CNA/PNA Inpatient Teamwork

Silver_Rik, ASN, RN · Jan 27, 2018

MHA (Mental Health Assistant, i.e. PNA) and SRNA (only required at my facility to work with geriatric and acquired brain injury pts, but it was a requirement for nursing school) at a state inpatient facility, adult 18+ only. Our typical shifts are 12's 7-7:30 (30 min lunch), though there are some 4's, 8's, and 16's. I've been on nights and just switched to days. I'm also an ADN student. Per unit census is up to 28 pts. Unit staffing on nights is typically 1-2 RNs, 1 LPN, 2-8+ MHAs (this depends on pt census, acuity, number of "closes" - i.e. LOS, 1:1, 2:1 - that to be covered.

7 PM we attend handoff report with the nurses. On most units they try to keep us engaged by passing out patient summaries so we can follow along, but some don't and kind of ignore us. Then we get our assignments for 7:30-11:30 - usually in 1 or 2 hour blocks. Assignments typically include: 15 min checks, taking vitals, charting vitals, close observations (1:1, 2:1, line of sight), passing snack, supervising visitation, transferring patients in from admissions, floor duty (cleaning, laundry, etc.), assisting with ADLs. There are some group activities on night shift but limited. Day shift of course has to take pts to group activities (therapy, occupational, music, computer lab, gym, library, etc.) As a male, I often sit 1:1 or 2:1 on high risk male pts for most of my shift plus maybe an hour or two of 15 min checks, taking vitals, preparing paperwork. As PRN/float without a home unit I probably dislike being assigned 15 min checks at the start of shift more than anything because I don't know the new patients. Similar situation with snack, since you need to know their dietary restrictions - especially fluids (volume limits and thickeners) and consistency.

At 11:30 we get our assignments for the rest of the shift 11:30-7:30. The assignment sheet is the primary form of structured communication. Usually the med nurse and another if we have enough nursing staff are in the med room to handle 8 PM med pass and follow-up, charge nurse is working in the conference room, and if we have another nurse they are in the conference room or chart room. They come out on the floor as needed to perform assessments, med administration, and other licensed tasks, plus help us - though how much they assist the aides depends on the nurse, unit, and staffing. If they need our help of course they tell us what they need - for example additional vital signs for medication admin.

I'm not sure if this helps you at all. Feel free to ask more specific questions, and I'll try to answer.

doulos1 · Feb 8, 2018

Thanks Silver_Rik! I apologize, completely forgot to respond back.

Looks like for the most part our units function similarly, except we have 3 shifts and a maximum of 3 PNAs with max census of 20. I think I figured out some of our largest issues on my unit so I want to ask you three questions.

1) What does handoff look like between your PNAs entering and leaving shift? On our unit, there really isn't anything formal. Technically, we're suppose to do 1 round of full checks together to acclimate the next shift's PNAs, but that rarely if ever is done. I've noticed with the lack of communication structure that the next shift's PNA don't know about laundry still left in washer, some belongings logs unfinished, etc...

2) Do you have anything like a PNA "team leader" of sorts? With the available activities/options patients have, things can get pretty hectic on our unit, especially when you incorporate admit/discharge, rounds, etc.. I've seen alot of times PNAs forget about requests the previous accepted to do for patients, or leave things half completed b/c something more high priority happens. My current thoughts for this remedy is to get everyone accustomed to trusting their fellow PNAs and completing whatever task he/she currently has at hand. To do that, I thought about maybe having a PNA as a 'team leader', maybe the one who holds the 15min checks duty to communicate and keep everyone on the same page, as well as remind them of whatever tasks still left to finish. I know there would be the issue of feasibility. Itd be hard for a team leader to constantly communicate and be on top of changes that occur. I wonder if there is something I could change/add more structure to, at the beginning and end of shifts to help.

3) Do you have any kind of "pseudo-reports" for PNAs? Our unit PNAs also sit in at start of shift to attend handoff report with nurses. I wonder if I could implement something like that for PNAs, so we're all on the same page.

Silver_Rik, ASN, RN · Feb 15, 2018

Now I'm the one taking my time to respond. Just really busy here with school etc.

- You have a cap of 3 PNA per unit with 20 max census. How do you handle 1:1's or 2:1's if you have them?

Now to your questions

1. There is no MHA (PNA) handoff at shift change. When the PNA doing Q15/Q30 checks is ready to hand off that responsibility they are supposed to physically transfer the check sheets - not just leave them at the nurses' station - and might give some updates on specific patients' whereabouts and behavior, but generally no.

2. We have MHA (PNA) leads but it's a supervisory (not sure if they have official supervisory authority) and support position with one per shift for the whole hospital. They split time between the shift coordinator's office and the units. They also respond to psych codes.

3. A PNA handoff with report at shift change sounds great; but you need one shift of PNAs out on the floor. You can't have your entire floor staff in the meeting room.

doulos1 · Mar 2, 2018

Sorry for the long delay haha. Just finished sending in my app for a direct entry MSN program. My timing sucked starting my nursing pursuit right after fall deadlines ended. But here's hoping for this one school which just started its rolling admission today.

- You have a cap of 3 PNA per unit with 20 max census. How do you handle 1:1's or 2:1's if you have them?

Yeah, usually if its a single 1:1 then with 3 PNA, one of us will do the 1:1. We don't have 2:1, if something like that came up, we'd call up a security officer to be stationed outside. Every once in a while things will get crazy and we'll have like 3x 1:1. In which case we have a pool of Patient care safety aides (Patient sitters). Or we'll ask if any PNA thats off wants to come in for a shift. Usually with 1:1, the nurse manager will try to predict number of days needed and will staff up accordingly. Worst case scenario is the morning shifts where theres only 2 PNA, 1 has to be on the 15min checks board at all times, the other would probably sit with 1:1. In which case things would run very slowly. Usually we can predict this early enough to call on an extra PNA for the day.

1. There is no MHA (PNA) handoff at shift change. When the PNA doing Q15/Q30 checks is ready to hand off that responsibility they are supposed to physically transfer the check sheets - not just leave them at the nurses' station - and might give some updates on specific patients' whereabouts and behavior, but generally not

We don't have Q30, only 15, 5, and 1. Our system is currently getting new changes b/c it used to just be physical handoff. Now I'm hoping to implement a more structured protocol for the handoff so messages don't get lost with shift transition.

That and making our night shift work a little harder: cleaning up areas, prepping some supplies we use, organizing patient storage area for new belongings, etc... I'm hoping if we can do this, it'll make day shift run a little smoother since its the most chaotic time.

My only challenge left is how we can improve the communication between PNAs. Since the only time waste I see is PNAs accidentally doing the same task, 2 PNAs without realizing, trying to fulfill a patient's request, or all PNAs getting stuck on something, not realizing checks need to be done, etc... Still more like a headless group of 3, but since we only have 3 PNAs during evening shift, maybe I could tailor some new procedures specific for evening shift. And also tailor some protocols for how the 2 PNAs work during day and night shift (hmm just thought that on the spot, I kinda like it).