Crackin the whip with LTC 11-7 CNA's?

  1. I've started my new job. I am the new 11-7 nurse at an LTC. I have a set unit where I'll be scheduled to work full time. I need to start changing the daily routine for CNA's but how can I do it without destroying my relations with these CNA's who have been there for 20 sum years?

    I use to be a CNA for about 5 years. I know by heart what it takes and what needs to be done. Since December 2nd, I've been on my own as a first time nurse. I wanted to learn my role first and at the same time observed CNA's and their daily routine. At this particular LTC, when they come onto shift they do their paperwork and do two rounds. One at 2am and the last round which is at 5 along with their get-ups. Where I use to work as a CNA it was very descipline. And it was to the benefit of the residents which it is how it always should be. I want to follow and continue what I was taught.


    1. When start of the shift I want them to conduct rounds for proper positioning (on side), all alarms checked for placement. All heel protectors on.

    2. All residents who are monitored for I & O, Alert list, ABx tx, are to be given fliuds atleast once during the 11-7 shift. Mind you that some of these resident last drink was during supper time 5pm, or 1 cup from the 8 or 10 pm med pass and go without fluid until 7am. These residents are elderly, immuno compromise the whole 9 yards. We all know the importance of hydration.

    What I'm doing currently is insteady of coming out hard, I'm slowly adding something new daily.

    One night, I told them that anyone incontinent are to be lathered with house cream. Last night, I nicely, professionally told them that everyone who is incontinent, chair bound should be on their side esp if they have dementia. They are the residents who are at risk. For a census of 29, only 17 have to be repositioned. That is not hard. Did I mention that 6 of them have ulcers. That leaves me doing the dressing changes to which I don't have a problem doing, but this SPELLS NEGLECT!!! Had they been providing quality care, we all can anticipate the outcome. My rationale is that if they don't do their job, that means I'm not doing my job either. The facility is not that great either but a circus is a circus, same nursing principle, different policies. We are nurses and we all know what is needed. I understand that CNA's are the back-bone and their role is changing too at LTC. Perhaps I should provide a rationale for the routine change so they can understand and learn a few points. They have care plans in place, but it looks like a bunch of jiberish words that they don't read daily. I'm not a know-it-all type of person. I'm a bottom line team player and I will help them with their job because I'm not afraid to get my hands dirty. How would you approach this situation??

    Hx: The company hires agency nurses & CNA's daily. No nurse enforces nursing interventions for CNA's to follow for preventive measures. When I was on orientation, I remember a nurse telling my "these resident's need their rest, so 2 rounds is good enough. She doesn't want them to be sleepy throughout the day." Basically, there has been no order at night for the past few years.


    Just me, Just Wondering
    Last edit by Just wondering on Dec 12, '05 : Reason: bad title
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    About Just wondering

    Joined: Nov '05; Posts: 24


  3. by   yvonnemuse
    I understand your position. I work 11-7 and have seen some managers come in and try to make changes by the "I say so" rule. You are right in believing you will step on the toes of the long timers. change is difficult to implement in the ingrained habits of people. These CNAs probably feel as though they know these residents more than you and resent the intrusion etc. Personally I have always used the "do as I do" rule. I work with my CNA. I turn, wipe butt, and lotion. I do this over and over . My CNAs begin to notice this and respect me that I will not ask them to do something that I will not practice right besides them > Sometimes when I work with someone who is not accustomed to my routine, it makes more work for me and puts me behind, but the regular CNAs DO pick it up and become independant with the new routine. I make it known that it is not an option and not for MY benefit, but for the residents benefit.
  4. by   rn/writer
    One method that might give you some success is to state the need or the problem, ie. "Our frail elderly patients are frequently dehydrated because many of them don't take in any fluids for 12-14 hours." Then ask for the CNAs' input on how this need might best be addressed. Be clear that the problem WILL be taken care of. That point is not negotiable. But seek their ideas and input on HOW to meet the need most effectively. They might come up with possibilities you hadn't considered. If they don't, then suggest several ideas and ask for their thoughts on the pros and cons of each one.

    If they see that you are genuinely trying to meet a goal and not just throwing your weight around to established that you're the boss, they may feel less oppositional and become more invested in helping the unit collectively meet that goal.

    Once you have identified a target and come up with, say, two or three ways to meet it, you could alternate methods by time (we're going to try Method A for two weeks and then we'll switch to Method B for the same amount of time) and then compare results. Or you could do a parallel study with different wings trying different approaches at the same time. What's good about this is that you, yourself, will have some objective data for supporting any decisions you decide to implement on a permanent basis.

    This doesn't have to take a long time. Nor does it need to become complicated. Make up some simple forms for what ever area you're evluating. These should NOT become part of the official charting and as QA materials, they are exempt. Get some of your more trusted staff on board and enlist their help with encouraging everyone to cooperate. Keep track of the efforts and the results and when you have the data, meet with your CNAs and tell them what the material shows.

    Start with the most important items first. Then implement additional improvments as you can. Be open to--and even solicit--staff suggestions for areas of concern. It is so much better if THEY speak of your concerns and it puts them on notice that you will listen to their observations.

    This might seem like an unnecessarily tedious approach when you already have a pretty good idea what needs to be done. But, unfortunately, if you come in and just "lay down the law," you are not likely to get the results you want. If you don't go the extra mile to inform, educate, involve, and inspire your staff, they will focus more on how the changes affect them than on what they might mean to the residents' long term health. It is up to you, as management, to create a vision that includes the importance of their role as caregivers so that the extra effort required is seen, not as punitive toward them, but essential for the residents.

    It is also of utmost importance that you acknowledge and appreciate their cooperation. You don't have to (nor should you) come off like they're doing you a favor. Rather, you can express your satisfaction and pride that together, you are taking better care of the people who are depending on you to meet their needs. Let your staff know in tangible ways how their efforts make a difference. Report things like fewer skin tears or UTIs d/t better hydration. Speak to the residents and relay positive comments about being thankful for a drink in the middle of the night. Train your people to be alert to similar items they might share with the group.

    I suppose the essence of this kind of approach is that if you want the residents' needs to matter to your staff, you have to first show that the staff members' needs (for education, acknowledgment and affirmation) matter to you. You will lead by example, not only by doing hands-on cares, but by connecting with them in the same way you want them to connect with the ones they care for.

    It is part of the human condition to want to be seen, accepted, and cared for right where we are. We want to matter. We want to be taken care of whether or not we deserve it.

    This is true of your residents. It is also true of your staff.

    I wish you well with your efforts. Your CNAs are fortunate to have a caring person as their leader.
    Last edit by rn/writer on Dec 12, '05
  5. by   Just wondering
    As you can see, I changed the title b/c it sounded to harsh.Thank you both for your time you took to post. Your information is a resource tool....RN/writer, your member name says it all.

    Just me