Bridging the CNA Divide

After my session with Evelyn, who painstakingly typed her thoughts on her computer, I stopped at the nursing station to relay her message.

“Can you tell me which aide works with Evelyn Booth in 302?” I asked the nurse.

“Ms. Johnson,” she said, and pointed to a Certified Nursing Assistant (CNA) in a light blue uniform.

Hearing her name, Ms. Johnson turned and glared at me. “How do you know it was me?”

Surprised, I smiled and spoke in a soothing tone to reassure her. “Did you work with Ms. Booth this morning?”

She put her hands on her hips and spit out a single word. “Yes.”

“Well, she wanted me to let you know she really liked the way you did her hair today.”

“Oh.” She appeared surprised by the compliment, but unwilling to discard her initial suspicion. “Thanks.” She turned and walked away.
In 14 years as a psychologist in long-term care, I’ve occasionally come across an aide who was willing to collaborate with me in helping a resident. We discussed troublesome behavior and found ways to work around it, shared information, and developed a friendly collegial relationship. I’m disappointed such instances are exceptions rather than the rule, and I’d like to see this change. The way I see it, the psychologist is the CNA’s friend, here to make your job easier, not to write you up.
The current punitive system, where CNAs are more likely to be disciplined than rewarded, poses challenges to collaboration, but I think we can do better. I’d like to find ways to bridge this divide, and I need your help. If you have suggestions, or experience with developing alliances between nursing staff and other members of the team, please leave them in the comments section, or send me an email via the Contact Me button. Let’s start the teamwork right here.

20 thoughts on “Bridging the CNA Divide”

  1. CNA’s are not taught much about the team. We learn about doctors and PT, OT, dietary and of course, nurses…but rarely are we told much about the role of the psychologist in the long term care setting. In all my years of working as an aide, I have only seen a psychologist twice in a nursing home! That’s sad.

    CNA’s do work under the constant threat of being written up. Our work is task orientated, in spite of what so many wish to believe. Aides are responsible for bathing, feeding, dressing, weighing, getting VS, etc, and documenting all these tasks. If we take a few minutes away from our assigned “tasks” (ie residents) we fall behind on our work…this makes us unpopular. If a peer has to step up to help one of us, we’re really unpopular. We literally run against the clock. Minutes count.

    We get defensive- because of what is expected of us. We do act like we’ve been caught in the act…usually we have no idea what the “act” was. Residents, their families, our bosses and peers judge us on different elements. Everyone has different expectations of us. It’s a wonder most CNA’s stick with the work when one steps back and looks at all the negative things we put up with, day in and day out!

    Another block to CNA’s feeling like they can’t speak with other members of the team is how we are perceived by so many: Lowly uneducated aides who are not professionals, who don’t know much. Our opinions are not asked for; we’re often told it’s not our place to speak up when we DO SPEAK; we’re not respected. We sense this perception and it plays a large role in keeping our mouths shut.

    I read about some nursing homes allowing the aides to attend Care Plan meetings. This is a step in the right direction for sure. But these mtgs only occur every few months. When issues arise, we need help and clarification and guidance, right there and then. Not two months down the road.

    Also, many people who work in long term care do assume resident behaviors, aggressions, depression and the like are “normal” and therefore just par-for-the-course. When Mrs. Smith starts crying, we’re apt to tell her “it’s ok and you’ll be fine” without ever knowing WHY she is upset. We mention to the nurse that Mrs. Smith was crying, and that’s IT. We never hear back about it. Until tomorrow, when Mrs. Smith is crying again- a never ending cycle that repeats itself in hundreds of facilities.

    Resident centered policies, where the aides are a central part of the team would rectify much of this. If aides were encouraged to seek out the psychologist (dietitian, OT, PT etc) I think residents’ lives would improve a lot. Chains of command, stiff rules and silly regulation are all part of the problem. Before this can happen, aides need to be respected more; they need support and education that fosters collaboration. They need to be set free to use skills most people already have: Empathy, a desire to help others, and the freedom to seek help from the right team players.

  2. Dear Patti,

    Thanks for taking the time to give us your perspective, which was illuminating. I agree, it's sad you've encountered a psychologist only twice in your years of work.

    When I was a child-care worker for emotionally disturbed adolescents, a position similar to that of the aide, I found it remarkable that the people who spend the most time with those receiving care were offered the least opportunity to share information with the treatment team. I find that's the case in many settings, and it takes top-down management to shift to a more egalitarian approach, such as resident-centered policies and teams.

    I firmly believe the time spent hashing things out with the psychologist will be rewarded many times over by smooth sailing with formerly troublesome residents, but I can understand the time pressure of the CNAs.

  3. Management needs to fix the time issue. They have the power to do that; I'm not sure they have the will though. Meetings can work wonders when the info/agenda is set up correctly. Some forward thinking Directors of Nursing might read this blog and re-think the value of CNA's who are involved and who actively participate in resident needs. Nothing can replace a well respected and regarded group of aides!

  4. I am a psychologist working in a LTC setting. I also have an innate interest in languages (my B.A. was in French), and I work with many staff members from non US cultures/countries. I have made it a point to learn a few words in the native tongues of the CNA's, nurses, housekeepers etc, such as Hello, Goodbye, How are you? Thank you, It's raining (I'm in Seattle!), etc. I have learned a smattering of Russian, Polish, Swahili, Vietnamese, Amharic (Ethiopia), Ibo (Nigeria), and Romanian. I feel that asking about languages shows staff that I have an interest in THEM as individuals, as well as in the residents we serve. I enjoy learning, it creates a bond between us and perhaps they feel complimented at my desire to learn from them about their language. The other thing I do is occasionally scrub the sinks in the staff lunch room & one women's restroom. I'm a little OCD about shiny sinks, but I also hope that staff seeing (that I care enough about their/our working conditions to pull out the BonAmi powder) will help them feel taken care of. Perhaps they'll be moved to 'go the extra mile' for residents as a result. It may be a little crazy, but these are two things I do that I can think of… Oh. a third thing – sometimes I bring tea bags or cake & put it in the lunchroom for general consumption. One day, the tea bags were all suddenly gone & I expressed surprise. A CNA said 'well someone took them all home, of course.' At that point I realized that some staff members might be feeling 'needy' and rather than be angry about it, I decided to keep bringing more, as a way of addressing that perceived neediness.

  5. Patti and Marlo, I once worked with a brilliant chief psychiatrist in the psychiatric hospital who would lead one unit at a time and train them in his approach. One of the things he did was have the Mental Health Therapy Aides (MHTAs, the psych equivalent of CNAs) at every team meeting. The meeting wouldn't start unless a MHTA was there. He also answered the telephone if he was in the nursing station, and was frequently the typist when entering info into our computerized treatment plans. Marlo, the actions you suggest are great for individuals trying to improve team relations, but when they're done by the Chief of Psychiatry (equivalent of Medical Director), they carry the weight of authority and administrative backing that creates change on a facility level.

  6. Patti,
    You have made some valid points, I have often thought CNAs work in an overly punitive environment with few rewards (from either residents or administration). That being said, I have worked in many facilities and can not think of one where administration did not recognize the value of a good CNA, even if they are not a part of the care plan meeting. I have known so many dedicated hard working aides through out the years, but have also known many who are angry, resentful and anti-administration.

    While I do agree, many aspects of care plan meetings can be improved upon and certainly CNAs should be a part of them, however, when they are not, it does not necessarily mean they are not respected or well regarded. Health care cuts continue, but new regulations continue to demand more. Many facilities have been forced to cut back on staff and everyone is working harder.

    I think you have some good ideas showing your staff your interest in them as individuals. You may want to think twice about cleaning the sinks, going above and beyond within the boundaries of your position is one thing, stepping over the edge (cleaning the sinks) can have adverse effects. Maybe you could just answer the phone on the unit from time to time?

  7. Thanks for your comment, Anonymous. A way to include more CNA feedback, as an alternative or supplement to taking them away for a lengthy care plan meeting, is to add an element to shift reporting. Currently, the report is done by the nurses to the aides in the beginning of the shift. It would be valuable information, along the lines of "behavioral rounds" (a topic I need to blog about one of these days) to have a brief end of shift report with the CNAs noting to the nurse any behavior/medical changes they see in the residents.

    Regarding your comment to Marlo, it's a point well taken: one person's kind gesture might be seen by others as strange doctor behavior or an insinuation of a job poorly done. There are many points of view in the nursing home community, which make it both fascinating and challenging.

  8. As a CNA, I think it's important to come across as capable and intelligent, even when you really want to bite someone's head off. I find the nurses and the administrative staff have a better attitude toward me when I stick with the facts v/s the emotions. Not that I haven't bitten off my share of heads, but I get better results when I act sane and rational. Acting defensive and "butt hurt" can sometimes get you the treatment you appear to be asking for.

    Also, it works the other way. Administrative folks will get better response if they go in with a positive attitude. "I have a compliment for the aide that worked with Mrs. Booth this morning" would have netted a different response than saying "Did you work with Mrs. Booth this morning?" which would make me cringe even if I had been able to do everything perfectly that day (HA!).

  9. To K. Tree,

    As a CNA, or anyone else, I think it usually better to stick to facts rather than emotions if you want to get your point across no matter what position you are in. The question is why would a simple question, " Did you work with Mrs. Booth today" spoken in a "soothing tone", make anyone cringe? Why would anyone have to preface it with the purpose for the question? Should a CNA expect their charge nurse to begin the question, "K. Tree, I need to know if Mrs. Smith had a bowel movement, did you work with her this morning? Or, K. Tree, " I need a weight on Mrs. Smith, did work with her this morning? We generally do not speak this way, (although we could) we first want to find out if we are talking to the appropriate person before seeking the answer to our question or relay in the information we need to convey. More importantly, I think it is the tone of how we are a speaking that we need to watch no matter who we are speaking to.

  10. Dr. El,

    "Behavioral rounds" at the end of each shift is an amazing idea! In the many facilities I have worked I have never seen this done. We all know what valuable information the CNA can provide, what a simple solution for something so important. In my observation CNAs are generally winding down at the end of their shift, and I imagine it shouldn't create any added stress on their already heavy load.

  11. K. Tree, I've been hoping to hear from you. I read your blog regularly and I've never heard you sound anything but capable and intelligent. I agree that coworkers respond better when we're calm rather than emotional.

    The comment "Did you work with Mrs. Booth this morning" could be taken badly if not for the tone and facial expression I was using, as Sue pointed out. In fact, the aide assumed I was going to criticize her even before I had a chance to say anything. I hear your suggestion that I start with a compliment or some sort of specific reassurance (more than tone or body language) prior to discussing a resident and I'll give that a try.

    In addition to altering one-to-one interactions, it seems this is a system-wide issue. If readers know of programs that address this dynamic, please share them so we can make greater progress as a community.

    Sue, regarding the behavioral rounds, once everyone gets used to the process it takes about five minutes, provides volumes of important information, and enhances team communication.

  12. Thanks for your comments & perspectives. I'll re-think the sink. 🙂
    Another obvious but often neglected team-building response is giving written compliments. Our facility has concern/compliment cards for anyone to fill out. Staff Development folks have started posting the compliments in the staff lunch room. (The concerns are addressed privately, of course)

  13. Marlo, I like that idea of posting compliments. It creates a positive environment and gives staff members an idea of what's compliment-worthy behavior. Thanks for the suggestion.

  14. Write the aides up. Catch them in the act of doing something GOOD…and write them up for it. make 3 copies: One for the CNA, one for his or her file and one for his or her supervisor. Not just aides- but all staff. Collect all these "Caught In The Act" forms each quarter and then have a raffle activity.

  15. That's a good one, Patti, and I like that it's for all the staff. We could all use some positive reinforcement. If the administration starts up this program, they could be one of the first compliment recipients!

  16. Sue and Dr. El.

    Sorry, I'm just getting around to reading this again.

    Asking someone if they took care of a certain resident shouldn't make us cringe, regardless of the tone of voice. I guess I was just responding to that specific situation.

    Still, I don't think there's anything wrong with starting the question with "I have a compliment for…" And it will immediately reduce any defensive response from the CNA. Obviously, if you are asking about medical information, you wouldn't announce it first. Someone would surely be screaming "HIPPA Violation!" if you did.

    "Caught you being good" was a program that my son's elementary school ran back in the day and it really was a good motivator. I don't think anyone ever grows out of the need to feel that others notice when they've done well. So, "Go Patti!" on that suggestion.

  17. My kids had a great public school and they also did "caught doing a good deed" or similar things. All the kids got a lot out of these programs. I am in a long term care on a 4 month placement in a social service worker program. Social workers are not normally found in this long term care facility but are there is work for them nonetheless. I am thrilled to find your blog and going through it for ideas. At the moment I am putting together ideas for an effective "welcoming committee" and looking for ways that other nursing homes help make transition to long term care easier. Your "Resident's Top 5 Complaints" will be very useful. Thanks so much.

  18. Love this idea, "caught in the act of doing something good" ! I recently spoke to 2 very wonderful hard working CNAs. I told them, how much I wish the perception of their profession could become elevated in terms of better pay and respect. I told them that in my mind, "they are the "Special Forces" in God's Waiting Room!" Akin to the Navy Seals. They perform such an elite task. Keeping Elders away from harm, keeping them safe, comfortable and loved! So much of what they do that is a holistic "art" is done behind closed doors!


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