pepto Bismol; she told me report for duty. If I didn't feel any better in an hour to come back and see her.

Is this legal???

Answer:
Your email tells me your employer is having a hard time with staffing. It appears that the place is going through a downward spiral of problems and management is part of that. When an aide shows up for work, sick with fever and infection, she exposes not only the residents, but her co workers as well.

It's very likely more than a few will catch the illness. So, it spreads like a fire. As each aide comes down with the bug and misses work, management feels it has to do something to curb what it perceives to be an abuse of attendance policy. Management should be prepared for a staffing crunch knowing a virus is going around. But, this facility's management is punishing the very people who are out in the battlefields where the germs are located. It's old fashioned and autocratic.

Instead of being proactive, the DON is being REACTIVE and in a very negative manner. Her actions are telling her staff that she doesn't trust their judgment on their own bodies health. She is also telling them she has no respect for them. A warm body on the schedule is all that matters, even if that body's temp is 101.

The Legality of this:
If this is a policy, it must be written as such.

I called a lawyer friend and relayed this scenario and she gave me the following advice: Is the DON a doctor or a Nurse Practitioner?? If not, she is straying from her nurse practice laws. Nurses cannot diagnose illnesses, diseases, disorders and the like. Perhaps she is sending staff to a doctor who is legally licensed to perform a medical assessment. She would be smart to do this. She should NEVER give staff ANY medications without a doctors' order. She is putting her license on the line by doing so. She knows this. And is counting that you don't know this.

Legally this practice is not advised for management. They are risking a discrimination lawsuit if this "policy" doesn't cover ALL employees of this facility- so, when the dietary aide or the cook or the maintenance man calls out, the DON/Management must apply this same requirement towards them. They too must come in, be assessed, and determined if they're "healthy" enough to work or not. And this would mean doing so 24 hours a day, 7 days a week. Even on holidays and weekends.

What To Do?
If you find yourself too ill to perform the duties of your job, you can and should call out. However, you should also make every attempt to get better or try to reduce your symptoms so you can work. In other words, do take Tylenol/Advil to get the fever down. Immodium will end just about every episode of diarrhea. After this, if you still feel too sick, call out. Make sure you follow the policy- most facilities require 2 or 4 hours notice.

Have your spouse or a friend make the call for you if you're concerned with being harassed by the DON. Instruct your spouse/friend to take a message but to be firm: You will not be showing up for work. Make sure your reasons are given: Details- fever, vomiting, ect. and the actions you have taken to try to make it better. Then call your doctor and make an appointment. You'll need to be assessed and diagnosed properly; and the MD will need to write you a note excusing you from work. Often, this note will include actual dates you are not recommended to work.

A doctors note will not protect your job.
We need to know this and not rely upon it. The note does give credibility to you though: You're putting the effort into seeing the doctor to find out what is wrong and get better; you're paying money to do in most cases; you want to show your employer you weren't goofing off, ect.

You can still be terminated unless you're a member of a union which has rules on this.

I would not wish to continue employment at a facility where this practice occurs. I would leave on my own free will and seek employment at another place with more enlightened management.

Professional Boundaries

In this article, I want to present a concept that should be well understood by all CNA’s. Here, we’re going to discuss what can happen when we become overly attached to a resident, or their family and the implications this has upon the facility.

One of the better changes for some LTC facilities is consistent staffing. However, this staffing model has created some unintended consequences.

CNA’s develop long term relationships with those we are charged to care for. We grow to love them and will do all the little “extras” for them. Usually this doesn’t present a problem for anyone. But there are times when our relationships become unhealthy- for us, for the resident, for the other residents we’re assigned to; to our peers and to the facility we work for.

Over Attachment
In nursing homes, CNA’s can become too attached to a certain resident, in different ways. The CNA will be very upset if they are not assigned to care for this resident, or, will use their relationship with this resident as an excuse for being exempted from floating to other units. The CNA might spend inordinate amounts of time with this resident, and therefore shortchange the others assigned to him/her. The aide will always cater to this residents’ every whim before all others. This resident will have more needs than all others as well- and these “needs” will increase as times moves along.

Sometimes, the resident develops a fondness for an aide that isn’t healthy. The resident becomes dependent upon the aide’s presence to be happy. He or she refuses to allow other aides to work with him/her. Residents have “bad” days when their favorite aide isn’t at work. I have seen residents who believe they are “in love” with their favorite aides, especially those with mild dementia. I’ve also seen aides who care for patients in short term rehab centers develop “crushes” on these patients. The age difference between patient and aide isn’t that far apart.

Other assigned residents are neglected. Often. Or, the needs of these residents are tended to by the CNA’s peers. This creates a problem for everyone. Resentment sets in and working relationships suffer.

Being Objective
A huge problem with this arrangement, as it’s often called, is when the aide loses his or her ability to be objective. This is a serious concern. We must be able to truthfully report the conditions of our residents. This includes, but isn’t limited to, the residents progress or decline in all areas: Ability to speak, bath, dress, feed self, walk- are all very important. The CNA who is too close to certain residents isn’t able to accurately describe the resident’s true abilities.

This effects the resident directly: A resident who cannot really dress herself can be assessed as being able to do so. This might end up in a care plan…and other aides who work with this poor resident will get frustrated at THEIR ability to motivate this resident. Families are told their loved one can still dress herself when in fact she cannot, and hasn’t been able to perform this task for awhile.

We have professional boundaries
CNA’s are considered to be the professionals in the care giver-patient relationship. A CNA is expected to maintain a therapeutic relationship and not anything else. We have the upper hand because of our knowledge and skills. We are responsible for the care we deliver. Within the ethical discussions on this subject, the care giver always has power over the patient. Many times these relationships are for the benefit of the care giver and not the patient.

When the care becomes intertwined with personal friendships and over-advocacy, it’s not healthy. What is OVER ADVOCACY? It’s when we demand residents be given care, therapies and attention they don’t truly need. This is often where over attachment to a resident’s family starts. This is another whole problem- and the legal implications are high.

Ask yourself these questions. And be honest. If you can answer more than two of these with a YES, then YOU are crossing the professional boundaries. And setting yourself up for a lot of trouble.

* Have you ever spent off-duty time with a patient/family?

* Do you keep secrets with patients/family?

* Do you become defensive when someone questions your interaction with a patient/family?

* Have you ever given gifts to or received them from a patient/family?

* Have you felt possessive of a patient/family, thinking that only you could provide the care the patient needs?

* Have you ever flirted with a patient?

* Have you chosen sides with a patient against his or her family and other staff?

If you find that you’re overly attached, how to manage that? It’s not easy. The first step is recognizing you have a problem. Then, its a matter of distancing yourself from the resident. For some aides this is best done gradually. For others, a total cut off is appropriate. Many times, when the bosses see these problems, they’ll assign the aide to another unit altogether, effectively ending the relationship. I don’t think this is a good way to do this.

A CNA can ask for a change with their assignment. Being open and honest about this will almost always result in getting the changes you seek. Part of being PROFESSIONAL means keeping staffing issues to yourself. The urge to tell the resident, or the family, a change has taken place might be very high. Its best to leave these discussions with the nurse. And, after the resident and/or their family is informed, THEY will prod the CNA for information. Again, professional boundaries must take precedent over individual staff needs.

A note about being attached to resident families.
It’s not as common as resident-CNA friendships. But its much more dangerous. And, many times these relationships are initiated by the CNA.

Often times:
A family will block out all others in the facility and depend upon the aide for all communication. The aide will be put into situations they are not trained and educated to handle. Every word the aide speaks will be heard and recalled. If the aide doesn’t have the right information, or misspeaks, a lot of trouble can arise, legally.

The aide will become a spy, for the family. CNA’s are privy to some information that is private and confidential. The levels of care for other residents is an example. When we have over bearing families seeking information from aides who are all to willing to share, it creates huge management problems. It sets the stage for a turbulent relationship between the FACILITY and the family.
Some aides like to think families have some super power over a facility. This is simply not true. Government regulation and oversight have “power”; as do legal standards.

Other aides will use the family in an effort to be assigned to the resident they want. From my experience, these residents are almost always the ones who are considered “easy to do”– and the aide is simply seeking a guarantee of being assigned to this resident. There has been some evidence of aides seeking permanent assignment to certain residents in hopes of getting some monetary award. These situations are always unethical. The aides involved in this should be terminated from employment and barred from working as aides ever again. They are opportunists.

No matter whether a CNA is overly attached to a resident or their family, it’s not usually healthy. Most times the only way to stop the problems associated with these relationships is to separate the aide and resident. Perhaps, consistent staffing would better serve all if the assignments changed every so often. A couple times a year and all aides would be required to change no matter what family requests are. We all want what is best for the residents. Sometimes though, in order to insure this is happening equally across the board, we have to make adjustments and changes.

Two Week Notices: Why It's Important

Over at the Network 54 CNA Forum a CNA brought forth an issue that must be addressed. This is about giving proper notice when an employee decides to quit their job.

NO MATTER what, a CNA must give a two week notice in order to be considered for re-hire status. Also, it’s the right thing to do. Think about it. If an aide is scheduled to work many shifts but suddenly quits, it leaves ALL those shifts open and often unfilled. Who suffers? The residents, patients, clients fist and foremost. Then the aides left behind to do the extra work. Management has to fill the position and do all the human resource things associated with this: Background checks, abuse registry check, hiring, orientation, mentor-ship if there is any, and on the job training.

In any line of work, it is considered absolutely vital to give at least two weeks notice of intention to leave a position. If one holds a college degree, usually this is a four week or one month notice.

In the Network 54 thread, the aide uses the excuse she was sick and couldn’t manage to work- which is a reasonable issue but would have been better handled a different way. She should have gone to her doctor and got a note excusing her from work for several days. We cannot expect to just ask for time off with no notice and get it. The DON refused to grant the aides request.
The aide quit her job..and then when she felt better she tried to go back to work at the nursing home. She was told she wasn’t eligible for re-hire, because she walked off her job. Her action had a consequence. Further, when she applied for work at other facilities she was not given a good reference- another consequence to her action.

While I sympathize for this aide, I also resent that she felt it was appropriate to simply quit. And leave her co workers the brunt of the work, probably many unfilled shifts of hours open and most importantly, left the residents in jeopardy of poor care. Had she brought in a doctors note we would have seen the same thing, perhaps. But at least we would know she was truly ill (which I don’t doubt) and management would have kept her on staff; she would have returned to work and spared us all the time and effort of training new hires and all that.

Giving proper notice for leaving a job is just the right thing to do. When it isn’t done, there are many who pay the price.

Shift Report: It's Very Important

I have been reading here and there about shift report.

How some nursing homes don’t seem to think the CNA needs to hear report. I think this is not only wrong, it’s bad business and a law suit waiting to happen.

CNA’s are the hands on care giver.

They are the eyes, ears, noses and hands of the health care team charged with providing care to residents. When a resident’s condition changes, does it not make sense that the first, and more often than not ONLY people who will have any direct contact with the resident KNOWS of the change?

Nursing home management, that decides CNA’s don’t need to get shift report are setting the residents AND AIDES up for potential injury, harm and distress. Physical and emotional. Nurses, going down the hall, barking out orders to the aides, AFTER the nurse has heard report is not acceptable. By then we have often done our first set of residents and it’s too late for some orders to be carried out. Or, the resident must be placed back in bed or otherwise inconvenienced. And it wastes time, that which CNA’s don’t have a lot of.

Consider this. A resident fell on evening shift. At the time no known issues resulted from the fall, but the resident needed to be observed and assessed periodically until the doctor could see them the next morning. The doctor tells the evening nurse the resident is not to do any weight bearing activities until he sees the resident. Day shift staff arrive and are given their assignments and are told to go about their job. The aide assigned to the resident who fell has no way to know that a fall occurred… The CNA doesn’t get this info and transfers the resident via a stand pivot. SNAP. A hip is broken.

Consider this. A resident’s urine is noted to be dark and foul smelling. The resident cannot speak for herself but is continent. The day shift aide assists resident to the toilet, where she voids a medium amount of dark smelly urine…the residents usual habits indicate she won’t be voiding again until sometime after lunch. A sample was needed from the morning void but that info was never passed on to the aide in time. Now the resident must endure many more hours of discomfort and pain from the UTI she has, all because of a lack of communication.

A resident was up most the night. For whatever reasons, he could not get to sleep. He is known to have behaviors, and a trigger to this is being tired…the aides don’t get report. They find him in a deep sleep and think, “Oh well, he has to get up to eat!” and wake him up…and the aide gets punched in the face. A nice black eye and broken nose are the result. And time spent at a doctors office, ex rays, pain and suffering…all on worker comp billing. Because it was never passed on in report to allow the resident to sleep this morning.

Shift report is vital to CNA’s.

We NEED the information…even when it is repetitive and mundane, it is important. CNA’s must have this information BEFORE they asked to provide care. The little details are often so helpful to us. When we know Mr. Jones hasn’t slept all night, we will allow him to sleep in, to be the last resident we get out of bed. When we know Mrs. Smith might have a UTI, we will collect a sample – many times without being asked. When we hear that Ms. Brown fall last night, we will ASK if she is able to do any weight bearing.

Report doesn’t have to be this long boring ordeal.

Many facilities only pass on information that is out of the ordinary; the typical, usual and common information doesn’t always need to be shared. Normal vital signs, BMs, percentages of meals consumed and cc amounts of fluid intake are not overly important, especially if this information is logged in a book somewhere. On the other hand, elevated temps and B/P’s DO need to be passed on; a lack of a BM in 5 days NEEDS to be passed on; consumption of NO fluids has to shared.

Part of what every CNA needs is information.
We use our training and experience to make everyone’s jobs a little easier; to make our residents comfortable. We depend upon good communication from previous shifts and nurses to provide care that is safe and appropriate. Nursing home management should always insist CNA’s take part in shift report. It should be a mandatory expectation; and, taking this one step further, if an aide shows up late for work, he or she should NOT be allowed to take an assignment until they hear report.

Observation Skills For CNA's

First, make sure you understand the nursing process and how CNA's fit in with it.



When we think about it, CNA’s are the eyes, ears, hands and nose of the nurses. We use these senses when providing care and with the right skill, we can assist the nurse with valuable patient information that may avert a serious problem. Things get confusing though when we make judgments about the things we’re seeing, feeling, smelling and hearing.

There are two types of observations.
Subjective and objective.

Objective observations are fact. They are measurable.
• Vital Signs
• Bruises
• Open Areas and other skin conditions
• Blood in urine
• Urine output from a cath

Objective observations are reported in the same manner by many people. They are not biased and they do not rely on statements and guesswork.


Subjective observations are made by the patient:
• “I have a headache”
• “I feel sick to my stomach”
• “My sugar levels are off”

Subjective observations are reported by the patient and are just as important as objective observations, except they are not measurable. The nurses need to know when patients have complaints such as those listed above; the nurse can assess the patient and determine what course of treatment or intervention is needed. CNA’s cannot pass judgment on these statements.
It’s not in our role to do so. Our job is to REPORT the statements, accurately and without added
flair. I often see CNA’s report observations- with their own opinion added in. This isn’t necessary and it’s not good to do. Just the basics is all that is needed. If you’re asked for more information, like, “What do you think is going on?” then by all means give your opinion. But don’t offer it up front as part of the observation.

Examples of CNA statements that are not correct:
Incorrect:
“Mrs. Smith says she has a headache. She does this whenever it’s her bath time!”
Correct:
“When I went to assist Mrs. Smith with her bath she stated that she had a headache.”

Incorrect:
“Mr. Jones ambulated ten feet today; he said his foot hurt…yesterday he was fine and walked a hundred feet and his foot didn’t hurt! He’s being lazy.”
Correct:
“Mr. Jones ambulated ten feet today.”

Incorrect:
“Ms. Hawthorne had a really loose BM and it smells like C Diff.”
Correct:
“Ms. Hawthorne had a loose BM that was very foul smelling.”

I think we get the picture here. Many of the things we know from experience with our work turn out to be true. Ms. Hawthorne probably does have C Diff…we can tell by the odor. BUT it’s not up to us to report that as fact. Are we absolutely sure Mr. Jones is being lazy? What makes us assume that? IS it possible that his foot really does hurt? As CNA’s, our job is NOT to make assumptions and diagnose conditions. We observe, we report. It’s pretty simple. No need to embellish our reports with our own opinions. We’re not always right.

How we observe
Using our eyes we see things:
• Broken skin, open areas, cuts, bruises
• Blood- in urine, in and around the mouth
• Changes in the patient’s ability to walk, speak, eat

Using our hands we feel things:
• Pulse
• Skin temperature (warm, cool)
• Lumps and bumps under the skin

Using our ears we hear things:
• B/P readings
• Respiration problems (wheezing, coughing)
• Patient’s statements

Using our noses we smell things:
• Body odors
• Foreign odors not normal to what we are doing (gas and oil, chemicals and the like)

Observations must be accurate.
Observations must be made in a timely manner and the nurse must be notified of unusual findings.
Observations must be free of our opinions and bias.
Report patient statements word for word...directly quoted. Don't add your own thoughts.

© 2007. All Rights Reserved Nursing Assistant Resources On The Web
This material can be used freely for educational purposes.

Horizontal Violence

Horizontal Violence

The stories are all too familiar. CNA's treating each other poorly. New CNA's often receive the worst assignments and are blamed when things go awry. Experienced CNA's participate with this "hazing" of new staff. The overwhelming need to fit in is important. But at what cost? Does anyone consider the consequences of their actions? Increased turnover is the result of Horizontal Violence and job dissatisfaction. This means increased workloads for those left behind and this results in poorer quality care for the residents. Another possible ramification is the image the general public has of CNA's and of Nursing in general. CNA's aren't considered to be professionals. A case for professionalism isn't made when patients hear CNA's telling each other off or arguing with nurses. All CNA's should work together to stop Horizontal Violence. What can the CNA do to help stop this?

It is easy to say: "I refuse to participate in any activities that may undermine another person's worth"...But some lack the courage to say this. A lot of changes must take place in workplaces to create an environment in which CNA's need not fear communicating the truth, and where others invite their input and listen to it. In reality, actions speak loader than words. Those who are looked to as role models or have the courage of their convictions should act to create such a workplace. It is acknowledged that where Horizontal Violence occurs management is a part of the problem. Behaviors begin at the top. If their is a perceived lack of support then there is little likelihood for change. Policies need to be in place, and supported, which clearly state the work ethics of the institution. Change is difficult but it is to the advantage of the CNA, the resident and the entire facility.

The average CNA can contribute. Follow the simple Golden Rule: Do onto others what you would want them to do to you. Treat people the way you want to be treated.

Try adopting the following into your everyday work habits:
Use kindness, concern and respect in all dealings with others.
Respectful listening-look peers in the eye when talking
Lead By Example (Make a bed for another CNA who is behind)
Own up to your mistakes, don't attempt to shift the blame
When making requests, be polite, be tactful.
Use a positive and respectful tone
Don't participate in gossip
Invite loners and newcomers to breaks and meals
Tell the nurse she did a great job or compliment her for something extra special she did to help.
When others do a kind act, thank them in front of others,
Bring your whole self to work and give it your best shot
Accept your fair share of the work load.
Respect others privacy
Be respectful of shared working conditions
Be willing to help when requested
Work together despite personal dislikes
Don't denigrate to superiors
Address peers by their first name
Ask for help and advice when needed.
Repay debts promptly
Stand up for peers in their absence, don't be critical of them.
Smile

Some of the effects of the above acts:
Increased job satisfaction
Higher self esteem
Personal power
Happiness
Faith in Self and in Others
Lower absenteeism rates
Work environment deemed more "family like" than"just another job"

A Note About Vertical Violence (from nurses to CNA's):
The manner in which nurses treat each other as well as CNA's needs to be addressed. How do we handle a situation such as being yelled at by a nurse because we didn't get something done? When a nurse (or CNA) is yelling at us, it is virtually impossible to maintain any sense of control. We get embarrassed, we are humiliated and get red faces. While being yelled at we cannot even begin to defend ourselves or explain what has happened. The best thing to do at this point is to ask the nurse, in a respectful manner, to leave the area and go to a private place. This is where these discussions should take place in the first place, and CNA's should always insist on this. Ask the nurse to restate her concern without the load body languages and tones. Once you think you understand what the nurse is saying to you, rephrase it back to her. This is called validating. Once she agrees that you understand each other, explain to her what happened. Remember that nurses are also victims of Horizontal and Vertical Violence; they get yelled at by doctors, DON's, administrators, patients. Collectively we are get yelled at and we are all victims. Together we can work to bring an end to this, and maybe someday we can say with pride that we are professionals.


The CNA can do all these simple things to bring about change within their work units. By refusing to undermine others, and by maintaining a high work ethic, CNA's are in a good position to help create a positive and enriching environment in which to work. CNA's should consider meeting with management to discuss "Horizontal Violence" and describe it's negative impact upon quality care.

Some things to consider when meeting with management:
Look at turnover rates...Ask why so many leave. The usual high ratios and low pay are always there, but look into the way staff treat each other. Honest and open discussion are required in order to truly change. If staff feel a sense of belonging and personal satisfaction they will continue to work under less than perfect conditions.

Ask management to add a lecture about HV in CNA Training Classes
Ask management to form an Employee Mentor Program(for new staff)
Ask management to form Quality Teams (who will tackle all areas of quality within the facility)
Ask management to consider forming a policy about all forms of Workplace Violence- Horizontal,
& Vertical. The benefits will outweigh the costs involved.
Ask management to write a statement of position about workplace violence.

Bring to management's attention the following early warning signs of impending physical violence:
Weak or non-existent policy against all forms of workplace violence-physical as well as horizontal and downward.
Negligent Human Resource Practices: (weak hiring practices, negligent training, poor supervision)
Ineffective or non-existent reporting procedures for violence and threats
An autocratic or abusive management style (unfortunately, typical in nursing)
An atmosphere of indignity tolerating sexual and non-sexual harassment, disrespect and intolerance.

Many nursing homes have adopted the following list of "Rights of The Employee":

YOU HAVE THE RIGHT...
1) To insist on a reasonable workload and fair expectations
2) To put family obligations first when necessary
3) To refuse to do something that conflicts with your principles
4) To receive fair compensation and increases for the work you perform
5) To be treated with dignity and respect
6) To refuse to be responsible for someone else's performance
7) To be kept informed about decisions that impact your job
To refuse to participate in office politics without fear of emotional or economic retaliation
9) To stand up and take action against any kind of harrasment, threats, intimidation attempts and discriminatory behavior, verbal abuse, violations of trust and confidentiality.
10) To performance expectations that are clear, consistant, rational,honest, stated up front, and free of unwritten rules.
11) To adequate training
12) To question procedures that seem contradictory, overly complex or excessively bureaucratic.
13) To be treated as an individual, and to refuse to be treated as a unit or a statistic.
14) To insist that stated or implied promises and commitments be kept
15) To move on if your job doesn't meet your needs

***UPDATED***

Some links to workplace violence, Horizontal Violence and Nursing:
Ending Nursing Violence

Horizontal Violence: A Male Nurse's Perspective

Are you being bullied?

The Costs of Workplace Discontent

A Management Toolkit: Ending Nurse-to-Nurse Hostility

And remember that by complaining about the situation at work and not doing anything towards changing it you are contributing to a negative work environment. Each CNA had within them the capacity to help make a difference.

Try it....Today.


© Originally printed: 1998. All Rights Reserved Nursing Assistant Resources On The Web
This material can be used freely for educational purposes.

The Nursing Process & The CNA

The Nursing Process, And The CNA

In my experience working as a CNA in a nursing home, I rarely heard the term “Nursing Process”; I often heard about care plans- but that was about as descriptive as things would get. I remember asking a nurse- “Just what is a care plan, anyway?”- and she didn’t know how to answer me! So I have spent a long time researching this elusive term- “Nursing Process”- and trying to figure out exactly where the CNA fits in with it.

First, the medical team is broken into several layers. At the top is the patient- who has an illness, or condition requiring on going care. The Doctors are next- we all know they are well educated and have spent years learning how to diagnose and treat problems, illnesses, disease ect. Doctors are the only person within the medical team who can actually diagnose. Nurse Practitioners- in reality- cannot DX anything without checking with the MD. Physician Assistants often will see a patient and DX simple problems such as ear infections, but an MD will always go over the PA’s notes to make sure nothing has been missed. Same with Nurse Practitioners- the MD always double-checks the work.

So this brings us to the next point: A patient, client, resident is admitted to a nursing unit. This can be in a hospital, nursing home, rehab center, even to the patient’s own home. Nurses are called upon to perform several steps to assist with the healthful and positive outcomes for these patients. The nursing process is a relatively new thing; in the 1960′s team based nursing came into fashion, but nurses had no way to let other team members know what to do with patients.
A process, based upon what scientists use, was developed. Over the years this process has been refined to what we know today.

The nursing process is divided into five steps.
1) Assessment
2) Nursing Diagnoses
3) Planning
4) Intervention
5) Evaluation

Where does the work of the CNA fall here, you may ask yourself? Let’s see if we can find some pretty common things CNA’s are asked to do, that are a part of helping the nurses with this process. It is assumed here that the patient/resident/client has a top level diagnoses from an MD, and a treatment plan is in place from the MD. This plan would include medications, treatments, special diets, procedures ordered by a doctor.

Step One: Assessment
Assessment involves continuous data collection to identify a patient’s actual and potential health problems. This data should be as objective as possible, and nurses should be as non-judgmental as possible as well. To perform the assessment, nurses should:
· Get Nursing History from patient
· Perform a physical examination
· Review lab and medical information

The nursing history is mostly subjective data. Often, the patient’s perception of his health problems makes up a large portion of the health history. Nurses should find out how the patient coped with a similar illness, what interventions worked, didn’t work ect.

A physical exam is the next step. This is where the CNA often assists the nurse. When we are asked to get heights and weights, vital signs, record food/fluid intake and output, it is almost always for the purpose of assessment. Although CNA’s do not make assessments, nurses depend upon us to report timely and accurate data. Things we see, smell, hear, feel and touch should be reported.

Nurses should perform a thorough exam by doing the following:
· Body Inspection- observation of patient- direct and indirect
· Palpation- feeling body regions for masses, smoothness, muscle tone
· Percussion-using fingers in a tapping motion to feel for abnormal sounds over body regions
· Auscultation- listening for sounds over body regions such as lungs, bowels…

Nurses are taught skills to perform a physical assessment in their schools.

Step Two: Nursing Diagnoses
Nurses are licensed to identify and treat certain human reactions and potential health problems associated with the illness, disease ect.
As we see, nurses have a huge responsibility when it comes to giving accurate diagnoses of a health/potential health problem. All the care given is based upon the proper Dx, the proper plan of care being written and the right interventions.
Based upon all the data collected- both subjective and objective, the nurse next will form a nursing diagnoses drawing from the above list of possible problems.

It is these terms in the list that we will often see when we look at a care plan. It isn’t something that comes lightly for nurses- this is one of the big reasons they need a college degree. Assessment is a big part of being a nurse, and it is an even bigger part of what we, CNA’s, do. It is absolutely vital that we report back accurate information. The care a patient gets, and hence the outcome of his health, depends upon good sound information.

Step Three: Care Planning
The Care Plan is a term we should all be familiar with. We all should know that the care plan is the bible for nursing care of patients, but what else should we know about this document? It is a legal document promising care being delivered as written; the nurse can get into huge amounts of trouble if her care plan isn’t followed. The care plan is designed to assist team members in delivering high quality, consistent care that is needed. Time spent performing tasks and care that is not needed results in wastes of money, resources. Effective care plans take into account unit staffing patterns, patient wishes and abilities, and should reflect who the patient is. A good nurse will seek the opinion of the CNA when writing the care plan. CNA’s can offer invaluable insights into the patient’s abilities and desires. All facilities should encourage CNA participation in care plan conferences.

Cookie cutter care plans are easily recognizable:
· They have the same nursing Dx
· They have the same interventions for all patients (seen often in nursing homes, where all residents have been known to be on a two hour bladder program)
· They don’t work!

A good care plan will be specific, realistic, clear and brief. It doesn’t need to be a long novel.
Anyone who is expected to deliver care from a care plan should be able to read the plan and understand it, including the patient when applicable, as well as the patient’s family.

Step Four: Interventions
This is where the CNA really comes into play! Often, the interventions are WHAT we do. All that turning, repositioning, toileting- are all interventions listed in the care plan. Also, a great amount of the documenting we do is designed to assist the nurse with evaluating these interventions. So it really makes sense to document accurately- in time- if an intervention IS NOT working, it will be noted (and perhaps removed from future care plans). Interventions can be anything from special baths to back rubs to repositioning, to toileting, to using special creams and lotions, to offering certain supplements. Often, an intervention must have an MD order along with it. This is kind of strange I think- if nurses are allowed to formulate their own Dx then they shouldn’t need an MD’s order to carry out some of the treatments to reach the goals. The most important part a CNA can play in this intervention stage is to accurately report all reactions to the interventions. Be as specific and objective as possible.

Step Five: Evaluation
This is the final step in the nursing process. This is the time when nurses look at their care plans and check to see if the plan has “worked” in solving the patients’ health issues, concerns, ect. As stated before, a good plan will work and a poor plan will not. Nurses will check to see if the interventions have been effective- they look at subjective as well as objective data. This is when they will see your good documentation! For example, if a patient were incontinent, and the patient wasn’t so until recent illness, the nurse might try a timed program approach to help the patient gain control again. IF the initial voiding assessments, done by the CNA, were not accurate (i.e.- CNA just wrote in times she guessed patient voided)- and the nurse put the resident on a two-hour program…when patient actually needed to go every hour- you can see how this intervention would fail.

The nursing process doesn’t end here- it continues until the patient is discharged or passes on or whatever. Sometimes a patient goes home with a care plan, and this is especially challenging for staff. If the nurse never saw the home environment, then chances are good that the care plan won’t work. Usually home health nurses do the plans for this population.

Some thoughts to Ponder…
As I said in the beginning of this page, I never knew what the nursing process was. I still have my books from my CNA classes, and I have several newer additions. It wasn’t until very recently that CNA’s were taught this process. This is too bad. I fear there are too many CNA’s out there who do not have a clue how important their work is. All the work, the documenting- would certainly take on a new meaning if CNA’s really understood their role, within the nursing process, as a whole. It would make a good in-service for any facility to offer: Nursing Process- What Is it?

Even of greater concern for me is the apparent lack of concern on the part of nurses who are charged with this process. Never mind those who don’t seem to know what it is, but what about those who DO know, yet follow their own approaches to deliver care. Hmm. I challenge all CNA’s to hold their nurses up to the standard when it comes to the Nursing Process. After all, if our work is to have any meaning at all, then the Process should be the standard. When a new patient is admitted onto a unit you work on, watch to see if a complete physical assessment is done by the nurse; see if any of the things you are asked to do may have a part in the assessment. Ask questions. Expect answers that make sense to you. A lot is at stake here, the patient’s well being. See if all your good documenting is worthwhile. Ask the nurses what will become of the notes you have written- those flow sheets should become a tool, not some paper put into a chart.

See if the system really works, or if it is just another process that is meaningless.

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