Plebian who wants to be tactful

Nurses General Nursing

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I just started a job as a CNA, and I have acknowledged that I am a plebian compared to the other CNAs who have been doing it for years. However, I've been spotting some shoddiness that I want to address, but I'm not sure how to be tactful about it.

Today I saw a CNA wiping a female resident from back to front, not even bothering to clean the front genitals first. I told her as tactfully as I could, "Wiping back to front causes urinary tract infections." She snorted, gave me a look, and kept doing it. She's been doing it for two years, and she's female, so I can't comprehend why she'd be such a Martha about it. I saw another girl not even bothering to wipe down a resident while changing her soaking wet diaper. I know that there's never time to do things as tediously as required in state testing, but there's time to at least make a few swipes. I certainly wouldn't want to be left in my stale urine or drying BM. I also see a them handling residents with the same gloves that they used during pericare, and even going on to the new residents with the dirty gloves. I'll "just happen" offer the CNA new gloves whenever I see them about to give the resident a drink while still wearing contaminated gloves, but how to actually address tha situation?

Also today, I asked another CNA if she had changed and showered one of the more severely demented residents, and she said, "No, she's violent. She's soaked and I tried to change her, but she started getting rough. I'm not going to bother." I pulled her aside and told her, "If a child is throwing a temper tantrum because he wants to play with broken glass on the sidewalk, would you avoid the racket by letting him play with it?" She told me that no, she wouldn't, because the child would know any better. I answered, "Correct. It's not wrong if you're preventing a worse situation. If you don't clean the brief or give a shower to a resident just because it's inconvenient, I can guarantee that they'll be several times more irate or require a more complex plan when they get infections. What's worse, a child can learn and remember the consequences of something, while (resident's name) can't even realize that we're removing her discomfort. It would be wrong to force residents do do things if they were in their right minds, but some of them don't know any better and are beyond communication." I then offered to hold down the resident so she could change her without getting kicked and punched, and decided to try the shower later after the resident had settled down. This CNA was also pretty new and has a much better attitude, but I'm still not sure if I was tactful. I'm trying to respect the hierarchy, but also do what is right. Help please!

As a "new" CNA it is best if you don't try to improve others at this time. The old-timers are going to resent you and will try to get you "fired." The old timers are going to think "Just see the new girl thinks she's better than us and she is trying to get us to do things "her way." That's not true of course but I have seen old-timers try to get rid of "new CNA's" for this reason so be careful. You know the right way to do things so yes you do it the right way. This is not the time to try to change others. Best of luck:)

^I thought so. Sigh... Should I at least offer glover to the people who should be changing gloves?

I know that I sound like a know-it-all newbie who tries to assert herself above others. Believe me, I know the kind and get annoyed by them. All the same, I doubt I'd be so shoddy as to leave excrement on their skin.

You won't change a lazy nurse's attitude by reasoning with them. I'd virtually guarantee that they know better. Just reading your replies, it sounds rather preachy to me. (Which is probably what they need to hear--but are not willing to listen.) I'd lead by example and keep my mouth shut.

^Yeah, you're absolutely right. The only reason I gave that speech to the CNA was because 1) she's younger than me (fresh 18), and 2) she's trying to get into nursing school and already comes to me for advice, so I felt... not condescending, but kind of appointed as an unofficial advisor.

You sound like my kind of CNA! The part about not cleaning them but just changing their brief kills me. I see this so much but now the CNAs that work with me know they have to wash with soap and water after a brief change. I n the past at other facilities had a bit of difficulty with consistency at first but then I started showing them reddened skin, told them why this was happening and it was UNACCEPTABLE. Of course I have 2 great aides that I dont have to watch at all, I frequently hear the sound of the sink when I work. I am a nurse though so I have a bit more authority.

You really do have to be tactful and careful here. While it may be the right thing to do, if you start off harsh you are going to create hard feelings and some of the older aides will probably try to harass you. Get to know your nurses and they are going to start recognizing your work. Pretty soon you wont be the new aide but you will be an experienced aide that can teach the new aides the right thing and new people usually listen better than experienced ones.

You can make changes for the better, just dont try to change everyone overnight. You will get to know some good nurses and bad ones but the good ones will support you and you can confide in them. Then they can be watchful for the CNAs who arent doing things right and when they see them, they can correct them immediately.

You also will learn so much, about 10 years ago I had 2 new aides on the floor with 2 experienced (and good) aides. One of the new aides called our compliance line and reported abuse. Another lesson those 1-800 anonymous lines arent really that anonymous. Anyway the complaint was the experienced aide was pulling on clients too aggressively. I knew the aide in question, constantly saw her work and knew she wasnt rough however to a new person it can appear that way. I explained that unfortunately we dont have 250lb men with muscles for aides--rather we usually have 110-120lb women. When you are dealing with patients who are often dead weight and 300+lbs then all the laws of physics/gravity etc are against that aide turning them. While you dont "jerk" patients you do have to use your whole body and follow through, which can appear to be rough but granted is not.

You will also learn we dont live in an ideal world. Nursing homes can have unique power structures/relationships and if you are too aggressive it can backfire on you. Lead by example, offer help and pretty soon I think you will see a difference.

I also would caution you on holding down just any patient (even though they may be severely demented). I am hearing from some people that deal with advocates/ombudsman that a patient can almost always decline any treatment or intervention they dont want regardless of whether it is for their own good. This is going to vary so much but just get the nurse's input on whether it is ok to put someone to bed and hold them down while you change them. Of course you are going to have to hold patients down unless you want your partner to get decked but there is such a fine line between this and restraining a patient. I posted on another thread but I read in my AJN a few years back that a confused patient may make decisions for themselves and it is not appropriate to hide their cardiac medication in applesauce if they dont want it. Also in the ER for drug overdoses you used to be able to restrain and pump their stomach if they wanted it or not as long as the doctor saw them and deemed them incompetent. Right when I was leaving the ER, we were being told that this was inappropriate and illegal. The patient could refuse any intervention and get this--we had to wait until they passed out or became so groggy they couldnt refuse.

Some of these laws or patient rights are just loopy. Anyway I really think you are a great person--your patients will notice you and the families of your patients can sleep well at night knowing you are there taking care of their loved ones. Keep up the good work!

well, if patient health is being affected--which it sounds it is--I think you owe it to your clients to speak privately to the nurse manager about your concerns. Document what you see and when, keep it very private, and then show it to the NM.

Me, I am all for advocating for patients and this is what I would do. It could lead to losing your job, or the other CNA's making your life miserable. But patient care is the first priority.

It wouldn't hurt to keep looking around for another job at the same time. It could be possible that the other staff is turning a blind eye to this stuff--you're saying its been going on for two years so you can bet you're not the first one who's noticed it. You may not be able to effect change in this facility. So your job may be on the line if you say something, but you have to ask yourself if you could live with yourself working for a facility that provides such shoddy care.

You can also make a report to your Board of Nursing anonymously if you feel the residents are in danger or being cared for improperly. But again, remember that the others already know that you see what they are doing, and it won't be too hard to guess who made the report.

I agree that you should not correct your coworkers at this time. You can't change them. The NM is the way I would go, at first. Then if the NM doens't do anything or doesn't take your observations seriously, go up the ladder.

I think you did the right thing- you are caring for the patients. The patients come first, and you did try to be tactful. Also, by offering to help you showed respect to your coworker. I can appreciate that it is difficult to point things out to coworkers, and at risk of being resented, but you can and should assure that proper care is being provided.

^Yeah, you're absolutely right. The only reason I gave that speech to the CNA was because 1) she's younger than me (fresh 18), and 2) she's trying to get into nursing school and already comes to me for advice, so I felt... not condescending, but kind of appointed as an unofficial advisor.

don't forget, CNAs cannot supervise or delegate. that is the nurse's job. this should be in your CNA book.

She wasn't supervising or delegating, she was giving advice and an opinion. Is there something against that in the handbook?

Personlly, I believe you are admirable. And it would annoy me to no end too. I would be livid if I knew someone was being so careless and halforificed with my relative. You go right to the NM like the previous poster suggested. And, if you end up being the "bad" guy and you realize the management doesn't care about the lack of care, you know to look elsewhere.

Specializes in Emergency.

you are also an admirable CNA to me. I'm a traveler , and I just felt the need to say that on my current assignment one certain CNA gives medical advice ALL of the time.........no, not nurse teaching, but medical advice. This girl has been there forever.........and nothing will ever change at this facility because everyone here will continue to do what they want to.........ahhhhhh

i simply walk into the room behind her and let the patient know her background and then proceed with MY teaching, and then refer their medical questions to the MD.

keep your head up, but you will soon learn how far you can step regarding tactfulness in your facility.

Jen

I'm trying to get a job at another place after all. This place is so horribly understaffed that they can't even afford to fire people who don't show up (I once worked a shift in which there were 50 residents and 3 CNAs in my unit during the 2nd shift), and no-shows are so common that during the overlap of shifts, they assign rooms and distribute workloads based on who shows up that day. Now I can see why there are so many problems with decubitus ulcers, contractures, and falls in nursing homes. I'm also getting $6.90/hr for second shift in Houston, whereas the hospitals pay about 50% more (usually require at least 2 years experience though). If I'm going to be worked like this, I might as well get more money for it.

Actually, is the aforementioned scenario the norm in the nursing field?

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