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.

Shift Report: It’s Very Important

I have been reading here and there about shift report.

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

CNA’s are the hands on care giver.

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

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

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

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

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

Shift report is vital to CNA’s.

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

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

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

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

Professional Boundaries

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

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

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

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

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

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

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

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

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

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

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

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

* Do you keep secrets with patients/family?

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

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

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

* Have you ever flirted with a patient?

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

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

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

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

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

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

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

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