The most popular posts for the month of April, as determined by the numbers of emails about them, comments and page views.

Professional Boundaries

The 7 Habits of Highly Effective CNA’s

Asides: Managing YOUR Anger

Spot Light: Filling In The Blanks

7 Habits of Highly INeffective CNA’s

Survey Lessons: Resident Dignity and CNA’s

ALLNurses: Offer A Free Resource Page for Nurses and CNA’s!

I read an article over at Long Term Living/Nursing Home Magazine and it brought to light some issues CNA’s have with this work.

At first the article didn’t seem to say much new or different; the issues of low pay and poor benefit packages are discussed as being barriers to attracting good staff. We all know this is the number one problem nursing homes and assisted living facilities face- high turnover.

What disturbed me and caused me to write this post:

The study, which was funded by the National Institute on Aging, also revealed that assisted living workers, who are primarily black, often face racial discrimination from residents, who are primarily white. Nearly half of black employees reported experiencing racism, Ball says, with many of those situations arising from comments made by residents suffering from dementia. Overall, she says, facilities need to make sure their employees feel valued and appreciated.

This is in Georgia. But it happens in every state.

Of all the careers one can chose to work in, nursing is one of the most rewarding. To help another person in need is a good feeling. In no other profession, though, do we see management allowing discrimination to happen, daily, as a matter of routine course. Under the guise of resident/patient rights, aides of color are constantly victims of resident harassment and disrespect. Management bars these aides from caring for said residents- and this leads to resentment and bad morale among all the aides.

No where in any Resident Rights document is the right to ask for or turn down care from nursing staff based on their the race, sex, religion or sexual orientation. Period. Not only is this illegal, it’s immoral. It’s also just poor management when the leaders promise residents and their families only female aides will work with their loved ones. What happens when only male aides show up for work? Don’t say it won’t happen. It has and it will.

In most businesses the customer is always right, no matter what. Business owners and their agents will do most anything to satisfy those who purchase their products or goods. This is, after all, customer service. But what do we do when it’s a patient/resident, demented or not, who overtly displays racism against a nurse or an aide of color?

I’ve seen it at my work. Most of my residents (patients actually) cannot speak for themselves and they are not of age anyway. Some of our best aides, who happen to be black, have been singled out as not being good enough to work with some of our residents, by their families. They insist upon “white aides” for caregivers and that their child never have to have a permanent aide of any other color…and management cowards right down to them. They send out announcements to the nurses (via emails) stating “only so and so CNA’s are allowed to be assigned to Mrs. Smith, per family wish”…and the only names listed are of Caucasian aides. The nurses keep this all quiet of course but we hear them talking about it when they’re making out the assignments. How does it make one feel if you’re an aide of color?

Oftentimes families cite a language barrier as the problem. This is a legitimate concern. We’ve had aides from Haiti, Mexico and other nations, who barely speak any English. How they passed a CNA course and state test baffles us, because they often cannot read and comprehend care plans, assignments and other written directives. Concepts of math are not well understood either- so weights and percentages of meals consumed are huge problems for these aides. I can understand and justify a request for non- English speaking staff not be assigned to certain residents/patients. These staff CAN take charge of this problem themselves and learn to speak English fluently; as well as learn to truly understand this language and work with it. They have a choice here.

But we cannot choose the color of our skin.

In any kind of work the management should never stand for this quasi-discrimination that they excuse or write off as resident rights. While we want our customers to be happy and content, we have to take a stand that’s morally right as well as legal. Discrimination is wrong on every level and for any reason.

How can facilities make sure their staff feel valued and appreciated?

Simple. Tale a stand to this nonsense right from the get-go.

Nursing home administrators and DON’s need to tell residents and their families upon admission that they never ever have a choice or say in which CNA is going to care for their loved one. It doesn’t hurt to mention aides (and all staff) of color, or certain religions or sexual orientations are protected by labor laws. Administrators and DON’s need to make it clear they will not tolerate any form of discrimination.

Demented residents will make comments and sometimes these will be very nasty. Some demented residents will always react poorly to having certain aides care for them, and be fine with other aides. I don’t have an answer for this dilemma. I can say it certainly burdens everyone when this happens. One of the good things about dementia is it causes people to FORGET…usually within minutes of any event or problem or escalation. Sadly this memory deficit can be of help in situations where derogatory remarks are made. Usually these residents are able to become very tolerant of their aide, regardless of race, sex, religion- when the resident realizes on some level that the aide is not out to harm them. This can only happen over time, through consistent assignment.

One of the things so many people like about the Culture Change movement is the upside down chain of command structure. Residents call the shots; next the CNAs have this “power”. Nursing homes that are seeking to change their culture often do a lot of window dressing but actually change very little of the management and leadership culture. Fear is the reason for this.

When a facility is looking to really change, actions do speak very loud. Pioneer Network has been working tirelessly to assist nursing homes and assisted living facilities with culture change. Matt over at Setting The Nursing Home On Fire found this gem of an article at the Pioneer site:

Low Cost Practical Strategies to Transform Nursing Facilities
it is a pdf report.

One of the things I noted quickly was the attention to the staff break room. When the staff are respected and trusted, it shows in many ways. Having a retreat style break room is a viable and cheap idea most nursing homes could manage. With the right motivational leadership, the nurses and aides would be more than willing to assist with creating this room.

Staff Amenities
Overall Goal:
Routinely staff members have been assigned break room space in the basement of a facility that is
furnished with cast offs, has equipment and appliances that often malfunction, and space that is expected to serve the dual purpose for staff who want to socialize as well as those who want a quiet time. Reverse this trend and provide staff with an abundance of spaces including tables in main dining room, a computer station and quiet space for reading or meditation.

Really now? Do staff need all this? DO we really care if our break room is nicely outfitted with decent working microwave ovens and fridge large enough to accommodate ALL our bagged meals and drinks? And who has a computer in their break room? Management would never trust the staff to go online because they might be wasting time, right?

Get with the times, management.

Examples of Improvement Strategies:
• Enhance the staff break room. It should have good lighting, comfortable chairs, conversation arrangements, appliances that work, flat surfaces for both eating and writing and a quiet corner

• Provide computer area or computer station for private staff use

• Designate a table and regular day as “give-away or exchange” where children’s clothes, extra produce from gardens, reading material, videos, and other items can be exchanged or given away

• Provide prayer corner or small meditation room designated for staff

• Encourage staff to use lounge or dining spaces to hold baby or wedding showers or other celebratory events. Invite residents to participate along with members of the community

A big bulletin board might be the only resemblance to the “old” break room.

Wow. Comfortable chairs and seating arrangements that mirror a living room more than a waiting room? Why not? When respected, staff deserve such spaces. Most of the furnishings for such spaces can be purchased cheaply through group purchasing associations, trade group memberships and, the old fashioned way- yard sales and thrift shops.

Another GREAT source of help is the resident families. I am quite sure most would donate a chair or small table; an area rug and some table lamps. The residents themselves could make wall quilts and other artwork. Bookcases and ottomans (YES- so the tired feet of CNA’s have a place to rest UP on);
everyone has a book or two they would be willing to give to the new staff LIBRARY located in the break room (same with DVD’s and the TV/Player to go with it).

Think outside the lead box. A transformation can happen within a week if it is truly wanted. Under the culture change movement every room has significance and front line staff have much more value and respect.

Another example of how CNA’s can have a huge impact upon the survey of a nursing home. The following are samples of a real surveyor’s findings; then we’ll look at how the CNA could have prevented these scenarios from ever occurring in the first place.

1. Interviewable sample resident #2 was admitted to the facility on 2/6/01 with diagnoses including rheumatoid arthritis and a thyroid disorder (according to the face sheet). The quarterly Minimum Data Set, dated 6/12/07, coded the resident as having mild short term memory loss.

Observations of the resident on 7/1/07 at 10:30 a.m. revealed a certified nurse aide (CNA) was preparing to transfer the resident from her bed into a wheelchair using a Hoyer lift. The resident stated she needed to go to the bathroom prior to being transferred. The CNA stated the resident experienced pain using the toilet in the bathroom, so he had her go in the trash can by suspending her in the lift and placing the trash can underneath her.

A follow up interview was conducted with the CNA at 1:55 p.m. The Unit Manager was present during the interview. Both stated the day shift and evening shift used this method to toilet the resident. The Unit Manager stated the night shift had the resident use a bedpan, and did not get her up.

And:

On 7/1/07 at approximately 1:00 p.m., supplemental sample resident #27 was heard calling for help in a loud voice. The resident was seated in a wheelchair in the Silver Key office and appeared in no distress. There was a CNA seated in the Siver Key (sic) office with the resident. The CNA stated that was her job for the day, to sit with the resident. The resident could be heard calling for help in the hall outside the office. The CNA asked the resident several times why she was calling for help when there was nothing wrong. The resident yelled for help again and the CNA stated, “You are just a problem child.”

In the first example. the staff used a mechanical lift and trash can to assist with toileting a resident. Is this normal? Is this digified? What are some options?

Commodes: They make commodes in all sizes and shapes, out of soft and hard plastics. Most CNA’s have seen these PVC models. The CNA’s are the resident’s advocate. In this case they should have (and perhaps did) ask for a comfortable commode for this resident to use.

Bed Pans: They also come in many shapes and sizes. Some are made of softer plastics as well. The CNA’s should always encourage the resident to use this before getting OOB.

In the second example things aren’t so clear. Just the name of this room suggests dignity is an issue. When a CNA is expected to be a sitter, they need to have clear expectations of what they are to do with the resident. Just sitting there and watching them often isn’t enough and is very undignified. Usually a resident who needs 1:1 supervision really needs to be occupied. To be kept busy and somewhat distracted.

The CNA’s working with this resident could have foreseen situations where 1:1 time would be needed; and anticipated the need for activities and other things to do. Seeking the help of the Activity Director or other person, puzzles, board games, reading materials or any number of other items could have been available. Smart aides know these times will come and have a box of items at the ready for these moments.

We never tell a resident they are a “problem child”. To do so is border lining on verbal abuse.

To wrap this up, when we are caring for a resident who has special equipment needs for ADLs, ask to see one of the medical supply books to see what is available. If you find something that will work ask for it to be ordered.

Plan ahead. Anticipate needs. Ask for equipment. If your facility employs the services of a physical and/or occupational therapist, seek out their input on resident comfort and equipment issues. Document all of this in your personal log. Ask the charge nurses to document equipment requests in the resident’s medical records.

If you’re a smoker, you’ll want to read this article. If you’re not, you should still read this.

At work smokers take their breaks and usually light up. Having that cigarette often relaxes us and keeps us even keeled. Many facilities are now smoke free- no smoking on the actual grounds of the property or within certain distances from the buildings. BUT most allow staff to smoke inside their vehicles. This is a privilege and not a right. Be grateful when you can.

One thing is noticed often by smokers and non smokers alike: After you have smoked, YOU SMELL like cigarettes. It’s the natural course of events here. The smell gets in your hair, your uniform, your skin. And your breath. It’s not a nice thing to smell.

Do yourself and everyone else a favor: Clean up after a smoke…when you come back inside, WASH your hands first of all. Then brush your teeth or at least use some mints or gum. Some aides I know also do a little more: They use the hand gels to help rid their body of the scent. How? They simply rub the gel in their hands and before it dries they quickly rub it all over their arms, neck and uniform top. It works wonders. One aide actually briefly runs her gel soaked fingers through her hair as well.

Other aides wash up and then use a lotion with a light scent, to cover up the odor. At a local nursing home down the road from me the staff use the unscented Febreeze-like spray over themselves- this is probably the best thing I have seen yet, that really works.

Residents and patients can get nauseated when they smell cigarette odors. Others may become agitated because they WANT to smoke but cannot. Either way, it’s gross and no one likes the smell. So be considerate of others.

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