CNA Task Delegation & Patient Care Coordination Advice Needed

joprasklpn · Nov 27, 2010

It may sound mean, but you are talking about neglect to patient care so maybe try writing them up. They may not like you after that, but at least they might do their job better. I have always been fortunate to work with great CNAs so I really have not dealt with this problem, but goodluck and keep doing a great job. Maybe helping them less would let them see how it feels.

blamejoe · Nov 27, 2010

I have the benefit of working with great staff as well. I try to keep in mind that I am not helping the techs with their job, and they are not helping me with my job, but we are helping the patient. It makes it easier to cope when you're stuck there late finishing charting, etc. But I've also found that since I have vocalized this to many people when they've voiced a frustration, now when I have to coach anyone about care not being complete, I feel like there is more of an impact because I reiterate, "I'm not asking you to help me, I'm asking you to help the patient." Moments when I've had to actually do that are few and far between.

bhanson · Nov 27, 2010

What is your nursing ratio?

Lying is never condoned, but if your aides routinely have to take care of 29 patients (1 CNA on the floor) it is helpful to know that this is an impossible ratio. At 1:29 you'll be lucky to see each patient every couple of hours, often times not even more frequent than would be needed to complete a q2 turn.

Lets say the goal is to see every patient every two hours. At 1:29 you get barely over 4 minutes a patient, or 2 minutes per patient per hour. Think of how long it takes you to do a simple basic nursing task (or even walk from the farthest patient room to the supply room), now see how it may be difficult to do that when understaffed? Not to mention the work actually becomes tougher when understaffed as well. If you answer a call light late to someone that needs assistance to the bathroom you now have to do a linen change because they soiled the bed. This could take 10 minutes but uh oh, that's over twice their allowed "allotment of time"! A bed bath could take up to 30 minutes which is over 7 times their allotment of time.

It also severely depends on the acuity of the patients. I've worked 1:8 CNA shifts before that were busier than 1:16 simply because of the level of care needed. It might only take 1 or 2 "difficult" patients to completely kill your time table and make completing the rest of the tasks nigh-impossible on time.

Now I have no idea how hard your CNAs are actually working, but my point is that as the RN it is your responsibility to know how busy they are. You need to be able to distinguish tasks not getting done because the CNA is lazy or incompetent vs overworked and in an impossible situation. It's about finding a balance between finishing your advanced nursing tasks in an appropriate time-frame and attending to the "basic" needs of your patients as much as possible.

Orange Tree · Nov 27, 2010

Some CNAs just need a little more direction than others. Let them know what needs to be done. Let them know what the priority is. Follow up! Some people really need that follow up. Knowing that you're going to keep bugging them until it's done is what motivates them to complete the task.

Instead of, "Can you please assist patient x to the bathroom?" you say, "I need you to assist patient x to the bathroom, please."

And when you hear, "I'm busy taking midnight vitals." you respond with, "Let's put that off for a bit and take care of patient x first- she needs to go right now, and she actually fell last night trying to ambulate on her own."

Or sometimes you hear, "The nursing director told me that I have to polish the chrome on the chairs in the break room first." and you reply with, "Noooo, we don't have time for that. If you get to it, you get to it, if not I accept full responsibility for the fact that it didn't get done. If anyone says anything to you about it, please tell them to talk to ME. Patient x first please, the chairs can wait."

A short time later....."Did patient x make it to the bathroom ok?" and then hopefully, "Great! Thank you so much."

tokidoki7, ASN, RN · Nov 27, 2010

My floor has 29 beds and is almost always full. We are to have 3 CNAs with a full house but lately rarely do.

Sounds like a staffing issue. If there are 29 beds and there are fewer than 3 CNAs, you can't expect them to do everything they're supposed to do, espcially if there are high acuity patients. I work on a unit with 35 units where there is supposed to be 4 CNAs. Half of the time there is only two because someone had to be pulled or called off. On days like that, you can't expect everything to be done if the CNAs are being overworked due to short staffing.

Cinquefoil · Nov 27, 2010

From the oral care and skin conditions you're describing it sounds like the care isn't getting done on the other nurses' shifts, either.

Management is not responding to the chronic shortage of care by offering more support but by reprimanding the CNA's. Tread carefully. I don't know your CNA's so don't know if they're really doing their all, but what this means is that your management is treating a SYSTEMIC problem of lack of care and understaffing by trying to apply PERSONAL pressure to the employees. They sound aware of the lack of care but OK with it as long as the budget is happy.

I have several friends who are CNA's that have worked these ratios and they describe them as "h*ll". And these are Type A, VERY hardworking people, who have genuine compassion for patients yet acknowledge that they had no time to do much other than brief changes, and sometimes not even that.

If you're getting any nursing care done at all with all the extra work you're doing you rock. If you're only missing "a few" major nursing actions you're downright amazing.

You may want to consider looking for another job. It doesn't sound like you can save this unit.

Batman25 · Nov 28, 2010

Are the CNAs gooding off? Are they watching tv, texting, talking, etc. when they should be working? If they are then you need to start delegating and checking up. When work isn't being done you need to write them up and start a paper trail immediately. It is much easier for management to brush things under the rug when nothing is in writing because no proof exists of the ongoing issue. Once it is in writing they are on formal notice.

If the CNAs are working hard and just can't get to the work that is a staffing issue. My guess is you are dealing with some great CNAs who do their best and others that slack. You need to differentiate between the two so the good ones aren't lumped with the bad ones. They also could be taking advantage of you because you are new. Delegate in a firm yet respectful way. The bad ones will either straighten out after they know you mean business or hopefully be shown the door after being written up a few times.

Lying should never be condoned. That should be an immediate write up. Patients are suffering and that should be documented as well. Management should be on the hook here as well so make them aware in writing and keep on doing it.

canigraduate · Nov 28, 2010

If I understand your post correctly, you're supposed to have 3 CNAs and usually get two for 29 people. That's freaking ridiculous. It's unsafe. Unless you have a lot (say 90%) of your patients who can take care of themselves, then there is no way 2 CNAs can take care of that many people. My personal limit on day shift is around ten (depending on acuity). Any more than that and I refuse the assignment. 14-15 is beyond my physical capability and I refuse to be responsible for the people who are mistreated because I simply can't get to them.

So, I wouldn't worry about motivating your CNAs. I would worry about helping them get your patients taken care of, because they certainly can't do it.

As for the lying, make sure. If they are lying, it's probably to cover their butts because they know they can't do what is asked of them and they are afraid to speak up because they aren't being supported by their nurses or by management. Still, lying is unacceptable, and should be dealt with according to your facility's disciplinary policy.

DC Collins, ASN · Nov 28, 2010

I'm with those who say you need to be checking up on the CNAs. You are already wasting time on answering lights, so spend that time instead of checking up on the CNAs.

IF you find they are slouching, write it up. Patient care is the number one goal.

IF you find that they are working their butts off and still not keeping up, then don't "just" answer a call light - grab a CNA and say something like, "I'll grab that call light - you go get vitals in room X." They will appreciate both the direction and the help. Do your assessments, take the next meds in, etc., while you are in with that call light. Less wasted time.

Don't just give the CNAs a list of what to do at the beginning of the shift. Know what needs to be done by them and keep on it.

Overarching all of this, *leand them, and treat your CNAs with respect and recognition for their hard work - even the ones who might not deserve it. By doing so, you can sometimes turn them into ones who Do deserve it.

Best of luck in a tough sitch!

DC :)

tech1000 · Nov 28, 2010

I worked on a floor for awhile as a tech. I usually had 8 patients a day, sometimes up to 12 or 13. I'll tell you, with 8 patients a day, I NEVER shampooed hair UNLESS a patient asked for it. Even then, it was just a shampoo cap. In 8 months on the floor, I saw 1 person actually get shampooed. There is just not time to be shampooing hair. Dirty hair doesn't hurt somebody. Dirty skin, yes. If I even did a shampoo cap on a patient, I had the family do it or I did it after my baths, if vitals and accuchecks were done, and if all my patients had used the bathroom. Oral care is also something techs usually don't do on a regular basis. If I had the time and I had a patient who needed their teeth brushed, I would offer to help, but it was not part of daily care. If a patient had a disgusting mouth, I would definitely clean it out. If you haven't been a CNA, I think it's hard for nurses to understand the work. I could always tell which nurses had been techs before. There is a difference between a lazy tech and a tech without time. My RNs all loved me because I worked my butt off, but when you're helping half your patients up to the bathroom and changing the other half, there is rarely time for things like shampooing and oral care. Priority on our floor was accuchecks, feedings, vitals, bathroom/diaper time, bath time, and anything else. My biggest pet peeve as a tech is when nurses think something is a "tech" job. That is ultimately the RNs patient. If your techs are being lazy, tell the supervisor. If they're genuinely busy, you'll have to take care of the rest.

Umrn1 · Dec 28, 2010

Great and very helpful responses! Some time has passed since my post and I've been trying harder and harder to follow up and to let the CNAs know that I completely understand the staffing issues we have from time to time. I've spent more time and effort in helping the CNAs know where we stand right from the beginning. I get my assigned CNA (s) and start the shift not only by turning in my "assignment sheet" we are required to fill out for the day, but by actually giving report to them. I have had several tell me that no one has ever taken the time to do that and it seems to help them really understand which patients are the priority ones and safety risk ones and the results have been better cared for patients and happier CNAs. I'm getting done on time more often now and feel much better. The management has not actually repremanded a single CNA ever that I know of and I don't want that unless there is proven neglect or injury to a patient. There have been management/CNA staffing meetings to give over all reminders of tasks, delegation, priortizing, etc. My charge nurses are doing better job of following up for the nurses also and helping out as necessary when have low staffing. I still have a major problem when patients are not fullly cared for, I do not take a break etc, but the aids are in the office chatting it up, eating snacks, and taking multiple breaks. This is the root of the majority of our problems, call lights going off, nurses in procedures or in patient rooms already, yet one or two CNAs in office ignoring a call light and having to be told to help out. I really see this happening on super busy short staffed days. It's like they are overwhelmed and just have to stop for a moment. But who hasn't felt the need to do that sometimes, right??? I have also noticed there are one or two nurses who can't seem to ever help a patient to the potty, change a linen or anything else. Perhaps they are the real problem by taking up all the CNAs time by doing all their work for them. Hhhuuummmmm.

Anyway, things are going better. Thanks for the advice!