Shift Wars

In my years as a CNA I have seen many good aides 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. There are ways to manage the transition between shifts. It all starts with an attitude change. It also helps to have Charge Nurses and Nursing Management on board with this modern and positive attitude and mindset.

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. You won’t believe the aide coming off shift when she says a resident was up all night sick and required 10 changes and a shower and that’s why she didn’t get 3 residents up for you; you won’t care if there were 2 call outs on the previous shift. Stuff didn’t get done, and your day is more difficult because of it.

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? You’re different and everyone knows it.

STOP right here. Let’s look at this mindset.

Stuff happens. To everyone, on every shift, every day. Residents get sick; they have major accidents, they die. They also have rights that they are exercising more and more. 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 its own set of unique problems, staffing patterns, nursing issues, demands, and 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 coming together for a common cause. 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. Are they true problems? Or situations that result from people being human? First and paramount should be the resident’s safety, comfort and well being (not staff’s comfort and convenience). For example, review the following typical things that cause dissension between shifts:

  • Smith is always soaked. Her bed linens have brown rings! Her clothing is wet all the way up to her neck!
  • Jones was not bathed today!
  • Doris didn’t get weighed.
  • How come the linen cart isn’t stocked?

2) Once problems are identified seek out to understand why tasks and care were not completed. Stop assuming the worst in others. Let’s look back at the problems and list up reasons:

  • Smith was changed at 2pm; she 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.
  • Jones HATES morning bathes and prefers them at night so he refused;
  • Doris was getting therapy today and she was exhausted; she asked that we weigh her tomorrow.
  • Laundry only had one dryer working today so there’s linen wasn’t stocked.

All of this changes things. We go from assuming the other shift has lazy good-for-nothing staff working to a group of people working with residents who are exercising their rights, and other issues out of their control. So while solutions are not always forthcoming, reasons for so called **problems** are human in nature and can’t be fixed.

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.

Another area I frequently hear about is specific to 3rd shift and 1st shift and expectations that a certain number of residents be up by 7am. 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, Resident Council, families, the DON and Administrator.

The reasons for early get ups should be resident based and care planned and 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. Residents who get up too early will not thrive, they are apt to be tired, grouchy, and unable to eat well, drink well and behavior problems can result. Getting residents up before 5am should not be allowed.

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? 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 them sort out assumptions and balance the needs of each shift. A charge nurse should never take th **side** of any shift as this in of itself adds to the highly charged environment between shifts.

Nurses and CNA’s may need to learn 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 an example by getting along with the next shift.

 


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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…


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Filling In The Blanks

I’ve read at various online forums tales of how CNA’s literally fill in he blanks of vital sign records- without actually getting them.

What if we we all did this? Blew off getting the T, P, R and B/P? What if the resident has developed high B/P and because we couldn’t be bothered to be honest, it went unchecked? What if a real temp wasn’t measured for a couple days, while the resident is coming down with a infection? What if the resident is on a new medication that has a side effect of changing their respirations, but this isn’t seen because no one took the time to count them??

This is very bad. And illegal. And unethical. And most importantly, dangerous. What’s a new CNA to do? Or an experienced CNA? You stand up and advocate for the resident. You MUST not allow this to happen, when you see it, witness it, hear about it or otherwise KNOW of it.

How do you go about advocating in situations like this?

It seems pretty simple to me. Here’s what I would do (and have done many times):

1) Tell the CNA involved that she is committing fraud and that she needs to get the VS in question, right now. While you watch.

2) Report the incident to the charge nurse immediately; explain what happened and leave your personal thoughts out of this.

3) Seek the DON and report the incident to he/she as well. In writing. ASAP…Make a copy of your report to keep for your own records. Even if the charge nurse says she will make the DON aware, go to the DON yourself. You’re covering yourself by doing so. Otherwise, it could come back to haunt you in the misconception that you were aware of the incident but didn’t report it…and so on.

DON’T BE ONE OF THOSE AIDES.
The CNA who fraudulently documents care is opening themselves up to numerous problems. They could lose their job; their certification/license; their chances to work in health care as a career will most likely be ruined for good. If actual harm came to the patient/resident because we slacked off, patients and their family can pursue legal remedy. The facility and the state body in charge of regulating CNA practice can turn the “case” over to the Attorney General and hence start the criminal justice process. You get the idea.

Trust is big in health care.
Do we really think we can trust the aide who doesn’t measure vital signs but who writes in fictional numbers?

It’s not just vital signs. When an aide fills in the blanks in this one area, I question their honesty and integrity in all areas. The box is checked for the bed bath, but did the resident really get one? There are numbers in the intake and output record, but are they truthful?

Patients trust their health care providers to be skilled and honest. Our employers, the nursing homes and hospitals and assisted living centers trust that we’re using our skills and being honest as well. Our charge nurses depend upon our skill and honesty to assist with providing timely and needed treatments and medication administration. Our co workers trust that their peers are doing the right thing for their beloved residents.

The right things mean filling in the blanks with real, honesty measured/provided numbers/care. The right thing means when something isn’t done, it’s documented as not being done. We all know there are days when we can’t get IT all done and that’s the way of this work.

Experienced aides can prioritize their work- they KNOW what care or task needs to be completed vs what can wait. New aides should feel confident to ask for direction and HELP when they need it (which might be often the first couple weeks they are on the job!)

Charge nurses should always provide guidance to help sort through these issues. When it comes to actual skills- some newer aides really have trouble measuring blood pressure. The new aide should seek the help of her mentor, or the charge nurse to really learn this skill.

Paperwork overload is no excuse.
There is WAY too much paperwork in our work. Everyone knows this. Yet, facilities don’t get paid and pass inspections if the paperwork isn’t done. In the medical chart, if it isn’t documented it wasn’t done. Sadly these are facts.

The burden of documenting has become overwhelming. The original purpose of charting was to provide a clear record of a patients’ medical condition, where members of the health care team could go to see updates and alter their interventions and treatments as needed.

The chart is rarely used for this anymore. Now, it’s a place where endless pieces of paper are stored- and kept, in the event of a lawsuit. Nurses and others document on the defensive now. This is the world many have created and our little part in it has tremendous consequences. Those vital sign numbers better correlate with the sudden medical condition discovered on the next shift. When it doesn’t, red flags are spotted and questions are asked.

Maintaining Integrity Isn’t Easy in This Work
The CNA must always be honest in the care and tasks they provide. We are the front line. The first to see and know. We are extremely valuable because of our place. If we don’t feel skilled enough in providing tasks/care, we need to speak up to this and ask for help. Those of us who hear the cry for help need to be willing and able to teach. We need to recognize when a peer is having a bad time, a bad day, and offer assistance. We do this not for the aide but for the patients/residents she is assigned to.

Why is this happening more and more?
In the past few years I have seen an increase in aides who graduate from these small medical-skills schools who don’t have (or are not taught) the same foundations of honesty and integrity. I’m not sure honesty and integrity can be taught either…we either have these ethics or we don’t. Better screening might be one solution.

The quick turnover rates of graduating “classes” of aides amazes me- and the fact they can pass the state tests tells me they know the basics. The basics aren’t good enough anymore.

It gets lost when these fast food CNA’s get on the units and are totally overwhelmed with their assignment. They feel pressured to get everything done and this is where I often see the cheating occur. I have to wonder if these schools are not doing an adequate job teaching the students everything they really need to know. I wonder if the new aides thought the job would be much easier.

When we see cheating happen we have to speak up. Loudly at times. We might even need to make a stink once in a while. Life and death decisions are sometimes made based upon our honesty. As I said, we’re the front line. Our words have HUGE impact upon everyone’s word, all of whom are above us. If we’re not honest, then neither are they. Yet we know it, and they don’t. Remember that.

 


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We have seen high turnover for years in Long Term Care; not just CNA’s, but nurses, Administration, housekeepers. The work is brutal and there are few benefits to sticking it out. CNA’s in particular have a very high rate of turnover. It’s not uncommon to hear of aides leaving a facility to go work down the road at another nursing home for a dime more per hour. This is leads into this topic of this article: Giving proper notice.

In most lines of work, across all the various industries, people give 2 week notices. They do this in order to give the employer a chance to replace them. In Long term care facilities, there are often several openings for aides to begin with. When another aide leaves, it just compounds staffing issues even more. 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.

I understand the reasons for wage shopping in jobs in this field. Money is tight and people need to make a living. Some people would laugh at a dime an hour increase in pay but when you’re living paycheck to paycheck every dime counts. Still, it is so important to leave on good terms. When an aide or anyone else quits without a notice, they almost always end up on the “No-re-hire” list- which is important if one wants to get a decent reference. Trust me- a bad reference is not a good thing in this work. And very often, the DON of one nursing home is friends with many DON’s of many local nursing homes- they usually have a network. They warn one another about staff who quit without notice as well as staff who are placed on LOA pending an abuse investigation.

Some other reasons for two week notices:

  • In the future at another agency, you might end up working with some of the nurses and aides  of the facility you left. One of those nurses could be a DON of a nursing home you want to work at, or hospital.
  • You may want to come back to this facility in the future. Now you think I’m truly crazy. You’d never want to work for this horrible nursing home again! Well, remember that whole turnover thing? 5 years down the road, the new management of the nursing home may very well increase pay rates and offer better benefits. You would love to go back now. But you can’t because there’s that “No Re-hire” comment attached to your SS number.
  • There are financial benefits to giving notice. If you have any vacation time accrued you may lose it if there is a policy about giving two week notices. Also, consider any health insurance facts as well. You will lose coverage.

As well there are some valid reasons to NOT give any notice:

  • An employee has been physically abusive.
  • A supervisor has sexually harassed you.
  • Your mental health is being seriously endangered by job stress.
  • You have not been paid the agreed-upon wage or wages have been withheld for an unreasonable length of time.
  • You have been asked to do something which is clearly unethical or illegal.
  • Personal or family circumstances are such that you need to leave the job.
  • A crisis has happened in your life, and there is no way you can continue on the job.

Remember it WILL be the residents who suffer the most when you leave. If you have relationships with them, cutting out without notice will be especially painful for them. It will feel like a death in their family. Only you can decide but it seems to me there are better reasons to give the 2 week notice than there are to just walk off the job.

 

 


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Hard Truths

In our work as CNA’s, we see many contradictions. A lot of DO AS I SAY but little of DO WHAT I DO. We have well written care plans that, in the perfect long term care setting, would be ideal for each resident. We have leaders who brag about the “excellent” care facilities provide.

But the CNA knows the truth.

Sometimes these truths are uncomfortable.

And the truth can hurt. It hurts our residents. It hurts US. It hurts humanity when it becomes the norm. Sadly, this is how it is in most nursing homes. Staffing ratios that change from one shift to the next. But the care plan goals and objectives do not. Why is this?

I read all the wonderful programs and processes at the various nursing home trade web sites we link to. The ideas, and the thoughts behind them are based upon good nursing care practices. Much emphasis is placed upon involving the CNA’s in the programs such as eliminating wheel chair use. CNA’s aren’t stupid. We know how these things are harmful.

Much effort is put into making sure staff “understand the importance”; many hours are logged into convincing staff (namely CNA’s) that these ideas are best for our residents. Care plans are written with great detail as to exactly when and how far a resident needs to ambulate (or whatever the program demands).

CNA’s aren’t stupid.

Yet, all this “education” and “staff buy in” baloney only goes so far.

The baloney shows its true colors when there aren’t enough staff to follow through with the programs. A CNA can assist several residents with walking to the dining room, for sure. But to expect the CNA to ambulate 10, 12 or more to meals is a bit much- when we add in the meal set up, assisting with eating, cleaning up and the myriad of other tasks we’re charged with.

The baloney shows its true colors when 3 aides are assigned a unit on evening shift that is staffed with 5 aides on days. It has always baffled me why evening shift has less aides…the claim that the shift isn’t as task-orientated is crap!

Some more uncomfortable truths:

Evening shift aides could keep all their residents out of wheelchairs IF they had enough support in the form of adequate staffing. But NO. Management cannot justify the ratios based upon the low standards of care they like to pretend are excellent.

Evening shift aides could make sure their residents are brought to the bathrooms more often and therefore decrease incontinence; which could lead to less brief use and…wow…less need to purchase all the products designed to “manage” incontinence. And a nice side effect would be less odors.

I am quite sure more than a few residents would appreciate a shower more than once a week- evening shift staff could do these. Clean residents are happier residents. They smell good, look good, feel better and often want to participate in their lives more.

Residents would not have to go to bed right after dinner, or even at 7:30pm, if there were enough aides. What adult retires THAT early in the evening? When residents are in bed, they are at risk of bedsores, contractures and all the problems associated with immobility. In the end, these problems cost far more money and time to correct than a couple extra CNA’s would cost.

I am quite sure nursing homes save money when they don’t have to keep Activity Staff on the clock past 4 or 5pm each day. Most residents would like to stay up later at night, and socialize and enjoy some activities and outings and other similar things. Having things to do is what keeps life interesting and entertaining. Looking forward to nothing is depressing and demoralizing.

I am quite sure nursing homes save money when they purchase chair and bed alarms vs. having a couple more aides scheduled. The alarms don’t require an hourly rate of and the other costs of employing an aide.

I am quite sure nursing home management can do little to change these truths. They can, however, try very hard to provide the right ratios and activity staff and other supports needed to enable carry through of these excellent (and medically sound) programs. Either that, or down grade the expectations to what can reasonably be done. In other words, care plans and programs should be, and must be, formulated and written with staffing ratios in mind.

Ideally, the resident’s needs should justify the ratios. The CNAs know the truth though.


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