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Why CNAs Matter in Wound Care | Isaac Zralii on Frontline Patient Care | Healing By Design EP 2
3 Plays2 seconds ago
What happens when the healthcare professionals who spend the most time with patients are often the last to be included in the conversation?
In this episode of Healing By Design, host Jennifer Bierhup sits down with Certified Nursing Assistant, healthcare advocate, and PAWSIC Board Member Isaac Zralii to discuss the critical role CNAs play in patient care, wound prevention, and preserving skin integrity across the continuum of care.
Drawing from more than 21 years of experience in acute care, long-term care, behavioral health, rehabilitation, and COVID relief efforts, Isaac shares a perspective that is rarely heard in healthcare leadership discussions. As the first CNA to serve on the PAWSIC Board of Directors, he brings valuable insight into the challenges, opportunities, and realities facing frontline caregivers every day.
Together, Jennifer and Isaac explore why CNAs are often overlooked in healthcare conversations, the communication barriers that exist between nursing assistants and nursing staff, and how education can empower CNAs to identify changes in patient condition before they become serious complications.
This conversation is a powerful reminder that improving patient outcomes requires listening to the people who spend the most time at the bedside. From early wound identification to preserving skin integrity and preventing avoidable complications, CNAs are often the first line of defense in protecting patient health.
In this episode:
• Isaac's journey to becoming a Certified Nursing Assistant
• Why CNAs are often overlooked in healthcare discussions
• The communication gap between nurses and nursing assistants
• The role of CNAs in wound prevention and skin integrity
• Why frontline caregivers need better wound care education
• Burnout, staffing challenges, and patient ratios
• The concept of the CNA as the "ultimate observer."
• Creating pathways for early wound identification
• Building stronger interdisciplinary care teams
• What healthcare leaders need to understand about CNAs
Interested in supporting CNA advocacy and recognition? Explore the official PAWSIC CNA Collection and help celebrate the frontline caregivers who play a vital role in patient care every day.
Shop the CNA Collection:
https://pawsic-shop.printify.me/collection/cna
Healing By Design is a podcast powered by PAWSIC that explores the people, processes, and perspectives shaping better outcomes across the continuum of care.
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Transcript
Podcast Introduction and Purpose
00:00:00
Speaker
Hello everyone! Welcome to Healing by Design, the podcast where we amplify the voices that matter most in wound care. I'm Jen Bierup and I am here with my co-host Therese Laub. We are so glad you found us and we can't wait to dig into today's conversation.
00:00:13
Speaker
Before we jump in, I do want to take just a quick moment to cover a few things. Everything we talk about on this podcast is meant to educate and inform. It's not medical advice and it shouldn't be taken as a diagnosis or treatment recommendations. Your situation is unique and your health care provider is always your best resource for decisions about your care.
00:00:31
Speaker
The opinions our guests share are their own. They don't speak for POSIC or our sponsors. And if any of our guests have professional or financial ties to products or companies we discuss, we'll always be upfront about that.
00:00:43
Speaker
One more thing, if you're ever dealing with a wound care emergency, please don't look to us for that. Go to a provider right away. Now that we have all of the disclaimers out of the way, let's dive right into our show.
Meet Isaac Zareli: Career and Educational Background
00:00:55
Speaker
Hello and welcome to our next installment of Healing by Design, the Pawcic Podcast. I am ridiculously excited today. i have a guest on that I am been waiting to interview for a very, very long time since I first met him. His name is Isaac Zareli.
00:01:11
Speaker
And Isaac is the very first certified nursing assistant to join the post-acute Skin and Woon Integrity Council Board of Directors. And it is phenomenal to have him on the board of directors. He brings over 21 years of hands-on clinical experience and is a fierce advocate for systemic change within the healthcare care industry.
00:01:32
Speaker
Isaac is an alumni of the Liberty University and Old Dominion University, both of Virginia. He has extensive media presence regarding CNA equity issues, LGBTQ health advocacy and mental health issues as well.
00:01:47
Speaker
When he is not tackling tough conversations, he enjoys bringing cooking. He enjoys watching cooking shows with his fiance and his three cats. So Isaac, welcome to Healing by Design.
00:01:59
Speaker
Thank you for having me. So first off, i want I want to get to know you a little bit better. so So tell us a little bit about yourself and then tell us a little bit about your journey to becoming a CNA. You kind of made a comment about being maybe a reluctant CNA. So give us a little bit about that background.
00:02:18
Speaker
um I am definitely the reluctant CNA and I don't think that I'm... um any different from any part of my community that says we are all kind of reluctant CNAs in some aspect. um So I got my CNA license initially in 2005. So um I've been at this 21 years um off and on. um I have made sporadic breaks um to try different industries, but somehow scrub life keeps pulling me back into the fold. As much as I want to run away from it, I can't. um
00:02:51
Speaker
And it's it's really been a fantastic journey. um I never thought as a young 18 year old with my CNA license leaving high school that I would say that I am now 40 years old and a CNA and very proud of what I do. um So that was definitely a turning point because if I had looked at my younger self, I'd be like, wait a minute.
00:03:11
Speaker
um But um a lot of, well, The last about seven years of my CNA experience has been doing short-term contract work. So that has taken me literally around the country and sailing in the Caribbean. um So that was really, really fantastic.
Experience During COVID-19: A CNA's Perspective
00:03:30
Speaker
um So I worked all throughout the pandemic. I was in five different states in 2020, helping with COVID relief. and um have worked in inpatient behavioral health, um acute care hospitals, med surge, long-term care, skilled nursing rehab, um mental health support detox centers. So it's really been a fantastic journey.
00:03:53
Speaker
Wow. So if I'm hearing correctly, you have a huge amount of experience as a CNA in multiple ah settings. So not only post-acute, multiple different types of post-acute, but also acute as well. so Correct.
00:04:08
Speaker
that is an extensive career. So it's... I cannot wait to get some of your feedback on some of these questions then because you're going to bring that from all different settings, all of that experience. So tell me a little bit. up Tell me a little bit about Liberty University and Old Dominion University. Tell me. Oh, oh Liberty. Yeah.
00:04:31
Speaker
wow um Yeah. ah if If you're not familiar with Liberty University, they are known as the world's largest evangelical Christian university. They are centered in Lynchburg, universe are you know in ah lynchburg Virginia. um the It was founded by Jerry Falwell in 1972, and it is um very Southern Baptist forward. um So that was a different kind of experience for me um because I come from a very complex background.
00:05:03
Speaker
um But I do have an associate's degree through them. i was working on my bachelor's degree and took a kind of a left turn pivot and ended up finishing that at Old Dominion. Wow. Okay. So I'm curious, what is your bachelor's degree in? We don't have to be curious. um So I um do have a bachelor's of science in psychology. um I was working on a minor in nonprofit or public service and didn't quite finish that minor, but um do have the bachelor's of science. Yeah.
00:05:33
Speaker
That is fantastic. Wonderful. And that kind of explains. um Again, you know, I have the great pleasure of of being on the board of directors with Isaac over at POSIC. And you really do bring such a fantastic perspective about people and personalities and how people should communicate. And so that makes absolutely perfect sense to me that you have your bachelor's in psychology. I totally see that for sure. Yes. Oh, so tell me a little bit. So if we talk about wound care and CNA, tell me a little bit about what you, we we talked about this earlier, what got you into POSIC?
Role of CNAs in Wound Care and Education Gaps
00:06:05
Speaker
Like what, what was your draw? Cause I think that's important for everybody to hear.
00:06:09
Speaker
Um, so I, I consider myself a lifetime learner. Um, it's something that I am very proud of. I'm always listening to audio books, podcasts, kind of what's going on in the media, my realm on politics, not so much, but, um, as far as like what's going on as, um, in the industry and within healthcare, I try to stay on top of things.
00:06:31
Speaker
And, um, I'm very active on LinkedIn and LinkedIn was advertising a wound con conference, which is specific to advanced practice providers and wound prevention and management. And i was like, well, I'm sitting at home. I can log in and catch the seminars and see if anything is pertinent to CNAs. And a lot of the information is, but not framed in a way that makes sense.
00:06:55
Speaker
um So POSIC did have a um a presentation and I followed along to it and they were talking about how we are all part of a holistic care team. And they mentioned advanced practice providers like nurse practitioners, DOs, um and then the the classic dieticians, occupational therapists.
00:07:15
Speaker
And then there was this gap. And I was like, so is that gap where the CNAs belong or is that kind of like a placeholder? Because i understand that, you know, as a holistic team, there is always room for more people at the table and more perspectives. So I got in touch with Palsik and I said, hey, so let's let's kind of continue this conversation of what I saw in your presentation.
00:07:37
Speaker
And it created this fantastic dialogue about where CNAs are not. always at the table to have the discussions. And I constantly say the same statement, which is CNAs do not have the vocabulary to have the conversations.
00:07:57
Speaker
And that's where... What do you mean? Yeah, explain that to me a little bit. Like, I mean, just so just just to so so I can understand that a little bit better. So um in the acute care setting, I was working on a med-surg floor and we had um one of the um product providers come in and give us training on how to use the creams and the barrier creams. And that was super informative, but that was a very specific product for an acute care setting for specific med-surg issues.
00:08:24
Speaker
The products that are out on the market in long-term care, we don't get a lot of proper training for. They were just like, here's this cream, use it. um oh So when we're not seeing improvements in in some of the wound issues or we're not seeing... um any change, then we don't have the vocabulary to tell our nurse, you know, we're using this cream, we're using it every day, we're using it, you know, as prescribed, but it's not doing anything. And the wound on Ms. Jones's backside is getting worse.
00:08:58
Speaker
But we can't say what it looks like because we don't have that vocabulary. And we can't say, you know, it has now exceeded the the parameters or it's now, you know, three inches or or whatnot, because wound prevention, education, and management is not part of CNA curriculum.
00:09:17
Speaker
And I think that that, you know, one of our questions was, is what does the wound care industry need to understand about CNAs? And I think you just said that, is that that vernacular, if you will, um is not extended, that education is not extended at all to CNAs. I mean, almost completely blocked out, if you will. Correct.
00:09:37
Speaker
we We almost lock that, that whole CNA group just gets completely locked out of it does any of that true education. And I think, if I'm not mistaken, Isaac, if it was done in the correct fashion, wow, what a difference that would make if we brought that education to the CNAs.
00:10:00
Speaker
hu Now, one of the issues that we have as CNAs is there's not a national ah expectation of what a CNA class is. You know, ah for a nursing board generally it's, you know, accepted that there's a two-year associates and a four-year bachelor's and then you have, you know, you build on that. CNAs across the nation have a variety of different training programs. In Florida you can get certified with the enough requirements to take state licensure in three days.
00:10:33
Speaker
Wow. Yeah. i don't think I realized it was that short. I always thought maybe in Ohio. I'm in Ohio, so I feel i feel like it's different here, but it maybe it's not. I don't know. Right. So in Florida, you can literally have all of the requirements necessary to take the state licensure exam in three days. um In Virginia, the ah CNA training program that's part of our school district is a two-year program. So see the vast difference between three days and two years. Wow.
00:11:03
Speaker
Oh, my gosh. Wow. okay Oh, wow. Is that for like the like the like the certified? So like you would be certified then after that, like the like the certified nurse assistant type of You have, for Virginia, for the two-year program.
00:11:18
Speaker
Well, you're right. Ohio has the STNA. For Virginia, it's the CNA. And um in those two years, they have met the criteria for the the licensing for state of Virginia to be able to take the licensing exam. Yep.
00:11:29
Speaker
Wow. Wow. So what a difference. Mm-hmm. I wanna take a moment to tell you about something I'm really proud of, and that is Lebellin Learning. For years, wound care case management has existed in this space where clinical expertise meets care coordination, and yet there has never been a dedicated educational home for the professionals doing this work every day. Nobody was building for the wound care case manager specifically, so we did.
00:11:53
Speaker
Lebellin Learning was founded to fill that gap. We are pioneers in developing education designed specifically for wound care case managers. The nurses,
Lebellin Learning and Educational Empowerment
00:12:02
Speaker
the coordinators, the clinicians navigating complex patients across every care setting.
00:12:07
Speaker
The ones who are often doing everything right, but without the resources and recognition they deserve. We believe that when wound care case managers are educated, supported, and empowered, patients heal, systems work better, and the outcomes, they speak for themselves.
00:12:24
Speaker
If that sounds like the work you're doing or the work you want to be doing, Lebellin Learning was built for you. Find us on LinkedIn and come grow with us. Wow. Oh my gosh. that is That is amazing. But I know that because I did actually get asked to teach some CNAs, some some skin and wound care.
00:12:45
Speaker
And what I found most intriguing about it was that they were hungry for that information. They were so excited. There were so many questions. There was millions of questions. And these questions were incredibly good and they were necessary. And what hit me is that, oh my gosh, we have an entire army of of of people, of professionals that are with the patients.
00:13:13
Speaker
at the most important times, as in feeding, as in getting bathed, as in changing beds, as in helping them to and from, as in being there for them as a person. And we don't empower our CNAs with the information that they need in order to, you know, move information back and forth between, you know, RNs, LPNs, things like that, like what you said.
00:13:37
Speaker
It's mind blowing to me. i'm I'm overwhelmed at the fact that we have, as a profession, left you out. And that's, you know, it's terrible.
00:13:50
Speaker
Absolutely terrible. So and there was something that you would say. Well, go ahead. Your observations is that, um you know, we do want the information. We do want to learn. And that kind of goes against the grain of some of the sentiments that we hear from nurses about, you know, CNAs aren't interested. They're disengaged. They don't want to learn. They're just here for a paycheck. So that you can see what the reality is on your side, and I can tell you what the reality is on my side and what the sentiment is coming from the other side.
00:14:23
Speaker
Now you said to me that you are on a lot of forums, so you do a lot of communication with other CNAs, and obviously you've done this across the country. So I think what brings what makes you so important is your unique perspective, not only on all the different spaces that you've been in, but also in all the different states that you've been in. So to me, you're able to see trends.
00:14:44
Speaker
You're able to understand as a whole what CNAs need and you're able to see trends, I think, in all the hierarchies of nursing. I mean, would that be a fair thing to say that you can kind of see what really is going on across the country with CNAs?
00:15:00
Speaker
um Amongst the the forums and my very large network of friends and co-workers, yes, I think that um I pretty much have a ah pulse of what's going on and what's kind of the undercurrent of frustrations.
00:15:15
Speaker
Ah, my goodness. All right. So tell me a little bit about if if we were to build education for CNAs, if if the wound care, if we said we're going to build education for CNAs, Isaac, what what would you want to see us build? What do you need? What do you need from us as an industry to be successful?
00:15:38
Speaker
um The number one thing is the power and belief that we want to learn.
00:15:49
Speaker
Because when you know that somebody wants to learn, then that changes how you interact with content and material and you match people where they are.
00:16:01
Speaker
So we know generally that CNAs are predominantly women of color. um They are generally working um on average hours a week.
00:16:12
Speaker
between one or two jobs. um The general shift is between 12 and 16 hours for most. Most are living pretty close to the poverty line.
00:16:23
Speaker
And the assumption is that these women um are not smart enough um to engage in material. Now, I am of the the camp to say,
00:16:38
Speaker
Let's adjust the material to where people can understand. A good example is um the POSC library is very vast. It's got some really great information.
00:16:50
Speaker
If you can translate some of that information in a way that makes sense to somebody that isn't an advanced practice provider, then that really changes the system.
00:17:02
Speaker
Oh, absolutely. Absolutely. i mean, just introducing basics of skin, even. Just basics of skin. Just starting there. Mm-hmm.
00:17:14
Speaker
I think would be incredibly helpful. And yeah as an educator, i I know that we can literally take everything we have on POSIC and we could. And you're laughing because you know. Absolutely. yeah we We could take every piece. I mean, I'm thinking about everything across the board. I'm thinking about stuff that that that I've developed. I mean, we can absolutely make it into something that would be so reasonable and dynamic for the CNAs.
00:17:41
Speaker
Mm-hmm. because that's what we should be doing right we should always be teaching at the top of people's licenses and we should always be empowering them to want to learn more because that's what we do as educators correct that's our passion so us as a cna's we know where the cap of our education is we know that we cannot assess we cannot diagnose um there's a lot of things that we can't do and we have been told over and over again you can't do these things So we are yeah and very sure didn't know our limitations.
00:18:16
Speaker
But if we can at least go to a nurse and say, hey, so, you know, I've been putting Miss Jones shoes on for the last three days and she's got this little spot and it started as, you know, a little pin and now it's the size of a dime and now it's red and Miss Jones is diabetic.
00:18:32
Speaker
You know, that's something that we need to be discussing. okay yeah And and so it could literally could be as simple as changing her shoes. And absolutely. And it is, i mean, it quite literally is as simple as changing her shoes. I think that's that that's the crazy thing about wound care, right? Is it is quite literally as simple as doing a bed bath.
00:18:51
Speaker
It is quite literally as simple as watching somebody move from the bed to the chair or helping them move, watching them walk, taking off their shoes, washing their feet, looking at their hands. That is absolutely, hands down, the most important thing for us to risk mitigate and assess for things that are going wrong. And the people that do that are you, are the CNA.
00:19:21
Speaker
And yet we haven't empowered you enough with basic information to be able to bring that observation back to where it needs to go. Mm-hmm.
00:19:34
Speaker
Yeah, absolutely. You made a comment and in a meeting um that really hit me. Now, I will say i have never done long term care. So I'm going to put that out there like as like a little like asterisk, right? Like I've done home health. you know, I've been in the hospital, been, know, outpatient. Um, but you made a comment that really hit me is so as a CNA, you might be in Mrs. Jones room. You might've taken off the shoe. You might've said, Ooh, Hey, wait a second. Oh, this can't be good. And then you might've taken that information back to maybe the lead RN or whoever is on that team. And you said that they don't hear you.
00:20:15
Speaker
They don't listen. tell me Tell me a little bit about that and tell me about that across the country. Tell me what your experiences are. um And I always sound like a broken record on this one. um CNAs are licensed healthcare professionals.
00:20:32
Speaker
We sit for boards, we are background checked, we are CPR certified, we are fingerprinted. We have the same stringent um licensure measures as if we carry an LPN or RN licensure.
00:20:47
Speaker
So a lot of the issues is that we don't get the same recognition as a licensed healthcare care provider. And that really sets the tone. That's number one thing that sets the tone.
00:21:00
Speaker
um There are, and i'm I'm going to say this as a generalization, there are a lot of really excellent nurses working in long-term care. They have dedicated their lives to working in geriatric populations and they love what they do. And then there are the outliers that are there either for convenience, whether it's, you know, able to pick up, you know, random shifts on gig sites or um this is where they've kind of landed in their career. And
00:21:33
Speaker
when a CNA um will come to them and say, you know, hey, Ms. Jones isn't really looking right. And i'm I'm not quite sure what's going on, but this isn't her baseline. We have a lot of nurses that will be like, ah, it's just Ms. Jones and just go about their day.
00:21:46
Speaker
And, you know, we'll come back and we'll like, hey, you know, it's now two o'clock and Ms. Jones really isn't looking so great. And I'm i'm concerned. ah Right. And, you know, it'll just get dismissed again.
00:21:59
Speaker
And a lot of that...
00:22:03
Speaker
A lot of that is just um the the disregard to the CNAs and some of that is generally burnout. um Absolutely. I mean, yeah yeah, we can't, we can't discuss this without discussing the very real reality of of burnout on all levels from all scopes of work. So yeah absolutely. I mean, you know, if you have 50 patients as an RN or whatever that you're in charge of and calling docs on back and forth and all of that, you know, and then somebody brings that, somebody doesn't look great.
00:22:34
Speaker
You're, On my end from an RN, I'm like, oh my gosh, this is one more thing I have to add to my list of things to do. Yep. And you deprioritize it in your brain because you've already had five other things that you have to follow up on.
00:22:51
Speaker
And so, I mean, I i do get it. i It's not okay, but that's what happens. That's what happens. Yeah. Mm-hmm. And so it's like, it's hard, you know, I don't want to, you know, we're not, i don't think Isaac, you and i we're not here to like demonize any profession by any stretch because we're all really doing the best that we can and hanging on by, I think like the tips of our fingernails most of the time. But I mean...
00:23:17
Speaker
If we could stop just and take a deep breath for just a minute, collective deep breath, and if a CNA really is coming a couple times and saying, I'm really not liking how Ms. Jones looks, you know, we need to check this out.
00:23:32
Speaker
That really, from an RN standpoint, that has to go to the top of my list now. It does. It absolutely does. So it's just an interesting conversation for all of us to have.
00:23:47
Speaker
And we don't talk about this enough, I don't think, out in the open. No. And I'm definitely not... trying to pit RNs against CNAs. I mean, that is, you know, that's the fable of the decade. I know. We're not trying to do that. Like, let's not do Yeah. But I had mentioned to you, you know, before we started the deep conversation is, you know, I'm in a forum and they said, you know, what is what is the hardest part about being a CNA? And I'm reading through the comments and I said, you know, lack of supplies and not enough staff and You know, having 30 residents, which is obscene, but it happens. And 30 is I've seen worse. I've had worse. But the number comment was not having nurse that is able to help.
00:24:35
Speaker
Oh, okay And it could be literally, you know, can you get Miss Jones water while I'm giving, you know, Mr. Smith a bath? Or can you catch that call light because I've got my hands full with someone else? Like, it's literally these small little moments.
00:24:52
Speaker
And then I always, when I'm working, I always catch the nurse and I say, hey, so I'm going to give Miss Jones a bath. Do you need to do a skin assessment? You know, now is the time for you to put your eyes on this patient. Perfect.
00:25:03
Speaker
And some of them are like, I don't have time. You know, I got to go do wound treatments. I got to go do meds. I got to, you know, do paperwork, you know, Smith Smith down the hall fell. Now I got to do neuro checks. And I understand that, but I always try to open the door. And a lot of my CNA friends also try to open the door and say, do you need to do a wound check? Do you need to do a skin assessment? Do you need to do, you know, anything nursing related? Cause now I've got Ms. Jones in the perfect position.
00:25:29
Speaker
Right, now you can do the entire head to toe check that you normally wouldn't be able to do. oh that is phenomenal. That is phenomenal. Yeah, absolutely.
00:25:41
Speaker
And yet, you know, the nurse can't always go. cant It sounds like they're not always able to actually stop what they're doing and go. And so again, that's that that's the complete circle back to the basic skin and wound training for the CNAs to be able to recognize that something is wrong. We're not asking for an assessment. We're just asking for recognition. Hey, this isn't right. Correct.
00:26:05
Speaker
I know that this patient has these things and this isn't right. And then being able to describe it or something along those lines. Yeah. If you are using the CNA as your ultimate observer, then they have to have the vocabulary to describe what they see.
00:26:21
Speaker
okay, can we put that, we need to, we need to write that down. Like, that's really important. Like the CNA is the ultimate observer and they need to be educated to be able to, to speak to what they're observing.
00:26:33
Speaker
Like they need to be, and then they need to know how to escalate it. Oh, I think we just figured out our first class together that we're going to teach. Isaac, I'm pretty certain. Like, don't forget this because this needs to happen. I mean, it just does. i mean, you know, hands down, it just it just has to happen. And yet and again, we i think this is necessary. I think this is a necessary conversation right now.
00:26:56
Speaker
Yeah. We have to open up this dialogue absolutely
Challenges in CNA Workloads and Staffing
00:27:00
Speaker
right now. It is imperative. Wound care is over a $22 billion dollars a year. Wounds are over $22 billion dollars a year of a problem.
00:27:10
Speaker
And we have an entire ah group of people that we need to teach that could so that could theoretically identify something before it gets to the point of...
00:27:24
Speaker
you know, hospitalization. I have worked with some really amazing teams. um One, believe it or or not, was um psychiatric, geriatric, state-funded health.
00:27:35
Speaker
So it was a facility dedicated to people over the age of 65 with psychiatric issues that were in state custody ah for a number of reasons. Oh.
00:27:47
Speaker
And it was anything from maybe they have a criminal record to maybe they have bounced around different facilities and they've gotten to be too violent to be at a regular nursing home. um And that particular facility was incredibly difficult for a lot of reasons because that was a very hard population.
00:28:06
Speaker
But they had a dedicated and I hate to use the phrase, but this is what we use in the CNA vernacular is the check and change team. And if you were assigned on the check and change team, that is all you did. Every two hours, you were taking your folks to get them checked, changed, make sure that they were clean and dry, powdered, lotioned, whatever was necessary in their care plan.
00:28:28
Speaker
Zero skin issues in that facility. because you literally had like an entire team that their only job was to check and change. Yep. Wow.
00:28:38
Speaker
Wow. Yep. Wow. Yep. And zero skin issues, you're saying? like Zero skin cash issues. Wow. Nope. And if things were starting to percolate, they were caught early, you know, because you had a lot of eyes on that patient at any given time. And, you know, you were working with these folks 12 hours a day. And so you're like, oh, hey, I see this spot. You know, maybe we need to put some lotion on it. And is it going to go away in the next couple days? And if it doesn't, all right, now what?
00:29:06
Speaker
Right. Yeah. Zero skin. Yeah. I boast about that facility all the time because they understood what it meant to keep skin integrity.
00:29:18
Speaker
Wow. Wouldn't that be amazing if a check and change team could become standard across the country in every setting? Wow. Oh my gosh. That would be absolutely phenomenal. And maybe it's something we need to work on. I mean, maybe it's something that we really need to, you know, how how can we make that happen? I don't know, but it would be amazing if we could.
00:29:36
Speaker
there There's a lot of issues on why it's not
00:29:41
Speaker
not possible in some facilities. And a lot of that has to do with how nursing homes are managed. The Centers for Medicare and Medicaid, um ah they're they're a little tight with their policies.
00:29:55
Speaker
True. Yep. Yep. Yep. i guess that's I guess that's true. I guess that's true. yeah Yeah. Well, let's let's move on. Let's talk a little bit about, and because you and I had such amazing conversations. i I always enjoy my time with Isaac. Every time I jump on a call with him or something, we always we always have great conversations. Yeah. You know, I think let's talk a little bit. I want to talk a little bit about the the patient ratios, the staffing, the responsibility, all of those types of things. Give me a little bit of insight as, again, somebody who doesn't necessarily, you know, live in the in the sniff world or the long term care world. But give me a little bit of an idea of what that like what your day to day looks like with that as a CNA.
00:30:33
Speaker
um So I don't I will preface this as i don't have a um a staff job um right now. yep Right now I do per diem shifts through some of the gig apps. So I fill staffing needs across the area that I'm at right now. And I have done that across the nation and I've done that in what's called short term contracts, which is three to six months or it could go longer based on staffing needs. um There are some contracts that are literally a week long, 14 days, a couple months. And it's in the hopes that a facility can onboard enough home staff to not have to use us agency folks.
00:31:17
Speaker
um So a lot of the the things that I see when I come into a facility, I'm seeing with brand new eyes because I haven't been there six months. I haven't been there a year. I haven't been there five years. So the issues that I'm seeing that I'm picking up on, I'm just like, oh, wow, that's that's a problem. And oo that needs that might need a policy. But I'm not at the point where I can say, hey, so do you guys have a policy on ABC? Because I'm seeing this as a major issue.
00:31:44
Speaker
um Oh, yeah. Yeah. how do how do you How do you internally handle that? Like, how do you internally go, oh, gosh, this is a really big problem here, but you don't have the ability to shed light on it?
00:31:55
Speaker
i um depending on Depending on what it is, sometimes I do shine light on it. um i i definitely have gone to um charge nurses and been like, hey, so...
00:32:07
Speaker
let me tell you this is a safety issue or this ah could be a potential safety issue i'm not afraid to kind of ruffle the feathers because i'm i don't depend on that particular facility for my paycheck So, yeah. So actually, you do have the freedom and the ability to ruffle the feathers because you aren't there long term. And so you can bring up the problems and you can say, ha, now I'm leaving for the next time. Yes. Here's your major problems. I'm out the door. I'm going to go to the next facility. Yeah. Yeah. I do. If if I'm somewhere three to six months, I do ask for an exit interview and I do say, OK, so here's the challenges that I faced in the last six months. Do I always get exit interviews? No.
00:32:46
Speaker
Most of the times I don't. Makes sense. Yeah. But I do ask for them because it is important for somebody to be able to say, you know, here's why I would choose not to be part of your staff.
00:32:59
Speaker
Right. Here's why i'm I'm dipping out. Like I'm done. I'm not coming back. It's not happening. No. Hello, my name is Max Bierup and I'm the owner of Maximilian Kratos and the video producer helping bring Healing by Design to life.
00:33:13
Speaker
I've been the wound care space for over six years and I've seen firsthand the challenges clinicians and patients face every single day. It's a complex problem and honestly, it's one that's still incredibly underrepresented and definitely undereducated.
00:33:27
Speaker
That's what pushed me into this space. I help healthcare and wound care brands bring what they do to life through video production, commercial photography, and even multimedia design that makes it clear, credible, and meaningful enough to create real change.
00:33:42
Speaker
I take complex care and turn it something that people can understand, trust, and actually act on. Because better communication doesn't just grow a brand, it supports better care. I'm especially passionate about working with people who are trying to move healthcare forward and not just exist in it. Make real change. And if that's you, i would love to connect. My name is Max Bierup, and I'm the owner of Maximilian Creatives.
00:34:05
Speaker
I mean, so let's let's kind of roll into that whole idea of of moral injury.
Moral Injury and Systemic Issues in Healthcare
00:34:12
Speaker
Because I think every single, you know, and we're going to talk a little bit about the nursing hierarchy as well. But the moral injury, because ah all of us in every single position in the medical field right now, regardless of who we are.
00:34:25
Speaker
We are all in immense amounts of moral injury. um We cannot take care of our patients the way that we were trained to or the way that we would like to on an everyday basis.
00:34:41
Speaker
I know we could talk probably for hours about how the system is not allowing us to do that. But shed a little bit of light for me on on how a moral injury affects you and how it affects other CNAs that you talk with.
00:34:55
Speaker
um Well, i'll go I'll go back to the previous question because that kind of leads into moral injury. So when I go into a facility um on any given day in any given state because of state mandates or lack thereof, I can have anywhere from about 15 residents to I've had up to 45. 45? 45.
00:35:17
Speaker
forty five forty five
00:35:21
Speaker
Yeah. I literally just read somebody had 60 the other day um because of call outs. Wow. Yeah. I mean, that is actually like physically impossible. I mean, it's not possible. It's physically impossible.
00:35:36
Speaker
Right. Yeah. So if you can imagine that you and i I'll preface this with the idea of, you know, people Most CNAs, again, are um predominantly women and predominantly minority women. So if you could put yourself in a position of saying, you know, um I am now a mom of 60 people.
00:35:58
Speaker
that I have to make sure are fed, dressed, clean, ah toileted, um ready for dialysis, ready for doctor's appointments, dressed for Sunday church. you know Whatever the given day is, i now have you know this ratio of people.
00:36:13
Speaker
And CNAs are very common to say, these are my people. We do take ownership of the people that we're assigned to. And when you go into a facility and a CNA says, oh, these are my people, these are my 12th,
00:36:26
Speaker
you know just by that statement that that that cna takes their job seriously because they are going to make sure that those 12 people are clean and hydrated and fed and turned and whatever is needed within their care plan but if they have on monday 12 people and on tuesday they now have 24 because there's been a call out and on friday they now have 40 because there's been two call outs the amount of care that they're able to give over the course of the week, one, they're already tired because they've you know worked all the way Monday through Friday, but now they have tripled the amount of residents. And at that point, it literally becomes a war zone of signs of life.
00:37:06
Speaker
Right. You're triaging as best as you can. Signs of life. Signs of life. You know, you are doing your check and changes probably once a shift. And I hate to say this, but it happens. You are getting vitals if you can or as the nurses recommend.
00:37:22
Speaker
You are doing positioning if you can. and All of this leads into the the moral injury. And so what moral injury is, is when you are put in a situation that morally you know what the right thing to do is, but you don't have the staff, resources, or ability to act on your morals.
00:37:43
Speaker
And CNAs, again, we're left out a little bit. So nursing has a code of ethics. CNAs do not have a unified code of ethics, but what we do have in our curriculum is the, you will always treat patients with dignity and respect, and you will always provide them with the care that is necessarily necessary for them to thrive in their environment. So if you have 12 patients, then you know that you can do Ms. Jones's hair and you can make sure her dentures are extra clean, versus when you have 30, she's not going to get the same dedicated care.
00:38:18
Speaker
And that creates moral injury. And when you have a system that continually creates these little chips, it's like you have a teacup and you start chipping away at it. It can't hold water anymore.
00:38:30
Speaker
And so you have these CNAs that love what they do. They love their residents, but they literally do not have the emotional or spiritual reserves to keep going.
00:38:42
Speaker
And it is so much deeper than PTSD and it's so much deeper than burnout because burnout is when you're like, ah, I've had enough of this versus i am now injured from doing what I'm supposed to be doing.
00:38:56
Speaker
And it takes a long time to recover from. Yeah. And you can't necessarily, you don't have the luxury to recover. You have to keep going. Mm-hmm. So you're literally, you have no cup. You've chipped away the whole cup at this point. Like there's nothing, there's no cup left.
00:39:13
Speaker
Correct. And we're all, I mean, all of us You know, every, I mean, docs, NPs, PAs, everybody across the board.
00:39:27
Speaker
So I, and I think you explained that so well. We hear that word moral injury, but what does it mean? And Isaac, so I appreciate it. You did a great job explaining what that actually means and what that does to a soul.
00:39:39
Speaker
Cause it really, it just, it takes chunks out of your soul is what it does. does. yeah i Yeah, I had the pleasure of of presenting a presentation on moral injury at a CNA conference. And I struggled with, you know, what do I name this presentation?
00:39:54
Speaker
And I sat on it and I thought about it. And I said, soul on fire. Because that is literally what I felt. Because, you know, you can take days off and you can take a vacation, and you can kind of recharge yourself. But that doesn't deal with the wound.
00:40:11
Speaker
You know, where POSIC is all about wound care prevention and education, moral injury is a wound. Oh, well, now that's, we just have a whole new podcast. No, you're absolutely. just just right Moving on to podcast number two. Number two. Number two. Moving on. Yeah. I mean, but that is, I mean, oh my gosh, think about that. Moral injury is a wound that festers constantly yeah and it is never allowed to heal.
00:40:40
Speaker
Mm-mm. it isn't it's It's never, you know, if we talk about wound care, you know, you're perpetually locked into the inflammatory phase of moral injury. ah Well, you know, in in a lot of my CNA populations, you know, not only is it inflamed and it's infected, but we're now septic.
00:41:00
Speaker
you know Right. I mean, you're septic. Yeah. what you you have you have You have moved on from from, you know, the moral injury is is is is no longer, you know, surface. It has gone, you know, body wide. It is now the entire body and you are now septic and you are in ah systemic inflammatory response at this point. Your blood pressure has bottomed out. Your heart rate's gone through the roof and now you're losing your toes and your fingers. Yep. And that's where you're at. Yep. this is why this is one of the multi-component issues. um of why CNAs are leaving the industry.
00:41:33
Speaker
wow Yeah, absolutely. you know it's It's complicated and you know there's a lot of facets to it. But if you sat down with a CNA and you ask them, why are you leaving? you know What's your exit interview? They'd be like, well, you know I try to tell the nurses what's going on and they don't listen.
00:41:47
Speaker
And you know I never have enough supplies for Ms. Jones and I just need more laundry and you know I just need extra help. And it's really small things that can be changed in the system.
00:42:02
Speaker
Yeah. But again, you know there there are limitations, and I understand that there's limitations. But we are losing really good CNAs because they don't know what they're feeling.
00:42:15
Speaker
you know a good therapist will say, you know tell me about what you're feeling, and maybe we can put a word to it. you know And so when I started talking about moral injury, people were like, oh, oh,
00:42:28
Speaker
Well, yeah, that that makes a whole lot more sense because I'm not just burned out. I'm not just like, you know, i don't want to go to work on Monday. it's It hurts, you know? And there there are a lot of nurses that are doing the same thing when they're coming home from work and they're sitting in their car and they they're literally in tears.
00:42:44
Speaker
And that I had those moments, you know, during the pandemic, I would come home and I literally could not get out of my car because I'm just like this ball of ouch.
00:42:56
Speaker
Oh, yeah. And I think we're all still, I mean, you know, we could talk about this for hours and hours and hours. I mean, we, as a profession, the nursing profession, the whole, the whole nursing profession from CNAs all the, all you know, on up.
00:43:12
Speaker
i mean, we are still in recovery mode from the pandemic, very much so in recovery mode. And quite frankly, I'm not even sure if we're ever going to really recover to what we were prior to the pandemic at all. No. And and i working through the pandemic and and like I said, I was in five different states in 2020.
00:43:33
Speaker
One of the states that I was in was New York. And I was there, um yeah yeah, I was there April to July of 2020. And I usually tell ah everybody what you saw in the news was true and then some.
00:43:46
Speaker
um And I left New York with a lot of ouch. And it wasn't oh in the way that I expected. I've worked in long-term care and hospice and um seen the dying process and seen the grieving process.
00:44:04
Speaker
What I saw in New York was not that. What I saw in New York was a lot more of just overwhelm. And people put in situations that had we not been in a global pandemic, they would have made different decisions.
00:44:24
Speaker
Right. Yep. Yep. Absolutely. I was in a hospital at that time during 2020. I was inside of a hospital. So I completely 100% agree. There would have been different decisions made for certain um had we had the ability to just stop for a second and just take a deep breath and and think through even our basic standards of care. Correct.
00:44:50
Speaker
Correct. So I, yes, absolutely. And so again, so we really haven't recovered. I mean, us as a profession, we just, we haven't, we haven't recovered. So we keep hearing about, oh, the nursing shortages or the CNA shortages. And it started, i mean, it was not great prior to the pandemic, enter the pandemic.
00:45:08
Speaker
And now I'll the other end of it and the moral injury, we don't even have a cup left. There's no cup. No, there's a giant wound. Yeah. It might be covered in maggots.
00:45:20
Speaker
Oh, it's definitely. Yeah. it's it's It's definitely festering. Yeah. And one of the things that I i bring up all the time with CNAs is that for some reason we are seen as highly expendable. And right they put us in what's called, and I hate to say this, the churn and burn cycle. Yeah.
00:45:42
Speaker
If we burn, let's pretend, you know, I'm a brand new CNA and I burn out within the first six months to a year, that's expected. Somebody else is going to take my place. Yep. The average turnover rate for CNA is about two years.
00:45:57
Speaker
Wow. Yeah. And that's for a number of reasons. Oh, absolutely. Absolutely. I'm really curious. I do not know the stats of my own profession, but I don't think it's super great either. You know, of my own license like level, I don't think it's super great either. I think that, but that is, yeah, absolutely. You are expendable. Bring in the next person because that's what we're going to do. Oh my goodness. So, you know, we have covered so many topics really, you know, from, from how, to how can we educate? How can ah the wound care industry really bring in, how can we, how can we bring in the CNAs? Because truly you're our eyes and our ears and our hands.
00:46:37
Speaker
And so how can we educate? I think we've kind of talked about let's, let's change some of the wording. Let's figure out what's important. Let's listen to the CNAs. What do they want to learn?
00:46:49
Speaker
And then i think understand that CNAs are like super excited and very hungry to learn and understand. let's Let's think about that first. And then how can we repurpose some of the education that we've already made? Because it's absolutely repurposable for our CNAs.
00:47:07
Speaker
Absolutely repurposable. And then, you know, the question is, is that how can we value our CNAs? can we give me How can we step outside of ourselves and really start to look at CNAs in a different light and value what you bring to the table for certain?
00:47:25
Speaker
Very, very, very important. um And we've talked a little bit, we've talked a lot about the moral injury of CNAs and really the moral injury of the medical industry you know as a whole. And I really love how you described that. That was that was that was phenomenal. um I know we wanted to talk you know a little bit about you know the toxic cultures of the nursing hierarchy. and And I think we've kind of covered that a little bit is that you know I think ultimately, boy, wouldn't it be great if we could just all work together? Yeah.
00:47:54
Speaker
oh yeah yeah did we just all work together yeah well you know i as as a nurse you know you know the saying that um you know nurses like to eat their young oh yeah yeah they particularly enjoy snacking on cnas yes you guys for some weird reason you have like frosting on top of you i don't understand like i don't like you have sprinkles and stuff like i mean it's terrible you're extra tasty apparently Yeah, yeah. And, you know, again, i i always go back to its the vocabulary because i am versed enough to know when I'm getting a particularly snarky nurse what it is, which is lateral violence. And I can say, hey, so that's not okay.
00:48:39
Speaker
You know, but my rest, the rest of my CNA network may not be able to say, oh, that's a microaggression. That's a macroaggression. That's lateral violence. um You know, what is I just know that this nurse is picking on me and she just doesn't like me and she never listens to what I have to say.
00:48:56
Speaker
It's a little deeper than that. Yeah, no, absolutely. And you know, I've, I, somebody made a comment to me as a whole, and I think this resonated with me and, and, and we can talk about this just for a little bit was nursing as a whole has been a a marginalized profession as, as a whole.
00:49:17
Speaker
Um, and so we respond appropriately. We do. And, um you know, the the latest um political news, you know, with nursing being declassified as a as a professional really set the stage for some folks to say, okay well, now I'm going to change my behavior.
00:49:43
Speaker
Right. And now I'm going to change how I move forward. And, you know, maybe that graduate degree where I was going to become a nurse practitioner, I'm not going to do anymore. Yeah, I'll just, i'll I'll stay here. I'll stay where I'm at.
00:49:55
Speaker
Right. Absolutely. It just, it helped me when somebody described to me that, you know, we've always been kind of an oppressed, because you know, ah really an oppressed ah profession all the way through. At first I was like, nah, I didn't. like And then i the more I thought about it, I'm like, oh my goodness. Absolutely. and and And that is kind of why we...
00:50:14
Speaker
and I say we as a whole tend to eat our young or climb on top of each other is because I think of the oppression that we've had as a collective profession. It's just, I never really understood that until I really sat back and spent some time thinking about it. And it is absolutely true.
00:50:35
Speaker
um Well, there's there's also the expectation and as TNAs, we are constantly um hit, bit, scratched, spat at, had things thrown at. I've had glasses broken. And this is not just in behavioral health. This is working in long term care. um when you know When you go home and like my partner is super supportive and i' be like, oh, man, I got scratched by Miss Jones again. and She's like, oh, they didn't trim her nails. you know She understands. um But if I'm sitting in a a mixed population and I'm like, oh man, I got beat up again by like my little Grammys and Pop Pops.
00:51:08
Speaker
I've had some people say, well, you chose that life. Oh. And i'm I always look at them going, yes, I chose to be a health care provider, but I did not choose to be abused at my workplace. Right.
00:51:23
Speaker
Right, right. Yeah. And that seems to be escalating um more and more. i we i can forgive all of my sundowning, beautiful sundowning.
00:51:34
Speaker
i can totally forgive them. can. Yeah, I i do. I totally forgive them. We can definitely forgive them. But I mean, de there is there is a huge, huge increase in violence and all. And and I think i think in all in all settings. And so not only do we have our moral injury, right, but now we're being physically,
00:51:54
Speaker
you know, injured as well. So, oh my goodness, my goodness. So to wrap this up, i I think you and I could probably talk for the next three hours about all of these things. To wrap this up, um I think the takeaways here are in in wound care, CNAs are are truly vitally important for us to move forward as a profession. I just was at a conference and we really talked about the patient voice. We talked about the patient goals. We talked about paying attention to the patient. And we can't do that without incorporating the entire nursing care team, which includes the CNAs. And so therefore, then we need to educate the CNAs. um
00:52:33
Speaker
And Isaac, I have to say, i am so excited to have you on POSIC because I really see you as a pioneer as a CNA pioneer in the wound care industry to bring um your knowledge about your profession, bring it to us so we can all work together to make the change that's needed.
00:52:53
Speaker
appreciate that. Yeah. So we are so excited at POSIC to have you. um I'm going to wrap it up. Isaac, this has been a wonderful conversation. i have learned so much. I have so much enjoyed having you on Healing by Design, our POSIC podcast. Who knows? We might speak again.
00:53:14
Speaker
All of our listeners out there, i hope you had a wonderful time listening to Isaac and I today. And I hope you have a great rest of your day. Thank you so much for joining us. And that's a wrap on today's episode. Thank you so much for spending time with us. These conversations are why we do this, and we don't take it lightly that you chose to listen to us today. Before we head out, just a reminder. Everything you heard today is meant to educate, not to replace the advice of your own healthcare care provider.
00:53:41
Speaker
Please don't make medical decisions based on what you hear on this show. Your provider is the right person for that. Our guests share their own opinions and experiences, not the official positions of POSIC or anyone who supports this show.
00:53:53
Speaker
If you're dealing with a wound care emergency, please get to someone who can help you right away. And if today's episode was useful, subscribe and share it with someone in your corner of wound care.
00:54:04
Speaker
It helps us reach the people who need it the most.