I have some thoughts about performance evaluations. Annual evals should be tools for improvement. Not only should our past performance be measured, our future goals should be laid out as well. Managers and leaders, real ones anyway, know this. To often, in the nursing facility, evals are not important; they are dreaded, thrown out and disregarded and by many. We often feel under the gun and undervalued when we read our evals. Its one reason so many of us leave this work.

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One of the best things we’re seeing from the Culture Change movement involves how CNA’s are assigned to the residents they care for. The consistent staffing model has gained some popularity over the past few years. Research shows how this model benefits residents and aides.

Fast forward a couple years and some challenges are presenting themselves.
In my region, hospitals, nursing homes and other health care facilities have faced a shortage of nurses and aides. In order to attract these skilled professionals, most facilities up here are moving away from the standard nursing schedule model to a more flexible one. Gas prices and travel time play into this.

Instead of scheduling staff to work the typical 4 days on, one day off, every other weekend model, where I work we have staff working all sorts of different hours. Many are choosing to work two double shifts and one 8 hour shift per week. Others have opted to work three 12 hour shifts per week. Not all of these positions require weekend work either since we have a group of staff who work two 16 hour days each Saturday and Sunday.

This means different aides working every day.
So, consistent staffing is almost impossible to achieve. Rarely does an aide work two days in a row. Nurses are doing the same thing.

Many of my co workers travel from distant towns to my facility to work the weekend only; they stay at a small local hotel (paid for by my work). The benefit of this for my co workers is using far less gas which is expensive. My employer is happy knowing the units are staffed for the weekends. Other than the weekend staff, no one is expected to work two 16 hour days in a row. Nurses are offered the popular Baylor program: Work the 32 hours each weekend and get an 8 hour bonus which equates to 40 hours pay.

Facilities have to make tough choices. Either keep the strict medical schedule model and have a shortage of nursing staff, or, offer flex hours and have adequate staffing each shift.

How does this all effect residents in nursing homes and assisted living facilities? They don’t have a core staff. There is NO one CNA who is assigned to them on a daily basis.

My own schedule has changed at my request, due to the price of gas. I was spending a quarter on my earnings filling up the gas tank, just to get to work five days a week. Now I work two double shifts and one 8 hour shift, a week. Five shifts in 3 days. I have saved a respectable amount of my income by making this change.

I like the schedule in many aspects:
-I have four days a week off to be with my family and tend to home and hobbies. I’m not nearly as stressed and tired as I was when working the 5 day schedule.
-I’m saving gas, for sure- but also wear and tear on my vehicle.
-When I am working, I keep the same assignment for the long (16 hour) day. Those residents I assist with getting am cares done, I also assist with doing the pm cares as well. If we don’t get the bath done in the morning, we know to fit it in at night. My assignment is consistent for the entire two shifts and my residents and their families really like that. We haven’t seen an increase in falls or skin issues.

This week we ask the Questions:

What kinds of schedule options do others have? Is flex scheduling allowed? If so, what kinds of shifts and hours are typical?

What’s more important? Having enough staff who may be working flexible shifts, or not having enough staff who always work the typical nursing model schedule?

Question:
At work today I got into trouble because one of my residents’ fell. This man is independent and never needs our help. He can do his own care- showers, dressing, walking, meals, toileting…the works. As far as I know he has never fallen before. I was busy with one of my other residents who requires total cares. I was in the middle of bathing her when the nurse came in to tell me the man fell and why wasn’t I with him? After I finished up with my lady’s care, I was told to fill out a report which wanted to know what I COULD HAVE DONE to prevent the fall; THE LAST TIME RESIDENT WAS TOILETED; THE LAST MEAL consumed- all things that had nothing to do with this fall!!

Later, I was written up for the fall. I told the DON that everyone is responsible for ALL the residents on the hall I was working. Yes, he was assigned to me, but when I am busy with other residents, my co workers should step up and cover for me. What do you think of this?

Answer:
You should not have been written up, in my opinion.

Every resident must be assigned to a CNA. It’s law. No way out of that. Every aide accepts their assignment and therefore responsibility for the residents on it. Each CNA is responsible for her assigned residents and the unit, as a whole, cannot do this.

It’s tough when bad things happen to good aides, though.

Did you read the man’s care plan? Are you absolutely sure he is independent in his cares? If so, did you check in with him to see if he needed any help, with anything? I think sometimes we assume these residents who are able to do their own care never need ANY help- and this isn’t always the case. When doing this check in, it’s always a good to ask when they’re planning to get up; what they’re bathing plans are and the like. This way, you can have some awareness that Mr. Smith is going to be up and about around 9am, and might need someone to just peek at him.

Of course this is where team work comes into the picture. Every time an aide is going to be tied up for awhile with residents, its always a GOOD thing to let as many peers know where you’re at. And include the nurse with this info as well. If you’re so inclined (and I would be) I would ask peers to keep an eye and ear out for your other residents…especially if I was going to be tied up for a longer period than usual with the other resident. A good charge nurse would make sure your other residents are covered as well. It’s a balancing act though: Asking every aide to cover the others’ residents every time personal care is being performed is just not practical.

As for the report: It’s called an Incident Report. The questions asked do indeed have everything to do with the assessment of a fall. By asking you what you could have done to prevent this fall, the answers you provide are supposed to be helpful to prevent a repeat in the future.

Did you know most residents fall because they are trying to get to the bathroom? If they’re hungry they might be trying to rush out to a meal. Usually there are other questions too on these reports- about all sorts of things. Often we don’t know the prior condition of any resident when they have fallen without a witness.

It’s very important for CNA’s to answer these things honestly…however….when we’re written up it takes away the desire for CNA’s to have any respect for these reports. These things should never be used as a means for punishment. When independent residents fall, it is NOT the direct fault of the aides. It was caused by something else. It IS up to management to figure out why the fall occurred- but by placing blame on the aides they are short changing this process. This is another example of autocratic management style- which isn’t helpful. And, I have to wonder if nursing homes with high fall rates have these kinds of managers.

I’m sorry you got written up. Of all the things CNA’s don’t have control over, the FALL tops the list. The work loads alone should tell all that it’s impossible to be everywhere at the same time- or even once an hour. A good fall prevention program begins with a trusting environment where no one is disciplined for falls unseen. Once that is in place, true prevention strategies can be developed AND the CNA’s are the most valuable asset to this process.