Working with inexperienced CNAs

[Virgo_RN, BSN, RN]

This is a spinoff of another thread, since I didn't want to hijack it with my own question.

Where I work, there is a mix of experienced aides that have been around for a while, and some new ones who are very inexperienced, one right out of high school and a couple of career changers. These new ones haven't even worked in LTC, and were hired for our acute care cardiac unit with no experience (but that is another subject).

Some of the issues I have are with the lack of self directed work habits, lack of proactive work habits, and lack of self sufficiency.

For example, last night I was taking care of a dying patient. The CNA who was assigned never came to me for report, never communicated with me about this patient, and I never even saw her until about 10pm (we start at 3). CNAs are supposed to round on the patients at the start of the shift and change the names on the white board and start a new I&O tally. I went into the patient's room at the very beginning of my shift and was in there frequently throughout, and never once saw the aide in there, and the white board never got changed. I repositioned the patient myself, just pulling his shoulders over one way and his legs over the other to straighten him out, pulling the draw sheet over to take pressure off one hip and onto the other, and fluffed and replaced the pillows under his arms and legs. It was easily done with one person. I did oral care. I lotioned his hands, arms, and legs, and washed his face with a cool washcloth. Now, none of this stuff do I mind doing for a dying patient; I enjoy it, actually. But, the aide could have easily done these things as well. I'm just assuming that due to her inexperience, she doesn't know what to do. She finally approached me at ten, while I was in the middle of something else (my new MI admit's 3 hour troponins had been missed by the lab during the journey from the ED to the floor, and I had meds to pass) to ask me to help her turn the dying patient. I told her I was in the middle of something, but would be glad to help her in a little while. When I had a moment inbetween everything else I was doing, I went in to assess the dying patient, and since the aide wasn't around, I repositioned him myself.

I had another patient with pretty good bed mobility who could assist with turning himself, so I was able to do a complete linen change and clean him up without any help. Instead of finding someone to come help me boost, I put the bed in a reverse trendelenburg and had him push with his legs while I pulled on the draw sheet, and we were able to get him back up to the head of the bed, me and the patient working as a team. I have used this approach before with many patients who can push with their legs. Another thing I do is if the patient is able to stand, I just have them stand up and move up to the head of the bed. But for some reason, the aides haven't figured this out and will come to me to get me to help with a boost, even with patients that can boost themselves, or with patients that can stand up and walk to the head of the bed.

I suppose the answer is to take the time to teach the aides these little tricks of the trade that I learned when I was an aide. I had to learn these things out of resourcefulness, in order to complete my tasks with little to no help (I worked LTC and hardly ever had assistance with linen changes, undergarment changes, dressing, repositioning, etc. and learned to judge whether a patient has good bed mobility and can help, and when help is truly needed). The problem is that I am so short of time, it's just more efficient to do things myself, or to just pop in and help with a quick boost or turn, than to take the time to teach the aides.

Perhaps I've answered my own question, but has anyone else encountered this, and what approaches have you found to be the most productive?

[ChristineN, BSN, RN]

Did your hospital provide any sort of orientation period for them where they were trained by other aides? I would think that the other aides training them should be responsible for teaching them their job responsibilities, safe tricks of the trade, etc.

[caliotter3]

The only advice I can give is that I would pair a new CNA with my good CNA(s) and make sure they didn't spend too much time with our bad apples. I would also do as much teaching as I could. Spending that extra time with someone shows them that you care about them as an employee and goes a long way to keep the lines of communication open. You don't have to worry about them hearing the negatives, they will hear that anyway. Just try to keep them around positive influences.

[Virgo_RN, BSN, RN]

ChristineN, they get five shifts with an experienced CNA.

caliotter3, I wish I could control who orients new aides. Unfortunately, some of our newbies have been paired with the less than stellar performers.

One suggestion I have made to the NM is to pair the new aides with a nurse for their orientation. I'm not sure that will happen, but I'd love to train new aides.

[ChristineN, BSN, RN]

ChristineN, they get five shifts with an experienced CNA.

caliotter3, I wish I could control who orients new aides. Unfortunately, some of our newbies have been paired with the less than stellar performers.

One suggestion I have made to the NM is to pair the new aides with a nurse for their orientation. I'm not sure that will happen, but I'd love to train new aides.

5 shifts is not enough, especially for someone inexperienced, IMO. I also work in a hospital and we have hired unexperienced aides, but they get two months with an experienced aide. I think turning someone that has no clue what their doing lose after 5 shifts is a little scary.

[caliotter3]

ChristineN, they get five shifts with an experienced CNA.

caliotter3, I wish I could control who orients new aides. Unfortunately, some of our newbies have been paired with the less than stellar performers.

One suggestion I have made to the NM is to pair the new aides with a nurse for their orientation. I'm not sure that will happen, but I'd love to train new aides.

I find it hard to believe that someone who knows what is going on would pair the new CNAs with those who don't do their job well. But then, I suppose, this person is not aware of who is less than a good worker. You need to stay involved with this and convince them to make better training assignments.

[HouTx, BSN, MSN, EdD]

Have you tried tightening up on your delegation? Don't assume ANYTHING and don't expect any pro-active behavior. I know it's a real pain, but it may be helpful to be much more explicit even though it is more work for you at the beginning. Provide a written list of tasks to complete, timeline for completion & instructions to report back to you when they are complete. Offer positive feedback frequently, especially when she(?) completes a task according to the parameters you gave her.

Don't hesitate to offer information about your expectations for her behavior -- "I want call lights answered immediately", "never leave a patient room without checking to make sure that the call light is within reach and the water pitcher full", etc.

[CoffeeRTC, BSN, RN]

I find that I tend to teach alot when I'm in the room doing care or helping a cna. It just comes out of my mouth and for the most part, the new CNAs are appreciative of this and I have been told that they were never taught xyz.

Try to get to know your CNAs and delegate appropriately. Some CNAs I just give report to and then they are off and going while others need more direct instructions.

I'd definately discusss this with upper management and see what can be done for a better training period.

[RNperdiem, RN]

CNAs need mentors too.

When I was an brand new aide, I was paired with the best CNA I have ever worked with. She taught me the tasks, the attitude and the work ethic(I once took a lazy shortcut and she let me have it; I have never done that again).

If the CNAs are being oriented by the marginal performers, you will have to help guide them. Give them very specific tasks.

Maybe they are not lazy or careless but need to be shown exactly where their responsibilities are.

[1stloveistobeanurse]

I worked ALF, as a new aide and it was so horrible, that I refuse to go back to another ALF again. Most new CNA just want to be taught correctly, they maybe coming to you for help because they are not ready to be on the floor after such a short orientation. I once worked a facility and was told I would be orientated well, the DON herself, spent 1.5 hours with me and without even showing me the care plans went to let me go on the floor, 21 residents. I was lefted on the floor with another aide the next day, who did not even want to give me a key to the room never mind orient me properly.

When I went to the DON I mention this to her, and her response was we really dont do orientation, my response to her was I really dont work here

[pagandeva2000, LPN]

I find it hard to believe that someone who knows what is going on would pair the new CNAs with those who don't do their job well. But then, I suppose, this person is not aware of who is less than a good worker. You need to stay involved with this and convince them to make better training assignments.

Actually, I am not that surprized. I am just guessing, but it can be several factors that lead to this. Some of what I am thinking of is that the good, experienced aides may be far and few, and of thin distribution. Another may be that if there are so few good aides (and even nurses, etc...), that they may have complained about being tired of being the only ones training newbies. They may love to teach people most of the time, but when one is constantly in demand, so to speak, it does get tiring when sometimes, they may just want to whisk through their day with ease. It could be that the powers that be may not want to totally burn their better ones out, so, they balance out who trains. Then, there may be other issues, such as days off, vacation, sick calls, etc... The unfortunate disadvantage is that the newbie is cheated out of a good training and begin to imitate the actions of the less than stellar folks.

A better orientation is the best deal, but, I have seen that this is a wish similar to a pot of gold at the end of the rainbow. I remember when I started as an aide. I had several years of working with psych and mentally retarded patients, but, while I had the bedside routine reasonably downpact, I didn't have to do it as often as a LTC CNA. When I went for the interview at the nursing home, I boosted up my bedside experience. This was a mistake, because I had a one day orientation, and had no idea about the careplans, side rail rules (we would put them both up in psych, and in LTC, they were considered as restraints). I had no idea about what assistive devices were, where they were to be placed on the patient or even where they were located. Within two months, I was written up for a fall patient. I placed both side rails up, thinking I was keeping him safe, but he was to have one siderail down. I didn't even know where to look on the careplan to see this requirement for that patient. Have had similar experiences as a nurse. A more informative orientation increases safety, and the enforcement of these facts early in the game reduces the confusion for new people imitating what others are doing that are less effective and less safe.

[litbitblack, ASN, RN]

Well I don't want to make you mad or anything but why did you not find her prior to 10pm if you guys started at 3. You wouldn't let a knew nurse you were orienting go that long without some guidence. If she only had 5 days orientation then im sure it was not enough for her to know all the little things that can be done to make things easier. I would take the time to show her and even though it does take your time your teaching her and then when she gets to the point she will be teaching someone everyone gets a piece of the good advice. She probably wasn't comfortable enough to move that pt by herself. Had i been in the same situation i also would have waited for help. Sorry don't want to rattle any feathers, but 5 days really isn't enough and then it comes down to the nursing staff to show them the shortcuts. Heck ive been a nurse 10 yrs and left the hospital for ltc and am now learning different short cuts everytime i work