What Not To Wear At Work

Our appearance is important in how we are perceived. When we dress appropriately, people respect us more.
Lately I’ve seen some aides come to work looking like they’ve been run over by a truck.

Wrinkled and stained scrubs might be OK to wear around the house, but please don’t wear them to work. Thread born, tattered and ripped uniforms are another pet peeve…they present an image of laziness. Really old and faded scrubs also come across as tacky. One can purchase a couple sets of scrubs at Walmart for under 30.00.  When funds are tight as they often are for CNA’s- buy one set one pay period and a second set the next pay period.

Scrubs can last for years with proper care and handling. Some of the newer materials are really easy to care for- wash, dry and wear…There’s no need to iron uniforms but ALL scrubs need to be FOLDED after being dried. Folding them while they are still warm keeps the wrinkles away. It’s always a very good idea to have an extra set of scrubs with you…I keep a set in my car; one never knows when an accidental spill or other event will happen, that requires a change of clothes. Better to be safe than sorry.

Old sneakers are another image buster. And do consider that these shoes probably have an odor as well, that others can smell. When you have newer shoes, spraying them daily with Febreze or a similar product works wonders to keep these odors from ever forming.  Lysol even works well. They also have Odor Eater powers and sprays made for shoes. Clean your shoes, sneakers too- with a damp cloth to remove stains.

Keep your hair neat. Wild hairdos just look unprofessional in our work. Make sure your hair is clean! Greasy slick hair is nasty to look at. It smells. And very few patients/residents want your hair in their face or over any other part of their body as you do personal care. I have witnessed  aides’ beautiful hair fall into a brief full of feces. The hair wasn’t pulled up. It was GROSS. Strips of hair that has been dyed look awesome on folks of all ages-even older aides are dong this- and is very popular right now. Just be aware that the dye can run off– into your scrubs, and face/neck if  you’re working in a humid environment (as most nursing home bathrooms are).

Scents? Nope. Don’t wear perfume to work. Many patients/residents have super sensitive smell and these odors can nauseate them. Same with cigarette odors.

And one final thing: Keep the makeup off as much as possible. It runs. It makes you look like a clown. Even the mascaras that promise 12 hours of wear…smudge under your eyes and make you look more tired than you probably already are. The work we do involves a lot of running around, bathing, showering activities that make us sweat…perfect situations for make up to melt off our faces.

 

Lifts & Transfers

Keeping your back healthy is very important. We all know this. And yet, at every long term care facility I have worked at, I have seen aides cheat the systems and policies and rules when it comes to LIFTING. Aides will lift heavy residents by themselves; they will also refuse to use mechanical lifts designed to save our backs.


Mechanical Lift Cheating
Most aides will cite time as a major factor when it comes to using the mechanical lifts (ML). Time involved with seeking assistance, as most facilities require two people attend a ML transfer; and time involved with setting the resident up for the transfer. The placement of the lift pad, attaching it to the machine, operating the machine…the positioning of the resident into the wheelchair or bed; removal of pad…the process takes about 4 to 5 minutes. Whereas a two person lift takes about a minute at most.

I’ve asked aides how they manage to perform these lifts, on really heavy or otherwise unsafe residents. They tell me they feel confident with their strength and ability to do the lifts. They are sneaky about it too: Many an aide will go to the trouble of getting the ML and bringing it to the room. But it just sits there, unused. The only time they will use the machine is for the extremely overweight resident, or for a resident who is with it and KNOWS they are not to be lifted/transfered by staff. Even with this, the resident sometimes insists upon being lifted as it is faster. And some residents will badger the unsure aides into lifting them.

Staff Assisted Lifts/Transfers
As for two person “human lifts”, aides will not bother getting help. They do the transfers alone, placing themselves and their residents at risk. Again, the aides have a level of confidence in themselves to do this. The aides don’t consider that these movements might hurt the resident, might be rough or terrifying. And they don’t seem to understand that a few months of doing this will result in soreness and back, shoulder and knee pain. I know aides who’ve been doing this work for years who have bad backs, who are forever complaining about being in pain…who gimp and limp around all shift…who speak of being on different pain meds all the time…it’s no wonder!

Once a facility has enough aides who prefer to transfer residents the wrong ways, it’s very difficult for newer aides to turn this around. The newer aides feel compelled to work on their own. They have asked for help but have gotten nasty looks, rolled eyes and heavy “sighs”, along with comments such as “I do this by myself!” To the defense of the old timers, they probably got stuck one time too many waiting for someone to come help them. In the nursing home environment, time is everything. Once you get behind, you cannot catch up unless you cheat. And that means cheating residents out of the care they deserve.

Fixing the Problem
How to fix this? Should management be concerned? Is management even aware of these practices occurring? Good questions and only each facility can answer. Of course the leadership should be concerned. After all, the worker comp costs are in direct line with staff compliance on lifting policies.

Should punitive steps be taken towards non compliant staff? Speaking as an aide, I say YES. Because the non compliant aide is a virus- and viruses spread. In my experience, aides who are non compliant in this area are non compliant in many areas.

Having said that, I also believe facilities should have a hard look at their policies and promotion of teamwork vs. being task and time driven. If more value is placed upon the timing, then facilities are just asking for the aides to do whatever they can to survive- up to and including cheating. If value is placed upon teamwork and healthy body mechanics, the aides relax a little and are much more apt to be compliant.

If you’re an aide who does cheat, remember you only have one back. Remember too, your shoulders and knees will only put up with so much of these bad lifting habits. It will catch up with you. If it’s in the residents’ care plans that they are to be transfered via a ML or with two staff, you are breaking rules and could lose your certification over this. Especially if you document the transfers were performed as care planned: You’re participating in fraud if you sign it off as done. And if you get hurt, how will you explain it? Worker comp claims are often denied when they find out (and they do investigate) you did an illegal lift.

Is it worth being out of work with an injury, with no pay coming in? Consider your reputation as well…you will probably be fired for not following policy and this will follow you in your future employment opportunities. And remember this: You’re teaching the next generation of CNA’s some pretty poor work ethics- and worse, you’re planting the seeds of a painful future for another person (the new aide)…and keeping this cycle alive and well.

New aides can set the standard, as can aides with more experience who decide to change their attitudes on these things. Do it right! Save your body. And think of the resident’s safety! Use the proper lifting guild lines for each resident…if a ML is called for, USE IT. Get your resident all ready for the transfer BEFORE getting help- remember your co workers time is valuable. Don’t waste it. Work efficiently and with purpose. Make teamwork as simple as possible.

Legal Issues For CNA’s

Legal Standards

These are guidelines to lawful behavior. When laws are not obeyed you can be prosecuted and found liable (responsible) for injury and damages. Legal guilt can result in fines and imprisonment, as well as loss of certification/license to work as a CNA.

Laws are passed by local, state and federal governments. All citizens are expected to obey these laws…when you disobey a law you are liable for fines and/or imprisonment. CNA’s can avoid this by:
• Knowing and staying within their state’s scope of practice rules.
• Do only those tasks and skills you have been taught; if you’re asked to do tasks you have not been trained to do ask for guidance (and if necessary seek the advice of your supervisor).
• Carry out your tasks and procedures carefully and only as you were taught.
• Keep up to date with your skills and education and in-service requirements.
• In questionable situations, seek the advice of your supervisor.
• Make sure you fully understand your assignment and what is expected of you
• Know your facility policies and procedures and follow them.
• Do no harm to your patients.
• Respect the personal property of your patients

Legal Definitions and Examples
As a CNA the legal issues you might encounter and witness would be negligence, theft, defamation, false imprisonment, assault, battery and abuse. You need to understand what these are.

Negligence:
The failure to provide a degree of care that others would consider reasonable under the circumstances; when injury results to your patient. Negligence is often caused by rushing around to get your work done and by not thinking FIRST.
• YOU give a patient a bath…and don’t check the water temp first. The patient is burned.
• YOU place a tray of food in front of a patient and don’t check the menu; the tray belonged to another patient. The patient who got the tray eats the wrong consistency food and chokes.
• YOU transfer a patient by yourself even though the care plans states two staff should be present for the transfer. You drop the patient.

Theft
One would think this is pretty simple. It should be but often isn’t. Taking ANYTHING that doesn’t belong to you is considered theft. It doesn’t matter how cheap or expensive the item is. When you see another person take something that isn’t their’s, and you fail to report this, you are guilty of aiding and abetting the crime. Keep your standards high. We need all the honest people we can get in this work- don’t be scared or indifferent to report theft you witness. I’ve seen aides take wash clothes, briefs, deodorants, soaps ect from their facility (for their own personal use at home). I’ve also seen aides steal jewelry and clothing from patients. It’s NEVER acceptable to do this. EVER.

Defamation
This means making statements about another person, either verbally (slander) or in writing (libel)
when the character of that person is injured. Examples would be you telling a co-worker wrongful and inaccurate information about patients. I’ve seen this happen: We had an admission coming and the chart was available to all of us. The patient had Crohn’s Disease. One of the aides I worked with at that time went around and told everyone this patient had C-Diff. Not a good thing to do. Unless you know something to be actual fact, (and even then make sure you hear it from a reliable source), keep your mouth SHUT. And never put anything like this in writing.

False Imprisonment
This is an area many nursing staff have trouble understanding. It’s not just about restraints. It’s about a mindset. It is defined as restraining a person’s movements or actions without the proper authorization. Patients have rights and we must respect these rights. In the hospital setting, a patient CAN leave the hospital without a doctor’s permission. They can also leave a nursing home/assisted living home. Under very few circumstances can we interfere with this right. If you do, it’s called false imprisonment.

Physical Restraints
Using them requires a doctor’s order. Threatening to use them is considered false imprisonment.

Physical restraints are defined as any manual or physical device, material, or equipment attached to or near to the patients body, that:
• A patient cannot easily remove
• Restricts movement of ANY and ALL body parts
• Restricts the patient from accessing their own body or parts of their body
Examples of physical restraints:
• Wrist, Arm, Leg and Ankle restraints
• Vests
• Jackets
• Hand Mitts
• Geri chairs, recliners
• Seatbelts, safety belts
• Bed rails and the pads sometimes used on them
• In some populations the use of certain clothing would be considered a restraint: For example, donning a one piece undershirt on a child to prevent him from having access to his body. Or, a long sleeved shirt to prevent access to an IV site.

Also, many practices are considered a restraint. When a patient doesn’t have the physical strength to remove a device it is a restraint.
• When a patient doesn’t have the strength to sit up from a low rise sofa, for example, this practice is considered a restraint.
• Tucking in blankets and sheets so tightly the resident cannot move is considered a restraint. Using Velcro and tape to secure sheets is also a restraint.
• A lap tray being used with a wheelchair is a restraint if the patient cannot remove it.
• Using recliners and Geri chairs, tilted back, is a restraint.
• Moving chairs and beds so close to a wall that it prevents a patient from rising is a restraint.
• Placing a patient up into a table so close they cannot move their chair is a restraint.

In short, any action or device (designed for the sole purpose or something put together by you) that prevents the free movement of body parts is a physical restraint.
Some patients require splints and other appliances to maintain alignment and posture. These are restraints as well, but are often referred to as enablers because they assist the patient with ADL’s.
The patient may not be able to remove the splints, but it’s not an overt restraint. An MD order is always in place for these items.

Many medications are considered restraints. This is called chemical restraining and it is a very different thing than physical restraints. Nurses and doctors must understand the ramifications of using meds to induce sleep, states of relaxation, pain control that could be considered restraining activity.

Assault and Battery
There is some confusion about the meanings of these terms. Assault means purposely attempting to touch the body of another person without their permission, and threatening to do so. Battery is when you actually doing this. These terms are not all about hitting and hurting patients like so many of us have been taught.
Every task we perform is done so with the patient’s informed consent. This means the patient needs to know what it is we want to do, why, the benefits of the task-and they have to agree to it.
Informed consent can be withdrawn at any time and we must honor this. More and more patients are taking their healthcare into their own hands these days, and many will question the value of treatments. In spite of our best efforts to explain the need for treatments, the patient always retain the right to refuse. If you continue with the treatment you are guilty of battery. And threatening to get the nurse or others to assist you with said treatments is battery as well. You must report to the nurse any and all refusals of care by your patients, but do so quietly and not within hearing distance of the patient. Let the nurse handle the situation from this point forward.

To avoid being charged with battery:

• Tell the patient what you plan to do
• Make sure the patient understands what you’re saying
• Asking the patient if they have any questions or concerns
• Allowing the patient some time to think about this
• If the patient refuses, don’t push the issue. Quietly report the refusal to the nurse and document facts only.
• NEVER carry out the refused treatment

In our work we will come across a lot of coercion– which is forcing a patient to do something against their will. Unfortunately, it’s a problem within nursing in general. We always think we know what is best. This happens more with patients who are confused, mentally incapacitated or those with dementia. Almost always, these patients are not their own legal guardian, their family is. This makes it difficult for us to do our job at times because the patient is still refusing the care but we have to do it anyway- because the family has consented on behalf of the patient. It’s ALWAYS best to try to get the patient to cooperate with us vs. a full struggle. It really helps to wait and come back later when a confused patient refuses care. They tell us to always assume the patient would want our care if they were not confused so we have to think of things differently. It’s a hard spot to be in.

Abuse
Abuse: Doing harm to a patient. Abusing a patient is ethically wrong as well as legally wrong. Ethical standards require us to do no harm and legal standards enforce this through laws. There are severe penalties if you’re found guilty.

Abuse is defined as the act (or failure to act) that is non accidental and causes or could cause harm or death to a patient. It’s not just about hitting here. It’s also about mental abuse, verbal abuse and other more subtle forms. Abuse comes in many shapes:
• Physical
• Verbal
• Emotional
• Sexual
• Involuntary seclusion

Physical Abuse:
• Handling the patient roughly
• Hitting, slapping, punching, kicking, pinching a patient
• Performing the wrong treatment on the patient

Verbal Abuse:
• Swearing when you’re dealing with the patient
• Raising your voice, yelling
• Calling the patient unpleasant names
• Teasing the patient
• Embarrassing the patient at anytime
• Using gestures
• Making threats
• Use of inappropriate words/terms to describe a patient’s race or nationality

Sexual Abuse:
Using physical means and verbal threats to force patients to perform sexual acts.
In most states sexual abuse is ANY behavior that is seductive, sexually demeaning, harassing. As with Sexual Harassment policies, this harassment need only be considered as such by the patient without regard to your intentions. Be careful. THINK before your interactions with patients (and everyone else for that matter). Be considerate of your patient’s values and morals.

Emotional/Psychological Abuse:
THIS can be the worst kind of abuse because it’s typically ongoing and subtle.
• Causing a patient to be afraid of you (through threats, actions, attitude, and body language)
• Threatening the patient
• Threatening to withhold treatment
• Threatening to tell others about the patient’s condition
• Making fun of the patient
• Belittling the patient (and this would include all those cute little nicknames we tend to have)
• Calling the attention of others to the patient’s behavior.

Involuntary Seclusion
I see this happen a lot in nursing homes. A resident is being noisy and disruptive so we remove them to another area. This is another one of those hard spots to be in- trying to balance the needs of the larger group of residents without violating the rights of one. A good care plan, communication with everyone, documentation and other interventions should really be in place to prevent the resident from having outbursts in the first place. The nurse should always be the one who directs you to remove a resident. Don’t ever make this decision on your own.

Other forms of involuntary seclusion:
• Closing the door to the patient’s room when they want it kept open
• Placing a patient in a wheelchair away from others
• Leaving a patient without a means to communicate- removing the call bell for example

Abuse by Others
There are times when we will witness another CNA or nurse do harm to a patient, as described above in all the various forms. Often the CNA/nurse will not realize they are doing these things. It doesn’t matter whether she knows better or not. The abuse MUST be reported. As soon as it occurs, not at the end of the shift, the next day or next week. All healthcare workers are required by law to report actual or suspected abuse. When you don’t report, you’re just as guilty.

Sometimes it is a member of the patient’s family who abuses them. This is difficult to see happen, to suspect is happening. Again if you suspect this you are required to report it to the nurse. I’ve seen nursing home residents go out on a day trip with a family member and return to the facility with bruises and cuts; or with complaints of hunger and thirst. These things caused me to suspect some sort of abuse or neglect and I reported the findings to the nurses. I made sure they came down and looked at the bruises and cuts firsthand as well.

Neglect
Neglect is failing to provide the services, care and treatments necessary to avoid physical harm, mental anguish or mental illness. Neglect can be intentional or unintentional. Neglect is against the law no matter what. CNA’s are not expected to decide if neglect has occurred- that is the nurses job. However, you must report signs of neglect. Some examples of neglect we might see on the job:

• Routine hygiene and care not being provided. Patients not being repositioned, bathed, toileted, ROM exercises not being performed according to the care plan.
• Patients not being given enough time to eat
• Patients not being offered water and snacks

Invasion of Privacy
This is an area where every CNA should put themselves in the patients’ shoes. Would you like it if someone went around talking about your medical condition to anyone? How would you feel if you were in a hospital room and the nurse came in, started to do a treatment without closing the privacy curtain? You wouldn’t like these things at all. Most people don’t. Every patient has a right to expect their medical information will be kept confidential and that only those who NEED to know will have access to this information.