A few observations about the nurses I work with from a new CNA...

Equinox_93 · Apr 7, 2009

I would imagine that working in dialysis, the odds of coming into contact with blood are quite high, so gowning up would be reasonable, and wearing a gown to protect one's clothing from spillage is quite different from wearing one simply because a patient is HIV positive.
~Puffing on my evidence based pipe.~

Ahhh- I see the problem here- you're thinking that I'm suggesting that I'd gown up "simply because a patient is HIV positive". This is not the case. It's that, coupled with other factors such as history of seizures, combative behaviour, Parkinsons (examples of possible unanticipated movements by the patient) or dependant on what procedure I'd be doing with them- as I'd said before. It's something I would assess on a case by case/procedure by procedure basis. Again- having had unexpected blood contact in similar situations- I would be more inclined to take that precaution. Probably regardless of HIV status- but definately in the case of a positive status. (Puts out evidence based pipe- this is a no-smoking thread. )

nursemike, ASN, RN · Apr 7, 2009

I always take my lunch and my two breaks. I'm not letting myself be worn out and exhausted from working. I like to leave work, knowing I accomplished a lot and made a difference in someone's day. It's not supposed to be about me feeling bitter towards the patients and nurses or about not getting a chance to sit down for a few minutes. Regardless of where I work at, I am my first priority and I will go out of my way- like I do for everyone else- to make sure I have nourishment and peace of mind for at least 60 minutes in a twelve hour shift. If I don't advocate for myself, who will? Maybe when I become a nurse I'll have a different perspective, but I'll cross that bridge when I get to it.

Hopefully, you will have a different perspective. You aren't wrong to take care of yourself, and you should continue to do that as a nurse. I don't entirely agree with those who say it's all about the patient. I try to distinguish between giving all I can and giving all I have--I've got to save a little something for myself, my coworkers, my family when I get home. But it is mostly about the patients. If you aren't committed to them, you shouldn't be a nurse. And most of the aides I work with have that same level of commitment.

In eleven years in healthcare, I've missed lunch twice--once in my unlicensed position, and once as an RN. I have taken a lot of 10-15 minute lunches, in both jobs. It's embarrassing to go out to dinner with civilized folk. Nurses should get discounts at fine dining establishments, because we don't tie up their tables as long as normal people. Even on a really quiet night, I find I can't eat lunch away from the floor, no matter how much management wants us to. Too many things can go too wrong too quickly. The last two times I had a patient fall, I was off the floor, smoking. Others were there to keep an eye on them, they might just as well have fallen while I was helping another patient (I've had that happen, too.) or even if I was right outside their room, charting. I still go out to smoke at least once a night, twice if I'm lucky. I usually smoke in what I refer to as the "Go ahead and fire me," section, by myself. Too many people around the smoking areas; as much as the nicotine, I need the few moments of quiet. Sometimes--many times--I just need to let my nerves unwind a little, although sometimes I smoke to celebrate being all caught up and everything going smoothly. I can be a little more sociable, those times.

I don't resent others having a good shift. I rarely have time to read a newpaper or play on the internet, but if you have your work done and have a little downtime, good for you. Most nights, I do have a little time, here and there, to joke around, chat, and sexually harass my co-workers. It's rarely all high-pressure all the time. But it's usually high-pressure some of the time, and at least a little pressure most of the time. I once heard an aide remark, "I could be a nurse. I could sit on my butt all night and chart." I was very tempted to remark that she had the first part of that perfected, but I guess I'm glad I didn't. She has become a good worker over time, and while her attitude toward nurses could still use some improvement, she hasn't been overtly disrespectful to me. And I can recall when I thought nurses had it pretty easy, too.

Still, it's a bit much to hear someone who is having a good shift, getting their breaks, taking a full 30 for lunch, maybe having a little time to order Avon between tasks, say you aren't doing enough to help them when you're running your butt off and still staying over to finish charting. I get paid more than the aides. I expect to have to earn that difference. I typically don't earn that difference with my back, although my muscles are sore at the end of the shift, too. I'm lucky not to have to say that the difference is that I care more, either. Most of the aides I work with do care about the patients as much as I do, so I don't spend a lot of time asking whether they've been turned or toileted. If I find a patient soiled or wet, it's fresh. I've seen plenty of them have nights from hell right alongside me. But, still, on a typical night, I think it's safe to say I worry more, because I know more things to worry about. The patient whose butt is getting red after three days of frequent liquid stools is a problem for both of us, but the aide doesn't know their potassium level is 2.9 and trending downward. I'll help clean them, if I can, but I also need to call the doc before they start having lethal dysrhythmias.

That said, it really is fun, being a nurse. I've left work smiling more than a few times. But I will never, ever forget leaving work wondering whether my patient would still be alive if he'd had a better nurse. I work really hard not to feel that way, again, and until you've done that, don't tell me my job is easy.

daisy9980 · Apr 8, 2009

I am also gonna try to keep this as short as possible.

I think truly it all comes down to poor STAFFING. If staffing was better, no one would be looking for others "help" them do there job desciption their facility.

I have to say that working at where I am, a nursing home, I have 40 residents that I have to medicate. 4 passes on each shift with accuchecks, vitals and charting in between. Do you really think that I have time to help? I give a lift, boost, help feed when possible. For instance if I have people out in the hosp, less ppl to medicate. Therefore I have a little extra time. But when you are the desk nurse, and you have one other nurse passing meds to all 40 residents, the amount of work you have to do alone is tremendous. To get into it is pointless, unless you are a nurse and you carry out these duties. Debating is pointless. I know I will get written up if my CNA doesn't say, get me a readmit weight.. Not the CNA the nurse. But if I don't put a coumadin lab on for the correct day, does that CNA get my write up? No. There is always a heirarchy. Someone above you, and responsible for YOUR actions. Do your job within your scope of practice. And if my administrator found out I stopped my med pass and was changing a res, b/c your behind with YOUR residents assigned to you, and I didn't give that insulin one time, there would be BIG trouble. Enough said. I could go on for hours.

There are different jobs & titles for a reason. If you don't like how it is, get another job or title. There are plenty out there.

Kunzieo · Apr 9, 2009

Here's my issue...

I was a CNA for 2 years. Worked nocs on a stepdown/ccu.

When unit was full, we had 38 pts. (And it frequently was)

I was the ONLY CNA on nocs.

Nurses had a 4:1 ratio.

My original job description was: stock supplies, fetch equipment, help RNs answer call lights, do the am accuchecks, and help pts set up for breakfast.

Because I was willing, eager, and a fast learner- my job soon grew to include drawing all stat labs, and the am lipid panels. Tallying and recording I/Os. Getting daily weights on the dialysis pts. Getting q4h vitals on ~8-10 pts per night.

All this PLUS the original tasks assigned. And I was to do all this while helping nurses do their q2h turns and whatever else they needed help with.

The better CNA I became, the more competant- the MORE tasks I had heaped upon me.

To me, this is the elemental flaw in the system. The lazy CNAs are the ones who have it great. The "good" CNAs became overworked, frazzled, and burnt out.

And the more the more I had to do, the more guilty I felt that I wasn't getting it all done. I felt myself looking for shortcuts, becoming very impatient vith pts who put their light on for what I considered to be insignificant things. I got very frustrated with having 8-10 nurses to report to, each one having a list of tasks for me that was a million miles long, each counting on me to help them out- because I was the good CNA and could do it all.

Or not.

So I quit. I couldn't take the pressure anymore.

Why does it have to be like that? If I work hard, why do only find more work to be done? Why do the lazy CNAs get to do just the bare minimum - and get by with it?

I think it comes down to staffing. A CNA should only be responsible for, lets say, 10 pts. Then they could do all the bathing, toileting, ADLs, vital signs, meal set ups, etc. and it wouldn't be an overwhelming amt of work.

But nobody cares about the CNA staffing ratio.

lamazeteacher · Apr 9, 2009

Ahhh- I see the problem here- you're thinking that I'm suggesting that I'd gown up "simply because a patient is HIV positive". This is not the case. It's that, coupled with other factors such as history of seizures, combative behaviour, Parkinsons (examples of possible unanticipated movements by the patient) or dependant on what procedure I'd be doing with them- as I'd said before. It's something I would assess on a case by case/procedure by procedure basis. Again- having had unexpected blood contact in similar situations- I would be more inclined to take that precaution. Probably regardless of HIV status- but definately in the case of a positive status. (Puts out evidence based pipe- this is a no-smoking thread. )

I'll say it again, Equinox____93, it would benefit you to discuss your facility's policy and procedures regarding universal precautions, with the Infection Control Nurse there (who is the PPE "police"). You contradicted yourself in the enboldened part of your post that is quoted above, and have the idea that if there's blood there's exposure. There's only exposure if the patient's blood gets into an open or not yet healed over sore that you have.

If a combative patient bites you, their saliva is not possibly contaminated with HIV (although bacteria in the mouth does cause other very treatable infections), unless recent dental work left their gums actively bleeding, and, again that blood got into a sore on the nurse's body.

Policies and Procedures in the loose leaf binder on every unit must be followed for all cases and situations, so nurses don't change them, depending on how they feel at the time. I think you're right to judge the possibility of exposure according to what you're anticipating might happen, and the intact or not intact status of your skin.

If I was changing the dressing of someone with uncontrolled, frequent seizures or very jerky motions due to Parkinsonism, depending on where the dressing is applied and how bloody the wound is, I might wear a gown only if the wound was very bloody, and a seizure would probably happen; and probably not with jerky Parkinson's movements. I might ask a nurse's aide to stand by, during the procedure, in case it was necessary to restrain arms or legs, gently.

diane227, LPN, RN · Apr 9, 2009

Man, it sounds like you either have nurses who are spread too thin or lazy. On my floor, the nurses spend a LOT of time with patients. It is a med surg ortho unit. We have a 1:4 or 1:5 nurse patient ratio. The charge nurse (me) does not take a patient assignment and it gives me time to get around on the floor. I hope that if any of the nursing assistants on my shift feel like they are not getting help, they will come get me. We have a real strong team on 3-11 and everyone seems to help everyone else and they are proud of the job they do. They don't complain and they don't call in sick. I guess I am just lucky to work where I do.

sicushells, RN · Apr 9, 2009

I'll say it again, Equinox____93, it would benefit you to discuss your facility's policy and procedures regarding universal precautions, with the Infection Control Nurse there (who is the PPE "police"). You contradicted yourself in the enboldened part of your post that is quoted above, and have the idea that if there's blood there's exposure. There's only exposure if the patient's blood gets into an open or not yet healed over sore that you have.
If a combative patient bites you, their saliva is not possibly contaminated with HIV (although bacteria in the mouth does cause other very treatable infections), unless recent dental work left their gums actively bleeding, and, again that blood got into a sore on the nurse's body.
Policies and Procedures in the loose leaf binder on every unit must be followed for all cases and situations, so nurses don't change them, depending on how they feel at the time. I think you're right to judge the possibility of exposure according to what you're anticipating might happen, and the intact or not intact status of your skin.
If I was changing the dressing of someone with uncontrolled, frequent seizures or very jerky motions due to Parkinsonism, depending on where the dressing is applied and how bloody the wound is, I might wear a gown only if the wound was very bloody, and a seizure would probably happen; and probably not with jerky Parkinson's movements. I might ask a nurse's aide to stand by, during the procedure, in case it was necessary to restrain arms or legs, gently.

At first I though this was an education deficit that we could help correct. There are hard and fast facts about HIV and transmission to healthcare workers that have been presented in this forum (which, in fact, has nothing to do with the original topic, except as an example of the CNA feeling uncommunicated with by the RN). Equinox_93 is not interested in the facts, because she already KNOWS that if she gets "contaminated" blood on her (and really, when would you welcome having someone else's blood on you?) she will have an increased risk of getting AIDS. No facts, no statistics, no research will convince her otherwise. No discussion of the patient's feelings will sway her. She already KNOWS what she is doing, and she doesn't need data to tell her otherwise. When she is ready to learn about Evidence-Based Practice, she will. Until then, I don't think there's anything when can tell her that will change/open her mind. She's already told us that We've agreed to disagree.

nursemike, ASN, RN · Apr 9, 2009

[quote=Kunzieo;3555623

I think it comes down to staffing. A CNA should only be responsible for, lets say, 10 pts. Then they could do all the bathing, toileting, ADLs, vital signs, meal set ups, etc. and it wouldn't be an overwhelming amt of work.

But nobody cares about the CNA staffing ratio.

I care. Not that I usually get to do much about it. But my unit does run with 10-12 pts per aide. Each aide covers two nurses. We have a stepdown sub-unit with 9 pts divided among three nurses and one aide, sometimes a floor aide picks up three stepdown pts along with 4 floor patients. So it isn't usually terribly unreasonable, but it's still often a lot of work.

Awhile back, we tried running with a 5:1 ratio for nurses in an effort to reduce falls. Our norm is 6:1, outside of stepdown. I know a lot of people have it worse, but these are pretty busy patients, and 5:1 seems a lot more manageable than 6:1. But 5:1 didn't seem to help our fall rate, or overtime, enough to justify the expense.

I wondered, at the time, and still do, whether adding aides might have been money better spent. For the price of one "extra" nurse, we could have two extra aides and assign each aide to a single nurse. 6:1 for a nurse/aide team would be a lot more eyes on each patient (reducing falls) and shorter waits on call lights (pt. satisfaction.) I'd still have to chart on six--arrgh!--but I wouldn't spend nearly as much time doing stuff the aides could do.

As the poster notes, not all aides are equal, and my idea would fail if it just meant the aides had more time to goof off. I've seen some who would, but none of the ones I currently work with are like that. They typically do get their breaks and lunches, and a few minutes of downtime here and there, but mostly they work their butts off. As I noted previously, they care about the patients just as I do, and I firmly believe they'd use most of the extra time to do better patient care. And free me up to do more RN stuff.

But I fear this idea is a pipe-dream, and even if it were implemented, it would only take one or two deadbeats to spoil it.

Mahage, LPN · Apr 9, 2009

Our Pct came up to me last night and said, "I have 15 patients so I will need a lot of help from you." I told her that I have 5 and I was certain to need a lot of help from her also. As it turned out, she only had 13. She finished her rounds and charting long before I finished my first rounds. I put two pts on the bed pan and she took them off, cleaned them up and did another one by herself. then we both gave the surgical bath to the quadraplegic who was going to surgery. She was very upset because come 6:10 she had not got all her paperwork in computer, I had not got mine in either. I gave report, finished up and was out by 7:45. She got out by 7:15. She is a good tech, better than some, but she really gives off the attitude that she is the tech and has to work harder than we do.......I know she works hard, but that doesn't discount the hard work the other RN's and I do. I think everyone just needs to realize that we all work very hard and give one another credit and support for the care we give our patients. We may not always do the clean ups(we do a lot) when a patient can be handled by one person, but on our unit we always work together with the tech to clean up the patients that are too heavy or disabled for one person to handle. My techs have to often tell me how it is done as we go step by step and I appreciate it when they do it, instead of acting like I am retarded because I can't remember to put the clean sheets under the dirty roll or to use a towel to guard them or what ever. I would never ask my tech to do anything that I won't do myself, but sometimes I have to ask them to do things that I could do, just don't have time. Changing dressings is not something that I would ever ask a tech to do. I personally like to review my own lab results because I am responsible for treating, not them, so I want to know for sure it is not misread. I generally even do my own blood sugars with an occasional exception. I do some lab sticks too. Part of that is because I am trying to learn how to be a "super sticker!"

Got to go to bed now, just meandering here.

Mahage

mochabean · Apr 9, 2009

The better CNA I became, the more competant- the MORE tasks I had heaped upon me.

To me, this is the elemental flaw in the system. The lazy CNAs are the ones who have it great. The "good" CNAs became overworked, frazzled, and burnt out.

And the more the more I had to do, the more guilty I felt that I wasn't getting it all done. I felt myself looking for shortcuts, becoming very impatient vith pts who put their light on for what I considered to be insignificant things. I got very frustrated with having 8-10 nurses to report to, each one having a list of tasks for me that was a million miles long, each counting on me to help them out- because I was the good CNA and could do it all.
Or not.
So I quit. I couldn't take the pressure anymore.

Why does it have to be like that? If I work hard, why do only find more work to be done? Why do the lazy CNAs get to do just the bare minimum - and get by with it?

I think it comes down to staffing. A CNA should only be responsible for, lets say, 10 pts. Then they could do all the bathing, toileting, ADLs, vital signs, meal set ups, etc. and it wouldn't be an overwhelming amt of work.

But nobody cares about the CNA staffing ratio.

I agree with you 100% because I have seen this done many times before. You could be working on Side A, but if a nurse on Side B is working with a CNA who is not dependeble, she will go to Side A and hunt down the CNA who does get the work done. Not only does that CNA have to work on Side A, but also has to go to Side B to do another CNA's work. It's gotten so bad that everyone sticks to their own patients. This was discussed with the DON and she even agreed with us. We all met with DON to discuss this and I still think there was minimal impact on the ones who aren't doing their work. A nursing assistant I was working with the other day didn't even bathe her patient and I knew it for a fact because I had the same patient the day before and recognized the gown she had been wearing that day. If I could have at least 5-6 then I'd be able to do so much more. But when you're on a large unit where there aren't enough nursing assistants scheduled for that day, someone calls off, or your the only nursing assistant on the floor, you can be stretched very thin.

meluhn · Nov 11, 2009

A good post that touches on a lot of issues. I am currently working as an LPN and going to RN school at the same time, so I have seen both sides of the nurse/aide delegating issue. I'm going to paste a post that I read on another thread that I thought was really great and thought it might be relevant to this post too. I do like what you said about aides and nurses giving report to one another. I've worked on floors where this does happen, and I've worked on floors where it doesn't happen. It probably goes without saying, but there seems to be better continuity of care and better team cohesiveness when all team members talk to one another. On another note, you also mentioned a nurse who asks you to do things outside of your scope of practice. BE CAREFUL! I love learning and trying new things as much as the next nurse (maybe more!), but if you go through with something that is not within your scope of practice (check out the Nurse Practice Act in your state), you WILL be held accountable if something goes wrong......you never know what may be going on underneath that gauze!!! Anyway, here's that post I was talking about...
Originally Posted by PlaneFlyerRN
Mr. So and So rings the light. He's lying in about 15 minutes worth of poop-detail cleanup, but he's physiologically stable.

Meanwhile.........

I've got a patient in the other room with a b/p of 78/42. I've paged the doc, and I am busy trying to get an IV in this same patient so that I can give fluids. Meanwhile, I have someone else who is working with me who can't start the IV, and can't take orders from the doc, but CAN help by doing peri-care on my other patient in the other room.

Meanwhile...........

I've got a patient whose abdominal wound is seeping bloody drainage around the dressing. The patient's lying in a big pile of ooze. Gosh, I sure hope the wound hasn't dehissed. I need to change the dressing and see what's going on underneath all of that gauze, but I'm still waiting for that call back from the doc for my patient with the low blood pressure. I should probably take another blood pressure, go ahead and start IV fluids without a dr's order, and.......

Darn....My patient whose got the poopy but is on the light again. "I need some help!"

I poke my head in the door. "Sorry Mr. So and So, I'll be back in to take care of you in just a moment."

In the distance, I hear an IV pump start alarming. "Shoot - my blood infusion is already finished in room 424........I need some help."

I'm on my way to the IV alarm and the doc calls back. I'm sitting at the desk talking on the phone with the doc when my coworker/CNA comes to me to see what I needed. I'm writing down a lengthy order that needs to be faxed to the pharmacy, then I have to get the med, give the med............

"Can you please go help Mr. So and So - he's all dirty". (I get a dirty look from the CNA as she walks away.)

By the way.......I do care. I care about the kidneys that are about to go south on the patient with the low blood pressure if I can't get the blood pressure back up. Meanwhile, I'm taking matters into my own hands in order to address that issue - I finally get an order from the doc to cover me for what I just did.

I also care about the patient whose leaking out about two cups worth of serous/sanguinous fluid from their abdominal wound that I need to assess.

I also care about what the CNA thinks of me, but I can't even begin to explain all the reasons why I need the peri care done by the CNA instead of doing it myself.

As I get off the phone, I hear a loud crash from down the hallway. A patient tried to get up by themselves and has just fell on the way to the BR.

So much for waltzing out the door on time tonight.

To the OP: This excerpt hits the nail on the head. You will never know what you don't know until you have walked in the nurses shoes. We have to delegate the tasks that you can do so that we can take care of the things that you cant do. You will still walk out the door on time and we will be sitting there when you leave, sometimes for hours after. You may know the persons favorite color, and that is great for the pt to have a relationship with you like that, but we know the pt BUN/Creat, their K+ level, h&h and other crucial info that you have no clue about. Please do not be quick to judge a nurse, it takes a while to get good at all the stuff that you do as a tech. If you did not practice it everyday, you would not be good at it either. Do not join the rest of the medical community in undervaluing nurses. You will see soon enough, provided you can get through all that it takes to graduate, pass your boards and get your RN. Good luck to you.

Cmatt13, BSN, MSN · Jul 23, 2010

I was a paramedic prior to becoming a nurse, and worked for several years on the ambulance, then in an ICU, an ED and an office before finishing my degree. I can say that you will learn things about nurses during your time as a CNA that will probably affect how you practice once you are out. For example, I'm one of the "nice nurses" when it comes to my techs and aides--I don't expect you to do my patient care, and I spend as much time as I'm able to with my own patients. It's how all of the best nurses I learned from practiced, based on mutual respect and the idea that we are all part of the same team with the patient as our focus.

That said, there are nurses out there who don't, or won't, or aren't able to because of the work load. Some nurses are just lazy. Some are disorganized. Some don't know there's a problem until it comes along and bites them in their nether-regions. Some are just overwhelmed with the number of patients they are expected to take care of.

Do yourself a favor, speak up. Be polite but stand your ground. I'm not a quiet person, nor do I shy away from letting people know that I'm upset/irritated, yes sometimes even happy. It was this trait that got me through my nursing degree and allowed me to build a relationship with nurses that 20 years later I still know (and look up to!!). It is also this trait that will help you once you graduate from becoming one of the nurses "eaten by their own" as our profession has a tendency to do.

Good luck!