Nursing Assistant Resources On The Web

I found these videos at YouTube and thought it would be a good resource. I’m including them here in two posts…

Transfer Techniques p.1 of 4

Video Two from the series.

Transfer Techniques p.2 of 4

Recently we highlighted a program offered by death and dying expert Donalyn Gross: She is a thanatologist and has had lots of experience working in nursing homes and hospitals. Her program, “Good Endings” is an excellent resource for all who provide end-of-life care.

I asked Donalyn for an interview here, to get her thoughts and opinions on this issue. Presented here, is the interview which was conducted via email.

1) How long have you been a Thanatologist and what prompted you to get into this profession? What are your perceptions of the death process in institutions such as nursing homes? At your site you offer workshops for staff. I strongly believe this education is needed. How many workshops have you done? Who attends the program? Are CNAs a part of them?

DG: I’ve been a Thanatologist for 30 years now. My dad was a physician, my mother is a nurse, so I was raised in a medical household. I was a Candy Striper at a local hospital in high school, and all the jobs I’ve had since then were in hospitals or nursing homes. I’ve been a medical secretary, transcriptionist, dr’s assistant, nurses aide, Activity director, and a social worker.

In the 1960’s when Elisabeth Kubler-Ross came out with her work with the dying, I decided that’s what I wanted to do. All of my schooling (colleges) was based around medical counseling, etc.

Working in the nursing homes, when someone died, it was like “bag “em and tag “em”. The dead were hidden behind curtains, the roommate was brought into another room if possible, the funeral home was called and the body removed. Many nursing homes put the residents into their rooms, or closed them off when the morticians wheeled the body out. Out of sight, out of mind.

Some more liberal homes now allow residents in to see the person who is dying, or the deceased person. Sort of closure. That’s the way it SHOULD be. Why hide the dying/dead? I also am a Certified Music Practitioner, and play therapeutic bedside harp for the dying. I am on call at local nursing homes and a hospital.
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2) What has been your experiences in nursing homes/long term care facilities with regard to residents’ end of life care? What is the ideal environment for a dignified death within the boundaries of the average nursing facility?

DG: You know how busy nursing homes are= who has time to sit and visit with residents, never mind sit with someone who is dying. That’s why I created the Good Endings Program, with the Vigil Team= we recruited volunteer staff to sit with the dying, around the clock. It is a great program, and many nursing homes around the world are following the program and creating their own programs.

When a resident is “actively” dying, there should be some kind of protocol= the staff should make time to go in and visit/say goodbyes to that person. CNA’s are the ones who work closest to the residents. They’re kind of like extended family. They should be allowed to be with that person if they want.
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3) Is staffing an important factor in EOL care? Many residents do not have family that can be with them during their last hours; some facilities will ask an aide to sit with the dying resident and provide optimal care, while others will not. What are your thoughts on this?

DG: I think every facility should have a specially trained group of volunteer staff, who when a person is dying, should be the ones to provide the last care of that person.

Some residents have family who want to be there all the time, and only need some respite care- example- meals brought in, someone to stay if they need to take a break. For those who have no families/friends, that is a definite focus for someone to be there for them. Some people can’t deal with death and dying, and that’s ok. They can assist in other ways. There’s no shame in it, and a person shouldn’t feel guilty because they don’t want to be there.
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4) Hospice vs Nursing Home Staff: The differences you see

DG: Many nursing homes have outside hospice people coming in to see hospice patients. Nursing home staff are always there, and see the patients constantly. Hospice personnel come in for specific times and visits. They’re not always around. Hospice is a good program- they have volunteers who are a big part of hospice work, but they have their time constraints.
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5) CNA’s: What should their roles be in EOL care?

DG: CNA’s should be allowed to be a part of end of life care, to work along with the nurses, if that’s allowed. Every facility is different. Everyone is so busy and overworked. Our vigil team members will often go in during their breaks, and many will come in before or stay after a shift to sit with people.
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6) Many CNA’s know little to nothing about the religious beliefs of residents; we get basic rundowns on cultures and the like. Should CNA’s have better understanding of religious values in the context of death?

DG: In my Good Endings publications, there is a Teacher Resource packet= it’s 29 pages of everything you wanted to know about death, dying and bereavement, and information on religions/culture. Very important. NEVER push your own religious beliefs on anyone, and ALWAYS know something about a patient’s culture! Lot’s of things to be aware of.
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7) CNA classes don’t do a good job preparing the students for death and dying and all the emotions that come with it. We’re taught signs of impending death and about post-mortem care, but in clinical terms mostly. How could this be improved?

DG: I created the Good Endings program specifically for nursing home staff to provide them with the basics of death education. They should be given information on the physical aspects of dying, as well as the emotional ones.

My Good Endings Guide, a 12 page booklet, is used for this purpose. Facilities should have in service workshops once or twice/year for ALL staff members on death and dying. We’re all going to face it in our lives. It should be mandatory for ALL STAFF. I provide training workshops for healthcare personnel in nursing homes, hospice programs, hospitals, healthcare agencies= anywhere where requested. I speak at conferences for all types of groups (social workers, activity professionals, etc.) I also teach Death, Dying and Bereavement at a local college. We’re ALL going to die and we should know how to deal with it.
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8) CNA’s are often close to their residents. When they pass away, we’re expected to “carry on” and perform our duties with as little interruption as possible. The emotional aspect of losing a favorite resident is hard on the aides. How can management support the aides and nurses, and other staff who are grieving?

DG:When a resident dies, at some of the homes I work with, a sympathy card is passed around for staff to sign and write memories, and then given to the family. Some light a battery lit candle and put a rose up on the nurses station to symbolize there was a loss.

We have memorial services, quarterly at one facility, where we invite the family, staff, other residents to share loving memories of those who died each quarter. (Hospice usually has a big one once/year). It depends on the size of the facility.

Most death occur between September and March due to the cold, winter, and flu seasons. We’ve offered bereavement to the families and staff, but many of the families don’t want to come back to the home, and it’s really hard to get staff members to get together after work hours.

They do know that they can always call me at any time if they want to talk. And talking does help- even if it’s while you’re working, during a break….it’s good to get your feelings out. Working in a nursing home, there’s always going to be another death coming up. Administration should be welcoming of any kind of emotional assistance for their staff. You’re lucky if you get a concerned, involved Administrator/DON.
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Donalyn’s web site is HERE. Make sure you visit it and check out her program. She also offers in house trainings for facilities located in the north east US.

The latest word from CMS on helping consumers decide which nursing homes are good: Star ratings.

June 18 (Bloomberg) — Nursing homes, like luxury hotels in travel guides, will soon get star ratings for quality and safety, according to Medicare, the federal health insurance program for the elderly and disabled.

Medicare’s new ranking system will help people choose the best nursing homes for relatives and push operators to do better, said Kerry Weems, the program’s acting administrator, on a conference call with reporters today.
[...]
“The public is hungry for information and this is an easy way to evaluate quality,” Weems said. “The new `five-star’ rating system will provide a composite view of the quality and safety information.”

All I can say is they should have CNA’s be part of this rating system. As in, asking CNA’s to actually rate the facilities based on the special insight and insider info they have. Bet most nursing homes would get two, maybe three stars at most if the aides were doing the rating.

I have seen a disturbing trend of late. Quietly, medical and nursing facilities have been laying off staff in higher numbers. Not just housekeepers and janitors either; but nurses and CNA’s. In my state, a couple weeks ago a highly rated hospital closed down a unit and laid off 23 nurses and aides. Another facility was going to trim down a nursing unit by 15 beds, and would have laid off about 20 LNA’s and several nurses; the facility changed it’s mind on this, for now.

What’s going on? Did we ever think CNA jobs would be targeted for lay offs? Times are getting tough.

Cape Cod Hospital has notified an employees’ union it intends to eliminate about 17 full-time positions, including jobs held by cleaning staff, shuttle bus drivers, nursing assistants and food service workers.

The hospital is looking to save $800,000 through a combination of layoffs and not filling currently vacant positions, said David Reilly, spokesman for Cape Cod Healthcare Inc., the parent company of Cape Cod and Falmouth hospitals.

The job loss affects only Cape Cod Hospital, which is feeling the brunt of a multimillion-dollar revenue decline.

The 16.9 positions are “full-time equivalents,” meaning each is the equivalent of a 40-hour-a-week job. But the job loss could actually affect more than 17 individuals, since several of the jobs are shared by part-timers.

Revenue is the income a facility receives to pay for it’s operating costs. Much of this money comes from the federal government and state government, as well as from insurance payments. But, because these sources are not increasing their rates of reimbursement to the facilities, we have a shortfall.

Don’t assume belonging to a union will save CNA jobs:

‘The entire health system is feeling the pressure,” said Jerry Fishbein, vice president of 1199 SEIU, United Healthcare Workers East, whose union represents the workers whose jobs will be eliminated.

As required by collective bargaining stipulations, the hospital gave the SEIU a “30-day notice” of its intent to lay off the employees.

The next step is for the union to meet with hospital officials to see if they can whittle down the list, said Fishbein, whose union has 1,200 members at Cape Cod Hospital. “At the end of the day, there will undoubtedly be some layoffs. We certainly think the numbers should come down. It’s process of negotiation.”

This process might save one job, or position. It’s not comforting to know this process, negotiation, is all the unions can offer us when we face a job loss.

Last month, Cape Cod Healthcare CEO Steve Abbott announced that the organization had suffered a $17.6 million revenue loss in seven months.

The company responded by laying off 11 employees, mainly in mid-management and clerical positions, requiring a dozen senior executives to take a 10 percent pay cut and asking employees to consider early retirement.

The cut backs weren’t enough. So now they take it to the next level.

“Cutting back on the nursing assistants is a big problem for us,” said Stephanie Francis of the Massachusetts Nurses Association.

The two nursing assistant jobs scheduled to be eliminated could require nurses to pick up the slack and spread themselves thinner among patients, she said. Such a move would be in direct opposition to the Patient Safety Act being proposed on Beacon Hill, which requires a certain ratio of nurses to patients, Francis said.

Well usually the nurses whine when it’s THEIR job on the line; they complain when they are replaced with the less skilled, lower educated unlicensed assistive personnel (as we’re known as); they cite patient care problems when there are more of US then them. Since UAP don’t fall under Nurse s scope of practice rules, this claim is disingenuous at best. BUT, at least she’s sticking up for the aides in this case.

Abbott, who is retiring this summer, has blamed some of the hospital’s financial woes on the rise of off-site, privately run surgical centers and on an independent physician association, Physicians of Cape Cod, that he says is making fewer referrals to Cape Cod and Falmouth hospitals and their affiliated laboratories and services.

By sending patients to private organizations for procedures that receive lucrative reimbursements, the physicians in the I.P.A. are forcing the nonprofit hospitals to absorb more and more of the cost of serving the community, Abbott said.

More disingenuous stuff here. First off, remember this is Cape Cod. Kennedy country. John Kerry country. Where the rich live and house up for the summers. These people will not utilize the services of a public hospital no matter what. Cape Cod is full of private facilities that offer services at far cheaper rates than the public hospitals, believe it or not. Private sector doesn’t always mean more costs. The people who reside in this area do have a right to pick and chose where they will receive their health care, surgeries and the like. I do know these private facilities offer jobs to nurses and CNA’s and pay them better.

Do we take away this choice in the name of saving jobs? I think not.

What is certain is times are changing. More and more medical and nursing facilities are going to be forced to make cutbacks; this will result in patient care being put in jeopardy in many situations. I would expect to read more and more similar articles in the next decade or so, too. The trend is only just beginning. Brace yourselves.

Cell phones are a wonderful addition to our lives. Communicating quickly with family and friends is a good thing most the time.

However, at work, in nursing, they are fast becoming a nuance. I see many nurses and aides who constantly check their cells for messages; or who are texting someone. Right in the middle of patient care! Or a residents’ mealtime!

Message to CNA’s:
Cell phones no longer interfere with most medical equipment. This is no excuse to use them while we are working. Surely any message can wait until a break. Nothing is more aggravating than watching your co-worker drop everything they’re doing to TEXT someone. Or to check a call. Not only is this aggravating, it’s very unprofessional.

Message to management:
What is YOUR policy on this? Where I work we are not allowed to carry our cells with us on the units. Equipment problems are not the stated reason either. Rather, common courtesy and professionalism are cited. Cell phones take time and attention away from resident care; residents and co workers perceive the use of cell phones during care as rude (IT IS!). Staff are allowed to use their cells on their breaks only, and in the break room only- not in patient care areas.

We all like to sit back and demand better pay, better benefits and what not. We all agree this might help solve the pending shortage of CNA’s and direct care workers. Yet we all forget where the money comes from for all this; and we forget to look at consumers’ choices and preferences.

I’d like to share a couple articles I found for the purpose of showing how states’ are grappling with health care decisions.

Paralyzed since he broke his neck in a 1996 diving accident, Clay Freeman depends on 11 machines and around-the-clock care to stay alive.

With assistance from in-home caregivers who took him to classes, Freeman graduated from Chemeketa Community College in 2006.

He also has relied on caregivers to take him to movies, on shopping trips and other outings, including school functions and sporting events for his five nieces and nephews.

Distressingly, the Salem quadriplegic has had a hard time retaining the caregivers who serve as his conduit to daily life. Some have burned out tending to his complex needs. Others have resigned to take less rigorous work that pays better.

When another caregiver called it quits early this month, Freeman, 34, was left with two of the five hands-on assistants he needs to monitor his machines and assist him with breathing, eating, toileting and more.

Mr. Freeman wants to remain free- he doesn’t want to be institutionalized. Who can blame him? His chances of complications with his health will increase a lot with an admission to a nursing home. His independence will cease to be. His education will go unheeded. Not to mention the sheer fact that staying in his own home costs MUCH less than living in a nursing home would cost.

The caregiver crisis posed life-threatening complications for Freeman and crimped his federally mandated rights to live with as much independence as possible, according to a lawsuit brought against the state of Oregon on his behalf.

“Mr. Freeman is now at risk of being forced to live in a nursing facility — an institutional setting — because he has been unable to hire and train three of the five personal attendants needed to meet his daily needs,” states the lawsuit.

The federal civil-rights lawsuit asks that the state be required to provide enhanced caregiver compensation so that Freeman can hire the help he must have to deal with his daunting disabilities.

Mr. Freeman is suing his state to ensure it increases the rate of pay for his home health care aides. A good thing. Home health aides are very important to consumers who rely upon them to keep them out of the nursing homes.

Under contract terms with the state, average pay for Oregon’s 11,500 unionized home health care workers is slightly less than $10 per hour. To recruit and retain caregivers for Freeman, the state must pay at least $12.90 per hour, his lawyers say. The state also has to ensure that his caregivers get proper training, the lawsuit asserts.

A federal judge has issued a temporary ruling in Freeman’s favor. A week ago, U.S. District Court Magistrate Thomas Coffin ordered the state to provide Freeman with five caregivers at the $12.90-per-hour rate. Coffin also directed the state to supply Freeman’s caregivers with training provided by a licensed registered nurse.

Freeman’s lawyers are asking for a permanent court order that would enforce the higher pay rate. Opposing lawyers are expected to make oral arguments before Coffin at a hearing this summer.

Of course no state or union can force anyone to work for a private citizen who is seeking services. We are free to choose. But it is cited as being the ideal working environment for CNA’s: Private home care.

The second article highlights the clash between state government and nursing home industry lobby groups, unions and others. Each state receives a certain sum of money to cover ALL nursing care- from the federal government. The states must match this sum with a percentage of cash as well. And the state has the final say in where this money goes to. In these tough times, and in good times as well, it makes fiscal sense to keep people in their own homes as long as possible. Preventing nursing home admissions is key to keeping costs low for everyone.

Nursing homes get 80 percent of the money Pennsylvania spends to help people who are too old or disabled to care for themselves. The Rendell administration says that must change.

The administration has the goal of an eventual 50-50 funding split between nursing homes and programs that help people remain in their homes and communities. Rendell’s proposed budget includes no increase for nursing homes, while giving a $20 million increase to programs that help people stay at home rather than entering nursing homes.

The federal government has marked certain sums of money given to each state to be used for home care situations only. These are not small amounts of money: We’re talking billions from the fed. By slowly cutting back the nursing home admissions and increasing the home health options, states are saving millions and millions of dollars that are budgeted to other programs. The nursing homes are fighting this move. The costs of a nursing home bed is falling short of the payment received. Who pays the difference? We all do via cut backs. It’s a lose-lose situation.

Groups representing nursing homes said state funding for nursing home residents covered by Medicaid — about 60 percent of Pennsylvania’s 82,000 nursing homes residents — is $12 per day short of what it costs to care for those residents. “Pay your bill,” one of their leaders shouted.

But what about Mr. Freeman? Doesn’t he have the right to stay at home? Or are we heading towards a society that forces people to enter nursing homes for the better of “all”?

In a separate rally, groups representing disabled people applauded Rendell’s proposal to increase funding for home and community-based programs. They characterized nursing homes as profit-driven organizations that underpay and overwork their workers while robbing their residents of freedom.

Very true. Are nursing homes bleeding the system so much now they have become a liability with regard to funding? It’s starting to look that way.

The Rendell administration says nursing homes receive an average of $173 per day for people covered by Medicare, and that rate is one of the best in the country. It costs about $70 per day for a home or community-based program, they claim.

I did the math quick and it’s a little off, but the costs savings are pretty close to these numbers.

The two states highlighted here, Oregon and PA, are facing the same issues every state is struggling with. The question used to be how can fund BOTH options. We can’t. As a country we would go bankrupt very fast. No one could afford the tax burden, which would be upwards of 50%…we already pay high taxes….and, to boot, our tax rates now are less than what they were ten years ago when these problems were just beginning to surface. We couldn’t afford this all then and we certainly cannot afford it now.

To give to one means taking away from another. The Robin Hood thing? Not really…it’s not about stealing from the rich to give to the poor. It’s more about stealing from all to give to a few. It’s also about being smart with budgets and choices.

I believe most of us have some form of a personal budget we follow. Cash for food shopping; cash for gas. Cash for the rent…the car payment.

When we decide we need more food to feed our families, we have to take from the other budgeted money- we might drive less to save gas money and move some of it to cover the extra food. Or the rent might be paid late. We have to make choices about where to cut back. When we’re at the grocery store, we might decide to spend less on store brand products or buy the lower octane gasoline to save money. In tight times we eliminate spending that isn’t required to live.

State governments must do the same thing. Funding programs and the like that cost much more than viable options is foolhardy and stupid. Nursing homes cost a lot more to maintain. Home health care is a viable alternative that consumers prefer. We can’t blame the states for standing up to what is fiscally sound and consumer driven, no matter what it means to us personally.

Question:
At my facility we’re not allowed to call out! Lately there’s been a lot of call outs and even more aides quitting. So we work short all the time. A couple aides have hurt their backs too cause we’re short all the time. Anyway I got the “bug” last week and had a fever, vomiting, and diarrhea. I felt horrible. I couldn’t eat anything; I couldn’t keep anything down. I called work to let them know I would be out for my shift and they put me through to the DON. who told me to come in for work, to report to her prior to clocking in so she could assess whether I was too sick to work. If I didn’t follow this directive, I would be terminated. SO I went to work and the DON took my temp (101.2)- she gave me Tylenol and a couple spoonfuls of Pepto Bismol; she told me report for duty. If I didn’t feel any better in an hour to come back and see her.

Is this legal???

Answer:
Your email tells me your employer is having a hard time with staffing. It appears that the place is going through a downward spiral of problems and management is part of that. When an aide shows up for work, sick with fever and infection, she exposes not only the residents, but her co workers as well.

It’s very likely more than a few will catch the illness. So, it spreads like a fire. As each aide comes down with the bug and misses work, management feels it has to do something to curb what it perceives to be an abuse of attendance policy. Management should be prepared for a staffing crunch knowing a virus is going around. But, this facility’s management is punishing the very people who are out in the battlefields where the germs are located. It’s old fashioned and autocratic.

Instead of being proactive, the DON is being REACTIVE and in a very negative manner. Her actions are telling her staff that she doesn’t trust their judgment on their own bodies health. She is also telling them she has no respect for them. A warm body on the schedule is all that matters, even if that body’s temp is 101.

The Legality of this:
If this is a policy, it must be written as such.

I called a lawyer friend and relayed this scenario and she gave me the following advice: Is the DON a doctor or a Nurse Practitioner?? If not, she is straying from her nurse practice laws. Nurses cannot diagnose illnesses, diseases, disorders and the like. Perhaps she is sending staff to a doctor who is legally licensed to perform a medical assessment. She would be smart to do this. She should NEVER give staff ANY medications without a doctors’ order. She is putting her license on the line by doing so. She knows this. And is counting that you don’t know this.

Legally this practice is not advised for management. They are risking a discrimination lawsuit if this “policy” doesn’t cover ALL employees of this facility- so, when the dietary aide or the cook or the maintenance man calls out, the DON/Management must apply this same requirement towards them. They too must come in, be assessed, and determined if they’re “healthy” enough to work or not. And this would mean doing so 24 hours a day, 7 days a week. Even on holidays and weekends.

What To Do?
If you find yourself too ill to perform the duties of your job, you can and should call out. However, you should also make every attempt to get better or try to reduce your symptoms so you can work. In other words, do take Tylenol/Advil to get the fever down. Immodium will end just about every episode of diarrhea. After this, if you still feel too sick, call out. Make sure you follow the policy- most facilities require 2 or 4 hours notice.

Have your spouse or a friend make the call for you if you’re concerned with being harassed by the DON. Instruct your spouse/friend to take a message but to be firm: You will not be showing up for work. Make sure your reasons are given: Details- fever, vomiting, ect. and the actions you have taken to try to make it better. Then call your doctor and make an appointment. You’ll need to be assessed and diagnosed properly; and the MD will need to write you a note excusing you from work. Often, this note will include actual dates you are not recommended to work.

A doctors note will not protect your job.
We need to know this and not rely upon it. The note does give credibility to you though: You’re putting the effort into seeing the doctor to find out what is wrong and get better; you’re paying money to do in most cases; you want to show your employer you weren’t goofing off, ect.

You can still be terminated unless you’re a member of a union which has rules on this.

I would not wish to continue employment at a facility where this practice occurs. I would leave on my own free will and seek employment at another place with more enlightened management.