Families: Why the Battle?

One of the issues CNA’s deal with on a daily basis is interactions with resident families. Like it or not, they are the most important part of our residents’ lives. I think an admission to a nursing home is not only a shock to the person, but to their family as well.

Families deal with many feelings when they decide to place their loved one into a nursing home: guilt, helplessness, financial worries. They hear the stories about abuse and neglect. They fear these things will happen to their loved ones. Usually families have little experience with how long term care facilities work- the daily pulse and beat. The nursing home becomes HOME to the resident and the second home to many of their families.

CNA’s on the other hand work in nursing homes for a living. We punch in, do our shift and go home. We love most of our residents and do the very best we can with what we have. Often, we work short of staff and this is heartbreaking for many of us. Few of us remember our first days in this work…the shock and dismay we felt at the lack of time to do really good work. We went home feeling guilty and a little shamed of the care we gave. Soon enough, we each realize this is how it is and we also know it could be much worse than it is. I think we become immune to that SHOCK effect.

Families go through the same thing. Some come to know how nursing homes operate. Some don’t bother to learn and others just don’t care. They expect the world to halt to their demands and they could care less about who ends up being neglected because of their demands. They tend to put the heat on management with complaints and needless accusations; and they have expectations that are really not in tune with the typical model most nursing homes follow.

At the message board for this site, a discussion was initiated about this very subject. We got hot handed, a little, because I believe aides can have a huge impact on the families perceptions of who we are and why we do things the way we do.

This one is for the families of nursing home residents
You know who you are, you are the one who likes to show up a few minutes after your family member was looked after but has had an accident and then claim they had been that way for hours. You think you know our jobs, but never had a hour of medical training. You think I am your servant but I serve only god and country. My boss is the nurse, hunt her down with your bitches.

I have a real nice question for you, here it is in little words that I know you can understand:

If you think that you can do a better job then why the f—k don’t you?

Now be honest.

Understand this:

1. I am a CNA, not whipping boy or girl.
2. I am worthy of respect and you will respect me.
3. If you do not do #2 I will talk real bad about you to my co-workers about much of a moron you are.
4. Again, I am a CNA. I take of more patients that just your family member, so if you want extra special care and attention given to Sally or Fred or Ann then you going have to shell out for a private sitter.
5. O if you think I got an attitude, well think no more and now you should know.

The familes are the single worse thing about this job. Nursing homes should have stricter visiting hours.

This is an extreme view, held by more than I would care to know of. I could not work with people who hold this opinion and I can see how negative the work environment could get, surrounded by aides who are seething to the brim with these feelings. Yet I understand where Kevin is coming from…I have had days where I just wanted to toss the towel in literally at a spouse of a resident- who was caught up in the middle of this battle. The demands of one family can have a very negative effect on the other residents we are assigned to care for.

This presents a problem for us. Management always applies grease to the squeakiest wheels, and this bandaid approach never truly heals the wound- instead it makes it worse. I do place blame on management for allowing this to happen. It is up to them to deal with the nitty gritty demands and expectations that truly do take away hours of care from other residents. Dealing with these people might mean telling them how things really are. It might mean letting the families know their petty concerns over missing laundry equate to another resident getting their medications late. It might mean holding a meeting and explaining to these families that they are disruptive and detrimental to overall morale of both staff and residents.

What can a CNA do when caught up in the middle of the family/facility battle?

My best tips:
Smile!

Apologize. It may not be your fault but it is your responsability as an employee.

NEVER say that you are shorthanded!!!! It maybe true but families and patient don’t want to hear it. (I know I don’t want to here it from the bank teller when I have stood in line for 10min.)

If it is something you can’t mend as a CNA then get the RN involved- use your chain of command. Get the risk manager involved if it comes to that.

That about sums it up, nicely. Try to be upbeat and positive, and at the same time acknowledge the families concerns. If there is ever a time to pass the buck, now would be the time.

Hopefully management can do some things to make this issue better for all:
*Before someone is admitted, a good educational session about the workings of the nursing home should take place. Families should always know and understand the aides are responsible for MANY residents, not just one. Timeframes should be disclosed- it should be well known that 20 to 30 minutes is the normal expected amount of time an aide can spend with each resident.

*The family could be asked to come in and watch part of a shift. To see how things work; to learn about how nursing care and treatments; to see the food and meals and laundry service. This is a good time for families to be introduced to the dept. heads

*Get this book, several copies of it…and lend it out to families:
The Eldercare Handbook: Difficult Choices, Compassionate Solutions

*And this book:
Living Well in a Nursing Home: Everything You and Your Folks Need to Know

It wouldn’t hurt to have everyone read these books to be honest- nurses, aides, laundry staff…

Lifts & Transfers

Keeping your back healthy is very important. We all know this. And yet, at every long term care facility I have worked at, I have seen aides cheat the systems and policies and rules when it comes to LIFTING. Aides will lift heavy residents by themselves; they will also refuse to use mechanical lifts designed to save our backs.

Mechanical Lift Cheating
Most aides will cite time as a major factor when it comes to using the mechanical lifts (ML). Time involved with seeking assistance, as most facilities require two people attend a ML transfer; and time involved with setting the resident up for the transfer. The placement of the lift pad, attaching it to the machine, operating the machine…the positioning of the resident into the wheelchair or bed; removal of pad…the process takes about 4 to 5 minutes. Whereas a two person lift takes about a minute at most.

I’ve asked aides how they manage to perform these lifts, on really heavy or otherwise unsafe residents. They tell me they feel confident with their strength and ability to do the lifts. They are sneaky about it too: Many an aide will go to the trouble of getting the ML and bringing it to the room. But it just sits there, unused. The only time they will use the machine is for the extremely overweight resident, or for a resident who is with it and KNOWS they are not to be lifted/transfered by staff. Even with this, the resident sometimes insists upon being lifted as it is faster. And some residents will badger the unsure aides into lifting them.

Staff Assisted Lifts/Transfers
As for two person “human lifts”, aides will not bother getting help. They do the transfers alone, placing themselves and their residents at risk. Again, the aides have a level of confidence in themselves to do this. The aides don’t consider that these movements might hurt the resident, might be rough or terrifying. And they don’t seem to understand that a few months of doing this will result in soreness and back, shoulder and knee pain. I know aides who’ve been doing this work for years who have bad backs, who are forever complaining about being in pain…who gimp and limp around all shift…who speak of being on different pain meds all the time…it’s no wonder!

Once a facility has enough aides who prefer to transfer residents the wrong ways, it’s very difficult for newer aides to turn this around. The newer aides feel compelled to work on their own. They have asked for help but have gotten nasty looks, rolled eyes and heavy “sighs”, along with comments such as “I do this by myself!” To the defense of the old timers, they probably got stuck one time too many waiting for someone to come help them. In the nursing home environment, time is everything. Once you get behind, you cannot catch up unless you cheat. And that means cheating residents out of the care they deserve.

Fixing the Problem
How to fix this? Should management be concerned? Is management even aware of these practices occurring? Good questions and only each facility can answer. Of course the leadership should be concerned. After all, the worker comp costs are in direct line with staff compliance on lifting policies.

Should punitive steps be taken towards non compliant staff? Speaking as an aide, I say YES. Because the non compliant aide is a virus- and viruses spread. In my experience, aides who are non compliant in this area are non compliant in many areas.

Having said that, I also believe facilities should have a hard look at their policies and promotion of teamwork vs. being task and time driven. If more value is placed upon the timing, then facilities are just asking for the aides to do whatever they can to survive- up to and including cheating. If value is placed upon teamwork and healthy body mechanics, the aides relax a little and are much more apt to be compliant.

If you’re an aide who does cheat, remember you only have one back. Remember too, your shoulders and knees will only put up with so much of these bad lifting habits. It will catch up with you. If it’s in the residents’ care plans that they are to be transfered via a ML or with two staff, you are breaking rules and could lose your certification over this. Especially if you document the transfers were performed as care planned: You’re participating in fraud if you sign it off as done. And if you get hurt, how will you explain it? Worker comp claims are often denied when they find out (and they do investigate) you did an illegal lift.

Is it worth being out of work with an injury, with no pay coming in? Consider your reputation as well…you will probably be fired for not following policy and this will follow you in your future employment opportunities. And remember this: You’re teaching the next generation of CNA’s some pretty poor work ethics- and worse, you’re planting the seeds of a painful future for another person (the new aide)…and keeping this cycle alive and well.

New aides can set the standard, as can aides with more experience who decide to change their attitudes on these things. Do it right! Save your body. And think of the resident’s safety! Use the proper lifting guild lines for each resident…if a ML is called for, USE IT. Get your resident all ready for the transfer BEFORE getting help- remember your co workers time is valuable. Don’t waste it. Work efficiently and with purpose. Make teamwork as simple as possible.

Tips & Timesavers for CNA's

Tips & Timesavers- For New & Seasoned CNA’s

So, you’re brand new and a little nervous? Thats ok and natural. Being a CNA is a rewarding career, but there are LOTS to learn and lots of cover in those first few days at work! Don’t be surprised if you feel a bit overwhelmed and anxious. Someday–soon- you will be an “old pro” at this stuff. The first part of this is for the new CNA…

The Basics
I remember my first few weeks as a CNA- it was hard to get to know all the residents as well as staff as well as the facility policies and procedures. I was very overwhelmed and looking back now- there were certain things I should have done that would have made my life much easier then! Live and learn….
First, it is a good idea to bring a little notebook to work with you. In here you can write down info you need about everything from phone numbers to resident issues. Jotting down info is a way to remember it! At periodic times during the day check the little book to see if there are things you still need info about. When you think of questions and no one is around to answer them- write them down. Later you can refer back to the book.

Facility Rules/Employment Issues
OK, now onto more things every new CNA should be aware of. It’s always a good idea to know the facility policies and rules before we start a new job. Sometimes this isn’t possible. You should make it a point to find out where to go to get this info if it isn’t provided to you. Again, looking back there were things that I wasn’t clear about and I had to re-learn basic policy stuff. If I had asked in the first place:

1) Holidays/weekend pay differentials? Are there any?
2) Overtime pay: After 40 hours or after 80 hours?
3) Attendance/Tardiness: What are the exact limits/percentages?
4) Pay increases: Based on merit? Or length of service?
5) Performance reviews: When, how often, are raises included with them?
6) Uniform policy: Assistance with purchasing?
7) In service Hours requirements: Does facility offer enough hours to meet mandated 12 hours?
Phone numbers to call: For when you need to be out. Time limits?
9) Benefits: What is offered? When do they go into effect? What will cause termination of benefits?
10) Staff meetings: Times? Are the mandatory?

These are basic policy things every employee should know, and know well. Once you have this info, you can make choices about what you need to do- and when. Knowing this stuff will make your life a lot easier and will prevent surprises down the road.

Doing Your Job
For those ever important first few days, there are several things I recommend you get done, if possible. First off, find out which residents you will be working with on a regular basis. Why? You want to read their care plans as a tool to help you get to know them. Knowing what you are expected to do as far as nursing care is the reason you are there! Knowing what is in the plan will help you care for these residents in a safe and appropriate manner. You may not understand some of the things in the plan, if this happens then ask the nurse in charge of the unit. Nurses write the care plans, and they depend upon us to carry out the objectives to meet the goals in the plans. The nurse is an excellent resource for CNA’s. In your little book you may want to write down things about your residents- from the care plans. It will be awhile before you can actually place a plan with a resident! This takes time- getting to know them and what rooms they are in, never mind their care needs. Hopefully someone will be mentoring you; while being trained it is a good idea to relate what you are being shown to how it is worded in the care plan. Ask questions and learn. Your mentor has experience and can teach you much.

Watch how your mentor works- directly and indirectly with residents and staff. You should learn much just from observing. The next thing I recommend is that you check with the nurse at the beginning of the shift about what is expected of you:

Do any of your residents need VS, baths/showers, weights, or other care? When are VS needed by? Also ask about special snack/drink requirements. It is so much better to know this stuff ahead of time rather than ten minutes after they were due. Communication is vital in nursing homes- with nurses, peers, residents. Also make sure you find out where you are supposed to document your care? Ask about paperwork and where it is. It is very important that you get the paperwork done everyday.

After a few weeks, you will know which residents work well together; you will figure out how to prioritize your care to meet everyone’s needs. It takes practice and hard work. One thing that is very helpful is taking a few minutes at the beginning of the shift to plan your assignment- who gets done first, who gets showers and weights and what not. Gathering all your supplies you need before entering a room is a great time management skill all CNA’s have. Carry around a pocketful of gloves too. Check with the nurses, in most facilities you can bring in your own thermometers as long as you don’t bring them home for use. Having your own tools saves time- I have my own B/P kit too.

The next sections are what this page is really all about: Timesavers and tips CNA’s everywhere use to get their work done. Some things are pretty elementary and others are really cool. Try them.

Being Prepared:
Always be ready with a basic work kit: A waist pouch is a good thing to have- with a pen, tape measure, extra gloves, permanent marker, if possible your own B/P kit, watch and extra elastic hair things.

Keep a mental checklist of what you need before entering a room- linens, clothing, ect. Be ready.

When changing bed linens, roll all dirty linen into a ball within bottom sheet; this is easier to remove than several pces. of linen.
Type a copy of abbreviations to a little card, then get card laminated. Keep in waist pouch.

Plan your work day- check with nurse about nursing priorities and go from there.

Resident Tips:

A cool idea for shiny, soft hair: Get a little spray bottle; fill with one part conditioner to nine parts water. Spray in after shampoo and leave; this detangles as well.

Another use for little spray bottles: Fill with water and add a few drops of bath oil; after shower/bath spray a little onto residents skin. Make sure you mark these bottles with what is in them!

Bath oil can also be used in showers- small amount rubbed into your hands & onto resident’s skin. Also, add a drop or two into a wash basin during rounds….

Find residents slipping out of their chairs? A piece of rubber-type shelving liner works well to keep them upright.

For stubborn BM, a little shave cream with aloe works wonders with cleaning. Use sparingly as the cream can be drying. Apply a little lotion after.

For residents who have thickened drinks- and who don’t like the taste of the thickener, adding a pack of sugar /sweet & lo helps. Thickened water taste terrible. Some say that adding a few drops of lemon juice takes away the bad taste.

It may sound elementary, but do add salt & pepper to foods if it ok; also butter & margarine. Many elderly are used to these condiments being in their food.

If food gets cold, the wise CNA will take plate to a microwave oven to re-heat it.

Residents may eat better if they start with a clean mouth: Provide oral care right before meals.

Remember that meals are supposed to be a fun time; don’t force feed your residents; allow them time to enjoy their meal! Same with drinks- don’t force them down.

Allow the resident to determine when they are ready.

Residents who feed themselves may have trouble keeping their plates on the table. Use the rubber shelf liner under the plates.

You can build up a utensil by wrapping a washcloth around the handle and securing it with a rubber band. After each meal remove the cloth for washing.

When feeding a helpless resident- remember to tell them what you are doing, what you are feeding them- before each bite. If they constantly spit the food out, think that maybe they don’t the certain food and offer an alternative. During this feeding time, talk with the resident about current events or something like it. Don’t just sit there an stay quiet.
Foods you know the resident likes should be made known to whoever is in charge of meal planning. This is a way for you to advocate.
Documenting meal consumption is a part of every CNA’s job. Be realistic when figuring amounts eaten. Look at serving sizes and look at what wasn’t taken in- look at what was lost via drooling, spitting out…Check the clothing protector/bib!
Also, some residents like to hide their food…know this and keep an eye on it.

Remember that residents don’t always appreciate being made to wear a bib; ask them if they would like to. Don’t force it upon them.

Mentoring a New CNA
First, recall your first few days and weeks as a CNA. Have some empathy. And remember, the new CNA will watch everything you do and say. Be a role model.

Don’t expect the new CNA to know everything; yes- they have been certified but this doesn’t mean that they have hands on experience. You’r job is to teach them this!

Be respectful of the new CNA’s questions. Answer them all as best you can; if you don’t know an answer either find out or direct the CNA to someone who does know.

Allow the new CNA to observe you for a day or two. Let them see how you work; how you handle your residents. This is called role modeling. Don’t assume that it is ok to have them make your beds and get your supplies. One of the things you should be striving for is to teach them how to be prepared and how to work best to get it all done.

Plan your work and your day with the new CNA. Show them how you prioritize things. If you have questions for the nurse, bring the new CNA with you so she can see how you interact.

While you are working, explain every little thing you are doing. You want to be certain the new CNA understands why you are doing certain things in a certain order….or to please certain residents. Allow the new CNA time for care plan reading. This is vital.

Allow the new CNA break times. They might need more than you think!

If your facilty doesn’t provide one, make a checklist of things you want to teach. This way you will cover everything.

No matter what, NO SHORTCUTS should ever be shown to a new CNA! They might think these cuts are ok on a daily basis, which they are not. Show them the right way!

Peer Relations Tips:
Treat others how you would like to be treated.

Using manners can leave a positive impression to just about everyone.

If you get your work done early, offer help to others who aren’t done.

Don’t backstab, find fault with your peers. Instead find good – and offer praise.

When working short, it may be a good idea to “buddy up” with a partner. Doing things together is easier when we are stressed.

Always let your partner and nurse know where you are- even if you are only going to the rest room. This is true when you are doing care- if you know you will be awhile with a resident- say so ahead of time.

Be considerate of your peers: Don’t abuse your break times or meal breaks. Be prompt and on time.

Tell your family & friends that unless it is an emergency- not to call you at work.

Dealing With Dementia/Alzheimer’s

Keeping a sense of humor helps a lot.

Being positive is another trait that should be touted. Don’t assume something bad is always going to happen.

Once a struggle has begun, try to remain as professional as possible; don’t get into words and accusations. Don’t be the perpetrator of a power struggle. It’s not worth it. Make sure you report all behaviors to the nurse.

If a resident has become combative, your goal should be to protect the resident, other residents and of course – you. Try to act as a shield between the other residents, but don’t put yourself in a line of fire.

Sometimes it is better to walk away while a resident is having a hard time.

If you feel you might do or say something you could regret— LEAVE the room. Get someone else to take over; recognize your limits and respect them.

If you notice an increase in behaviors, ask the nurse about a special meeting to address your concerns. A team approach is always best. Now your good documenting will come in handy.

Documenting

When writing notes, be clear, concise and to the point. Be objective. Don’t write what you think happened or what you think caused an incident. Only write what you know.

Timely documentation is vital. If you take a set of VS and see that a resident has a fever, let the nurse know right away. Don’t wait until the end of the shift, or even wait until you’re done with this resident.

If your facility uses flow sheets, make sure you’re initials can be easily read.

Getting to know the particular types of paperwork you are required to do can take a little time; it is always better to ask before you sign your name to anything.

Never sign off anything you didn’t do. Never sign off something someone else has asked you to sign. Only document care YOU have given.
Being a witness to something and being asked to sign that you witnessed- this is another story.
Just make sure you write that you witnessed….

Use pens with facility approved colors. Don’t use pencils or markers. (KEEP IN MIND: Colored inks do NOT show up on copies- only B/W does)…

Taking Care Of Yourself

Don’t go to work sick. Ever. On the other hand, don’t call out over a simple hangnail either. Be respectful of giving enough notice when you call in. Also, never call to say you’ll be late and then call back to say you’re not coming in at all!!

Eat right- right is different for all of us. Make sure you are getting enough calories in daily to do your job as well as your home life.

Drink a lot of water. CNA’s don’t always think of themselves when it comes to fluid intake! Eight 8 oz. glasses a day is the least we should be bringing in; more is cool. If permitted, carry with you a covered water bottle at work. Drinking enough water may very be one of the best things we can do for ourselves!

Do some stretching before work! Really- it helps loosen up all those muscles we use and this helps prevent back injuries.

Lift people and objects properly. Use good body mechanics: Lift with your leg muscles, not your back muscles. Keep your balance and always work in conjunction with a partner during lifts.

Get enough sleep. Again, this is a personal thing, each individual has different needs. Whatever your need are, tend to them.

If you find that you are always getting upset about work, if you feel outraged at things- you need a break. Take a vacation. If this is not possible, then take a mental health day. I don’t condone taking time off that isn’t vacation – but there are those times that we all need a break. Especially right now when the nursing community is changing so rapidly.

Remember that you are a person who the new CNA looks up too; you are IT. So act it. Be professional, but friendly. Be there for those moments of self doubt and fear. Be a person who is positive and encouraging. NEVER rebuff a new CNA’s idea’s or observations: After all, they see things from a view point you haven’t seen for a long time.

The way you interact with the residents is very important during the mentoring period. Go over Resident Rights , and when the time is right use what you are doing as an example of honoring rights.

© 2004. All Rights Reserved Nursing Assistant Resources On The Web
This material can be used freely for educational purposes.

How Are The Pay Practices @ Your Work?

The New York Times has published an article about investigations of health care facilities pay practices. It rings true for many of us: Do we really get paid for actual time we work?

In St. Louis, the Labor Department has recovered more than $1.7 million in back wages for 4,000 employees of hospitals and clinics operated by SSM Health Care, a Roman Catholic system.

In Boston, the Partners HealthCare System agreed to pay 700 employees more than $2.7 million in overtime back wages to resolve a lawsuit by the department alleging violations of the Fair Labor Standards Act.

And under the proposed settlement of a class-action lawsuit in California, Kaiser Permanente would pay $7.25 million to hundreds of registered nurse coordinators, case managers and other medical workers. The employees said they had been denied overtime pay because they were improperly classified as exempt.

This is when they classify nurses as supervisors. They are, but they usually do not meet the federal standards for being exempt.

Nursing assistants, licensed practical nurses, janitors and cooks “are particularly vulnerable to wage violations,” Mr. Stripling said.

In many cases, employees say they were not paid for work performed during meal breaks.

“Most nurses put the patient first,” said Charles D. Boal, a registered nurse who worked in the critical care unit of The Western Pennsylvania Hospital in Monroeville, near Pittsburgh.

“We often gave up lunch breaks to see that a patient was taken care of properly,” he said. “If you brought your lunch from home or got food in the cafeteria and took it to the nursing unit, you would be interrupted by phone calls, by physicians and family members who wanted to talk to you. We really did not have an uninterrupted meal break.”

How many of us have given up a break, or shortened one, because of patient/resident care demands? I know I have. Multiple times. We need to MAKE sure we are being paid for those minutes given off our breaks. Don’t let the facility management con you into believing they don’t HAVE to pay you because a supervisor/other did not ASK you to give up break times.

Nursing Home Industry Heading for Crisis- Job Losses Will Happen

Why I haven't seen links to this article at other nursing home blogs is beyond me.

HARTFORD, Conn. (AP) - The nation's nursing homes are perilously close to laying off workers, cutting services - possibly even closing - because of a perfect storm wallop from the recession and deep federal and state government spending cuts, industry experts say.

The spending cuts are only just beginning. Wait until this health care reform really gets going. It's all in the details, which hopefully we will all have a chance to read and comment on. It appears that some of our elected officials are not even reading the devilish details.

A Medicare rate adjustment that cuts an estimated $16 billion in nursing home funding over the next 10 years was enacted at week's end by the federal Centers for Medicare and Medicaid Services - on top of state-level cuts or flat-funding that already had the industry reeling.

And Congress is debating slashing billions more in Medicare funding as part of health care reform.

Add it all up, and the nursing home industry is headed for a crisis, industry officials say.

"We can foresee the possibility of nursing homes having to close their doors," said David Hebert, a senior vice president at the American Health Care Association. "I certainly foresee that we'll have to let staff go."

So in order to fix one part of health care, we have to sacrifice another part? Seems so. A saving grace here might be that home care would be the most cost effective "choice"- which is far better for the elderly person than a nursing home admission.

Resident Rights Week and Refreshers for CNA’s

The week of October 5th- 11th is Resident Rights Week. Mark your calendars.

These are Residents Rights, with info and guidelines for CNA’s to follow when caring for residents after the first few.

The right to be fully informed—by word and in writing—of the policies and procedures that protect the person’s other rights

All of the rights of citizenship the person has in the United States
This includes voting in all elections.

The right to know all of the services available at the facility, including whether it is certified for Medicare or Medicaid residents, and the right to assistance in applying for those benefits

The right to be fully informed about the person’s own health condition
Believe or not, some residents do not know what their medical conditions are. Some families wish to keep this from the resident. Or, residents are not informed of disease progress (such as a cancer spreading). While the CNA should never disclose this information to ANYONE, we need to be extra careful when discussing it at the Nurses’ Station and other not-so-private areas.

The right to choose one’s own physician

The right to refuse medication, treatment, or care
Indeed. A resident can refuse to be medicated, to have dressings changed, to be weighed, bathed, fed, dressed- we cannot force them to do these tasks or allow us to assist them. When we do, against their wish, we are violating their rights and in some cases it would be considered abuse. It is very important to document these instances. Make sure the nurse is aware of the refusals.

The right not to be forced to perform therapeutic activities
These include PT or OT sessions, activities, special baths and the like.

The right to be free from punishment and involuntary isolation
THIS IS A BIG PROBLEM. CNA’s often take it upon themselves to remove residents from dining and other rooms and place the resident in their room. This is involuntary seclusion and in some cases is considered abuse. Don’t do it. Wait for the nurse to direct you on this. It is never within the scope of a CNA’s practice to make decisions like this. Withholding food, drinks, delaying care, when used to punish a resident is abuse.

The right to be free from verbal, physical, sexual, and mental abuse
For some residents, the sweet little nicknames we have for them is a form of verbal abuse. Others love to tease and tell jokes- but for some this is mental abuse.Yelling includes raising your voice. Or using short, sharp words- it’s all verbal abuse. Many aides don’t understand the varieties and the subjectivity of this. If it offends a resident, often it can be called some form of abuse.

The right to be free from chemical or physical restraints except on a doctor’s order and as a last resort for the person’s safety
This includes being put to bed against the will. It also includes placing residents into recliners and other furniture that they cannot freely get up from. Being tucked into a table so close movement is not possible is a restraint as well.

The right to be treated with courtesy and respect
Manners. Use them. All the time. Please, Thank you, Excuse Me, I’n Sorry. Referring to Sally Smith as Mrs. Smith until she asks you to use another name…

The right to privacy when receiving treatment or personal care

The right to get and send mail and to make and receive phone calls without anyone else’s interfering

The right to associate with anyone the resident chooses, in private if the resident requests privacy

The right not to be sent to a new room without a good reason, advance notice, and sufficient preparation

The right to keep medical and personal records confidential (except as needed to evaluate the facility and follow up on complaints about your care)

The right not to be transferred or discharged without good cause, advance notice, a discharge or transfer plan, and the right to a hearing to stop the proposed change

The right to make suggestions and complaints and to have the staff act promptly in response, and the right to be free from retaliation of any kind for making complaints or suggestions

The right to inspect the person’s own records, and the right to purchase copies of all records

The right to participate in any social, religious or community activity the person chooses

The right to keep and use personal clothing and belongings, as space permits, and to have lockable storage space for personal belongings

The right to be reimbursed for belongings lost or stolen by facility employees

The right not to sign any contract or agreement that claims the person agrees to give up any of these rights

The Nursing Process, And 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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