Charge Nurse did CNA work. Learned A LOT.

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    I did the work of a graveyard CNA last night on my Alzheimer's unit. There was no CNA to cover, so I volunteered to stay another 8 hours. I found out everything that my CNAs should have done, and didn't do. I also found out how hard they work. I know that they work the whole time they are there, and don't always get a break, and the facility quibbles with them over getting out as scheduled. The work that they do is emotionally, and physically exhausting. I have been screamed at, hit, cussed, invited to bed, and barely avoided having my fingers smashed by an angry resident. I feared for my safety during those moments. I moved lots of heavy people, and changed lots and lots of Attends, sometimes with the Rsdt. fighting me. My body hurts all over.
    I saw things that made me upset. Bruises that had not been reported. Teeth that had been left in, and not cleaned, with one resident's mouth bleeding. Heels not floated. Heel boots left off. Things that I just trusted that the CNAs would do. Things that I sign on the MAR as done. I don't have time to check on all of these things. I barely have time to initial the little box so that I can hurry and initial the next little box...You people know how it is.
    My CNAs need to take care of these things, and I need to make them. Not because my job is on the line, but because it is the right thing to do. The question is, "How?" How do you fo the work without time to do it, and staff to do it? How?
    I could tell them, "Ok, these are your residents, these things are what you have to do for them. Do a round with me before you leave, and prove to me that you have done these things before you clock out." That would be the thing to do, right? I know it is in my heart. But then, things will take longer for me, and longer for them, and administration will be all over us about the time.
    I am a fairly new nurse, and I want to be the best I can be. I want my unit to shine as an example of excellent care. Please give me ideas, fellow nurses. CNAs, I'd like to hear from you too. What do you think I should do?
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    You asked for advice, so here's my opinion. Don't refer to them as " your "CNA's. It's just disrespectful to them. They are the patient's cna's, and even if they are working under your supervision and direction, they are not "yours". If they hear you talking like this, It would be highly likely that they will resent you. Ask them to round w/ you and "prove" they are doing the required tasks? Umm, no. You will create even more resentment, and no one will want to work with or take direction from you. I think you need to examine your own attitude and learn how to delegate effectively.

    This is just my opinion and advice. I hope you don't take this as an attack. I am trying to help you as a new nurse.
    Last edit by oslogirl on Jun 23, '09
    Poi Dog, achot chavi, crazensweet, and 1 other like this.
  5. 3
    I am a new nurse and I understand what you mean. I work at a hospital where we have patient care technicians that assist the patients with ADLs, etc. It is a difficult spot to be in when you are supposed to delegate to someone who may be older than you and may have worked longer than you at your place of employment.

    Often times I find the same techs not doing the same things over and over again. Like turning patients. Or changing dirty gowns. Or assisting 1:1 feeds. Or not emptying out urinals and foley bags...I haven't really said anything because I don't know how. Then there are other techs that do their job and do it very well. If I had advice to give, I would give it! So far, I've just been using positive reinforcement for when they do a good job (because wiping butts all day SUCKS).

    I would love to hear from other nurses on how they handle these problems.
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    IMHO, every nurse should have to work as a patient care tech. These people are the day-to-day caregivers and know more about the patient than anyone else on the floor. Some things may not get done on a shift,(that's why it's 24-7 care) but not turning and not changing are not acceptable, EVER. I spent twenty years as a tech before I became a nurse, and my best advice is reward the good techs, and use whatever system you have in your facility to reprimand the sloppy ones. In the meantime, give them a friendly reminder that there was a time when depends were cloth diapers that we had to wash, there was once no such things as fitted sheets, and the patients were all jumbled together no matter their condition. Good luck.
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    Expectations for the position should be clearly explained during unit orientation, for CNAs, RNs and any other employees. Orientation should give them the time to learn and apply the expected care for all residents. If expectations are clear up front, then they are armed with the information and knowledge to do the job. And, if you must counsel anyone, you can base the counseling on the expectations that were laid down up front. Changing expectations after orientation is not a good idea, unless it is a policy change.
    Not_A_Hat_Person likes this.
  8. 6
    I'm a CNA and honestly I would be insulted and maybe hurt if you said I had to do a round with you to prove that I was doing my job. I don't skip things or provide shoddy care on purpose. Then again, our 3-11 charge nurse wouldn't touch a bedpan with a 10' pole. She would NEVER do what you did. And she seems to think we're all stupid and lazy. So it might not come off the same way if you do it, but I still think a more subtle approach would be better.

    Do the CNAs there know they're skipping these things, or is it not part of their routine? We have a book where we sign off on every little thing and document refusals. So if someone's dentures were left in the book might say "resident was combative when oral care was attempted," "resident refused heel boots" or something like that. If you're signing the book and something you haven't done comes up you can run back and do it. A list on the inside of each resident's closet door might be an idea too. Then the CNAs have something to refer to when providing care.
  9. 17
    I wish I had a good answer for you. I don't. But I just want to say that in my opinion a lot of the sloppy care is due to hospitals and nursing homes expecting more of nurses and CNA'a than is humanly possible to do in the time alotted, with the ratios alotted. And it is the routine, not the exception. We've all had days when we had to run like mad to get things accomplished. But when the expectation becomes that you run a marathon every time you come in to work, something is wrong, something has to give. People start taking shortcuts that they wouldn't take with a reasonable workload. People become cynical, "This is impossible and I just don't care anymore." It's the stress response in action. You can run on adrenaline just so long and then you crash. And I don't think saying individual nurses or CNA's don't care and don't give adequate care to patients because they're inherently lazy or uncaring is necessarily a helpful response. (I know you didn't say that, but many do.) Some may be there just to get a paycheck. But I believe many started out with good ideals and wanting to do everything possible for the patient and were turned cynical by a no-win system.

    I guess I would just go over what is the minimum standard that has to be accomplished this shift and what would be nice to also get accomplished. That way the CNA's know your expectations clearly. Think of it like working in a war zone. "OK troops, this is the mission for tonight." A good leader doesn't ask the troops to do anything he or she wouldn't do himself or herself, but the leader can't do everything, that is why there is delegation. I think stressing the "we're all in this together" is a better approach than "checking up" on people, for the most part. There may be indiviual exceptions.
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    I had an excellent bunch of CNAs that I worked with...and yes...they were mine and I was their nurse. (might be demeaning for some, but we worked well together...they knew me, I knew them)
    I think it is great that you got to see things from a different side. Now...what to do? Pitch in when you can. Easier said than done, but if it only takes you a second to to the task and 5 minutes to hunt down a CNA and that CNA knows it took you that long to hunt them down instead of doing it yourself...well...that isn't anything for team work, morale or for the resident.
    Look at the assignments..are they balanced? Are breaks balanced and scheduled? is everyone pulling their fare share? Is managament treating them with respect, etc? Do they have the necessary supplies and info to do thier jobs correctly? Do they get report at the start of the shift and are you communicating with them?

    In order for them to know that the splints, heel boots, creams, postioners etc need to get put on, someone needs to tell them and show them how. How is this done in your facility?
    When I do meds, treatments or just walk into the room...I check these things. If they aren't done...I will reposition them etc and then just remind the CNA...normally that is all it takes. Don't go hunting them down and making them to it...set and example and teach.

    Someone mentioned "checking up on the CNA". Um...yes..it is our responsibility to do this, but it all in your approach. If I have to sign for something and it wasn't done, it is my butt.
  11. 5
    First let me say that I have always had a great deal of respect for the CNA's and the CNA's have always seemed to have a lot of respect for me as well. I got started in this field as a nurses aide (long before there was any official certification process).
    I am never to good or to overqualified to empty a bedpan, assist with a transfer, etc. I also write personal thank you notes to the exceptional CNA's and mail them to their homes.

    But, yes, as the nurse it is every bit of my responsibility to check up on them and to ensure that they are doing their job. There are great aides out there, but we all know there are bad ones too and when the shift is over.. I am the one ultimately responsible for what did/did not get done. The good aides seem to like to "show off" their good care (& it is a good time to praise that good care) - it's the bad ones that didn't do their job that usually get defensive about me checking. Tough - to bad!

    I have often been guilty of referring to the aides as "my aides". After all their title is Certified NURSES assistant. I have certainly never meant any disrespect by this (and I kinda doubt anyone as taken me to be disrespectful). I see it as we are a team and I am entrusted to be the leader of that team. No different than a sports coach might refer to "his players". I think too many people over think the little things.
    Shannalynn, classykaren, ~MIA~, and 2 others like this.
  12. 6
    Dude.....just tell them........... " Hey guys can u make sure every ones teeth are out and cleaned and everyone has there booties on? I also need to know about all bruises so i can chart on them"...............no big deal sometimes we get in such a hurry we do forget to do stuff like teeth.......no good aid would get butthurt about being reminded to do something that isnt getting done.......at least thats my opinion
    NamasteNurse, LEN-RN, inshallamiami, and 3 others like this.


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