The first step is to recognize the daily challenges certified nursing assistants face
BY Jennifer Rinker, CNA, RDH, BS
"You cannot judge someone until you've walked in their shoes."
The same saying applies to their occupation. After a few years of being an RDH and being upset over the poor oral care of our elders, I decided to become a certified nursing assistant (CNA) too. I was sure I would be the best CNA ever since I already had the knowledge and experience as an RDH.
Upon arriving at work one evening, it was mentioned during our briefing that one of the patients to whom I had been assigned had just been seen at a dental office. A note was returned to our nursing home stating we were not taking proper care of her full upper denture and her few remaining lower teeth. The nurse told me she wanted me to make sure I did a thorough job on the brushing that evening. I knew this would be easy for me. After all, oral care is easy for an RDH.
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When I went to get my patient ready for bed, I gently reached around and cradled her head to remove her upper denture. She instantly started grabbing at me with her hands, moving her head in all directions, and clenching her mouth and lips together so tightly that I couldn't get my fingers past them. It was apparent she didn't want anyone near her mouth. As I was doing this, her roommate, who could not walk without assistance from a CNA, decided to get out of her bed. I quickly took off my gloves to go after her. As I did this, my patient tried to get out of her wheelchair, which set off her alarm.
I wondered if I was a negligent or substandard CNA because I wasn't able to provide denture and oral care for my patient. Until that very moment, I was an RDH who got annoyed when I saw patients come into the dental office with calculus and food from weeks ago on their dentures and teeth. I never understood why the CNAs weren't doing their job when it came to oral care. It especially upset me with denture patients. After all, how hard could it be?
Until I became a CNA, I had no idea each nursing assistant was responsible for seven to 10 people during a six- to eight-hour shift. Nor did I realize their responsibilities included toileting, bathing, feeding, combing hair, all while watching for and reporting physical or behavioral changes, ensuring residents' safety, answering questions, consoling them, talking to them, etc.
Nursing assistants also stock and clean resident rooms, are required to chart food and liquid intake/output and ADLs, and, of course, perform oral care. Imagine toileting a resident, while at the same time you have a call light going off. You cannot leave the resident unattended on the toilet, and she/he is not necessarily quick in the bathroom.
By the time you're finished with this resident, you hurry off to attend to the patient who still has his/her call light on. That person also needed to use the bathroom. However, you didn't get there soon enough. Now you're cleaning him/her up, changing his/her clothes, and possibly the bedding. Hold on, there is an alarm going off! Someone is in danger of a potential fall.
As hygienists, we spend the majority of our day working in our patients' mouths. Our daily routine ranges from cooperative patients to difficult patients. We deal with this every 30 to 60 minutes of our eight-hour workday. Do we ever have difficulty with thoroughly scaling and polishing any of our patients? Of course we do. Are there patients who you prefer not to see again because you just can't seem to access the teeth due to limited opening, pursing/tensing of the lips and cheeks, not sitting still, etc.? I'm certain there are a few.
Although you get better at tackling these difficult situations over the years, there are probably still patients who you would rather not work on. But, for the most part, hygienists are successful at accomplishing the treatment they set out to provide. This is in sharp contrast to the day of a CNA.
Think about how challenging it must be to clean someone's denture and/or teeth after a meal or before bedtime when they are falling asleep and resisting care because they are so exhausted. Feeding, toileting, and transferring are duties CNAs become an expert at because they do it nonstop throughout the day. The same isn't true for oral care.
If we are going to be successful at having CNAs provide better oral care, we need to become their allies. Why would CNAs want to listen to us when we are constantly sending them nasty letters? We need to be professional. Collaborating with them will work much better than being condescending.
Who do you want caring for your teeth and gums when you get to the point in your life where you cannot care for them yourself? Would you prefer a CNA with limited knowledge and experience with oral care, or a CNA who has partnered with an RDH as a resource and who may actually be able to provide oral care services?
We should be collaboratively encouraging the patient, caregiver, and health-care team to do their best to remove the dentures at night and brush them thoroughly. We can also recommend a referral for a soft reline if the patient, care team, or we notice the dentures are too loose for the resident to chew properly.
When the patient is in our office, it is our duty to inspect dentures and clean them to the standards of dental hygiene. If you see issues with denture care with one of your patients, then it's your duty as a hygienist to help the patient, or the patient's family, find ways to keep up with oral care. It is our duty to explain the risk of aspiration pneumonia, among many other respiratory illnesses, if someone isn't adequately brushing dentures and natural teeth.
An exciting service has been developed recently that provides a solution to this issue. HyLife, LLC, a group of dental hygienists who specialize in oral care services for dependent adults, provides weekly oral care for dependent adults. It is our responsibility as dental hygienists to inform patients and their caregivers about these available services to help keep them orally, and therefore systemically, healthy. RDH
Jennifer Rinker, CNA, RDH, BS, is a certified nursing assistant in a nursing home. She is also a clinical dental hygienist at a general dental practice in Wisconsin. She received her associate's degree in dental hygiene from Madison College in Madison, Wis., and her bachelor's degree in oral health promotion from O'Hehir University. She is an oral care specialist with HyLife, LLC, which allows her to take an active role in preventing dependent adults from "dying from dirty teeth." Email her at [email protected].