Patient report

caliotter3 · Jul 30, 2019

CNAs were given report at the start of the shift when the charge nurse provided them with their assignments.

Davey Do · Jul 30, 2019

We have "techs" on the geriatric psych unit- some are CNAs, but most are not. The CNAs who are psych techs are great on gero because they're not afraid of doing direct patient care, whereas most techs are squeamish about hands-on care.

The techs are suppose to sit in on the shift change report which the majority of the information, outside of behaviors and some heads up issues, isn't necessary for them to do their job.

I applaud those techs who hit the floor running by getting a report from the staff from the previous shift's floor staff, whether they be an RN, an LPN, or a tech. I think a lot of techs just like to waste 20-30 minutes sitting around in the NS.

A few techs will hit the floor jut in time to relieve the previous floor staff, especially if they worked the unit the day before. As a competent tech has said, "This ain't rocket science or emergency brain surgery!"

JKL33 · Jul 30, 2019

5 hours ago, Bri1231 said:
Things get missed!!!

What are some examples and/or problems you've seen in reference to your concern?

Bri1231, BSN, RN · Jul 30, 2019

1 hour ago, JKL33 said:
What are some examples and/or problems you've seen in reference to your concern?

Patient mobilzed out of bed when they have a low BP which was checked by the RN, not reported to the CNA and therefore not reported to the incoming CNA. CNA gets patient out of bed. Disaster.

Patient has had a physio assessment and it has been advised to use a hoist to chair transfer only. Patient taken out of bed with no hoist.

On an emergency ortho / surgical admissions unit patients offered diet and fluids at 8.00am. Patient NPO. Not written above bed by RN. So in a way that is the RNs fault. On same said unit the morning CNAs leave at 7.45am as the day staff come on duty. RNs take report until around 8.15am. So an entire half hour where patients are left with CNAs who have no clue about the patients. Which equaled to a patient with a #NOF being mobilized out of bed for breakfast.

That is a few of many witnessed issues.

Not only that but the way I see it is many CNAs are so in the know with basic knowledge of a range of diagnosis. Which leads them to provide better care to patients and report more valuable stuff back to me! In this system they are given no medical/social history whatsoever and they are providing care to patients. This morning when I came on duty I was walking around my assignments and I asked one of the CNAs who was sitting for a patient how was your night. She said all good apart from the fact I literally have no idea why this patient is here. The information given to her was

Assistance ×2 to mobilize

Can have full diet and fluids

My point is there are a whole range off issues from medical history to a patients current social history.

A staff member walks into a patients room and says Hi, I am your CNA for the day. The patient is feeling down, stressed , and generally in a super bad mood. Distressed. The CNA opens the blinds and says oh lets have a good day today everyday should be a good day all bouncy and cheerful, which is nice, but the CNA has no clue that two months ago this patient lost her husband in a crash and is now facing being homeless with two kids.

All caregivers from RN to CNA should know the whole story to be able to give appropriate, holistic, patient centered care.

Bri1231, BSN, RN · Jul 30, 2019

3 hours ago, Davey Do said:
We have "techs" on the geriatric psych unit- some are CNAs, but most are not. The CNAs who are psych techs are great on gero because they're not afraid of doing direct patient care, whereas most techs are squeamish about hands-on care.
The techs are suppose to sit in on the shift change report which the majority of the information, outside of behaviors and some heads up issues, isn't necessary for them to do their job.
I applaud those techs who hit the floor running by getting a report from the staff from the previous shift's floor staff, whether they be an RN, an LPN, or a tech. I think a lot of techs just like to waste 20-30 minutes sitting around in the NS.
A few techs will hit the floor jut in time to relieve the previous floor staff, especially if they worked the unit the day before. As a competent tech has said, "This ain't rocket science or emergency brain surgery!"

I second what that tech said! It is so true. I think that my concern is at least there is some kind of hand off to the techs/CNAs on your unit. As there are here.

But some units basically give less than basic to literally nothing for a whole half hour. It is unsafe to me. I always give the CNAs who are working alongside me a FULL patient handover before the morning care rounds start. So they have the bigger picture, know their patients and can provide good care based on the entire picture.

JKL33 · Jul 30, 2019

14 minutes ago, Bri1231 said:
Patient mobilzed out of bed when they have a low BP which was checked by the RN, not reported to the CNA and therefore not reported to the incoming CNA. CNA gets patient out of bed. Disaster.

This goes to mobility - one of the categories of things you mentioned that are commonly reported to the CNAs. The RN failed to update the report.

15 minutes ago, Bri1231 said:
Patient has had a physio assessment and it has been advised to use a hoist to chair transfer only. Patient taken out of bed with no hoist.

Mobility issue again. Either report not updated or else CNA didn't follow instructions/plan of care.

17 minutes ago, Bri1231 said:
On an emergency ortho / surgical admissions unit patients offered diet and fluids at 8.00am. Patient NPO. Not written above bed by RN. So in a way that is the RNs fault.

Dietary issue (should have been already shared by RN or otherwise made available where CNAs can check pt dietary orders/info).

***

My point in parsing this out is not to argue with you ? - - but to show that if RNs don't update information in a timely manner, it won't matter what kind of extensive report was given to CNAs at the start of the shift. It sounds like these are overall communication issues that might go beyond the shift report itself. And all 3 examples you have given are in regard to basic information that may change throughout the course of a shift.

23 minutes ago, Bri1231 said:
This morning when I came on duty I was walking around my assignments and I asked one of the CNAs who was sitting for a patient how was your night. She said all good apart from the fact I literally have no idea why this patient is here. The information given to her was
Assistance ×2 to mobilize
Can have full diet and fluids
My point is there are a whole range off issues from medical history to a patients current social history.

I understand, but I think I disagree with your angle. The safety person/sitter is not there to assess these things, and though it sounds bad, the reality/legal aspect is that they are not qualified to make official assessments related to the patient's psych/medical/social history or issues. The RN should be checking in with the patient and the attendant in order to gain information related to ongoing assessment.

With regard to HIPAA, the sitter/attendant should be privy to information required to do their hired and assigned role - not our role, although there is obviously overlap. However, I do share basic information that helps keep everyone safe as well as individualized information related to therapeutic purposes and/or safety. They do not generally need extensive run-down about the patient's med/psych/social history aside from what is prudent for everyone's safety. Your angle is sort of that the more they know, the more they can help you take better care of the patient, and in some respects that may be true/reasonable, but in other respects it is not. The only nursing personnel legally tasked with making nursing assessments and deciding upon nursing interventions is you.

34 minutes ago, Bri1231 said:
The CNA opens the blinds and says oh lets have a good day today everyday should be a good day all bouncy and cheerful, which is nice, but the CNA has no clue that two months ago this patient lost her husband in a crash and is now facing being homeless with two kids.

Now this I agree with. It is absolutely cringeworthy. We just have to use nursing discretion to provide basic information that is directly related to enabling the person to best serve the patient within their assigned role.

You also have to look at some of this from a different angle with regard to these social aspects - - there is something to be said for limiting information. It can appear that "everybody who walks in my room knows all of my personal problems" - and that feeling is a breach of privacy especially when some of the people going in and out of the room are there to perform specific tasks and are not there to assess or to provide therapy, etc. Patients need to know that only those who need to have their personal information are going to have it.

Each RN should give a brief run down to the CNAs working with their patients, and should promptly update it as needed throughout the day. That eliminates a lot of the problems you are talking about.

Bri1231, BSN, RN · Jul 30, 2019

27 minutes ago, JKL33 said:
This goes to mobility - one of the categories of things you mentioned that are commonly reported to the CNAs. The RN failed to update the report.
Mobility issue again. Either report not updated or else CNA didn't follow instructions/plan of care.
Dietary issue (should have been already shared by RN or otherwise made available where CNAs can check pt dietary orders/info).
***
My point in parsing this out is not to argue with you ? - - but to show that if RNs don't update information in a timely manner, it won't matter what kind of extensive report was given to CNAs at the start of the shift. It sounds like these are overall communication issues that might go beyond the shift report itself. And all 3 examples you have given are in regard to basic information that may change throughout the course of a shift.
I understand, but I think I disagree with your angle. The safety person/sitter is not there to assess these things, and though it sounds bad, the reality/legal aspect is that they are not qualified to make official assessments related to the patient's psych/medical/social history or issues. The RN should be checking in with the patient and the attendant in order to gain information related to ongoing assessment.
With regard to HIPAA, the sitter/attendant should be privy to information required to do their hired and assigned role - not our role, although there is obviously overlap. However, I do share basic information that helps keep everyone safe as well as individualized information related to therapeutic purposes and/or safety. They do not generally need extensive run-down about the patient's med/psych/social history aside from what is prudent for everyone's safety. Your angle is sort of that the more they know, the more they can help you take better care of the patient, and in some respects that may be true/reasonable, but in other respects it is not. The only nursing personnel legally tasked with making nursing assessments and deciding upon nursing interventions is you.
Now this I agree with. It is absolutely cringeworthy. We just have to use nursing discretion to provide basic information that is directly related to enabling the person to best serve the patient within their assigned role.
You also have to look at some of this from a different angle with regard to these social aspects - - there is something to be said for limiting information. It can appear that "everybody who walks in my room knows all of my personal problems" - and that feeling is a breach of privacy especially when some of the people going in and out of the room are there to perform specific tasks and are not there to assess or to provide therapy, etc. Patients need to know that only those who need to have their personal information are going to have it.
Each RN should give a brief run down to the CNAs working with their patients, and should promptly update it as needed throughout the day. That eliminates a lot of the problems you are talking about.

You are totally right. What I see here is a communication issue amongst all staff groups. It actually is quite bad here.

The reason I ask about this issue is because in a previous setting the patient report sheet was updated by each nurse for each of their assignments towards the end of the shift. When the next shift came on the charge nurse did hand off in a room with ALL staff present even down to Physical Therapists. There was literally not one single issue that I mentioned above because all patient related information was handed over to the next shift. Even the PTs knew well we can do this today with this patient and maybe leave the other patient until tomorrow or late afternoon for whatever reason. They could also plan their time properly. Then there was a get together at 12pm for post morning updates. Literally everyone knew what the other was doing and all patient needs where met. I would then just update the CNAs with brief, relevent information as needed. Patients where happy, staff where happy. No clinical issues really and never a HIPPA violation. We all know and abide HIPPA law and anyone that does not suffers the consequences. My point is that no one provided care without a full hand off and there where no problems.

Previous department to that it was the charge nurse dealt out assignments then the RN that you where taking over from did a direct patient report to both RN and CNA. Again there where minimal issues and not much chasing up.

Now when I go way back when to the days of taped reports. CNAs did not sit in. We listened and then filled in a report sheet for each CNA. I soon learned that I was not giving enough information and I stared to do so. Taking the lead from a seasoned travelling nurse.

I guess I have worked in so many different areas / hospitals I have seen many different ways of handing off information and the best one was when the charge nurse handed over the entire unit. To everyone. That also cut out RN mistakes when you had to step in and help out on another RNs assignment for whatever reason at short notice. You already knew the deal. So I guess I have gone from a safe effective patient report to basically a super fragmented one.

And I never take anyones comments as arguing. I take everyones comments as a helpful viewpoint ?

Bri1231, BSN, RN · Jul 30, 2019

And on the sitter one......at what point does HIPPA stop you from telling the perfectly competent sitter from another floor whether the patient is DNR or not. She actually did not know. That is so bad beyond belief. Yes it should have been up on the patient board but she said she was unsure and did not want to ask because CNAs are just dismissed as an annoyance here. I guess it just is a bad culture. For me it is do I move or help change it?

JKL33 · Jul 30, 2019

11 minutes ago, Bri1231 said:
I guess I have worked in so many different areas / hospitals I have seen many different ways of handing off information and the best one was when the charge nurse handed over the entire unit. To everyone.

The only issue with that these days would be that it, somewhat like taped report, may not meet newer standards for efficiency. At some point there are diminishing returns involved in giving everyone so much information, KWIM?

It does sound like your current situation could use tweaking. Or an overhaul. ?

FolksBtrippin, BSN, RN · Aug 3, 2019

On 7/30/2019 at 11:31 AM, Bri1231 said:
And on the sitter one......at what point does HIPPA stop you from telling the perfectly competent sitter from another floor whether the patient is DNR or not. She actually did not know. That is so bad beyond belief. Yes it should have been up on the patient board but she said she was unsure and did not want to ask because CNAs are just dismissed as an annoyance here. I guess it just is a bad culture. For me it is do I move or help change it?

Why should the sitter know DNR status? Would you expect the sister to respond to the patient according to code status? That's not appropriate to the scope of the sitter. For that reason it is not appropriate for the sitter to know. The sitter needs to know why the patient needs a sitter, gets out of bed and needs to stay there? Pulls tubes out? Is a suicide risk and should be watched? That's all.

I don't understand OPs outrage. I think CNAs should give each other report, or the nurse should give a basic report to the CNA. Relevant info to their scope only.

It is really unfair to burden the CNA with information that they don't need to know. These folks are not paid like nurses and don't need to take on the same responsibility as the nurse.

Bri1231, BSN, RN · Aug 3, 2019

10 hours ago, FolksBtrippin said:
Why should the sitter know DNR status? Would you expect the sister to respond to the patient according to code status? That's not appropriate to the scope of the sitter. For that reason it is not appropriate for the sitter to know. The sitter needs to know why the patient needs a sitter, gets out of bed and needs to stay there? Pulls tubes out? Is a suicide risk and should be watched? That's all.
I don't understand OPs outrage. I think CNAs should give each other report, or the nurse should give a basic report to the CNA. Relevant info to their scope only.
It is really unfair to burden the CNA with information that they don't need to know. These folks are not paid like nurses and don't need to take on the same responsibility as the nurse.

Do I get paid to take charge of the unit on some shifts. No. So it is like I never bring who gets paid to do what into nursing. When I do take charge I give out the assignments and then I take one patient from each nurse and charge and have four patients. Personal choice but do I get paid for that. No.

Now I will give you a true scenario. Patient coded and everyone went to attend same code. No one canceled the code alert so it continued to ring. At the same time a sitter was assisting a patient to the bathroom and in that bathroom the patient collapsed. She pulled the coder and no one responded fast. She made the decision to perform CPR immediately. Same sitter was a RN who left practice years earlier due to stress and workload to raise a family and help care for her mother. Was having a break from nursing proper. Now imagine if she had performed CPR on a patient with a DNR. Or did not perform at all. She saved that patients life. See. Not all sitters are just sitters and you would be very surprised at some of their backgrounds.

So I will continue to included all of my CNAs in pretty much every aspect of patient care. I will of course not bother saying oh this patient needs labs because of whatever reason. But you learn lessons in this job.

Scope can be kicked to the sidewalk if it is justified. And you know what. Twenty years and I have yet to have a serious error with a patient thanks to a CNAs quick thinking which I always always thank them for. I value them so much. They provide nursing care. Just not at a level that we do.

So as of next week there is a four week trial of patient report to include CNAs. And I welcome that with open arms.