Provider Magazine, a long term care trade publication, has an excellent article up about how CNA documenting can be streamlined and made much more efficient and, productive. In less time.

Read on (PDF File)

A new pressure ulcer reduction program—known as On-Time Quality Improvement for Long Term Care(On-Time)—was developed by the Agency for Health Care Research and Quality (AHRQ) with support from the California Health Care Foundation in an effort to close the gap between staff knowledge and staff practice.
[…]
Since certified nurse assistants (CNAs) spend the most time with residents, they are frequently the first to notice subtle health status changes; however, their observations often never reach the team members who are formulating care plans. In addition, nurses are sometimes reluctant to use CNA
documentation because it may not accurately reflect resident health status and is often incomplete.

More:

There are three key components of the On-Time program:
*Assessing current CNA documentation, streamlining CNA documentation, incorporating best practice elements into daily charting, and consolidating CNA documentation into one form;

*Establishing audit and feedback processes to confirm CNA information completeness and accuracy;

*Integrating weekly reports that identify at-risk residents into care planning processes and structures.

Sometimes I wonder about ALL the documenting we do- is it helpful, is it really necessary and, who reads it? Where does it all go? AND how much of the paperwork is geared towards making someone’s else’s job easier? Hmm.

Implementing The Program
Successful implementation of the On- Time model entails the following three steps.
Step One: Streamline and standardize CNA documentation to capture relevant information. The heart of the On-Time program lies in the daily care documentation conducted by CNAs. Prototypes of the CNA documentation form and the On-Time reports are the starting point for implementing the program.
During the first stage of the initiative, documentation forms currently used by CNAs are reviewed; cross-referenced against regulatory requirements, facility care protocols, and best practice elements; and compared to the On-Time CNA form prototype.
[…]
The result of this process is the development of a new CNA form designed to include best practice elements and to eliminate both redundancy and documentation of unessential items.

READ the entire article HERE; this is a PDF file and it’s very worth printing and saving. Any efforts to reduce the amounts of paperwork is worth looking into. CNA’s and nurses spend astronomical amounts of time writing, checking, noting and reading many forms, sheets, records, logs..much of it is inefficient and wasteful.

Often we hear the terms Restorative Nursing and Rehabilitation Nursing- the two terms are confused and intermixed in conversations and services. While similar, there are a few major differences between the two:

Rehab is a higher level of skilled care. Services are always provided by licensed staff- physical and occupational therapists and their assistants; Speech-Language Professionals, Nurses and others. Services are billed for by the hour. Government and insurance plans will only reimburse services delivered by licensed professionals. The use of CNA’s in Rehab is limited- and any care they provide is not “billable”. This means services provided by a CNA are not paid for. In Rehab, the CNA is not considered a professional.

Restorative care, on the other hand, is provided by nursing staff, including CNA’s. It is provided 24 hours a day, 7 days a week. Nurses can assess residents for needs and create special programs designed to restore or maintain the residents’ current and previous levels of physical health.

Read the rest of this entry »

National Nursing Assistant Week is coming up. The original idea behind this week was to honor those CNA’s who have chosen this work as a career. It now includes all nursing assistants, with June 12th being specially designated for CAREER nursing assistants.

The annual observance of Career Nursing Assistants’ Day and Nursing Assistants’ Week began in Ohio in 1977 as the Ten Year Club, and expanded nationwide by request in 1985. Since that time, this popular nursing assistant recognition program has grown to include thousands of facilities and organizations joining together each year to recognize and honor nursing assistants in long-term care services.
The title, Career Nursing Assistant © was developed by the Nursing Assistants’ Representatives’ Committee of NE Ohio in 1977. Today’s nursing assistant is proud to be designated as a Career Nursing Assistant, and the terminology is now in common usage to identify the experienced nursing assistant.

Nursing Assistant Week should be cause for positive reflections of the work CNA’s do. Too often, we are looked down upon. Too often, we’re an after-thought and our input is rarely asked for. We’re the most supervised group in the medical/nursing setting yet we are expected to deliver most of the hands on care, at dirt wages. Others have high expectations of us- not for our skills and education, but for our warm bodies and names on a schedule. More emphasis is placed upon our attendance than our skills; our pay reflects society’s overall disrespect of elderly and disabled people.

The Best Way to Honor CNA’s for National Nursing Assistant Week
Spread the celebration over time…Are we only to be recognized one week a year? How hard is it to recognize our good work and value all the time? Asking for our ideas and input isn’t difficult. Saying “Thank You” every so often isn’t hard, either. Both of these ideas cost nothing in terms of money; but would be considered priceless to most CNA’s.

One thing I hear all the time, from management, is how much these week long “events” cost; the strain on the budget…well, honoring the aides doesn’t have to cost a penny. At the National Network of Career Nursing Assistants’ web site, there are many things that management can do, that might require the expenditure of a stamp or two.

…these are just a few ideas.

Also consider:

…these ideas are what MAGNET hospitals call Best Practices- and there designed to attract and keep the best nurses.

When people are involved in their work, and feel their opinion counts, they will give feedback and participate. If you’ve had problems with attendance or attitude at these celebrations, blame yourselves. Once a year isn’t enough. It’s doesn’t feel real, or honest. It’s a slap in the face. Many aides compare it to the dreaded survey illness that infects nursing homes once a year…all’s crazy and phoney for a week than life goes back to normal.

So, what about the actual EVENT? The CELEBRATION?
Here’s where these things get testy. It’s NEVER a good thing to SHARE the celebration of the work of CNA’s, with Nurses, or Housekeepers, or Dietary Staff. Each group is a very valuable part of the big picture. Each contributes it’s own important set of skills and work. Each deserves their own time to be honored. To lump everyone into one big party, once a year, is not only disrespectful of the employees, it’s disrespectful of their work.

NCNA WEEK is 7 days long for a reason. Seven days are listed with events for each day…as a guideline.

No one expects a nursing home to spend seven days celebrating. Hardly..what is expected is a concentrated effort to truly honor ALL the CNA’s employed- on all shifts including third shift and weekends. This might mean coming into the facility at midnight, or on a Sunday afternoon.

When planned ahead of time, seven days will not be necessary. When planning a major event where we want to include as many CNA’s as possible it would help to get creative with the schedule. Nothing stinks more than not being able to go to the one event designated for the aide- when he or she cannot leave the unit to attend.

A facility I worked at filled up three DAYS with events to honor the CNAs: One day was scheduled to target third shift aides; the next day was for second shift and weekenders and the third day was for day shift. Aides from ALL shifts did their own schedules to ensure coverage of the units…so, it did mean some slight overtime for more than a handful. But it was worth it. Attendance for these events was close to 100%- the only aides who didn’t show up were those on vacations.

As for “gifts” or tokens, one creative facility grew houseplants for the staff…the residents, with the activity folks, planted and grew little African violets and Spider plants. Another facility had the residents hand paint little plaques “awards”; and yet another facility utilized the local community with discounted and free coupons for pizza, groceries and gas. There’s plenty of opportunities in the local community- management just needs to seek them out.

Specific items for CNA Week are available, of course, and when possible, should be purchased. The NNCNA web site has a store, that has lapel pins, T shirts and little TIPS booklets designed just for this event.

This post was written for the management of nursing homes…I will have another post for the CNA’s on THEIR part in this.

Over at the PHI Blog, an article about grief experiences with CNA’s is highlighted.

The problem is one cannot access the original article without coughing up some cash. Instead of going by whatever it indicates, I’m going to write here about how CNA’s are often forced to deal with the deaths of their residents.

CNA’s who work in nursing homes and assisted living facilities have long term relationships with residents; it’s part of what we do. We care for them, in many ways. Over time, aides become attached to the residents and even though it’s discouraged from management, friendships develop between the aide and resident. We’re all human and not robots. Feelings and fondness are natural.

When a resident declines, the CNA is the first to take note of it. In facilities where consistent assignments happen, the CNA’s work with the same group of residents over a long period. Sometimes though, without consistent assignments, CNA’s can see problems and decline as well. It’s difficult to watch this decline occur: The weight loss, the loss of function and ability. CNA’s grieve the loss of mental ability and physical health.

End of Life Policies

Far too many nursing homes go with a traditional mindset that death happens…get over it! It’s the expected outcome for most residents…and CNA’s should be tough enough to handle it.

I say: Not so fast. CNA’s are tough. But we’re also human. We don’t become immune to death simply because it occurs often. Anyone who IS immune to the feelings and emotions that are normal after a death, shouldn’t be working in nursing. When we lose that, we’ve lost a lot.

When death is imminent, CNA’s usually know it before anyone else. There are tell tale signs. A good facility will assign one aide per shift to work with a dying resident- be that the primary CNA or not. A dying person needs consistent staff more than any other. This isn’t the only resident the aide should be assigned to, but the group should be smaller in number so the aide can manage to spend more time with the resident.

CNA’s should be given the option of working with this very special resident: Some are just not comfortable with the dying process and this will make for a very sour experience for all involved. The attitude should not be one of, “It’s part of YOUR job!” Death and dying and the process of doing so isn’t just another task to be done. A human being’s life is about to end. We should strive to be as respectful as possible. Dignity for everyone is important. Including the CNA. Much of the caring at this time could go to family, who may be at the bedside. Who wants a CNA there who is nervous, scared, or otherwise not able to provide care and comfort?

When CNA’s are included in the process and planning of an impending death, they feel more empowered. They will be able to mentally prepare for events; they will be able to manage their time and afford the resident the best care. Often, the resident won’t need a lot of actual care. Limited movement and fuss is the norm; really good oral and skin care is important. And just being there is probably the most valuable form of care at this time.

When a resident has passed away, the CNA should ALWAYS be given the choice about providing post mortem care. Nine times out of ten the aide will not have an issue with doing this; but there are times when they won’t feel good about doing it. This should be honored. The charge nurse should be able to anticipate this and plan accordingly.

Mrs. Smith Died Last Night
When we come to work, we need shift report. When the news of a residents’ passing is shared, it can be a shock to some CNA’s. As well all know, many residents simply “die” with no prior “warning”. This is what concerns me. The shock factor is real and hard to manage for many. The CNA’s, nurses, and probably everyone else, will experience the five stages of dying:

Denial, anger, bargaining, depression and acceptance.

The first three stages are apt to be felt within minutes of learning of the passing. And this is where many facilities let the ball drop. Death is so common in nursing homes. It becomes another event- sometimes anticipated and other times not. Regardless, CNA’s are expected to go about their normal routines without any concern for their very human feelings. CNA’s do experience depression when a favorite resident passes away suddenly. They miss the resident. Perhaps the resident was on their assignment for a long time. There were no opportunities for a goodbye.

A relationship has ended. Abruptly. Think about how you would feel, and react.

Time should be allowed for grieving. A moment of prayer; a quick break; a hug- and a shoulder to shed some tears on, are all appropriate measures that should be acceptable at these times. The hours immediately following the death of a resident will be difficult for CNA’s. Reminders of the resident are everywhere: their room, their laundry, their place at the dining room table…maybe family trailing in and out. It’s a time to reflect and it’s okay to be SAD. In many cases, it’s a blessing as well and CNA’s will be sad AND grateful at the same time. Grateful the suffering has ended.

A range of emotions are to be expected. CNA’s will “get over” this, but they shouldn’t be rushed. Death is a part of life, but it’s a sad part. If a CNA is really overwhelmed with strong emotions that she cannot control, it is entirely appropriate to allow her to go home unpaid, I recommend. The pay issue is a stickler for me: Paying staff to stay home due to normal human reactions isn’t good policy. The lack of being paid is a factor many will consider; this is in an effort to really weed out those who can be SAD and professional at the same time, from those who might be newer to the work and inexperienced in these things.

Management should be supportive during these rough hours and days. Some facilities make religious counseling readily available to staff; others allow personal time off to attend wakes and funerals. Small memorials are set up- usually a table with flowers and a Guest Book in the lobby. The family gets the book when it’s been signed by staff and others.

The Involved Family: Mourning The Loss of Them
One more thing that isn’t often discussed: When a resident dies, not only do we miss the person, we miss their family in most cases. These families become a part of the unit; they visited often and we got to know them pretty well. These were the people who brought in Christmas gifts for all the staff; these are the people who thanked us each and every day for our very hard work; these are the people who looked to us as heroes. They made us feel good about the work we do. CNA’s especially will feel this loss.

A little planning and after-action briefings could go a long way towards helping validate the feelings and emotions of ALL staff after the passing of a resident. A facility that respects these very human traits will be a better place to work at. CNA’s are not robots, as much as we feel like so many times.

When we read about and hear people discussing nursing homes, remember this very important point:

I was thinking about this last night and realized something quite obvious. JCAHO, the organization that accredits virtually every hospital in this county, has established standards for hospitals to go by. These standards are considered optimally achievable outcomes — what a facility should aspire to be. CMS standards, the ones that nursing homes are required to comply with, are minimum standards — the absolute bare minimum you can do to get by with. Literally every single nursing home I have worked with has regarded the CMS minimum standards as optimal achievable outcomes.

So true…all these stories about CMS releasing it’s list of worst nursing homes should tell us how bad things really are. CNA’s know this- and have known it for years. We work in the bowels of this industry and every one of us can attest to the truth of this. When the standards are low to begin with the care isn’t going to be much better.

Continuing on the theme of online resources for CNA’s, Patti gathered several links to sites that offer continuing education opportunities. These are not free and pricing is a bit prohibitive for individual CNA’s. Facilities can certainly afford some of this though.

Read the rest of this entry »

The National Association of Health Care Assistants has been around for many years; it’s an excellent CNA advocacy group and offers individual and facility memberships. Through this group, CNA’s have an opportunity to engage in a professional course designed to further their knowledge and skills with caring for the elderly.

Description
The Geriatric Care Specialist Program is a 10-module correspondence study course for certified nursing assistants. This course is designed to assist nursing assistants with enhancing their knowledge and skills in the field of geriatric care. The certification expires annually. To maintain certification, submit annual verification that 12 hours of in-service have been completed, along with $5 renewal fee.

————————————
Syllabus

Module One
Anatomy and Physiology

Module Two
Age Related Disorders

Module Three
Geriatric Urinary Incontinence

Module Four
Pressure Ulcers, Wound Healing, and Skin Care

Module Five
Caring for Residents with Dementia

Module Six
Psycho-Social Needs of the Geriatric Resident

Module Seven
Communicating in Long Term Care

Module Eight
Restorative Care

Module Nine
Observation, Reporting, and Documentation

Module Ten
Survey Process and Federal Regulations
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Go HERE for more details.

If you’re looking for prepared programs to further you’re knowledge as a CNA, this site has a comprehensive listing of courses. For LTC facilities mostly, this site offers online classes that staff can participate in through their employer.

Academy of Certified Health Professionals

ACHP Educational Programs

A revolutionary continuing education program designed to meet the complete needs of health care providers. Programs are geared to real life educational needs based on feedback from nursing assistants, charge nurses, administrators, staff development coordinators, CNAs and nursing directors.

A sample list of course titles:
—————————————————-
Skin Integrity Management
Course Number 150
Professional Point Value 10
Level of Difficulty
Description: This course details the anatomy and physiology of the integumentary system, age related changes, and preventive care to maintain skin integrity.

Pressure Ulcer Prevention
Course Number 250
Professional Point Value 15
Level of Difficulty
Description: Knowing that prevention is the best treatment of pressure ulcers, this module outlines the risk factors identified for skin breakdown, causes of skin breakdown and caregiver implications related to pressure ulcer prevention.

Weight Loss Management and Intervention
Course Number 350
Professional Point Value 15
Level of Difficulty
Description: Adequate nutritional intake is imperative for skin integrity and wound healing. Unplanned weight loss puts the frail and elderly at risk for pressure ulcer development and impaired wound healing. This course defines the necessary nutrients, vitamins and minerals for optimal health, plus caregiver methods to reduce unplanned weight loss and optimize nutritional intake.

Wound Healing in the Elderly Individual
Course Number 450
Professional Point Value 20
Level of Difficulty
Description: Building on the material presented in Courses 150, 250, and 350, this module provides, in great detail, the phases of wound healing, the ideal environment to promote wound healing, and how the CNA can positively impact wound healing.

Developing and Implementing Resident Safety Protocols
Course Number 160
Professional Point Value 10
Level of Difficulty
Description: Nursing assistants are the first line of defense against resident accidents and injuries. This course will explore realistic and hands-on techniques to ensure the safest environment and care for the frail, elderly and disabled needing assistance.

Infection Control for the Nursing Assistant
Course Number 260
Professional Point Value 15
Level of Difficulty
Description: Because even the mildest of infections can be life threatening to the frail, elderly and disabled, it is imperative the CNA have a good working knowledge of the chain of infection and how to prevent the transmission of infection to those in their care. This course will cover those topics, plus other techniques to reduce the risk of infection both to residents and staff alike.
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There are MANY others.

Also, this service offers a CAREER LADDER PROGRAM based on the completion of the courses. This would be geared for facilities and not individual CNA’s.

White Coat writes about his experience watching an old woman die in an ER. She had been transferred to the ER from a nursing home:

As I walked in to evaluate her, I could tell she wasn’t going to live much longer. She didn’t respond when we called her name and she didn’t move when I gently gave her a sternal rub. She had agonal breathing and wasn’t moving any air. I just stood there for a second. Everyone was obsessed with her being a DNR. This is a woman, for Pete’s sake. She’s a grandmother, maybe a great-grandmother. Someone’s wife. A next door neighbor. The one who always seemed to win at BINGO in the nursing home. Someone who baked cookies for the church bake sale.

Then my mind began to wander. What songs did she used to sing to her kids to help them go to sleep when they were scared at night? What were her fears? Did she know how to bowl? How many people have her picture sitting in their homes somewhere and will forever look at it differently after today? Did she have any co-workers? Would they even know she was gone? How long had it been since she cooked her husband’s favorite meal, waiting to surprise him when he got home from work? It was like I was subconsciously overcompensating for her being a “DNR” by thinking about all the things that made her human. A whirlwind of these whacked out thoughts kept running through my mind.

How often do we label our residents/patients by their diagnoses or diseases, or, in this case, their Living Will status?

This is haunting:

I stood there and watched her for a little while. I watched her take her last breath. I watched her heart generate it’s last electrical impulse on the cardiac monitor. It felt strange not to be calling out orders for medications and chest compressions. For some stupid reason the whole scenario bothered me. She died in the bright lights of an ED room and the only ones at her side were a doctor and a nurse she had never even met before.

Is there a lesson to be learned here? When I worked in nursing homes, far too often we shipped off very ill people who we knew were going to die; the nurses knew it, the aides knew it. Usually the defense for uprooting the resident was incidental and based on legal fears; one nurse used to often say “No resident is going to die on my shift HERE!” Whatever. As the doctor says, why do the ER thing? Can’t we just allow our residents to die in the setting they now call home? Even those with no family deserve better.

Nursing Home Magazine does it again: AN excellent article about dysphagia and swallowing problems, some of which is aimed at CNA’s:

Dysphagia is not unusual among older adults living in long-term care facilities. One study recorded the presence of mealtime difficulties in nursing home residents and found that nearly 90% had impairments that included dysphagia, poor oral intake, positioning problems, or challenging behaviors. Furthermore, 68% of the residents experienced dysphagia, compromising their ability to enjoy meals, let alone consume the necessary calories to meet nutritional requirements. Dysphagia can lead to aspiration, choking, dehydration, malnutrition, and pneumonia. In fact, aspiration pneumonia is the fifth leading cause of death in people over 60 years of age and the third leading cause of death in people over 80. Clearly, food intake is crucial to many residents’ health and quality of life.

Residents with dysphagia often require modified diet consistencies, such as thickened liquids or pureed foods. In addition, nursing assistants must often comply with specialized feeding techniques, such as placing food in the non-impaired side of the mouth, limiting the use of straws, or facilitating the use of adaptive feeding equipment. In the dining room, nursing assistants who provide help to, monitor, or feed residents must follow the techniques for the residents’ safety and nutritional health. Failure to successfully comply with swallowing and feeding recommendations can cause inadequate hydration and nutrition and unsafe feeding.

More:

Through therapy, a speech-language pathologist can help many residents with dysphagia learn compensatory swallowing techniques. Researchers have found that poor staff training and a lack of understanding about feeding recommendations can cause malnutrition and dehydration in long-term care. McGillivray and Marland conducted a review of the literature on assisting people with dementia during meals. Their review found that mealtime assistance is often stressful for residents and staff because feeding becomes task centered and staff have not been sufficiently educated or trained.

I think ALL staff could use more training.

Did you know?

Signs and Symptoms of Dysphagia
Some signs and symptoms of dysphagia are not commonly known. For example, did you know that a persistent low-grade fever might be a sign of dysphagia? Did you know that if a resident is spitting food at meals, he or she might have oral phase dysphagia and might be unable to chew properly? Review the list below with your staff. Residents displaying the following signs and symptoms of dysphagia should be seen by a speech-language pathologist:

* Having trouble recognizing food
* Difficulty placing food in mouth
* Drooling or spitting
* Food falling out of mouth
* Pocketing of food in mouth
* Rocking tongue back and forth while chewing
* Food left in mouth after the swallow
* Chewing for a long time
* Coughing before, during, or after the swallow
* Delayed or absent rise of the larynx during the swallow
* Requiring 3–4 swallows after each bite
* Continuous throat clearing during or after the meal
* Wet or hoarse voice
* Complaining of something caught in throat
* Refusing to eat or very slow eater
* Lasting low-grade fever
* Unplanned weight loss or unexplained loss of appetite
* Pneumonia
* Malnutrition or dehydration

This article provides an excellent review of swallowing problems for nursing home residents and would be a timely and good resource for an in service.